In Conversation with Christie Allen about Maternal Safety and Perinatal Mental Health
Editor’s note: Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental healthcare, which is care for mental health conditions during pregnancy and the twelve months following delivery.
Sarah Mossburg: Welcome, Christie. Can you please tell us just a little bit about yourself and your current role?
Christie Allen: I am a nurse by background and have worked in healthcare for about 25 years. I started out working in critical care, and then moved into maternal health and neonatal health. During that time, I became very interested in quality improvement and patient safety, mostly from seeing gaps in care provided to patients at the bedside and hoping that care could be better overall. I pursued my Master of Science degree in nursing with a focus on health policy to drive change and began work in quality improvement. I currently work as the Senior Director for Quality Improvement and Programs at the American College of Obstetricians and Gynecologists (ACOG). In this role, I support the quality and safety department at ACOG broadly. I also lead the Alliance for Innovation of Maternal Health (AIM) Program and the indigenous health program. These programs are focused on improving the quality of care and are highly integrated within the health equity space, as quality and equity are interwoven.
Sarah Mossburg: Can you tell us a little bit more about the AIM Program and its purpose?
Christie Allen: The AIM Program began in 2014 and is a cooperative agreement between the federal government, specifically the Health Resources and Services Administration (HRSA), and ACOG. It focuses on addressing preventable maternal mortality and severe maternal morbidity. It uses a state-based teams approach to actively implement tools, known as patient safety bundles, which are developed by the AIM Program. Those bundles are developed in cooperation with working groups of subject matter experts and are focused on best practices. The mission and vision of the AIM Program is to support best practices that make care safer and improve maternal health outcomes. We work closely with our partners at the Health Resources and Services Administration (HRSA) to implement the AIM program more broadly.
Sarah Mossburg: The Agency for Healthcare Research and Quality (AHRQ) is another key partner you work with. Could tell us about how the AIM Program aligns with AHRQ’s maternal health initiatives, including the Safety Program for Perinatal Care (SPPC)?
Christie Allen: We have a shared vision about making birth safer. We know that one of the primary drivers of unsafe care or unfortunate outcomes is communication. In maternal health, that communication often crosses the care continuum, which makes it even more complex. In the AIM Program, our primary role is providing technical assistance and capacity building to the teams that are implementing on the ground. Part of that capacity building is integration of best practices, such as communication-based strategies including TeamSTEPPS® (Team Strategies and Tools to Enhance Performance and Patient Safety). For the last few years, we partnered with AHRQ on the development of materials focused on team-based communication skills, recognition of issues, and how to address communication as effectively as possible. We see these materials as a really valuable resource for the AIM teams, and have a good pathway for disseminating these resources with our teams. We really value the SPPC work that is focused on team-based communication in labor and delivery settings and look forward to finding more ways to disseminate it more broadly into other settings.
Sarah Mossburg: I understand the AIM Program has a focus around perinatal mental health and that you are actively working on patient safety bundles focused on improving perinatal mental health. Could you tell us more about this work, maybe starting with telling us about the AIM bundles and how perinatal mental health evolved as a safety bundle?
Christie Allen: The AIM patient safety bundles are available for different clinical conditions and address the leading causes of severe maternal morbidity and maternal mortality. We are focused on the conditions that the data support as the leading causes of severe maternal morbidity. We make decisions about bundle development based on data sources such as the state’s Maternal Mortality Review Committee (MMRC) data or use national MMRC data published by the Centers for Disease Control and Prevention (CDC).
The initial core bundles were focused on hypertension, hemorrhage, and other clinical scenarios. These bundles tended to focus on the birth setting. We know that is not where conditions often develop nor is it the only place where conditions are recognized. Because of that, the focus of the clinical conditions bundles has expanded. The postpartum period (the 12 weeks following the birth of a child) and the late postpartum period (the 12 months after delivery) is an important time for the health of both the mother and infant. We now have bundles on topics such as postpartum discharge and care for pregnant and postpartum patients with substance use disorder. The MMRC data identified that mental and behavioral health conditions, including substance use disorders, are the leading cause of preventable mortality related to pregnancy in the United States through suicidality and accidental overdose. There is a lot of complexity in the space because of the need for coordination, communication, and policy that helps support payers in making that care accessible.
These bundles are probably the hardest to implement, measure, and monitor because they cross peoples’ lifespans and the care continuum. Measuring whether a patient received optimal mental healthcare around perinatal mental health conditions or optimal care with substance use disorder, both of which are chronic conditions, is much more complex from a measurement standpoint than a single episode of care, such as a delivery admission. From a care standpoint, it is more complex because of our fragmented medical system in the United States.
The perinatal mental health condition bundle was released in early February 2023. The bundle is focused on best practices, including transitions of care, screening, and referral.
