Abstract
Maternal mental illness can occur during pregnancy and through the first year postpartum. While pregnancy and motherhood are often believed to protect against mental illness, research suggests otherwise. All women are at risk of developing maternal mental health issues such as depression, anxiety, and psychosis, but some appear to be at greater risk, including those with a history of mental illness, the poor, those who experience complications in pregnancy and childbirth, and those who experience intimate partner violence. Maternal mental health issues are serious and affect women experiencing symptoms, their children, their partners, and their communities. For example, the risk of completing a suicide attempt within the first year postpartum increases 70-fold if a woman had previously been hospitalized for a postpartum psychiatric disorder. Furthermore, untreated maternal mental illness is associated with poor fetal growth in utero and developmental delays in infants and children. Insufficient investment in maternal mental health has resulted in poor availability of services, inadequate infrastructure and workforce, and a lack of culturally appropriate approaches to identification and treatment. While maternal mental illness poses a significant public health challenge, prevention is possible and treatment options are effective. This policy statement advocates for a global effort to invest in improving maternal mental health through concerted efforts on the programmatic, policy, and funding fronts.
Relationship to Existing APHA Policy Statements
This policy statement builds upon and is consistent with the following statements:
- APHA Policy Statement 201113: Call to Action to Reduce Global Maternal Neonatal and Child Morbidity and Mortality
- APHA Policy Statement 201114: Reducing US Maternal Mortality as a Human Right
- APHA Policy Statement 200318: Safe Motherhood in the United States: Reducing Maternal Mortality and Morbidity
- APHA Policy Statement 7302: Current Scope of Maternal Health Services in All Communities
- Policy Statement 7924(PP): Alternatives in Maternity Care
- APHA Policy Statement 20004: Supporting Access to Midwifery Services in the United States
- Policy Statement 7501: Mental Health is an Essential Part of Comprehensive Health Care Programs
- Policy Statement 7524(PP): Suicide Prevention
- Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
This policy statement relates to existing APHA policy statements in two ways. First, it promotes one of APHA’s overarching priorities: building public health infrastructure and capacity in the global arena. Second, it supports APHA efforts to invest in maternal mental health by building on existing APHA policies addressing issues related to, or occurring as a result of, maternal mental illness (e.g., maternal mortality and morbidity). There is a gap in current APHA policy, as none of the current APHA policy statements comprehensively address the needs of the population that resides at the nexus of maternal mental health, which requires a distinct set of considerations and a different approach than other populations needing either mental health or maternal health services exclusively.
Problem Statement
While pregnancy and motherhood were traditionally considered protective against mental health issues, maternal mental illness—which occurs during pregnancy and up to one year after—is prevalent during this time period, in the forms of first onset and recurring mental illness.[1] The growing awareness of the prevalence and impact of maternal mental illness occurs at a time when the global health community is increasingly acknowledging the importance of mental health for overall well-being. Mental health was included as a United Nations Sustainable Development Goal (Target 3.4) aiming to reduce premature mortality through promotion of mental health and well-being.[2] In addition, the 2017 Report of the UN Special Rapporteur on the right to health noted that “there can be no health without mental health.”[3] Furthermore, the World Health Organization (WHO) projects that depressive disorders will be the leading burden of disease among women by 2020, indicating that maternal mental health is a timely, important public health issue.[4]
Maternal mental illness is typically characterized by three illness types: depression, anxiety, and psychosis (including psychotic disorder or illness with psychotic episodes).[5,6] While the exact prevalence of maternal mental illness is not certain because of the varying sensitivities of diagnostic instruments and different cultural norms surrounding mental illness,[7] up to an estimated 20% of pregnant and postpartum women globally experience depression and/or anxiety, and one to two women per 1,000 pregnancies experience psychosis.[8,9] Furthermore, gender norms across cultures may influence the ways in which maternal mental health concerns present or are recognized (precise diagnoses can be difficult because of similarities in symptomatology and frequent comorbidities between illnesses[10]).
