#Action4Jessica: Jessica Porten's Story Went Viral

This weekend something that has never happened in the maternal mental health happened: 
a mother's story went viral on Facebook. 

A mom in Sacramento California, went to her Ob/Gyn on Friday for help with postpartum depression with symptoms of anger and scary thoughts, and the next morning, Saturday, January 20, she posted this:

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How to Support Grieving Parents

Perinatal loss is an unexpected, traumatic, and life-changing event. It includes miscarriage, termination due to medical reason, stillbirth, and infant death. One in four mothers report experiencing perinatal loss, however the number may be as high as 50%. Annually, approximately 24,000 babies will be stillborn (>20 weeks gestation), and an additional 23,000 infants will die within the first 28 days of life.

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Our most Important Work in 2017, and Looking Ahead to 2018

2017 was our busiest year yet, we walked the fine line of balancing our passion to drive change and our real ability to do so with limited hours in the day.  

Our most substantial achievements this year were release of the California Task Force for MMH white paper in May, building a community of Ambassadors, and launching the Innovation Awards. 

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What Every Provider Type Should Know and Do For Maternal Mental Health

The following provider core competencies for maternal mental health were developed and published this year by the California Task Force on Maternal Mental Health Care.  The competencies were developed to address the need for baseline knowledge and skills among various provider types treating perinatal women with the aim of improving detection and treatment.

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Meet Maria Carola, 2020 Mom’s 2017 Ambassador of the Year

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Over 20 2020 Mom Ambassadors were in the first class to earn their badges this Fall.

Maria was one of them and also was named 2020 Mom’s 2017 Ambassador of the Year. We want you to know what she has been up to.  You can also learn more about Maria by visiting her website www.mommamosaic.com or following her on Twitter: @mommamosaic


What brought you to Maternal Mental Health?

I’m a mother of two.  My professional background is in psychology, public relations and documentary photography which placed me at an interesting crossroads when I was personally affected by postpartum depression. After my horrific experience falling through the cracks of the maternity care system, I knew I had to do something to help the countless women who were suffering silently as I had. Thus, as many survivors are called to do, I embarked on a larger journey to make a difference on the front lines of maternal mental health and maternity care. 

How did you become involved with  2020 Mom and the Ambassador program?

Five years ago when I was working with Wendy Davis and PSI as their PR/Marketing Chair, I heard about Joy and "The 2020 Mom Project." At the time, awareness and discussion about maternal mental health was still mostly limited to the tragedies of postpartum psychosis and the media's brutal portrayal of them. Frustrated, I remember thinking to myself, "We know what isn't working. Let’s try to identify what is working and springboard off of that." Wendy shared that Joy’s mission with 2020 Mom was exactly this — working within an existing infrastructure to identify and close the gaps in maternal mental health. When the opportunity arose to become an Ambassador for 2020 Mom, I jumped at the chance. 

Tell us about some of the projects you have been involved with.

This past spring, I was happy to participate in fundraising efforts for the NYC March for Moms team as well as raise ongoing funds for 2020 Mom via my "Wear Your Activism" Momma Mosaic tote bag campaign. The campaign was an independent fundraising campaign under the Ambassador program where I sold a tote bag, and proceeds went to 2020 Mom. What made it special is that each time a bag was purchased I provided the same bag, to a homeless woman, filled with items she needed, like personal hygiene items.  I was able to raise $210 for 2020 Mom and do good in my local community at the same time.

What are your plans as a 2020 Mom Ambassador?

Going forward, I am working to organize a diaper drive, a screening of When The Bough Breaks, and a series of fundraising events in New York City to amplify the issues and challenges surrounding motherhood in the U.S. today. 

What impacts do you see 2020 Mom and the Ambassador program having?

Today, as a doula, maternal health spokesperson and advocate, I have witnessed firsthand how the conversation is shifting towards a more open and honest dialogue about the state of maternal mental health in the U.S. Now, more than ever, we have to keep working and fighting to affect change in the field. 2020 Mom is doing important work in this regard and I am honored to be counted among their Ambassadors helping in this mission.

 

 

Delivering Moms from the Most Common Childbirth Complications: Depression and Anxiety

Bruce Spurlock, President and CEO, Cynosure Health
Joy Burkhard, MBA, Founder and Executive Director, 2020 Mom

First appeared on the California Health Care Foundation blog, July 11, 2017

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Every year, half a million babies are born in California. Alarmingly, the most common complications of childbirth are the mother's depression, anxiety, or other mental health disorders. The magnitude of suffering from maternal mental health disorders dwarfs hospital-acquired infections, sexually transmitted diseases, new breast cancer diagnoses, and many other conditions that attract greater media interest, public reporting, and performance incentives and penalties.

Maternal mental health issues arise in up to one in five pregnancies. In California, as many as one in four mothers (27%) have prenatal or postpartum depression (PDF), according to a survey by the California Department of Public Health. It's worse for underserved populations affected by race, poverty, or other social factors that increase the frequency and severity of mental health conditions. Low-income mothers are 1.4 times more likely than wealthier moms to exhibit depressive symptoms before, during, or after pregnancy.

Left undetected and untreated, these conditions can lead to negative health outcomes for the mother, undermine the mother-child bond, and damage the child's long-term physical, emotional, and developmental health. And the financial cost of untreated maternal mental health conditions can be significant because of effects such as greater use of emergency care services and higher rates of absenteeism at work.

While the disorders are highly treatable, few mothers are identified by screening or diagnosis, and among those who are recognized, only 15% receive treatment. And from a cost perspective (including lost income/productivity and negative outcomes for children), untreated maternal depression costs (PDF) an estimated at $22,500 per mother, which in California totals about $2.5 billion a year.

Maternal mental health conditions can occur anytime during or after pregnancy, with onset as late as the baby's first birthday. We are not talking about either of the two ends of this spectrum — a transitory (e.g., two weeks) and less severe condition known as the "baby blues" or the rare but more extreme psychotic episodes that make national headlines. It is the much more common "middle zone" of suffering where one in five women find themselves and don't receive the care they need.

California Task Force Addresses Maternal Mental Health

In California in 2014, the California Legislature passed a resolution calling for a multistakeholder group to study, identify, and recommend solutions to address these issues. The California Endowment and the California Health Care Foundation funded a diverse task force of public health experts, clinicians, consumers, policymakers, and representatives from health plans, purchasers, state agencies, and community-based organizations. The panel included project staff from 2020 Mom, a grassroots nonprofit working to close gaps in maternal mental health in California and nationally; Cynosure Health, a national health care improvement organization; and the Central Valley Health Policy Institute, which focuses on emerging health issues in Central California. Over an 18-month period, the task force explored the barriers, models, and potential solutions that affect a half-million California mothers and their babies each year. California accounts for one in eight births in the US.

This spring, this task force released a formal report and executive summary.

Women with maternal mental health issues face herculean challenges to receiving adequate relief from their suffering. These include:

  • Lack of understanding by health care providers about how to follow up with symptomatic women

  • Fragmented care systems that foster inconsistent approaches to the problem by obstetricians, pediatricians, and primary care physicians

  • Inadequate screening, sometimes caused by the mother's fear that her child will be taken away if the mother gives wrong answers

  • Poor access to appropriate treatment

  • Stigma that prevents new and expectant mothers from reaching out for help

Despite the availability of effective treatments, the health care system is tragically ill-equipped to identify and help the women who need them. The task force reviewed novel solutions that address social issues, family and generational expectations, travel limitations, and cultural sensitivities. Yet available services are often disconnected and uncoordinated across different care settings.

Two Ambitious Objectives

The task force set two bold aims for tackling this problem across vast expanses of California: By 2021, ensure that 80% of women are screened at least once during pregnancy and the postpartum period, and by 2025, increase that rate to 100%. The goals acknowledge the federal recommendations on screening and set the stage for effective treatment and symptom management. With these targets in mind, the task force developed recommendations to address barriers:

Select one of several maternal mental health screening measures developed by national organizations.

  • Promote a "no wrong door" approach to screening so it can be offered by health providers of all types.

  • Build capacity by expanding referral resources and telehealth consultation such as MCPAP for Moms, which operates in Massachusetts.

  • Persuade insurers to develop programs offering competent maternal mental health care, including arranging specialty care as required.

  • Take local action through community collaboratives that can help address social determinants.

  • Combat stigma with statewide and local public awareness campaigns spearheaded by the California Department of Public Health.