Sarah Mossburg: Broadly speaking, how would you describe perinatal mental health and why is it so important to address?
Christie Allen: Perinatal mental health covers a range of mental health conditions. Many people are aware of postpartum depression, but it includes patients with conditions such as anxiety that leads to repetitive behaviors or obsessive-compulsive disorder. The perinatal mental health conditions in the bundle include but are not limited to depression, anxiety, and anxiety-related disorders, like post-traumatic stress disorder, obsessive-compulsive disorder, bipolar disorder, and postpartum psychosis. That is an incredibly broad range, and the morbidity is also incredibly broad.
Sarah Mossburg: How common are perinatal mental health conditions relative to other morbidities of pregnancy?
Christie Allen: There are different ways to measure severe maternal morbidity, and a very specific set of ICD-10 diagnosis codes are used in measurement. Perinatal mental health conditions are uniquely challenging to measure prevalence. Mental health conditions may start during the prenatal period (during pregnancy), but they also may well predate pregnancy. Maternity care and postpartum care cross the care continuum in a way that makes it uniquely challenging to measure the onset. The fragmentation of care that patients receive in the United States has made it difficult to measure prevalence.
We have difficulty measuring long-term impact, which could be considered a morbidity issue. For example, the ability of the parent to bond with their infant and the developmental impacts on that infant if the parent is unwell and unable to care for them as effectively is difficult to measure with the current tools we have in our healthcare system. It really speaks to the incredible importance of the work around perinatal mental health conditions because some of these conditions have lifelong impacts that cannot be measured with an ICD-10 code.
Sarah Mossburg: Who are the target audiences of the perinatal mental health bundle?
Christie Allen: The bundle is a tool and could be implemented by any AIM team. The optimal AIM team is multidisciplinary and includes physicians, midwives, other advanced practice practitioners, nurses, and public health professionals. These teams can include state health departments, state Medicaid agencies, community-based groups, advocacy groups, and state perinatal quality collaboratives.
The goal is to have as many people as possible provide the safety net of services and work toward implementation of best practices. Those experiencing perinatal mental health conditions may or may not present to an obstetrician-gynecologist (OB/GYN). AIM is seeking to cross the care continuum, so patients are appropriately screened when presenting with perinatal mental health conditions. These conditions are uniquely challenging, and many clinicians may see patients, like a therapist or social worker, who may not be in the obstetric care spaces. We are seeking to bring them in and integrate care, which is optimal for patient outcomes. That is not limited to maternal health. The AIM Program brings experts together with aligned goals of improving care and that is more critical than ever with both our substance use disorder bundle and our perinatal mental health conditions bundle.
Validated screening tools unique to the perinatal period are rare, but some have been developed, such as the Edinburgh Postpartum Depression Scale. These screening tools are incredibly important as there are a lot of symptoms in pregnancy and in the postpartum period that mimic perinatal mental health conditions. The MMRC data that are collected after the death of people who have been pregnant or were pregnant shows very clearly that suicidality and mental health are the responsibility of everybody on that care team.
Sarah Mossburg: How has the way that we recognize and treat perinatal mental health conditions evolved over time? How do you think that’s impacted perinatal safety? What has improved and what has stayed the same?
Christie Allen: I think we have made amazing progress. Some of it is the de-stigmatization of perinatal mental health conditions. We could point to a lot of reasons for that. Celebrities have spoken about it, and the culture of social media has normalized talking about mental health. The places where I think it has been stagnant at the health system level is insurance coverage for mental health disorders and mental health conditions. It is challenging when people cannot access care or pay for care. For example, we do not have a lot of inpatient facilities that allow for co-admission of a parent who is experiencing a mental health condition and the neonate or infant they are caring for. Those gaps in our system are going to take time and innovation to fill.
Unique resources are being developed with a focus around perinatal mental health conditions. ACOG has an online perinatal mental health toolkit that is constantly being updated with new resources. It is very comprehensive and has more coming every day. The toolkit is a partnership with Lifeline for Moms and was partially funded by the CDC. It is a set of robust and evolving resources focused on the comprehensive care of perinatal patients with mental health diagnoses.
Some states offer psychiatric perinatal mental health access programs. These programs are implemented at the state level to provide resources to support OB/GYNs and other clinicians providing care for patients with psychiatric disorders. If you are an OB/GYN who has seen a patient who needs medication for their mental health condition, referring them to a provider who can prescribe that medication can be very onerous if the OB/GYN cannot prescribe the medication themselves. Some patients may not be able to follow up with another provider. Resources are available now to help with prescribing, such as a hotline with a clinician trained in psychiatric prescribing who can offer clinician-to-clinician consultation, medication management, and resource and referral navigation. Those resources are growing and are now available in more states. They are incredibly impactful because the OB/GYN is already a trusted clinician who can now support the patient in providing ongoing care.