While all women who become pregnant are at risk of developing maternal mental illness, some appear to be more vulnerable. Maternal mental illness is believed to be two to three times as prevalent among women in low- and middle-income countries (LMICs) as among those in high-income countries.[11] In addition, women with a history of mental illness prior to pregnancy,[7] those living in poverty,[12] and those who experience racism and homelessness are more likely to experience maternal mental illness, as are pregnant trans and gender non-binary individuals.[5,13] Women living with chronic conditions, including HIV, are at greatly increased odds of developing mental health conditions.[14] Furthermore, complications in pregnancy and childbirth, a feeling of loss of control,[15] and lifestyle changes related to the pregnancy[16] are associated with the development of mental illness.
Untreated maternal mental illness has deleterious effects on the health of the woman experiencing symptoms, her family, and her community. At the individual level, mental illness is associated with poor physical health in general, and this relationship persists during pregnancy and through the first year postpartum.[17] Research in the United States has demonstrated that the odds of suicidal ideation among mothers living with depression are nearly seven-fold those of mothers not living with depression, and the odds of a completed suicide attempt within the first year postpartum increase 70-fold if a woman had previously been hospitalized for a postpartum psychiatric disorder.[18] Findings from a 2018 global literature review suggest that suicides may account for as many as 20% of postpartum deaths, with variations across countries.[19] Trauma in the form of intimate partner violence (IPV), as well as comorbid substance use, can instigate or exacerbate maternal mental health issues, including suicidal ideation; a U.S. national study showed that 54% of suicides in pregnancy and the first year postpartum occurred among those who had experienced IPV.[20]
Another global literature review shows that untreated maternal mental illness in pregnancy and the first year postpartum is associated with poor growth in utero, developmental delays in infants and children, difficulty with breastfeeding, and early cessation of breastfeeding.[21,22] The impacts of postpartum depression can be long lasting; researchers from the United States found that children of mothers with postpartum depression had higher odds of mental and social impairment throughout their own life course and were twice as likely to have physical health problems as children whose mothers were not diagnosed with postpartum depression.[23]
Women who do seek care for maternal mental health issues face numerous barriers to accessing adequate treatment. The acceptability of different types of medication varies across families, communities, cultures, and nations; identifying culturally appropriate ways to treat mental illness is an important step in improving maternal mental health.[27] In LMICs, these concerns are complicated by structural factors that cause long-standing health inequities. While LMICs contain more than 80% of the global population, they benefit from only 20% of mental health resources.[11] Shortages of mental health specialists and mental health care facilities, particularly in LMICs and in rural areas of high-income countries, present significant barriers to access.[27]
Inadequate and outdated policies regarding maternal mental health compound the problem of access to treatment. They contribute to weak supply chains for psychotropic medications, insufficient coverage of mental health facilities, and poorly equipped maternal mental health workforces, among other issues.[27] In many health systems, psychotropic medications may be prescribed only by a psychiatrist or other mental health specialist.[28] Although intended to protect patients, such policies can create nearly insurmountable barriers to care in many LMICs, where there are acute shortages of such specialists.[27] Furthermore, maternal and child health policies routinely fail to include mental health components, and mental health policies typically overlook the distinct needs of mothers and children.[29]
The widespread lack of access to adequate maternal mental health screening and treatment services also has profound societal costs. Although research describing the financial impacts of maternal mental illness is scarce, a 2014 analysis from the United Kingdom showed a one-year societal cost of maternal mental health issues among a cohort of births of £8.1 billion (a combination of increases in health service use, loss of productivity, and loss of quality-adjusted life-years). The same study revealed that although increasing access to and uptake of maternal mental health services would require startup investments, the cost savings generated would be substantial: the current cost burden of maternal mental health issues to the public sector is five times the cost of enhancing service provision within the National Health Service.[28]
Moreover, poor access to maternal mental health services represents a failure to uphold mothers’ right to health and nondiscrimination.[30] Women who suffer from maternal mental illness do not enjoy the “state of complete physical, mental and social well-being” that is part of the WHO constitution.[31] Thus, whether viewed in terms of prevalence, health impact on the mother-infant dyad, societal cost, or human rights obligations, maternal mental health represents a profound and highly complex public health challenge.
