Maternal Safety and Perinatal Mental Health
Maternal patient safety is a critical aspect of healthcare given the complex processes associated with childbirth. The care for pregnant individuals during pregnancy, childbirth, and the postpartum period involves strategies and practices that aim to prevent adverse outcomes for both the mother and the newborn, including avoiding complications and mortality. Analyses from the U.S. Government Accountability Office show that maternal mortality has increased and that continued federal efforts are needed to address maternal harm. The Agency for Healthcare Research and Quality (AHRQ) leads several initiatives focused on improving perinatal safety, including the AHRQ Safety Program for Perinatal Care, which is focused on improving labor and delivery communication and avoiding system failures.
While much of maternal safety focuses on care provided during the in-hospital stay, perinatal care crosses the health continuum. It is essential to address patient safety challenges across the different healthcare settings, including during prenatal care (during pregnancy), the postpartum period (up to twelve weeks following delivery) and late postpartum period (through one year after giving birth). As this focus has shifted, new topic areas and opportunities to improve care have been identified and developed. One topic area that has become prominent over time is perinatal mental health.
Perinatal mental health refers to the mental health of individuals during pregnancy and the first year after giving birth. It is an essential aspect of maternal healthcare.1 Maternal safety considerations for perinatal mental health are important because untreated mental health problems can have serious consequences for both the mother and the child. Reports of the prevalence and incidence of these conditions vary; one study estimates that roughly 9% of pregnant individuals experience a perinatal mental health condition though this may be lower than actual values given the challenges with access to data.2 These conditions include a wide range of mood and anxiety disorders, including depression, anxiety, bipolar disorder, post-traumatic stress disorder, obsessive-compulsive disorder, and postpartum psychosis. If not addressed, perinatal mood and anxiety disorders can lead to significant negative outcomes for both patients and their children. These outcomes can include a higher likelihood of neglecting medical care, worsening of pre-existing medical conditions, diminished access to interpersonal and financial resources, increased use of drugs and tobacco, and a higher risk of self-harm, suicide, or harming their infant.3
Key Components of Perinatal Mental Healthcare
Organizations such as the American College of Obstetricians and Gynecologists and the U.S. Preventive Services Task Force have recognized the importance of appropriate mental healthcare throughout and after pregnancy. Programs such as the Alliance of Innovation on Maternal Health (AIM) and Lifeline for Moms at the University of Massachusetts promote safer care and have developed multiple resources aimed at educating healthcare workers and sharing best practices. The AIM program has led the development of patient safety bundles that provide structured processes to implement best practices at different levels of healthcare and released the perinatal mental health conditions bundle in February 2023.
One of the most critical patient safety considerations for perinatal mental health is screening, which can help identify individuals who may be at risk for developing mental health problems. Selecting a screening tool for use in the clinical setting, as well as developing processes and protocols for screening, is an important step in ensuring safe care. Healthcare providers should routinely screen for perinatal mental health problems, including depression, anxiety, and other mood disorders. A variety of mental health screening tools is available, including the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire 9, which have been validated for use with the perinatal population.3
Screening alone is not effective in addressing maternal outcomes, and appropriate methods for follow-up must be established to ensure that patients receive effective treatment. After a positive screening result, processes should be in place for determining safety and for referring for additional treatment. Healthcare providers should identify and discuss the available treatment options for perinatal mental health concerns, including medication, therapy, and support groups. As part of shared decision making with their providers, patients should be encouraged to choose the treatment that works best for them. Patients with perinatal mental health problems require ongoing follow-up care to ensure that they are receiving the appropriate treatment and support. Follow-up care should be personalized to the patient's needs and may include regular check-ins, medication management, and therapy.