Sarah Mossburg: We talked about the bundles that AIM is working on. What are some of the elements of those bundles? Where are you in the work?
Christie Allen: All eight of our core patient safety bundles are fully developed. Each bundle is organized into a framework under five Rs: readiness, recognition and prevention, response, reporting and systems learning, and respectful care. For respectful care, the focus is on a respectful, equitable, and supportive care for all people, including antiracism. Those further elements related to health equity are integrated into all of the Rs. In our readiness element, we include providing training and education to address racism, healthcare team member biases, and stigma related to perinatal mental health conditions, and we promote trauma-informed care. The readiness component speaks to being ready to provide this care and maintaining sets of referral resources. When we conduct screenings for social and structural drivers of care or mental health screenings, we should have resources to provide people, such as which providers are available in the community or a maternal mental health hotline that is available to all people. Our goal is that all elements of the bundle are implemented. There is an accompanying document with supporting implementation details. The bundles are multilayered and very rich in content.
State-based teams who are implementing these bundles decide at the state and facility levels which bundles they will implement. We ask that they do that based on their MMRC data to determine what their state should be working on. Every state is uniquely resourced, as are the jurisdictions or territories. We have received a lot of interest in the perinatal mental health conditions bundle so far, and I would imagine there will be high uptake. The bundles are valuable tools, but they are piece of paper until they are implemented by a team with strategies. There are often questions about measuring screening and referral to treatment. We can measure screening usually, but often we cannot measure whether a referral was actually followed up on or was effective. We are fortunate to have a whole AIM data and evaluation team and data visualization center to support state team implementation. You cannot do better unless you know better.
Sarah Mossburg: Are there other initiatives that either ACOG or AIM has that are focused on improving maternal behavioral health or mental health?
Christie Allen: Dr. Iffath Hoskins is ACOG’s current president. The primary platform for her term is mental health for both the clinician and the patient. Our goal at AIM is to address conditions that lead to maternal morbidity and mortality specifically. ACOG’s work around mental health spans the lifespan continuum. There are ways to optimize care before someone comes into pregnancy care and actively address medication and support needs. ACOG advocates for and collaborates closely with an expert working group on mental health conditions. We are always seeking opportunities to collaborate with our community and professional partners.
Sarah Mossburg: You mentioned a number of key challenges related to improving perinatal and mental health, clinical challenges related to the onset, screening, and the challenges around coordination of care, transitions of care, and access to care. Are there other key challenges related to improving perinatal mental healthcare?
Christie Allen: Coverage by payors is a challenge to emphasize. Many health plans don't have robust behavioral healthcare reimbursement support. We ask OB/GYNs to provide appropriate care to those experiencing perinatal mental health conditions, whether that's screening, treatment, or referral. It is worth noting however, that maternity care is typically a bundled cost in the United States and the OB/GYN receives one fee. It does not cover all of the pieces they are doing to robustly support those in their care. They are experts in perinatal care, yet they may not be reimbursed adequately for the work and the time required to treat mental health conditions.
There is also the challenge that feelings of shame create. Mothers may have thoughts such as, “I don't love my baby,” “I don't look like a mom,” or “On social media other patients make it seem like everything is fine.” I experienced a perinatal mental health condition myself, and I remember thinking that I must just not be good at this, parenting. It was years before I told anyone, and I presented really well at appointments. It took a long time before I had adequate support to address these feelings. I do not know what the long-term effects of that are, but I carry pieces of that still. I talk to grandparents about how they struggled after they had their own children. Mental health affects whole family units for a lifetime potentially, and the harm that can come in suicidality and self-harm can affect families for generations. For these reasons, safe care must stay at the center of everything we do, and we must be intentional about care as it could be saving someone's life. There is still deep shame in even admitting that a mental health condition is happening. We need to normalize the experience of how hard it is to parent even when everything is going well, and how hard it is to when you are also struggling with your own mental health. It is incredibly important for more people, providers included, to normalize these experiences.
Having a variety of resources is incredibly important, and those have been lacking. In May 2022, HRSA developed its National Maternal Mental Health Hotline. It is a resource available 24/7 in English and Spanish to people who have given birth as well as their partners and support people. If it is 3 o’clock in the morning, and the person that you care about, who has recently given birth, is having a mental health crisis, you can call 911, but the care you receive may be dependent on resources and may be limited. Instead, if someone calls the National Maternal Mental Health Hotline, they will be connected to a trained professional who can provide real-time emotional support, encouragement, information and resources.
Sarah Mossburg: One of the other things that you touched on briefly is equity and equitable care. We know that there are many recognized structural and social determinants of health that impact healthcare. Could you speak to any of the key challenges around health equity, as they relate to perinatal healthcare?
