Approximately 20% of birthing persons suffer from depression or anxiety sometime between conception and the end of the first postpartum year (Taiwo et al., 2024). These conditions are known as perinatal mood and anxiety disorders (PMADs) and are significant contributors to both maternal mortality and morbidity. Recognition by clinicians of the presence of these disorders may lead to treatment and, consequently, attenuation of symptoms and their sequelae (Combellick et al., 2024).
From 2017 to 2019, mental health conditions were determined to be one of the leading underlying cause of pregnancy-related deaths (Trost et al., 2022) in the United States. All deaths of pregnant or postpartum (up to one year) individuals are reviewed by state Maternal Mortality Review Committees (MMRCs), which are multidisciplinary committees that convene at the state or local level and make determinations of causes of maternal mortality as well as preventability.
It is well established that the United States trails other more economically advanced countries with respect to its maternal mortality rate, defined as the number of maternal deaths per 100,000 live births between pregnancy and the 42nd postpartum day. In 2021, the CDC reported a national rate of 32.9 deaths per 100,000 live births (Hoyert 2022). Similarly, in the same year, the state of Georgia’s rate exceeded most other states with a rate of 33.4 deaths per 100,000 live births (Hoyert 2022).
As we are concerned about mental health’s impact on birthing people’s health, we must clarify that the national maternal mortality rate only includes deaths between conception and the sixth postpartum week. MMRCs consider the postpartum to extend up to 365 days after the end of pregnancy, no matter the cause. The Georgia MMRC specifically reports four different ratios based on the following:
Pregnancy-Associated deaths consist of all the deaths that occur during pregnancy and up to one year postpartum, no matter the cause.
Pregnancy-Related deaths are a subset of the above, namely deaths from a pregnancy complication, “a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy.” (CDC 2023)
Pregnancy-Associated-but-Not-Related-Deaths occur during pregnancy or in the following year but the cause is not related to the pregnancy. Pregnancy-Associated-but-Unable-to-Determine-if-Pregnancy-Related, a final and historically smaller subgroup of deaths reported includes (Hirshberg & Srinivas, 2017)
In Georgia, a review by the MMRC of pregnancy-associated deaths found mental health conditions to be the second leading cause of pregnancy-related deaths from 2018 to 2020 (Department of Public Health, 2023). Mental health-related deaths include deaths for which the underlying cause was depressive disorder, anxiety disorder (including post-traumatic stress disorder), bipolar disorder, psychotic disorder, substance use disorder or another psychiatric condition not otherwise specified.
In its most recent report, the Georgia Department of Public Health (DPH) again reported mental health conditions to be a leading cause of preventable pregnancy-related maternal mortality from 2019 to 2021 (Department of Public Health, 2023). The Georgia MMRC has provided several recommendations to prevent future mental-health-related maternal mortality, specifically, the need to enhance access to perinatal mental health screening and treatment, particularly among individuals with limited resources.
DPH has partnered with Emory University on PEACE for Moms, a psychiatric access program that established phone consultations with a perinatal psychiatrist who provides support and education to providers treating pregnant or postpartum individuals.
In addition to mental health conditions being a leading cause of death, mental health conditions contribute to deaths by other causes (Maternal Mortality Report, n.d.). For example, mental health conditions may prohibit individuals from seeking the care they need promptly for other underlying conditions that result in death, such as hypertensive disorders. A greater understanding of how mental health conditions impact the lives of pregnant and postpartum individuals is needed in order to prevent future deaths.
During the period examined, 15 deaths were determined to be pregnancy-related and due to a mental health condition. Of those 15 deaths, 13 occurred during the postpartum period (Maternal Mortality Report, n.d.). It’s notable that many of these deaths occur after the sixth week postpartum, unlike those due to cardiovascular illness or hemorrhage.
These preventable deaths (Maternal Mortality Report, n.d.) occur after a birthing person ceases their regular visits with their obstetrician or midwife where standardized screening is recommended (American College of Obstetricians and Gynecologists, 2018; Giouleka et al., 2024). After the six-week postnatal visit, the new parent is more likely to be seen not by their obstetric provider, but with their infant during pediatric well-child and emergency department visits
While screening for PMADs during these child-related appointments is recommended (Emerson et al., 2014) (Earls et al., 2019), it appears that there is little consistency in the practice (Barrow et al., 2022). It is understood that pediatricians and primary care providers are overwhelmed with all that is currently required of them. Still, there is evidence that screening can result in recognition of PMADs (Chaudron et al., 2004).
There are no published recommendations for screening new parents during their preventive health or illness visits during the postpartum year, but in 2016 the U.S. Preventive Services Taskforce updated previous recommendations to suggest screening in all adults regardless of their risk factors (Archived: Final Recommendation Statement: Screening for Depression in Adults | United States Preventive Services Taskforce, n.d.). With this understanding, in the 2024 legislative session, the Georgia House of Representatives put forth a bill requiring all Medicaid recipients to receive screening for PMADs and education about related disorders; at the time of this writing, the bill was awaiting review in the state senate ( GA HB1302 | BillTrack50, n.d.)
Screening for depression and suicide amongst pregnant and postpartum individuals is highly encouraged, but it is understood that non-psychiatric clinicians may be uncomfortable evaluating and treating these individuals (Chin et al., 2022).
Drug overdose fatalities are among the dominant contributors to Georgia’s pregnancy-associated and -related death rate (Department of Public Health 2023). The Georgia MMRC has also determined that psychiatric illness and substance use likely contribute to other causes of mortality.
Recognizing and treating individuals who are actively using illicit substances is needed if we are to lower the maternal mortality rate in Georgia. In the index years of 2018-2020, the MMRC found that 18% of pregnancy-related deaths from other causes were adversely impacted by substance use, including 47% of the deaths due to mental health conditions (Department of Public Health, 2023).
In December 2022, the Drug Enforcement Administration began requiring prescribers to partake in eight hours of education regarding substance use disorders (Wu and Adashi 2023); this will likely be insufficient training for most treaters of perinatal patients.
To prevent future substance overdose deaths among perinatal individuals, providers will need to be encouraged to refer individuals for case management and appropriate treatment programs. In addition, in cases of known opiate use or use disorder, the reversal agent naloxone should be prescribed (Bechtol et al. 2024).
Screening and diagnosis of perinatal mood and anxiety disorders only identify those who are suffering. In one study of pregnant and postpartum patients who screened positively for depression or anxiety, only 15% of the pregnant patients appeared to have received any mental health treatment or referral when their medical record was reviewed. Among the postpartum women in the same study, 25% had treatment initiated, and 27.5% were given mental health and social work referrals (Goodman & Tyer‑Viola, 2010).
In their most recent report, the Georgia MMRC detailed numerous issues that they believe contributed to mental-health-related deaths. Among the problems acknowledged by the committee was a lack of case management services (Department of Public Health 2023). Georgia’s Medicaid organizations Ambetter, CareSource and Amerigroup offer case management services to pregnant subscribers, and patients can take advantage of these services upon referral (Perinatal Case Management | GNR Public Health, n.d.).
The committee also noted the problematic discontinuation of psychotropic medication or reluctance to initiate medication due to knowledge regarding their safety. Based on the lack of treatment initiation and the frequency of its discontinuation, the MMRC suggests Georgia physicians and advanced practice utilize the gratis consultative services of PEACE for Moms.
While PEACE for Moms will not take over psychiatric care, they will guide the clinicians regarding treatment and provide appropriate resources for the patient. Clinicians and patients who require more knowledge regarding medication safety are also encouraged to use the fact sheets provided by the MotherToBaby program (Fact Sheets ‑ Pregnancy and Breastfeeding Exposures | MotherToBaby, n.d.).
The significance of perinatal mortality has been made evident as approximately 20% of individuals will experience psychiatric symptoms at some time between conception and the year following pregnancy’s conclusion, and mental health issues are associated with a similar percentage of perinatal deaths. It is the dedication of clinicians, with guidance from subject area experts and the support of our state health infrastructure, which can alter the current reality by screening, recognizing and treating the mental health issues associated with pregnancy.
References
American College of Obstetricians and Gynecologists. (2018). ACOG committee opinion no. 736: Optimizing postpartum care. Obstetrics and Gynecology, 131(5), e140–e150. https://doi.org/10.1097/AOG.0000000000002633
Archived: Final Recommendation Statement: Screening for Depression in Adults | United States Preventive Services Taskforce. (n.d.). Retrieved February 25, 2024, from https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/depression-in-adults-screening
Barrow, K., McGreal, A., LiVecche, D., Van Cleve, S., Sikes, C., Buoli, M., Serati, M., Bridges, C. C., Ezeamama, A., & Barkin, J. L. (2022). Are Pediatric Providers On-Board With Current Recommendations Related to Maternal Mental Health Screening at Well-Child Visits in the State of Georgia? Journal of the American Psychiatric Nurses Association, 28(6), 444–454. https://doi.org/10.1177/1078390320971358
Chaudron, L. H., Szilagyi, P. G., Kitzman, H. J., Wadkins, H. I. M., & Conwell, Y. (2004). Detection of postpartum depressive symptoms by screening at well-child visits. Pediatrics, 113(3 Pt 1), 551–558. https://doi.org/10.1542/peds.113.3.551
Chin, K., Wendt, A., Bennett, I. M., & Bhat, A. (2022). Suicide and maternal mortality. Current Psychiatry Reports, 24(4), 239–275. https://doi.org/10.1007/s11920-022-01334-3
Combellick, J. L., Esmaeili, A., Johnson, A. M., Haskell, S. G., Phibbs, C. S., Manzo, L., & Miller, L. J. (2024). Perinatal mental health and pregnancy-associated mortality: opportunities for change. Archives of Women’s Mental Health. https://doi.org/10.1007/s00737-023-01404-2
Earls, M. F., Yogman, M. W., Mattson, G., Rafferty, J., & COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH. (2019). Incorporating recognition and management of perinatal depression into pediatric practice. Pediatrics, 143(1). https://doi.org/10.1542/peds.2018-3259
Emerson, B. L., Bradley, E. R., Riera, A., Mayes, L., & Bechtel, K. (2014). Postpartum depression screening in the pediatric emergency department. Pediatric Emergency Care, 30(11), 788–792. https://doi.org/10.1097/PEC.0000000000000260
Fact Sheets – Pregnancy and Breastfeeding Exposures | MotherToBaby. (n.d.). Retrieved March 9, 2024, from https://mothertobaby.org/fact-sheets/
GA HB1302 | BillTrack50. (n.d.). Retrieved March 15, 2024, from https://www.billtrack50.com/billdetail/1708943
Georgia Department of Public Health. (2023). 2018-2020 Maternal Mortality Report. https://dph.georgia.gov/document/document/maternal-mortality-2018-2020-case-review/download
Giouleka, S., Tsakiridis, I., Kostakis, N., Boureka, E., Mamopoulos, A., Kalogiannidis, I., Athanasiadis, A., & Dagklis, T. (2024). Postnatal care: A comparative review of guidelines. Obstetrical & Gynecological Survey, 79(2), 105–121. https://doi.org/10.1097/OGX.0000000000001224
Goodman, J. H., & Tyer-Viola, L. (2010). Detection, treatment, and referral of perinatal depression and anxiety by obstetrical providers. Journal of Women’s Health, 19(3), 477–490. https://doi.org/10.1089/jwh.2008.1352
Hirshberg, A., & Srinivas, S. K. (2017). Epidemiology of maternal morbidity and mortality. Seminars in Perinatology, 41(6), 332–337. https://doi.org/10.1053/j.semperi.2017.07.007
Home – PEACE for Moms. (n.d.). Retrieved February 25, 2024, from https://www.peace4momsga.org/
Perinatal Case Management | GNR Public Health. (n.d.). Retrieved March 9, 2024, from https://www.gnrhealth.com/services/maternal-child-adolescent-health-services/pregnancy-case-management/
Taiwo, T. K., Goode, K., Niles, P. M., Stoll, K., Malhotra, N., & Vedam, S. (2024). Perinatal mood and anxiety disorder and reproductive justice: examining unmet needs for mental health and social services in a national cohort. Health Equity, 8(1), 3–13. https://doi.org/10.1089/heq.2022.0207
Trost, S., Beauregard, J., Chandra, G., Njie, F., Berry, J., Harvey, A., & Goodman, D. A. (2022). Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services.
Dr. Toby Goldsmith
Dr. Goldsmith was educated at Cornell University and the SUNY-Buffalo School of Medicine before completing a psychiatry residency at Vanderbilt University. Since 1995, Dr. Goldsmith has focused on the psychiatric needs of women, especially during the reproductive period. In 2006, she joined the psychiatry faculty at Emory University and became director of the Women’s Mental Health Program in 2013. Named an Atlanta Magazine Top Doctor since 2017, Dr. Goldsmith now proudly leads Georgia’s perinatal mental health access program, PEACE for Moms.
Dr. Sarah C. Blake
Dr. Blake is an associate professor and Director of Graduate Studies in the Department of Health Policy and Management at the Emory University Rollins School of Public Health. A health services researcher, she applies a health equity lens to address women’s healthcare, particularly health disparities in reproductive and maternal and child health. She is an appointed member of the Georgia Maternal Mortality Review Committee. Dr. Blake received her PhD from the Georgia Institute of Technology/Georgia State University joint doctoral program in Public Policy.