Maternal mental health conditions disrupt the lives of many more women, children, families, and communities than people realize. It's likely that everyone knows many mothers — and their children — who experience unnecessary suffering from maternal mental health conditions that are treatable if we recognize and build systems to address them during the vulnerable perinatal period. Massachusetts, Maryland, and other states are doing just that. Will California step up, too?

Learn about CHCF's work with partners to develop solutions for delivering mental health care to California's mothers and expectant mothers in need.

What's Up With Health Care, Now?

Two weeks ago, it became clear (again) that congress was not going to succeed in repealing the Affordable Care Act (ACA).

It started with the Senate voting in favor of opening debate on two more repeal bills:

The Better Care Reconciliation Act (BCRA) failed to garner enough votes, and the straight repeal bill (with no replacement) failed as well.

The so-called “Skinny Repeal” also failed on a vote of 49-51. Republicans John McCain, Susan Collins and Lisa Murkowski and all Democrats vote against the bill.

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How to Enhance Support for Breastfeeding Mothers and Ultimately Improve Maternal Mental Health

By Noelle McCown, Psy.D.

 Updated February 14, 2022

My story

The first time my son nursed, it was painful, but I was prepared for it. I’d never breastfed an infant before, and I knew there would be a learning curve. What I didn’t expect was to find a bruised, blistered nipple when he unlatched. I remember my midwives looking slightly perplexed, proposing I try a nipple shield. Despite their suggestion, I decided to continue to try to feed him without one. “We’ll get the hang of this,” I thought.

The pain persisted however, and in addition, I found it impossible to keep my son awake long enough to drain each breast. He’d nurse for a minute, fall asleep, and wake again within the hour for more. After three weeks, I was exhausted. Looking for guidance, I dropped into a local breastfeeding support group run by a lactation consultant named Meg. Upon hearing our story, she suggested we meet for an individual evaluation.

Meg arrived at our house the next day. I’ll never forget the punch-in-the-gut feeling that accompanied the words: “It looks like your son hasn’t gained weight since last week.” Until my son was two weeks old, he had steadily gained. By week three, my milk supply had dropped due to our breastfeeding challenges. After performing a comprehensive exam, Meg recommended he be further evaluated for tongue-tie.

Tongue-tie (ankyloglossia) or “tethered oral tissue” is a condition that restricts the tongue’s range of motion. According to the American Academy of Pediatrics (2016), it affects up to 10% of the population. When a baby is “tongue-tied,” unusually tight frenulum tissue tethers the tongue to the floor of the mouth, making it difficult to breastfeed. It can also cause long-term health concerns such as speech problems, difficulty chewing and swallowing, dental decay, and migraines (Fernando, 1998).

Meg referred us to a physician who specialized in treating tongue-tie. As I filled out the patient questionnaire, I found myself ticking all the boxes. Baby’s symptoms: falls asleep while nursing, difficulty latching, gumming or chewing the nipple, poor weight gain, and short sleep episodes. Mother’s symptoms: bruised or blistered nipples, pain when baby latches, incomplete breast drainage, plugged ducts, and mastitis.

It was determined we could benefit from a procedure called a frenotomy, in which a laser or surgical tool is used to cut and release the tethered frenulum. After a challenging few months, the combination of the frenotomy and efforts to boost my milk supply paid off—we are still breastfeeding at 22 months!

Our journey to where we are today was not without it’s emotional challenges, however. I was anxious and sleep-deprived. There were days I didn’t leave the house due to how frequently I had to nurse or pump breast milk, and the pressure mounted until I was utterly exhausted.

During this time, I was incredibly privileged to have access to a breastfeeding support group, in-home lactation consultation, medical supplies such as a hospital grade breast pump and supplemental nursing system, and a local physician who specialized in tongue-tie. Furthermore, my insurance covered a percentage of these costs. This is not the norm. The vast majority of women do not have access to the resources needed to diagnose and treat complications like tongue-tie due to a dearth of support for breastfeeding mothers.

Barriers to breastfeeding support

I recently had the opportunity to discuss these issues and their impact on maternal mental health with Joy Burkhard and Genevieve Colvin, IBCLC. Joy is the founder and director of 2020 Mom, which spearheaded the California Task Force on the Status of Maternal Mental Health Care that issued its report this May. Genevieve is an International Board Certified Lactation Consultant (IBCLC) in the San Fernando Valley and member of the California Task Force. This is what I learned from our dialogue:

  • The Affordable Care Act improved women’s health coverage by requiring most insurance plans to cover breastfeeding support and supplies; however, many insurance companies still don’t cover lactation services outside of hospital settings.

