Stephanie Teleki, PhD, MPH, Director, Learning and Impact, California Health Care Foundation
Elizabeth Myung Sook Krause, ScM, Director of Programs, Perigee Fund
University of North Carolina Professor Alison Stuebe, MD, has poignantly noted that “the baby is the candy; the mom is the wrapper” in American society and that “once the candy is out of the wrapper, the wrapper is cast aside.” Today, too many new mothers and birthing people* are isolated and their well-being is overlooked, with severely negative consequences for maternal and child health and society.
Approximately one in five mothers suffers from perinatal mental health (PMH) conditions while pregnant or in the year after giving birth, making them the most common complication from pregnancy and childbirth up to one year postpartum— a fact that is both shocking and unknown to many people (Gaynes et al 2005). PMH conditions most commonly include prenatal and postpartum depression and anxiety; other conditions include obsessive-compulsive disorder, post-traumatic stress disorder, substance use disorder, and, in extreme cases, postpartum psychosis and suicide. Mothers who are people of color, immigrants, teenagers—or who have low incomes—suffer from PMH conditions at a higher rate (as much as one in two). The pandemic has increased the prevalence of PMH conditions. New mothers have experienced more anxiety, stress, and isolation during the COVID-19 pandemic, and consequently their mental health has suffered.
The good news is that these conditions are preventable and highly treatable, and early detection can make a significant, positive impact. However, mothers are not frequently or consistently screened, let alone effectively treated, for PMH conditions. Left undetected and untreated, these conditions often negatively impact a mother’s health, relationships, and ability to work, and the effects and symptoms can endure for years. Additionally, these conditions can be damaging to a child in utero, resulting in preterm delivery, low birth weight, and feeding problems. Once a child is born, PMH conditions can negatively impact the parent-child bond and healthy child development. And, as funders of early childhood health initiatives know, parental mental illness is an Adverse Childhood Experience (ACE).
Barriers to Care
There are many reasons that most PMH conditions are not detected or treated: challenges related to appropriate and consistent screening throughout the perinatal period, access to trained culturally and linguistically concordant clinicians, fragmented perinatal care, different lived experiences, and stigma. On top of those reasons, caring for a new baby makes accessing mental health care even more challenging.
For example, Medicaid is the largest payer for maternity care in the United States, but mothers with pregnancy-related Medicaid coverage typically lose their benefits 60 days after the end of pregnancy (though advocates are working to change this and states are adopting changes under a new Federal option). While the Medicaid clock is set for 60 days, PMH conditions know no such cutoffs. Additionally, integrated mental health care is still relatively rare and not properly incentivized in obstetric and pediatric practices.
Structural racism and implicit bias in the health care system and individual clinician bias exacerbate the low screening and treatment rates. Black and Latinx mothers, for example, are less likely than their white counterparts to be treated for PMH conditions. The United States does not yet have a robust auxiliary and clinical workforce that is culturally competent and responsive to community norms and stigmas around PMH conditions.
Collaborating on Solutions
Philanthropy has and should continue to play a key role in supporting transformative change across the nation to ensure that maternal mental health is prioritized, with equity and inclusion at the forefront.
We share a sense of profound bewilderment that the most common complication of pregnancy receives so little attention and resources. While the California Health Care Foundation and the Perigee Fund are based in different states and have different philanthropic areas of investment, both have identified PMH conditions as an intersectional issue worthy of attention, resources, and collaboration.
As individual funders, CHCF and Perigee Fund would not have tackled the necessary but complicated effort to estimate the societal cost of PMH conditions. But by joining forces, we were able to hone the focus of the project to achieve the biggest impact. Through a joint Request for Proposals process and additional funding from the Colorado-based ZOMA Foundation, we identified a skilled grantee, Mathematica, to estimate the cost of untreated PMH conditions in the United States and in our home states of California, Colorado, Washington State. The research found that the societal cost of untreated PMH conditions when following a mother-child pair from pregnancy through five years postpartum was $14.2 billion for births in 2017, or an average of $32,000 for every mother-child pair affected by, but not treated for, PMH conditions. This work has been widely cited and has been replicated in Texas with support from the St. David’s Foundation.
Recently, our foundations also collaborated to cosponsor a theme issue on perinatal mental health conditions in the October 2021 issue of Health Affairs. Over years of collaborating on several projects, we have accomplished much more with our pooled resources and ideas than we would have been capable of alone. And we have learned that perinatal mental health—which is vital to the healthy start and growth of families—needs more funders.
There are many urgent PMH-related issues for which funder collaboration could help significantly advance solutions. Here are just a few that we know about and have our eyes on:
Getting better data
CHCF and the ZOMA Foundation partnered with the National Committee for Quality Assurance to develop clinical quality measures for perinatal depression at the health plan level, as part of the measure set known as HEDIS that is widely adopted across the United States. Because of our work, there is now a way to assess a plan’s performance on identifying and treating perinatal depression. What we need now is a push to adopt these measures in public and commercial plans throughout the country, and to help plans field and report on them.
Supporting mothers where they are
There are opportunities for funders to collaborate on supporting mothers where they are—through approaches that are delivered in home and community settings. For example, doulas, home visitors, community health workers, and peer support specialists can make it easier for busy, tired mothers to engage in PMH prevention, screening, and connection to care. Part of meeting mothers where they are means delivering racially and culturally appropriate care. We need funders to support PMH models that offer help in ways that those who need it will best receive it.
Expanding the pool of providers
There are opportunities to emulate the very successful MCPAP for Moms program in Massachusetts and fund provider-to-provider telephone consult programs, connecting primary care providers and psychiatrists with reproductive psychiatrists. The perinatal psychiatric access program model has spread to at least 13 states.
Addressing PMH conditions can improve birthing and postpartum outcomes, family functioning, and child wellbeing. If we funders step out of our silos and collaborate on PMHs, we can achieve greater impacts in our individual focus areas. Helping pregnant and mothers at this pivotal time in life supports many issues we all care about. The wrapper, as it turns out, is very important to all of us!
Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, et al. Evidence report/technology assessment no. 119. Rockville (MD): Agency for Healthcare Research and Quality; 2005. Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes