By Joy Burkhard, MBA
Founder and Executive Director, 2020 Mom

The U.S. Department of Health and Human Services (HHS) and the U.S. Surgeon General announced on Thursday a coordinated agency plan and Surgeon General call to action to urgently reduce maternal mortality (reduce preventable pregnancy-related & associated deaths) and improve maternal health in the U.S.

The HHS plan is comprehensive and includes a focus on implementing evidence-based measures to reduce maternal mortality by as much as half in five years.

The administration-proposed 2021 budget includes $15 million to expand the Alliance for Innovation on Maternal Health (AIM) program, to support development of evidence-based outpatient practices and policies to reduce maternal mortality, and $24 million to expand maternal mortality review committees to all 50 states to ensure that every pregnancy-related death is examined.

Is Maternal Mental Health / Suicide Addressed in the Plan and Call to Action?

Maternal mental health, and more specifically postpartum depression, is addressed in the HHS plan, in Objective 3.1. The Surgeon General’s call to action is more comprehensive in addressing the range of disorders, though, like the HHS report, his proposed actions focus on the postpartum period.

Below I unpack the HHS and Surgeon General reports, including sharing my thoughts about each recommendation (which often addresses gaps).

Health and Human Services Plan

Let’s make sure moms stay healthy through pregnancy and beyond!HHS is committed to making the U.S. on of the safest countries in the world to give birth

Find the full report here.

The HHS Plan addresses maternal mental health in the context of the postpartum recommendations under Objective 3.1 and related Actions:

OBJECTIVE 3.1 Improve the quality of and access to postpartum care, especially mental health and substance use services.

“During the postpartum period: Extending coverage of Medicaid; integrating the mom-baby visit; requiring mental health screenings during the postpartum visit; addressing chronic conditions; utilizing other family members, especially fathers, to monitor the health of mom and baby; discussing family planning and easing barriers for women to obtain contraception; and creating a stronger economic environment by implementing social supports for new moms (i.e., breast-feeding rooms, paid sick leave, child care credits).”

Action 3.1.1
“Support policies to allow states to extend Medicaid coverage for postpartum women with SUD from 60 days to 365 days after birth. The Department will also pursue strategies to close coverage and care gaps for all postpartum women after pregnancy-related Medicaid coverage expires.”

My Thoughts:
While Substance Use Disorders (SUDs) are critically important to treat, Medicaid should be extended to women with Maternal Mental Health Disorders too - and ideally - to all mothers regardless of any named diagnosis discovered within the first 60 days postpartum.

The 2019 study by Mathematica highlights the significant cost savings to society when women receive treatment for maternal mental health disorders. I’d like to ask the researchers behind the Mathematica study whether these substantial cost savings could potentially pay for extended Medicaid coverage, and cover all treatment a mother may need, not just treatment for mental health disorders.

Of Note:
California was the first state in the nation to extend Medicaid to a year postpartum, and the extension is specifically for those with a diagnosed maternal mental health disorder. This was possible, because of the screening mandate, AB 2193, that 2020 Mom co-sponsored. Once the screening mandate became effective, obstetricians needed to ensure that if a mother was suffering from a maternal mental health disorder she would have coverage for treatment. With much advocacy efforts (legislative, budget, and ultimately a media push), the American College of Obstetrics and Gynecology, with 2020 Mom’s support, was able to secure a process and funding for coverage in the California budget for 2020/2021. However, the devil is in the details. The implementation is cumbersome, as mothers/the treating MD must complete and submit a form to extend Medicaid, and enrollment hasn’t yet been monitored. We don’t know yet if mothers will actually enroll so they can receive treatment.

Also of Note:
The federal bill, HR 4996 the Helping MOMS Act, gives states specific authority to extend Medicaid through one year postpartum. There is no additional funding being provided to the states, so the impact could be minimal, but baby steps matter and are more likely than a significant leap, even in the next Congress.

Action 3.1.2
Launch new non-hospital focused AIM maternal safety bundles to improve postpartum care for maternal safety: Postpartum Care Basics I: From Birth to the Comprehensive Postpartum Visit and Postpartum Care Basics II: Transition from Maternity to Well-Woman Care.