  • Most states, including California, do not license International Board Certified Lactation Consultants (IBCLCs). Therefore, IBCLCs have a difficult time contracting with insurance companies to provide reimbursable outpatient services.

  • Due to a significant lack of outpatient lactation services, it is unlikely a mother will receive additional lactation support outside of the hospital unless she is WIC eligible or can pay for the expense out-of-pocket.

  • In the United States, the vast majority of women give birth in hospitals. The 24-48 hour period spent in the hospital after delivery is generally a new mother’s only opportunity to work with a lactation consultant (if one is on staff). During these meetings, which sometimes last just minutes, complications like tongue-tie are screened for only if they are immediately apparent or if a parent insists.

  • If (despite the aforementioned barriers) an IBCLC performs a comprehensive evaluation and determines tethered oral tissue may be negatively impacting breastfeeding, he or she must make appropriate referrals to professionals who can diagnose and treat it. While lactation consultants are trained to recognize breastfeeding complications like tongue-tie, it is not within their defined scope of practice to diagnose them. Instead, they are expected to refer to professionals who can, e.g. physicians and pediatric dentists.

  • Only physicians and pediatric dentists can diagnose and treat tongue-tie, yet they frequently lack the training to provide breastfeeding support or to make appropriate referrals for necessary post-frenotomy therapies.

  • While multiple, empirically validated assessment tools exist, there is no universally agreed upon definition, examination method, or classification system for the diagnosis and treatment of tongue-tie. The American Academy of Breastfeeding Medicine (2004) offers a protocol for the evaluation of tongue-tie, yet many physicians do not use it.  

  • Doctors who perform frenotomies are often in high demand, so there can be a wait to see them. While a mother waits to see a specialist, she and her baby continue to struggle.

Why is this important?

There is a positive correlation between breastfeeding difficulties and postpartum depression; meaning, mothers who report breastfeeding difficulties demonstrate higher rates of postpartum depression than their counterparts. In a study published in 2015, Brown, Rance, and Bennet examined the relationship between specific reasons for stopping breastfeeding and postpartum depression symptoms in mothers with infants, ages 0-6 months.

They found that mothers who breastfed for shorter durations, specifically due to physical difficulty and pain, scored higher on a test measuring postnatal depressive symptoms. Moreover, they found negative breastfeeding experience to be predictive of postpartum depression symptoms, specifically when challenges are due to physical difficulties or pain. Inversely, Ystrom (2012) found that prenatal symptoms of depression and anxiety were linked to breastfeeding cessation, suggesting the correlative relationship between breastfeeding and maternal mental health is bi-directional.

The factors influencing the development of postnatal depression in relation to breastfeeding complications are still not fully understood; therefore, further studies are needed to examine this relationship.

How to enhance breastfeeding support

  • Increased support should be directed toward mothers who want to breastfeed but are considering stopping due to physical difficulties or pain (Brown, Rance, & Bennet, 2015). According to Hannula, Kaunonen, and Tarkka (2008), guidance that encourages self-efficacy while empowering new mothers is especially beneficial.

  • Due to the Affordable Care Act, federal law now stipulates that insurance companies must reimburse out-of-network costs if they cannot provide in-network lactation services. Unfortunately however, many insurance companies still refuse to cover services outside of hospital settings (Benyo, 2015). Taking necessary steps to comply with the law and reimburse outpatient services will increase a mother’s chance of receiving breastfeeding support.

  • Hospitals can support new mothers by opening outpatient lactation clinics. These clinics generally offer free, low-cost, or reimbursable services to women who need additional breastfeeding support after leaving the hospital. For example, the Lactation Resource Center at Good Samaritan Hospital in Los Angeles offers consultations with IBCLCs and Certified Lactation Educators (CLEs), support groups, educational classes, and supplies. The center is grant-supported; so all services are free or donation-based and available to any mother in the Los Angeles area regardless of where she delivered.

  • Individual states, such as California, can begin developing rules and regulations to license lactation consultants. Once licensed by the state, IBCLCs can join insurance networks to ensure their services will be reimbursed. Additionally, physicians may be more encouraged to include lactation consultants in their practices if their services are covered by insurance and regulated by the state.

  • Lactation support for mothers who want to breastfeed should be included in prenatal, pediatric, and postpartum checkups. Staffing lactation consultants in outpatient obstetric and pediatric clinics would further increase the likelihood of mothers receiving outpatient breastfeeding support (Farver, 2016).

  • Physicians treating pregnant women and new mothers should be familiar with the complications that can contribute to breastfeeding difficulties. Additionally, if health insurance companies reimburse doctors for time spent attending to breastfeeding issues, they will be more likely to include these services in their practice (Davis, 2013).

  • The diagnosis and treatment of tongue-tie and other complications that impact breastfeeding should be basic competency for all physicians and pediatric dentists (O’Callahan, Macary, & Clemente, 2013). In order to achieve this, a universal definition, examination method, and classification system for tongue-tie should be established.

  • Finally, instead of waiting until breastfeeding challenges arise, lactation consultants and physicians could adopt a more proactive approach to assessing tongue-tie. In Brazil, national law requires all newborns to be screened for tongue-tie using a universal, empirically validated assessment tool (Martinelli, Marchesan, & Berretin-Felix, 2012).

Research demonstrates that breastfeeding practices improve rapidly when appropriate lactation support is offered (Rollins, et al., 2016). Mothers experiencing difficulty breastfeeding need greater access to these resources. When breastfeeding is not made difficult by complications, it can actually serve to protect maternal mood by lessening reactivity to stressors and inducing calm (Groer, Davis, & Hemphill, 2002). Enhancing support for mothers who want to breastfeed can ultimately play a role in improving maternal mental health.

Resources

If you are experiencing difficulty breastfeeding, you are not alone in your struggle. The following resources are available:

Breastfeeding USA offers a national breastfeeding counselor directory. If you are in need of free/low cost services, please contact your local counselor for resources.

Women, Infants, and Children (WIC) provides breastfeeding support to pregnant and postpartum women in need of free or low cost services. You can use their online prescreening tool to determine whether you are WIC eligible.

If you are looking for an International Board Certified Lactation Consultant (IBCLC), the International Lactation Consultant Association (ILCA) offers a directory to find one in your community.

La Leche League International offers free local meetings, a national breastfeeding helpline, and many other resources for breastfeeding mothers in need of support.

Noelle McCown, Psy.D. is a Clinical Psychologist specializing in maternal mental health in the Greater Los Angeles Area. For more information about her work, you can visit http://www.drnoellemccown.com.

References

The Academy of Breastfeeding Medicine (2004). Protocol #11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Retrieved from http://www.bfmed.org/Media/Files/Protocols/ankyloglossia.pdf.

American Academy of Pediatrics and American Society of Pediatric Otolaryngology (2016). Tongue-tie in infants and young children. Retrieved from https://www.healthychildren.org/English/healthy-living/oral-health/Pages/Tongue-Tie-Infants-Young-Children.aspx.

Benyo, A. (2015, May 26). I know all about the ACA’s breastfeeding benefit, and I couldn’t get services covered. Retrieved from https://nwlc.org/blog/i-know-all-about-aca’s-breastfeeding-benefit-and-i-couldn’t-get-services-covered/.

Brown, A., Rance, J., Bennett, P. (2015). Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing, 72(2), 241–481. doi:10.1111/jan.12832

Davis, L. S. (2013, Jan 2). Is the medical community failing breastfeeding moms? Retrieved from http://healthland.time.com/2013/01/02/is-the-medical-community-failing-breastfeeding-moms/

Farver, M. (2016). A model for outpatient lactation care. MOJ Women’s Health 2(2). doi:10.15406/mojwh.2016.02.00025

Fernando, C. (1998). Tongue-tie—from confusion to clarity: A guide to the diagnosis and treatment of ankyloglossia. Sydney, Australia: Tandem Publications.

Groer, M. W., Davis, M. W., Hemphill, J. (2002). Postpartum stress: Current concepts and the possible protective role of breastfeeding. Journal of Obstetric, Gynecologic & Neonatal Nursing, 31(4), 411-417. doi:10.1111/j.1552-6909.2002.tb00063.x

Hannula, L., Kaunonen, M. and Tarkka, M.-T. (2008) A systematic review of professional support interventions for breastfeeding. Journal of Clinical Nursing, 17(9), 1132–1143. doi:10.1111/j.1365-2702.2007.02239.x

Martinelli, R. L., Marchesan, I. Q., Berretin-Felix, G. (2012). Lingual frenulum protocol with scores for infants. The International Journal of Orofacial Myology, 38, 104-112.

O'Callahan C., Macary S., Clemente S. (2013). The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding. International Journal of Pediatric Otorhinolaryngology, 77(5), 827-832. doi:10.1016/j.ijporl.2013.02.022

Rollins, N. C., Bhandari, N., Hajeebhoy, N., Horton, S., Lutter, C. K., Martines, J. C., Piwoz, E. G., Richter, L. M., and Victoria, C. G. (2016). Why invest, and what it will take to improve breastfeeding practices? The Lancet, 387(10017), 491-504. doi:10.1016/S0140-6736(15)01044-2

Ystom, E. (2012). Breastfeeding cessation and symptoms of anxiety and depression: a longitudinal cohort study. BMC Pregnancy and Childbirth, 12(36). doi:10.1186/1471-2393-12-36

I Lost My Daughter and Grandson and Headed to DC

By Millie Pagett

Millie and Ed, holding a picture of Charlene and Shane

Millie and Ed, holding a picture of Charlene and Shane

We would like to share our experience in National Coalition for Mental Health held in Washington D.C. on May 17 and 18, 2017.

We were honored to be invited by the coalition chair, Joy Burkhard, to share our personal story at a luncheon held at Art Club of Washington on May 17. Over 90 advocates from all over United States were the attendees. They were parents like us, husbands, mothers, survivors, clinicians, and practitioners who came to take part in this coalition. It was a pleasure to meet Jamie Zahlaway Belsito, Joy Burkhard and Maureen Fura from the National Coalition.

At the luncheon, May 17th we shared the loss of my daughter Charlene and grandson Shane who passed away on September 13, 2017 after Charlene suffered Postpartum Psychosis. Reliving our painful tragedy was hard, but our story has to be told. We lost a daughter and a grandson as a result of Maternal Mental Illness, which is the number one complication of Childbearing. Postpartum Depression is a disease and should be treated as seriously as any other medical diagnosis. By telling our story, we wanted everyone to know that Postpartum Depression is real, and could happen to any mother who just had a baby. We are the voice to help promote more awareness, more screening, and early intervention. We strongly feel that there should be more funding, more clinics, and more grants to help these mothers. 

The focus on May 18, was on Congressional meetings to ask State Congressional members to support and allocate the monies earmarked in the 21st Century Cures Act for Maternal Mental Depression. It was time to educate them on what we are doing in our State and how to see the issue of Maternal Mental Health education, support, screening and treatment. 

The preparation meeting was held at Rayburn House. Jamie Zahlaway Belsito did a wonderful job preparing us on our presentation, how to get the message across and telling them how they can support us. We had packets nicely put together for our presentation.

Our California Group Leader was Joy Burkhard, chair of the National Coalition and director of 2020 Mom. Joining us were a therapist from Victorville, survivor mom from Walnut Creek, and an infant feeding occupational therapist from Sherman Oaks. 

 

Our California Team

Our California Team

We met with representatives of Senator Dianne Feinstein, Senator Kamala Harris, Congressman Steve Knight, Congressman Paul Cook, Congressman Mark De Saulnier and Congressman Dana Rohrabacher, who we met in person.

 

Ed and Millie with Congressman Dana Rohrabacher

Ed and Millie with Congressman Dana Rohrabacher

We wouldn't have asked for a better team from California!  Overall, it was an amazing experience. Never in a million years did we think we would fight for what we think need major changes. It was a great day for everyone to come together with a goal in mind, to help in the improvement of mental health care. We met so many wonderful people who were passionate about making a difference. It was a blessing and very grateful for the opportunity. 

We felt encouraged and supported in one of the most difficult thing that we had ever done in our lives, to tell our own personal story of lost and to be the voice to make a change. We put on a fight and together we know we will make an impact in the future of Maternal Mental Health. 

No one should suffer like my daughter Charlene did.💜

Thank you for the opportunity to share our story and be part of this coalition.

The National Coalition Maternal Mental Health, Lobby Day 2017

The National Coalition Maternal Mental Health, Lobby Day 2017

NCMMH Goes to Washington!

