In Addressing Maternal Mortality, Mental Health Often Left Out
Abstract
Mental health conditions are the leading underlying cause of maternal mortality, yet mental health is often left out of national initiatives to improve maternal outcomes. Experts say much more needs to be done, including gathering data to better understand the significance of the problem.
In 2022, the Centers for Disease Control and Prevention (CDC) published data from 36 maternal mortality review committees (MMRCs). Deaths by suicide, overdoses, and other deaths determined by the MMRCs to be related to mental health conditions were far and away the leading underlying cause of pregnancy-related deaths (deaths that occur during pregnancy or within one year postpartum). Mental health conditions were the underlying cause of 23% of pregnancy-related deaths from 2017 to 2019. Hemorrhage was the second leading cause of death, at about 14%.
“The inclusion of mental conditions in maternal mortality statistics was long overdue,” wrote Katherine Wisner, M.D., M.S., and colleagues in JAMA Psychiatry in February. Research has long pointed to the significant link between mental health and maternal mortality, the authors wrote. They referenced a 2003 article published in the British Confidential Enquiry. In it, the authors reported that suicide accounted for 28% of maternal deaths in 1997-1999, and additional deaths were associated with substance use. Yet despite this research, Wisner and her colleagues noted that maternal mental health is often left out of efforts to combat maternal mortality.
“Mental health conditions remain stigmatized in our society,” Wisner told Psychiatric News. Wisner is the associate chief for perinatal mental health at the Developing Brain Institute at Children’s National Hospital. She pointed to a 2019 paper published in the American Journal of Obstetrics and Gynecology, which reviewed numerous studies that identified self-harm, including suicide or opioid overdose, as the leading cause of death in the perinatal period. “These self-harm deaths remain under the public radar,” the authors wrote.
Trauma’s Impact on Perinatal Outcomes
The myth that pregnancy somehow protects women from mental illness is persistent among the public, but research has consistently debunked it.
“The process of having a baby itself can be traumatic for some patients,” said Nancy Byatt, D.O., M.S., M.B.A. Byatt is the executive director of the Lifeline for Families Center and Lifeline for Moms program at UMass Chan Medical School, the founding medical director of the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms, and a member of APA’s Committee on Women’s Mental Health.
Some studies estimate that between 34% and 45% of women experience childbirth as traumatic, regardless of their need for medical interventions. Byatt and her colleagues conducted a qualitative study among 32 individuals, most of whom were White and privately insured, who reported experiencing a traumatic birth. Participants reported that their labor experiences were traumatic for a variety of reasons, such as fetal complications or poor communication with staff. Among the participants, 34% screened positive for posttraumatic stress disorder (PTSD), 19% for depression, and 34% for anxiety. The findings were published in General Hospital Psychiatry in 2021.
Most participants felt that they did not receive adequate mental health support while they were in the hospital following their deliveries. Others did not feel comfortable discussing mental health symptoms with their clinicians due to stigma surrounding mental health care.
“We need to support perinatal individuals, because then we can actually prevent some of the downstream effects of trauma and stressors families are experiencing,” said Nancy Byatt, D.O., M.S., M.B.A. “I think that’s the best chance we have of addressing this mental health crisis, because we’re not going to do it by reacting only when we see the illness.”
Byatt noted that births can especially feel traumatic for patients if they are entering the perinatal period with histories of sexual trauma or other kinds of trauma. Adverse social determinants of health, such as lack of housing or food insecurity, are also considered traumas or stressors that can negatively impact a patient’s birthing experience.
Maternal Mental Health in the VA
The impact that trauma has on birthing outcomes was noted in a January report by the Government Accountability Office (GAO) on maternal health within the Department of Veterans Affairs (VA). Research indicates that pregnant veterans are more likely to have experienced PTSD or military sexual trauma, which can increase their risk of adverse pregnancy outcomes, the report stated.
The trauma burden among women veterans is significant, said Amanda Johnson, M.D., director of women’s reproductive health in the VA’s Office of Women’s Health. About 40% of women veterans who use the VA for their health care have at least one mental health diagnosis, she said. “We also know that [women veterans] may actually have a higher trauma burden when they join the military compared with the general population,” she said.
The VA has seen the number of hospital deliveries it covers skyrocket in recent years, from 2,567 in fiscal year 2011 to 4,766 deliveries in fiscal year 2020, an 85% increase, according to the GAO report. The severe maternal morbidity rate also increased from 93.5 per 10,000 VA-paid delivery hospitalizations in fiscal year 2011 to 184.6 per 10,000 in fiscal year 2020. The rate was highest among Black veterans.
The GAO also investigated mental health screenings among perinatal veterans. Each VA medical center is required to designate a maternity care coordinator who serves as a liaison between pregnant and postpartum veterans and their health care providers. These coordinators, who are not required to have a particular degree, screen veterans for depression and suicide risk. As of last October, they were also required to screen for anxiety and PTSD.
The GAO report recommended that the VA begin monitoring the occurrence and results of those screenings. The VA concurred with the GAO’s recommendation and stated in the report that it would aim to begin compiling and reviewing data from the screenings by March, a goal that Johnson said the department was on track to meet.
While experts such as Byatt noted the importance of screening, what happens before and after a perinatal woman is screened for mental illness is just as important, if not more so, Byatt said. “Along the care pathway, we ideally start with prevention. If the illness cannot be prevented and the patient screens positive, we need to follow that with assessment, treatment initiation, monitoring, and follow-up,” she said. “Screening is just one step in the pathway, and ideally it’s the second step after prevention.”
Johnson explained that, in the VA, if a veteran screens positive for an urgent mental health condition during a call with a maternity care coordinator, she is connected with the department’s crisis line and a warm handoff is attempted to directly connect veterans to care. The veteran’s primary care team is also notified.
Johnson also noted that in recent years, the VA has made an effort to expand its capacity to treat veterans with perinatal mental health conditions and reproductive mental health across the lifespan. It maintains a national roster of mental health clinicians who have completed a foundational course in reproductive mental health care that patients can search by facility and region. It also has a Reproductive Mental Health Consultation Program, allowing clinicians to consult their reproductive mental health colleagues when they have questions.
Ensuring Enough Data Are Available
It has only been a few years since the United States joined the rest of the developed world in establishing infrastructure for systematically assessing maternal deaths, as the authors of a 2019 Health Affairsreport wrote. Congress passed the Preventing Maternal Deaths Act in 2018. The legislation authorized $12 million a year in new funds for five years for states to establish and support MMRCs. In a 2018 article, ProPublica called it “an unprecedented level of federal support.”
The law needs to be reauthorized this year. APA has been strongly advocating for Congress to pass the Preventing Maternal Deaths Reauthorization Act (HR 3838/S 2415), as it would continue the funding MMRCs need to continue collecting and analyzing data on these deaths. The bill passed the House with a vote of 382-12 on March 5.
Data from MMRCs can be invaluable, Byatt said. The biggest challenge is ensuring that policies and funding decisions are responsive to the findings from the data being collected and support interventions that truly work to prevent pregnancy-related deaths, she said. Further, MMRCs do not exist in every state, which creates gaps in knowledge about these deaths across the country.
In their JAMA Psychiatry article, Wisner and colleagues pointed out that precisely estimating maternal mortality rates and deaths due to mental conditions is challenging because data sources may use different methodologies.
“Clear consensus definitions of the criteria that are used to define a maternal death associated with a mental health condition that are applied across all MMRCs are the goal,” Wisner told Psychiatric News. “With this standard definition, the interpretation is transparent, and rates can be compared across MMRC sites and across time.”
Byatt said she has seen tremendous strides to address perinatal mental health over the last 15 years. But the need remains significant. “People are still dying. They’re dying at increasing rates,” she said. “I believe we have been in a mental health crisis in this country for decades, and now we’re in an emergency.” ■
