By the 2020 Mom Advocacy Team
We love April Dembosky, the reporter that has been covering maternal mental health here in California this year.
Last week, April published another story, "To Screen or Not to Screen - Doctors Debate Postpartum Depression Testing" which is scheduled to publish to Kaiser Health News and National Public Radio this week.
Do a quick read and then come back, as we want to share some points of our own in response to the article. Here goes:
In 2014, California's legislature called for the formation of a multi-stakeholder task force, the California Task Force on Maternal Mental Health Care to study maternal mental health barriers to diagnosis and care as well as best practices. The task force met for 18 months and issued its report last year. It set an aggressive measurable goal, to see 80% of women screened for maternal mental health disorders by the year 2021. (Yep, that's less than three years away!)
A Leader, Not Just a Practicing Provider
What the "To Screen or Not to Screen" story doesn't explain is that Dr. Laura Sirott is the leader ("District Chair”) of the American College of Obstetrics and Gynecology (ACOG) in California, nor does the article state that Dr. Sirott was a member of the task force.
This is important background for two reasons:
1. Though the task force recognized there should be a "no wrong door approach to screening," they also recognized there must be a single provider type designated the “home base" for screening and treatment management, and that responsibility should rest with the obstetric provider, the medical doctor who cares for a woman during pregnancy and the postpartum period. (There were three Ob/Gyns on the task force, including published researchers Dr. Elliot Main from Stanford's California Maternal Quality Care Collaborative and Dr. Tracy Flanagan from Kaiser).
2. What also wasn't mentioned was that as of 2015, the American College of Obstetrics and Gynecology's national office recommends that Ob/Gyns screen for MMH disorders. ACOG is developing a toolkit, training, and more which will be available at the end of the year (two members of the California Task Force are members of the expert workgroup creating these tools). "To Screen or Not to Screen" is the wrong question. We should be asking, "What else needs to be in place so obstetric providers feel comfortable screening?"
Right, Screening Alone Doesn't Work
We are lucky in California to be standing on the shoulders of other states who have experimented with screening mandates, and we have the privilege to be able to see what has worked and not worked. It's true that screening mandates alone don't work. That's why AB 2193 isn't just a screening mandate. The bill first requires development of a case management infrastructure so providers have support with connecting patients to in-network, qualified care and also provides teleconsults between obstetricians and reproductive psychiatrists. It's similar to the Massachusetts Psychiatry Access Program (MCPAP) which provides this lifeline to screening Ob/Gyns. Because California is much larger than Massachusetts (one of our 58 counties is the size of the entire state of Massachusetts), and our counties operate more like states with their own jurisdictional power, to scale the solution across CA, the bill proposes support for Obstetricians be provided through the framework of insurance companies who have already developed case/care management programs for other diseases and disorders to get insureds into treatment early. The bill also requires insurers to provide obstetric providers psychiatric tele-consults so they can manage patients who may need and desire medication for depression or anxiety. And also requires insurers to monitor utilization of the case management program and patient and provider satisfaction taking action to improve if needed. Imagine the steps insurers will take if things aren't going well, like increasing the number of qualified maternal mental health therapists in their networks, providing tele/video solutions to patients in areas where access is low, etc.
Why Home Visiting is Helpful, but not THE answer
We disagree with the researchers whose work was referenced in the article. Screening in home visit settings isn't going to solve the problem here in California or anywhere in the U.S. All women deserve to be informed about the most common complication of pregnancy by their obstetric provider (90% of births are managed by Ob/Gyns, the other 10% by family practice doctors or nurse midwives). Being provided information and being screened during pregnancy and the postpartum period normalizes these disorders as real clinical disorders and catches problems during pregnancy so women can be treated early, reducing the incidence of pre-term birth and likelihood of postpartum depression. Also, obstetricians should be developing treatment plans which may include prescribing medications (no one else can do that - not pediatricians, not lactation consultants, not WIC counselors, not home visitors).
We recognize however that some low income women don't see an obstetrician during pregnancy or the postpartum and we must catch them in other ways, like home visiting (which they may not enroll in), or through WIC's nutritional programs, or community centers for example. We also believe postpartum doula services and/or home visiting should some day be available to all women, in all counties, and of all income levels to provide support and potentially help to prevent these disorders. Sleep and support (practical help and someone to talk to who knows the ins and outs of early parenting) are foundational.
Right now there is no insurance coverage for doula services (the women who receive these services pay 100% out of pocket) and home visiting services provided by the state and delivered through counties are primarily available to those who qualify for MediCal. According to the latest report from the California Department of Public Health, less than 3,000 people were served in CDPH home visiting programs in 2016. Even if we include home visiting programs that are supported by our friends at First 5, less than half of all California counties have a home visiting program.
We Want to Hear from You, But First Read the CA Strategic Plan
If you have an opinion about this bill or our opinions in this post, we want to hear from you! If you haven't read the Task Force white paper, which is also being called the California Strategic plan, read it first and then get in touch. You can also learn more about California's Comprehensive bill package, #4Bills4CA Moms, here.