Following last year’s successful inaugural National Lobby Day that culminated in the important maternal mental health legislation, Bringing Postpartum Depression Out of the Shadows Act, getting passed by the House and Senate, NCMMH planned for another phenomenal year advocating for maternal mental health care in the Nation’s Capital this past May.

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Bringing Postpartum Depression Out of the Shadows Act Passes

In December of 2016, maternal mental health advocates celebrated the passage of the 21st Century Cures Act which included support for identification and treatment of maternal depression. The 21st Century Cures Act adopted language from Bringing Postpartum Depression Out of the Shadows Act of 2015.

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Teenage Girls are Suffering

By Juli Fraga, Psy.D. and Joy Burkhard, MBA

Did you know that America’s girls are getting sadder and have you thought about what that could mean for the field of Maternal Mental Health?

A recent study published in the medical journal, Pediatrics, shows a general increase in depression among teenagers. Of even greater concern, girls are more likely to suffer from major depressive disorder than their male peers and the number of girls struggling with depression  has risen sharply since 2011.

Why the Increase?
There are likely a number of factors at play (we’d love to hear your thoughts about potential causes in the comments field below). The researchers state that social media may be partly to blame: In an interview with NPR, Catherine Steiner-Adair, psychologist, and author of the study states, "young girls are continually impacted by media messages that convey that their physical appearance is more important than their intelligence.”

Teenage girls who struggle with depression are more likely to wrestle with low self-esteem, social isolation, and relationship difficulties. At a time when a teenage girl’s hormones surge, it’s easy for parents to misread the signs and symptoms of her depression as “teen angst” or normal moodiness. And unfortunately, many adolescent girls are not telling their parents about their sadness. Just like mothers suffering from MMH disorders, the majority of teens are never screened, diagnosed, or treated for their malaise.

Contrary to what parents and teachers may believe, the effects of this mental illness doesn’t vanish once these young women leave their teenage years behind.

A Young Woman’s Story
Ann, age 24, of Los Angeles has suffered from depression and anxiety since she was a teenager.  She says, “It’s a lonely condition because people rarely talk about it and for a long while, it affected my self-esteem, even as I reached my adult years.”

Ann says that if she had learned how to recognize the signs and symptoms of her mood concerns earlier in life, it would have made a world of difference.

“I spent a lot of time blaming myself. Other people told me that I was Type A and that I worried too much. Once I realized I had a mood concern, it made a world of difference because I could finally get the help that I needed.”

Ann also realizes that she's at risk for a relapse, which is why she makes her self-care a priority and uses some cognitive-behavioral therapy techniques to challenge her obsessive thoughts. Even though she uses these tools, Ann is aware that her mental health concerns may resurface if she has children in the future.

What this means for Maternal Mental Health
Girls who suffer from depression and anxiety are of course at a higher risk of developing a maternal mental health disorders, such as postpartum depression when they become mothers.

Early screening and detection of depression and anxiety among teen girls can also help to prevent maternal mental health disorders during new motherhood. Having a family and personal history of mental health concerns is a risk factor for postpartum depression and anxiety, but early diagnosis and treatment can catch these women in a safety net by providing them with the care that they need for years to come.

Girls who suffer from depression and anxiety are of course at a higher risk of developing a maternal mental health disorders, such as postpartum depression when they become mothers.

Our field should be ready for an Influx
We are bringing this up because we think the field needs to be prepared. This of course is not easy when we are dealing with a system that isn’t catching mothers now. But nonetheless we must be talking about this and using this to our advantage when making the case for access to services like telepsychiatry lines, hospital based outpatient and inpatient treatment programs and more.

Join us for important conversations like these at 2020 Mom’s Annual ‘Emerging Consideration’ forum in Los Angeles, February 2018.

Repealing the ACA: What it Could Mean for Maternal Mental Health

President Trump’s promise to repeal the Patient Protection and Affordable Care Act (ACA), also known as Obamacare, is stirring up controversy around the country. This week’s announcement that the repeal will occur in 2018 has provided a bit of breathing room, though the fear and uncertainty for many Americans who rely on ACA coverage still exists with the looming threat. Within hours of taking the oath of office, President Trump issued his first executive order instructing federal agencies, such as Health and Human Services and the Treasury, “to minimize the unwarranted economic and regulatory burdens of the Act, and prepare to afford the States more flexibility and control to create a more free and open healthcare market.”