Evidence-Based Interventions and Strategies
Despite the prevalence and impact of maternal mental illness, the evidence base on effective treatments is somewhat limited, in part due to concerns around involving pregnant and lactating women in research. While more rigorous research is needed, the current evidence base can provide guidance for prevention and treatment strategies. Hybrid effectiveness and implementation research designs can help to develop practice-based evidence and to support effective translation and adaptation of strategies from one context and population to another.[32] Priority should be given to maternal mental health prevention and treatment options designed by and for communities in LMICs. This policy statement advocates for a global effort to improve maternal mental health through the use of evidence-based strategies that can be implemented at the community and facility levels, with attendant program and policy changes.
Screening for depression during the prenatal period with linkage to treatment is an option for supporting pregnant women living with depression, one endorsed by the U.S. Preventive Services Task Force.[33] The American College of Obstetricians and Gynecologists and the American Academy of Pediatricians recommend screening for depression during the perinatal period, at both obstetrician visits and infant check-ups. In many low-resource contexts, women may not return to the health system for a postpartum visit, and so screening during prenatal care may be warranted. However, the lack of high-quality evidence on the effects of screening in contexts where appropriate treatment is limited, combined with concerns about stigma and difficulties in linking women to care, has led regulatory bodies in other countries to decline endorsing routine screening.[34] Rigorous research on strategies to improve linkage to care after routine screening, particularly in LMICs, is needed to inform appropriate screening and treatment procedures in the prenatal period. In the meantime, however, research suggests that there are numerous strategies for preventing, identifying, and managing maternal mental health issues, with a particular focus on improving women’s experience in pregnancy and the postpartum period.
Within health facilities, care integration is a promising approach to ensuring that women’s needs are met holistically, across the continuum of pregnancy, childbirth, and the postpartum period. Integrating maternal mental health services into primary care has been demonstrated to improve universal maternal mental health screening, referral, and retention in care; it has also been shown to enhance continuity of care and reduce stigma.[35] Many mental health disorders can be addressed in primary care settings with universal standardized screening, professional training, and teamwork among health providers (including physicians, nurses, and midwives), thus eliminating the need for referral to treatment. Furthermore, integrated care can incorporate mental health education and promotion into routine health care, which can improve mental health awareness and reduce stigma.[36] Integration of maternal mental health screening and services into programs for women who are currently experiencing or have previously experienced intimate partner violence, and vice versa, can also aid in identification of either issue because IPV is highly associated with mental health problems.[37] Trauma-informed maternal mental health services for survivors of IPV have the potential to improve women’s overall well-being. For example, the Cognitive Trauma Therapy for Battered Women with PTSD program has had measurable success in decreasing depression and anxiety symptoms and increasing self-esteem among diverse groups of women experiencing domestic violence.[38]
Integrated care may also increase health system revenue gains.[39] For example, a simulation of the integration of services over a 10-year period at U.S. federally qualified health centers revealed that collaborative care would result in gains for public and private insurers if private insurers matched Medicare insurance reimbursements, even after transition and ongoing costs to support integration had been taken into account.[39]
The emerging practice of telehealth may prove to be an important strategy to improve access to mental health practitioners. A 2016 review showed that telehealth had been used to address the mental health needs of pregnant women and mothers living in remote locations, as well as those for whom time constraints and other health considerations posed barriers to care.[40] In 2012, a successful partnership between Mbarara Regional Referral Hospital in southwestern Uganda and Massachusetts General Hospital in Boston demonstrated that teleconferencing systems could be used to effectively train clinicians in obstetrics and gynecology (OB/GYN).[41] This model could be used to develop parallel maternal mental health programs that could help rapidly train and capacitate providers in settings with mental health workforce shortages.
