Behavioral health in pregnancy and postpartum

©pressmaster - stock.adobe.com

Behavioral health refers to the domains of mental health and substance use and is an essential component of wellness. Pregnancy and the postpartum period are times of unique physical, social, and psychologic changes. We will review behavioral health conditions during pregnancy and postpartum with particular attention to the relationship between behavioral health and maternal mortality.

Considerations during pregnancy

Nearly 1 in 5 pregnancies are complicated by a perinatal mood disorder, such as depression, anxiety, and post-traumatic stress disorder.¹ Untreated mood disorders are associated with adverse gestational outcomes and can have lasting clinical and economic effects beyond the perinatal period for mothers and their families.² Despite guideline recommendations³ for routine screening with validated tools,^4,5 screening is infrequent and treatment is underutilized.⁶ A recent meta-analysis found that the majority of pregnant women suffering from mood disorders are undiagnosed, less than 1 in 10 receive adequate treatment, and less than 1 in 20 achieve remission.²

Overall, pregnant and parenting women use fewer substances than other women, and prenatal substance use decreases with gestational age.⁷ Women who continue to use substances during pregnancy likely have a substance use disorder.⁸ Opioid use disorder is prevalent in roughly 2% of pregnant women.⁹ Pharmacotherapy for opioid use disorder, with either methadone or buprenorphine, is recommended during pregnancy¹⁰ as it is safe, effective, and associated with improved maternal and neonatal outcomes.^11,12 However, most pregnant women receive no treatment for substance use disorders,¹³ and only 50% of women in treatment for opioid use disorder receive pharmacotherapy.¹⁴

Considerations postpartum

Women face a diverse set of medical, personal, and social challenges postpartum.¹⁵ In addition, newborn care can be stressful and isolating, sleep is poor, and mood changes, specifically postpartum depression, are common, especially for women with behavioral health conditions.² Suicide rates increase postpartum, especially among teenagers and those with psychiatric diagnoses.¹⁶ For women with substance use disorders, relapse is more common postpartum than during pregnancy,⁷ as is overdose and overdose death.^17,18

Amid this challenging time, some women also do not have paid parental leave from their employers, and others lose insurance coverage, especially in states without Medicaid expansion. Even when health insurance is maintained, continuing care is often fragmented and infrequent. Of those who died from self-harm in Colorado, less than half attended a postpartum visit.¹⁸ Opioid use disorder pharmacotherapy is rarely initiated postpartum, and treatment begun during pregnancy often lapses following delivery.¹⁹

Behavioral health and maternal mortality

Maternal mortality is defined by the Centers for Disease Control and Prevention (CDC) as a maternal death occurring during pregnancy through the first year postpartum. In contrast to other industrialized nations, in the United States, maternal mortality is increasing, driven in part by behavioral health conditions. Maternal Mortality Review Committees in several states have documented suicide and opioid overdose as the leading causes of maternal death, exceeding deaths from hemorrhage, emboli, preeclampsia and sepsis, a fact highlighted in a recent landmark report by the CDC Foundation.²⁰ Roughly 1 in 5 maternal deaths are due to an opioid overdose in the United States, and in contrast to other pregnancy-associated deaths, overdose risk increases throughout the postpartum period.^17,18 Overdose deaths are most likely among women whose substance use went unrecognized throughout pregnancy and delivery. In Colorado, only 17% of women who died of an overdose had any history of addiction documented in their chart.¹⁸ To properly address maternal deaths due to overdose, Maternal Mortality Review Committee membership should be expanded to include behavioral health expertise in addition to social service representatives.²¹

It has been well established that pharmacotherapy for opioid use disorder protects against relapse, overdose, and overdose death. Medicines, however, only work when people have access to them. To identify individuals who would benefit from treatment, assessment for substance use, misuse and addiction should be universal across all domains of health care, including preconception and prenatal care.²² Simultaneously, treatment capacity must be expanded; health systems and payers should work towards equitable access to evidence-based treatment services for all women.

