Joy Burkhard’s Opening Remarks

October 29, 2021

**Congresswoman Lisa Blunt Rochester** (D-DE), **Senator Bill Cassidy** (R-LA), **Kay Matthews**, Founder, Shades of Blue, **Sarah J. Dash, MPH**, President and CEO, Alliance for Health Policy (moderator), **Veronica Gillispie-Bell, M.D.**, Senior Site Lead/Section Head, Women’s Services, Ochsner Kenner and Medical Director, Louisiana Perinatal Quality Collaborative and Pregnancy Associated Mortality Review, **Carrie Hanlon, MA**, Project Director, National Academy for State Health Policy, and **Joy Burkhard, MBA**, Executive Director, 2020 Mom.

Hello. Thank you to the Alliance, Health Affairs, the funders, and Members of Congress who have taken leadership positions on maternal mental health, recognizing this is a bi-partisan issue that no U.S. woman or family is immune from.

Though we are here to talk about a daunting problem that has largely been unaddressed, it’s a very exciting moment for the field of maternal mental health. Thousands of cross-sector researchers, clinicians, and advocates have been working for years to get to this point, a tipping point in both awareness and identification of true and tangible policy solutions.

My name is Joy Burkhard, and as mentioned, I serve as the executive director of the non-profit organization, 2020 Mom. We are a 10-year-old organization that has been studying the barriers to screening, diagnosis, and treatment of these disorders and identifying solutions that can be implemented at scale.

I wish to acknowledge, and perhaps it should go without saying, that all women and families should have access to health care coverage, paid leave after birth, and have their basic needs met. And this infrastructure should of course be available without unfair racial or even gender identification bias. My comments today will focus on opportunities to improve the detection of maternal mental health disorders and access to care in the healthcare system.

Because the U.S. largely operates in a privatized health system, we all know it can be very difficult to implement standards of care and track national trends. Several years ago, because of the great work of reporters, our nation’s maternal mortality crisis was exposed.

These reporters highlighted the critical role of the CDC and its partners who were trying their best to support states in tracking these deaths with little funding and support. This reporting helped lead to the introduction and passage of The Preventing Maternal Deaths Act, signed into law in 2018. It created a framework for the CDC to support states investigating causes of maternal deaths - setting in place a strong movement toward improving maternal health care delivery. That work didn’t initially include - and has only just begun to scratch the surface of maternal death by suicide or even overdose.

Why is that? In part, because we are talking about two systems of care, the health care system and the mental health care system. And this is why the policy implications for maternal mental health care must be addressed both in the context of maternal health, mental health and on its own.

Let’s start with the basics, you might be asking, what exactly do you mean by maternal or perinatal mental health disorders? We have all heard of postpartum depression, which is where research first centered, and which for 10+ years has been declared the most common complication of pregnancy.

But there are many more disorders and symptoms that are equally as important to identify and treat with accuracy, like maternal OCD and intrusive unwanted thoughts, mania and psychosis, birth trauma and PTSD, and anxiety, which we now know is more common than even depression during the perinatal period - which we currently define as pregnancy through one year postpartum.

So we know about postpartum depression, and society is starting to understand its negative impact on not only the mother but on infant and early childhood brain and central nervous system development. But what about pregnancy? Research is clear that new onset of depression and anxiety is nearly as common in pregnancy as in the postpartum period and when untreated in pregnancy, these disorders can impact the baby in utero and lead to preterm birth.

We also know that, even prior to the pandemic, tween and teen girls and young women in the U.S. were suffering from their own epidemic -a mental health epidemic. Many of these young people are now having babies with preexisting and often untreated mental health disorders. Or perhaps they are stable on medication and are directed to go off meds by their obstetricians (ObGYNs, Midwives or Family Practice providers) without either the provider or patient fully understanding the pros and cons of doing so.

As a nation, we are also now tuned into the growing mental health problem in our country, which has now, because of COVID-19 become so pervasive that one in four Americans are suffering from a mental illness right now, and mothers certainly have not been immune.

So you may be asking, what do doctors think about maternal mental health and their role? What do the professional trade associations like the American College of Obstetrics and Gynecology and American Psychological and Psychiatric Associations, have to say?

They all agree that screening and identification should be a top priority for health care providers. The American Academy of Pediatrics was the first trade association to recommend screening (11 years ago) – recognizing the critical impact on infants, not just mothers.

It wasn’t until 2015 when the American College of Obstetrics and Gynecology first recommended screening that things really began to change for the field. Their recommendation triggered a chain reaction. Most notably, the US Preventive Services Task Force recommended screening in early 2016. Because recommendations by the USPSTF carry a requirement that insurers cover such services, there was a misunderstanding that suddenly screening would just happen.

The core problem was not insurance denials of screenings (screening was already being covered by most insurers), rather it was and remains a substantive barrier for both providers and patients in referring to and accessing mental health care.

But why is it so much harder to access mental health care over medical care? We believe there are three main reasons, which I refer to as the 3 Ps.

Payment: In the U.S. we have a separate payment system for mental health care, both for privately insured and publicly insured patients - it’s what we call “carve-outs.” We will hobble along trying our best to adequately detect and treat maternal mental health and other mental health disorders until mental health payment is reformed and carved into medical care.
Providers: This includes, education, shortages, capacity including care coordination & expert consultation, and incentives.
- We can start by supporting reimbursement of obstetric providers for screening and initial treatment plan development.
- We can provide grants to states and public hospitals to develop inpatient and outpatient treatment programs and look to SAMHSA so there is a continuum of care for maternal mental health disorders, not just an hour talk therapy session or the ER.
- We must also quickly address mental health provider shortages. One way is to proliferate the use of state-certified peer support specialists, which can be referred to as a form of community health workers. Every state now has a state-sanctioned certification process in place for peers. These peers can not only provide mental health support, but can be trained to screen and to provide clinical and social support care coordination.
Performance Measurement: In a fragmented health system, a framework for quality measurement that helps implement the standard of care and hold payors accountable is a must. We don’t yet measure screening rates or outcomes when patients are screened - are they getting well?

These three Ps, Payment, Providers, and Performance Measurement offer immediate and tangible next steps for policy and health systems change.

This event was commissioned by the editors of Health Affairs as a result of the dedicated Perinatal Mental Health issue. Ms. Burkhard was a contributing author in the article titled Perinatal Mental Health Care In The United States: An Overview Of Policies And Programs

Learn more about the Congressional Briefing event, including the other speakers here.