Social support is critical to promote good experiences in pregnancy, childbirth, and the postpartum period, which can prevent the development of new mental illness in the maternal period and mitigate exacerbation of existing mental illness. In the United States, the CenteringPregnancy® model, which actively engages women in learning about their health and increases access to social support during the prenatal period, is associated with lower prenatal and postpartum stress, better physical health, lower social isolation, and better attendance at postpartum visits.[42] However, a recent attempt at replication in Malawi and Tanzania showed that the success of CenteringPregnancy is context dependent,[43] suggesting that care should be taken to understand cultural settings and available resources before selecting and/or adapting health education and support models for new populations of pregnant women.
As there is some emerging evidence suggesting that poor birthing experiences contribute to postpartum mental illness,[44] the presence of birthing companions, including doulas (professionals who accompany and support a woman during childbirth), may help improve women’s birthing experiences, thus indirectly contributing to improved mental health.[34] WHO and the American College of Obstetricians and Gynecologists both endorse the use of support people, including partners and doulas, to improve the birth experience.[34,45]
In addition, engaging family members who are supportive and play a role in caregiving can promote good maternal mental health. For instance, in one study, mothers reported reduced depression and anxiety symptoms after participating in interventions focusing on conflict resolution, co-parenting, and other relationship strategies to promote healthy family communication and interactions.[35]
Opposing Arguments/Evidence
Arguments opposing this statement might include those related to the following factors: cost, ethical issues, priority, limited evidence for pharmacological treatment, health workforce constraints, and cultural acceptability.
Cost: While commitment to researching and adopting programs that focus on maternal mental illness is admirable, limited funding opportunities exist to conduct research on mental illness and promote mental health.[27] It may be difficult for some governments, organizations, health centers, and providers to implement new programs and policies due to economic challenges. Identifying startup funds for new programs is indeed a challenge; however, the limited maternal mental health cost-savings research suggests that upfront investments can reduce costs over time[27] as well as bolster average healthy years gained.[46] Integrating primary care and maternal mental health can reduce costs and improve access to care through pooling of funding and infrastructure and use of task sharing.[47] That said, improved availability of services and budgetary distributions does not reduce the potential financial burden of care in the form of out-of-pocket payments for individuals. Such payments are commonplace in many LMICs and can create substantial barriers to care.[46] Expanding health insurance to include mental health treatment[47] and equitably distribute services and financial coverage to the public sector[46] can significantly reduce financial barriers to care.
Ethical issues: Future research related to maternal mental illness in developing countries must consider the context to determine whether the standard of care related to research is affordable by the host country.[48,49]. Populations in developing countries are considered vulnerable due to lack of education, economic disadvantage, and a dearth of laws or regulations to ensure that international research is ethical.[48] It is important for researchers not only to protect the most vulnerable but to understand stigma, discrimination, and power differentials in the host country so that these factors are not carried into the study with consequences such as coerced consent or disproportionate experiences of the study’s risks and benefits.[48] Furthermore, consideration of language barriers and cultural perspectives and values is necessary to ensure participants’ full understanding of the study and respect for cultural differences.[48]
Priority: While mental illness is quickly being recognized as a critical component of overall health, at present other issues, such as cardiovascular disease, are considered more important in preventing morbidity and mortality among the greatest number of people. In situations of scarce resources, public health issues that are associated with the highest level of mortality or that affect the greatest number of people often take precedent. However, considering the significant burden of maternal mental illness throughout the world, and taking into account that physical health is correlated with mental health, investment in maternal mental health is complementary and necessary for overall well-being.[17]
Limited evidence for pharmacological treatment: Historically thin funding streams and challenges around conducting mental health research with pregnant and breastfeeding women have led to a paucity of robust evidence on pharmacological approaches to managing maternal mental illness.[11,22] However, pharmacological treatments can be less resource intensive than other behavioral health interventions and could be administered at the primary care level with oversight from a mental health specialist.[27] More research is required to fully understand the risks of psychotropic medications to pregnant and breastfeeding women as well as the cultural acceptability of such medications in different settings.[27]
Health workforce constraints: Ensuring quality maternal mental health services requires a robust and highly trained workforce. In many low-resource settings, mental health specialists are poorly distributed, and their caseloads are already quite heavy.[28] These providers may require additional training to prepare them to work with pregnant and postpartum women. In addition, community-level workers, such as community health workers, could be trained to support mental health providers through detection, care, and/or referral to treatment.[49] Investment in the maternal mental health workforce must be undertaken with care and consideration for the safety of workers and patients.