Conclusions

Prenatal care is a frequent point of contact with the healthcare system and is structured to maximize screening for conditions that affect delivery and birth outcomes. Hence the frequency of visits increases until delivery but typically encompasses just 1 visit postpartum. This artificial separation of pregnancy from the postpartum period compounds vulnerabilities, especially for women with behavioral health conditions. Recognizing the need to intensify how we address the medical, social, and emotional well-being needs of postpartum women and their families, thought leaders have recently called for re-structuring of the care provided in the “Fourth Trimester.” Rather than a single encounter, postpartum care should be an ongoing process, with earlier and more frequent contact delivering woman-center, tailored care through 12 weeks postpartum.¹⁵

Chronic behavioral health conditions require continuing care. This is clearly illustrated by the increasing numbers of maternal deaths among women with behavioral health conditions. Beyond the call to provide better care to our postpartum patients, we must also advocate for health insurance coverage to extend until at least 1 year following delivery. Such restructuring would allow clinical and payment structures to align with public health metrics, filling in gaps of coverage encountered more often by vulnerable populations including socioeconomically disadvantaged, racial minority, and adolescent women. Without simultaneous efforts at both the individual and population levels, the unfortunate trends of women entering pregnancy with untreated mental illness and mothers dying from overdose being seen today are only to continue.

Disclosures:

The authors report no potential conflicts of interest with regard to this article.

References:

• Mood and Anxiety Disorders in Pregnant and Postpartum Women. J Obstet Gynecol Neonatal Nursing. 2015;44(5):687-689.

• Cox EQ, Sowa NA, Meltzer-Brody SE, Gaynes BN. The Perinatal Depression Treatment Cascade: Baby Steps Toward Improving Outcomes. J Clin Psychiatry. 2016;77(9):1189-1200.

• Screening for perinatal depression. ACOG Committee Opinion No. 757. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2018;132:208-212.

• Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. B J Psychiatry. 1987;150:782-786.

• Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

• The American College of Obstetricians and Gynecologists Committee Opinion no. 630. Screening for perinatal depression. Obstet Gynecol. 2015;125(5):1268-1271.

• Ebrahim SH, Gfroerer J. Pregnancy-related substance use in the United States during 1996-1998. Obstet Gynecol. 2003;101(2):374-379.

• ASAM. Public Policy Statement on Substance Use, Misuse, and Use Disorders During and Following Pregnancy, with an Emphasis on Opioids. North Bethesda, MD: American Society of Addiction Medicine;2017.

• Haight SC, Ko JY, Tong VT, Bohm MK, Callaghan WM. Opioid Use Disorder Documented at Delivery Hospitalization - United States, 1999-2014. MMWR Morbid Mortal Weekly Rep. 2018;67(31):845-849.

• Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017;130(2):e81-e94.

• Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants. HHS Publication No. (SMA) 18-5054. Rockville, MD: Substance Abuse and Mental Health Services Administration;2018.

• Patient Safety Bundle: Obstetric Care for Women with Opioid Use Disorder. 2017; https://safehealthcareforeverywoman.org/patient-safety-bundles/obstetric-care-for-women-with-opioid-use-disorder/. Accessed 4 September, 2018.

• Terplan M, McNamara EJ, Chisolm MS. Pregnant and non-pregnant women with substance use disorders: the gap between treatment need and receipt. J Addictive Dis. 2012;31(4):342-349.

• Short VL, Hand DJ, MacAfee L, Abatemarco DJ, Terplan M. Trends and disparities in receipt of pharmacotherapy among pregnant women in publically funded treatment programs for opioid use disorder in the United States. J Substance Abuse Treat. 2018;89:67-74.

• Tully KP, Stuebe AM, Verbiest SB. The fourth trimester: a critical transition period with unmet maternal health needs. Am J Obstet Gynecol. 2017;217(1):37-41.

• Lindahl V, Pearson JL, Colpe L. Prevalence of suicidality during pregnancy and the postpartum. Archives Women Mental Health. 2005;8(2):77-87.

• Schiff DM, Nielsen T, Terplan M, et al. Fatal and Nonfatal Overdose Among Pregnant and Postpartum Women in Massachusetts. Obstet Gynecol. 2018;132(2):466-474.

• Metz TD, Rovner P, Hoffman MC, Allshouse AA, Beckwith KM, Binswanger IA. Maternal Deaths From Suicide and Overdose in Colorado, 2004-2012. Obstet Gynecol. 2016;128(6):1233-1240.

• Wilder C, Lewis D, Winhusen T. Medication assisted treatment discontinuation in pregnant and postpartum women with opioid use disorder. Drug Alcohol Depend. 2015;149:225-231.

• CDC-Foundation. Building U.S. Capacity to Review and Prevent Maternal Deaths. 2018; http://reviewtoaction.org/2018_Report_from_MMRCs. Accessed 4 September, 2018.

• Koch AR, Geller SE. Addressing maternal deaths due to violence: the Illinois experience. Am J Obstet Gynecol. 2017;217(5):556.e551-556.e556.

• Wright TE, Terplan M, Ondersma SJ, et al. The role of screening, brief intervention, and referral to treatment in the perinatal period. Am J Obstet Gynecol. 2016;215(5):539-547.