My Thoughts
The Alliance for Innovation in Women’s Health has already created a Maternal Mental Health “bundle” (aka recommendation set) that was not specific for hospitals. The bundle was not adopted as a Core AIM bundle. It’s likely this bundle will become part of the proposed Postpartum Care Basics bundle. While adoption of AIM Core measure bundles is monitored by the hospital accreditation organization, the Joint Commission, there is no mandate for hospitals to adopt these protocols. Additionally, there is no non-hospital/outpatient accreditation organization. Without an oversight body, mandate or tie to reimbursement, I’m concerned that, as with the current Maternal Mental Health bundle, any new postpartum bundle will simply sit on a shelf instead of save lives.

Action 3.1.3
Scale practice improvements in outcomes related to maternal depression and intimate partner violence to additional home visiting programs, apply a health equity lens to home visiting quality improvement by developing quality playbooks that include key influences that impact changes in health equity and postpartum care, and develop resources to apply home visiting quality improvement methods to increase mothers’ receipt of postpartum care through HRSA’s Home Visiting Collaborative Improvement and Innovation Network (CoIIN). These investments will also include a measurement strategy to demonstrate real-time improvements in advancing health equity and increasing rates of postpartum care among Maternal, Infant, and Early Childhood Home Visiting Program-supported agencies.

My Thoughts
Addressing postpartum supports in-home visiting settings, particularly the role of addressing social determinants of health (which healthcare providers are not positioned to address without funding for case management staff), is smart. However, surprisingly, it’s not standard that even those enrolled in Medicaid receive an offer for home visiting. HRSA reported 154,000 home visits in 2019 while there were 3.75 live births in the U.S. in 2019. For Action 3.1.3 to be meaningful, this lack of standardization should also be addressed.

Action 3.1.4
Launch [of] the Agency for Healthcare Research and Quality’s (AHRQ’s) Cross-Sectional Innovation to Improve Rural Postpartum Mental Health Challenge, which is a national $175,000 prize competition to highlight local innovations to improve postpartum mental health care for rural American families.

My Thoughts
I was honored to serve as a judge for these awards along with several esteemed colleagues. I was truly amazed to learn of many very innovative programs, which have the potential to change the landscape of maternal mental health in rural settings and beyond. The big question is, how can the winning programs be scaled for adoption across the country, and how can services be sustainable and integrated through health system delivery and/or public health?

Action 3.1.5
Encourage moms across the nation to report postpartum depression symptoms to a health care provider through a campaign that will feature video stories from real moms who have been treated for postpartum depression. This campaign will focus specifically on reducing the stigma of postpartum depression and anxiety so that more women will feel comfortable discussing depression or anxiety-related symptoms with their doctor, nurse, or midwife.

My Thoughts:
The Office of Women’s Health should think about partnering with those behind the current U.S. awareness campaigns (like TheBlueDotProject.org), where audiences of perinatal women have already been developed and connected, and on social media.

It’s also important that mother’s stories illustrate the process for receiving treatment is mostly fragmented and imperfect, and that no one size fits all experience occurs in the U.S.

Finally and most importantly, I’d like the government to seriously consider that most doctors, nurses and midwives still are not adequately educated to be responsive (i.e. helpful and not hurtful) when a woman reports symptoms of maternal mental health disorders. All too often, when mothers speak up, they are not taken seriously, they aren’t screened with a screening tool, or worse they are reported to child protective services when they share symptoms of intrusive thoughts or rage, or are sent to the ER only to be placed on a watch for 48 hours, unable to nurse her baby, often shamed and sent home without a treatment plan.

2020 Mom is launching a video storytelling series in 2021 with funding from Amare Global, to help tell the stories of struggle and of hope. Our hope is that videos will effectuate change, on multiple fronts.

My Closing Thoughts re: the HHS Action Plan

Though these are significant steps in the right direction, and we are incredibly grateful for long-awaited attention, the plan fails to acknowledge that maternal mental health disorders and maternal suicide are not limited to the postpartum period.

I was also struck by the fact that the prevention strategies that the U.S. Preventive Services Task Force released last year were not referenced in the plan.

So what does the Surgeon General Say about Maternal Mental Health?

The Surgeon General’s Call To Action To Improve Maternal Health

Find the full report here.