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What does the USPSTF Screening Recommendation Really Mean?

– POLICY –


by Joy Burkhard, MBA
Founder and Director 2020 Mom

It's an exciting development that the USPSTF no longer excludes pregnant women from its depression screening recommendations, and now notes the specific importance of screening pregnant and postpartum women due to negative consequences of untreated depression on fetus/infant development.

Patients are Already Provided Coverage
Insurers currently provide coverage to patients for depression screening in the full adult population.  However, most primary care doctors and OBGYNs continue (and will continue) NOT to screen because of lack of referral and case management support, which is a critical need for them in feeling comfortable when uncovering positive screens.

Provider Payment Still Depends on the Contract
Some are wondering whether this position means that insurers must pay providers for screening. It's an interesting question. The recommendation and ACA don't dictate how an insurer contracts or pays a provider. There are several types of insurance payment mechanisms. The two most well-known payment structures are Fee-for-service (a provider bills for every service s/he provides) and capitation (providers receive a flat payment per month for any/all services provided). Under a fee-for-service type arrangement, an insurer would reimburse for a depression screen. Under a capitation payment, providers are expected to provide all necessary services under their negotiated monthly payment, including depression screening. The USPSTF recommendation doesn't change these structures. Because of the focus on staying healthy, the Centers for Medicare/Medicaid Services (CMS) and others are promoting capitation type arrangements with primary care doctors, including pediatricians who may screen mothers for depression. Separate, and often in place for maternity, an OBGYN agrees to be paid a "global maternity rate" by the insurer for prenatal and postpartum services (through the postpartum visit). Under these types of arrangements, insurers generally expect providers to render all medically necessary screenings and services, which generally would include maternal depression screening and other types of screenings. Insurers are not obligated to pay providers for depression screening outside of this flat rate.
Note, however, that some payers/insurers have addressed this.  For example in Colorado, the state Medicaid program is reimbursing pediatricians and OBGYNs for conducting screening. Our sources tell us that there are challenges, including limitation on the number of times screening can occur (causing challenges as the pediatrician may not know if the OBGYN already screened) and low reimbursement levels, leaving many to not bother billing even if they do screen. Further, there is no measurement currently in place, so there is no evidence that payment is making a difference.  Furthermore, several years ago, Aetna, interested in improving depression screening and treatment rates, began reimbursing primary care providers for depression screening. They found it didn't increase depression screening rates (though those who were already screening were thrilled) pointing to the notion that clear referral and treatment pathways must be in place first, and additional payment really is secondary.

What should Insurers Do?
Insurers are in a unique position to provide this complex case management service (they do so now for many other conditions) but until there is also a way to locate psychiatrists as well as therapists who have training/experience in treating maternal mental health insurers will have difficulty making a dent.  Beyond the general difficulty in knowing who is qualified to treat these moms, there are also general psychiatry shortages, and most reproductive psychiatrists don't contract with insurers because they don't have to.
This is why the federal bill, HR 3235, Bringing Postpartum Depression out of the Shadows Act is critically important.  If passed states could apply for federal grants to implement innovative access solutions, like the Massachusetts telepsychiatry program, MCPAP for moms, which successfully addresses and integrates training of providers, referral pipelines for qualified therapy, and prescription consultation for OBGYNs and other MDs when necessary.  

Screening Rates Must be Measured
There is no measurement in place to capture how often OBGYNs (or others) are screening for depression.  "We don't manage what we don't measure" the adage goes.  It's critical that accreditation bodies and/or states require measurement of screening rates.  Insurers are in the best position to monitor these rates, through a program like the National Committee for Quality Assurance's (NCQA's) Healthcare Effectiveness Data and Information Set (HEDIS) measures, which involve monitoring medical records and/or claim submission data.   Cigna was the first insurer to adopt a HEDIS-like measure developed by external bodies, in 2013 but this measurement process needs to be implemented widely.  When health plans understand what gaps in care exist they invest resources to improve screening and health outcomes and work collaboratively with providers to support their needs.
 
Conclusion
Inclusion of pregnant and postpartum women in the USPSTF position is a critical step in validating the importance of this screen, but much more work is needed to ensure providers are actually able to screen.  2020 Mom is supporting this work through in several ways. Want to know more?  Drop us a line: 
info@2020mom.org