Cultural acceptability: Although maternal mental illness appears across a variety of settings, the ways in which individuals and communities understand and interpret mental illness and treatment are diverse.[28] Evidence-based practices that are effective in one context may not be feasible or acceptable in another, raising questions about the degree to which the evidence base holds after adaptation. In addition, resources for mental illness screening and treatment vary by location. Cultural, social, societal, familial, and religious norms, among others, affect the efficacy of treatments for maternal mental illness.[28] The culturally specific challenges associated with implementation of maternal mental health programs will also present themselves during evaluations in different settings. Development of culturally appropriate identification and management strategies is a common challenge in public health programs, and investment in culturally appropriate maternal mental health services merits the same efforts as other public health issues. That said, investment in culturally appropriate community mental health programs and ownership of these programs by local stakeholders will result in better identification and management of mental illness. In order to successfully improve delivery of maternal mental health care, local contextual factors must be considered, and this is especially the case in LMICs where implementation data are less available and resources may be scarce. Social, religious, and cultural norms may impact the effectiveness of certain maternal mental health policies.[27] Community health worker models, which rely on trained community members who deliver services and support, can reduce barriers to screening, support, referral, and treatment.[27]
Action Steps
APHA endorses the following activities in support of maternal mental health:
- The United States Congress and federal agencies should commit to sustained leadership on maternal mental health by facilitating the collaboration of all U.S. global health programs, including but not limited to the United States Agency for International Development, the Centers for Disease Control and Prevention, and the President’s Emergency Plan for AIDS Relief, that are addressing maternal and child health to promote maternal mental health as a core component of their missions.
- The United States Congress and federal agencies should ensure that U.S. international policies prioritize programs that promote accessible, affordable, and high-quality maternal mental health; also, funding for international agencies (e.g., the Joint United Nations Programme on HIV and AIDS, the Global Fund) should earmark budget lines for maternal mental health activities. In addition, the United States should advocate for other funders to support maternal mental health services.
- International, national, regional and community-level health training bodies should invest in the development of the global maternal mental health workforce by creating professional education programs and integrating maternal mental health training into primary care and OB/GYN provider training. Holistic maternal mental health workforce development strategies should include community health workers who ethnically and culturally represent the women they serve.
- Public health researchers should conduct maternal mental health research with an emphasis on culturally appropriate identification and management strategies.
- Domestic public health policymakers should implement programs and policies to improve women’s experiences in pregnancy, childbirth, and the postpartum period to prevent stress- and trauma-related maternal mental illness. Such policies might include allowing women to be accompanied by a birthing companion of their choosing, providing reimbursement for doulas, and removing maternal care user fees.
- Public health practitioners should develop and implement a standardized, integrated strategy to screen for mental illness and IPV and to integrate treatment for better outcomes in regions where IPV and mental health services are available. In regions where IPV and mental health services are not available, integrated programs should be developed to target these issues.
- The public and private sectors should develop and strengthen telehealth options to improve access to maternal mental health services among women in difficult-to-reach areas and/or areas where specialist services are scarce, as well as to enhance the capacity of available health providers
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