It’s helpful that the Surgeon General (SG) is addressing maternal mental health - thanks to partners like Sage Therapeutics who first spoke to the SG about maternal mental health. We also wish to thank Alice Lu, a 2020 Mom advocate, who after meeting the First Lady of NJ at Mom Congress in 2019, was invited to meet with the SG at a listening session he held in NJ with the First Lady. Here are the highlights from the SG’s call to action that concern the maternal mental health field:

The SG acknowledges maternal mental health disorders encompass a range of disorders which occur not just in the postpartum period; that they contribute to the U.S.’s high maternal mortality rate, and impact mother-infant bonding and infant development:

“Each year more than 20 percent of U.S. women experience a mental, behavioral, or emotional disorder, such as depression or anxiety. Mental health conditions are also common complications during pregnancy and in the postpartum period and may contribute to poor maternal outcomes. Data from 14 state [Maternal Mortality Review Committees] MMRCs between 2008 and 2017 showed almost 10 percent of pregnancy-related deaths were due (in whole or in part) to mental health conditions. These conditions serve as underlying factors in injury or death due to overdose or suicide. Mental health conditions in the postpartum period, such as postpartum depression, are associated with poorer maternal and infant bonding, decreased breastfeeding initiation, and delayed infant development.”

What is He Recommending in His “Call to Action” regarding Maternal Mental Health?

Increased Funding for Evidence-Based Program Implementation
“Provide funding for local implementation of evidence-based programs, such as home-visiting, substance use disorder treatment, tobacco cessation, mental health services and other programs as recommended by the Community Preventive Services Task Force. Support local efforts to prevent family violence and provide support for women experiencing [Interpersonal Violence] IPV. Educate the public about risk factors for high-risk pregnancies, pregnancy-related warning signs, risk-reducing behaviors, and the importance of prenatal and postpartum care.”

Improve Health Care Delivery in the Postpartum Period
“Communicate the importance of postpartum visits, including the [American College of Obstetrics and Gynecology] ACOG recommendation for an initial assessment within the first 3 weeks postpartum followed by ongoing care as needed and a comprehensive visit within 12 weeks after delivery. Non-obstetric providers can have an important role to play. For example, pediatricians could screen for maternal mental health during well-baby visits utilizing validated tools, such as the Edinburgh Postnatal Depression scale. Other nonobstetric providers should ask about prior pregnancies when taking a medical history and be aware of pregnancy-related morbidities that can occur up to one year post-delivery and those that raise lifetime risks, such as gestational diabetes, gestational hypertension, and preeclampsia, and follow recommended guidelines.”

The HHS plan and SG Note MH Access Challenges/Opportunities:
During the listening sessions held by HHS and the SG, noted opportunities to:

refer to mental health professionals more efficiently and effectively

The SG call to action notes:
Reducing disparities for rural women is essential to improving maternal health. He also shares the following general recommendations from stakeholders:

The SG recommendations to improve access include:

Extending Medicaid coverage beyond the 60-day postpartum period
Incentivizing providers to provide more timely postpartum care
Using more interdisciplinary teams to provide care, especially in rural areas
Creating more seamless transitions of care; increasing care management, especially for high-risk women
Integrating more community-based organizations to improve access to care for women
Expanding use of telehealth programs for e-Care and remote monitoring of chronic conditions
Expanding access to and reimbursement for midwives and doulas; addressing mental health issues before and after pregnancy
Increasing data sharing and linkages among different provider types and settings

The HHS plan and SG call to action also address Health Equity:
The listening sessions held by HHS noted opportunities to:

measure health equity
increase the rate of postpartum visits among the Medicaid population
address non-medical drivers of health

The SG notes the following themes were shared during his listening sessions:
Reducing disparity gaps among African-American, American Indian/Alaska Native and other women of color is essential to improving maternal health.

The SG recommendations to improve equity include:

Determining methods to hold health systems accountable for how they treat patients -Incorporating a patient experience metric into quality reporting
Generating more opportunities to listen and hear from patients about their experience -Identifying state-based innovative solutions that show promising results for improving equity of care and reducing racial disparities
Adding race/ethnicity fields to all administrative data systems for standardized collection
Improving race/ethnicity on death records and improving standardization for race/ethnicity for all vital records across all states

Finally, the Surgeon General’s report acknowledges the need for:
“Weaving health care and human services agencies and programs together.”

We couldn’t agree more, which is why we are continuing to direct our 2021 federal advocacy efforts around interagency coordination. Just like mothers fall through the cracks of a fragmented health care system where maternal mental health doesn’t fit neatly into one provider’s scope, maternal mental health doesn’t fit neatly in any one federal (or state agency’s) framework. It’s time for agencies to come together and directly address maternal mental health. Stay tuned for more about our federal advocacy work.

Here is to a very hopeful 2021.

Do you have something to say about these recommendations? If so, share your thoughts with us by commenting below.