Christie Allen: Perinatal mental health conditions can have more impact and potentially more harm to populations that are underserved or who are under-resourced. People with socioeconomic needs may have less access to care and less time and energy for that care because they may be working multiple jobs or do not have transportation to receive care.
People may struggle to disclose their mental health challenges to clinical providers who have different race, ethnic, or economic backgrounds then they do. In some communities, disclosing that you are not the optimal or “ideal” parent may create an environment that may lead to separation and not being allowed to parent that child. I do not think we even scratch the surface around these layers in health equity. People may be less willing to disclose mental health conditions for a number of very fair reasons, and I think that makes it all the more important that we should be screening and intervening whenever we can.
OB/GYN offices and clinicians must be able to provide a meaningful referral to any clinicians needed for care, and for social-structural needs that may impact health, such as food security and access to housing. It is very difficult to find robust referral pathways in some communities, which highlights the importance of clinician and community-based partnerships, particularly Black-women-led organizations and patient advocate-led organizations. We can envision what might be most meaningful, but only community members can tell us with certainty what might be the most meaningful. You cannot separate equity from quality and cannot separate quality care from equitable care. We must recognize the privilege of being able to call and make an appointment with a therapist for next week because an individual has a phone, health insurance, friends who can refer the clinician to a therapist, and very little stigma because mental healthcare has been normalized in their circles. Patients may not have any of those resources. We know across the board that care for other health conditions, such as congestive heart failure and pediatric asthma, have disparities in outcome due to health inequities. Perinatal mental health is no different.
Sarah Mossburg: As we wrap up this conversation, could tell us what you see as the next steps for this work overall? Are there any areas around perinatal mental healthcare that you would like to see as the focus for future research?
Christie Allen: I would like to see more opportunities for providing care that does not require maternal-infant separation, or dyad care, and seeing spaces where safety can be maintained for the parent–child dyad to allow people to effectively parent in those healthcare spaces. I would also like to see increased awareness of what resources exist now. I do not think people avoid using resources, but often they are unaware of resources like perinatal access programs for clinicians, community support groups, and social work supports.
From the ACOG perspective, topics such as payer models can be critically examined to determine whether they are meeting the needs of the community on the ground. Bundled costs do not build in perinatal mental healthcare effectively or at all.
I would also like to see more research and progress in developing data. As I mentioned before, we do not have good data in many communities and facilities. Much of our data are based on MMRCs, which is incredibly valuable, but those data focus on cases where patients are no longer with us. We need the ability to have more accessible and timely data on maternal child health broadly in the United States.
Sarah Mossburg: There have been so many groups that have worked diligently and hard on these challenging data issues related to maternal healthcare. Is data availability one of the key challenges that you have seen in moving forward?
Christie Allen: From a data capacity-building standpoint, we have far to go. In the United Kingdom, the National Health System can track outcomes and interventions across multiple care settings. Here in the United States, different OB/GYN practices use different electronic medical records (EMRs) and deliver at a hospital that uses another EMR. The pediatric provider will use another EMR, and the psychiatrist they may receive treatment from will use another. There is very little interplay. There may be some connection through their insurer, but there may not be, especially if someone is paying out of pocket for psychological counseling or psychiatric services. The system is so fragmented. There often is very little way to tie someone's outcome or mental health condition back to a pregnancy admission.
The challenges surrounding data availability is a factor in the AIM Program’s data management plans. When people see our data management plans, they often wonder why we didn’t recommend that they measure specific things. It’s often because we cannot adequately collect data in some spaces, and we have a long way to go. It is less an issue of stagnation because I think people are working incredibly hard on it, but we must move the needle somehow when we are in this fragmented healthcare system.
Sarah Mossburg: Is there anything that we did not discuss today that you would really like to cover before we close?
Christie Allen: There are some models that I have not touched on that are impactful. One area the perinatal mental health condition bundle emphasizes that other bundles may not mention is the topic of pediatric well-child visits and integration of mental healthcare across those spaces. Specialized departments, like emergency departments and pediatrics, may not focus on the mother, conduct screenings, or focus on pregnancies. We all have to do it and focus on perinatal mental health. Patient navigators can be one strategy to address that lack of integration. This role may sometimes be filled by a doula. Dr. Lynn Yee is researching perinatal navigation at Northwestern University. This role would be filled by a non-clinician, who is culturally and linguistically aligned with the patient. This person can help patients navigate their experience and ask questions like, “Do you have a ride for your appointment tomorrow?” Helping patients navigate these spaces can be valuable for ensuring the continuation of care across different conditions, and that does not always have to be the role of the clinician.
Sarah Mossburg: That is really exciting. Thanks for sharing and thank you for taking the time to talk with us.
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