Preventing Patient Safety Adverse Events Related to Perinatal Mental Health
As highlighted by the patient safety bundles and clinical guidelines, developing robust processes for screening and follow-up are important in ensuring that appropriate care is provided to perinatal patients in need. Outlining and enacting processes for follow-up and referral in case of a positive screening can ensure that patients are receiving appropriate treatment and obtaining interventions that could lower the likeliness of an adverse or sentinel event, such as suicide or severe psychosis event.4 Follow-up and treatment may require coordination among various healthcare providers, including obstetricians, primary care physicians, mental health professionals, and social workers. Effective care coordination can help ensure that patients receive the appropriate care and support they need.3
Providing education to the entire care team, including the patient and the patient’s support network (such as a care partner or family member), is a crucial component of ensuring patient safety and can increase awareness. Individuals should receive education on the signs and symptoms of perinatal mental health problems, as well as the potential risks associated with untreated mental health problems during pregnancy and postpartum. Patients should be educated on the importance of seeking help and the available resources and support systems. On the healthcare work side, clinicians and office staff should receive education on how to screen patients appropriately, when to administer screening, and the processes for referring for follow-up.3
Much like other areas of healthcare, communication is a critical aspect of maintaining a safe environment to support care transitions and provide high-quality perinatal mental healthcare. Effective communication among healthcare providers, patients, and family members is essential in ensuring that perinatal patients receive support and are comfortable with discussing mental health changes throughout and after pregnancy. Patients should be encouraged to share their concerns, and healthcare providers should take the time to listen and address any questions or concerns.
Ongoing Challenges in Improving Perinatal Mental Health
Although maternal safety related to perinatal mental health has improved, challenges exist that require additional attention across the healthcare continuum to improve patient safety. Mental health stigma is a prevalent reason why patients may avoid seeking care, as the stigma of receiving treatment for mental health conditions can make it difficult for individuals to seek help or to receive support from family and friends. Perinatal mental health issues may be underreported due to stigma, lack of awareness, availability of services, or a reluctance to seek help. The lack of reporting by new mothers can result in inaccurate prevalence estimates and hinder efforts to provide patients with optimal care. Discussing mental health openly and providing consistent education and encouragement can help address these challenges in providing care.5
Health equity and maternal health is another area of continued concern. Perinatal patients from marginalized racial and ethnic groups, particularly Black and Indigenous women, are at higher risk for perinatal mental health conditions but may face systemic barriers to accessing appropriate care, including lack of insurance, transportation, and culturally responsive care.6 Patients from economically marginalized backgrounds may be at higher risk for perinatal mental health conditions but may also face barriers to accessing care, including a lack of insurance coverage, a lack of access to transportation, and difficulty taking time off work.7 Other factors, such as English proficiency and sexual orientation may lead to struggles to access appropriate perinatal mental healthcare due to a lack of interpreters or culturally competent providers. Continuing to create inclusive care spaces for perinatal patients will help ensure that patients and families are informed and provided safe care.
Last, access and availability of data is a challenge in efforts to improve mental healthcare provided to perinatal patients. From a research standpoint, without a standardized approach to screening and diagnosing perinatal mental health issues, inconsistencies in data collection make it difficult to compare findings across studies. Further, many data sources for measuring morbidity and mortality related to perinatal mental health are obtained from Maternal Mortality Review Committees on the state and local levels. Because these retrospective data are collected to understand maternal mortality and complications from pregnancy, they may have limitations in adequately showing the full context of mental healthcare and treatment. When considering patient management, sharing and reporting data is difficult because maternal care is often provided across settings by a network of providers and that specialist that may not have the same electronic medical record. Improvements in data access and availability would enable providers to identify when screening and follow-up are completed as well as when care is provided for perinatal mental health conditions. As a part of its bundles, the AIM program highlights important data collection resources and measures for tracking improvement to help influence decisions by care teams.
Looking Forward and Research Opportunities
Perinatal mental health and caring for the perinatal patient across care settings will continue to be a priority, but opportunities exist to broaden research related to mental healthcare. While much of the current focus is understandably placed on mothers, concurrent perinatal depression, in which both mother and partner experience depression symptoms, may affect up to 3.18% of couples. This fact highlights the importance of considering the mental health needs of both parents in perinatal healthcare.8 Additional research can improve our understanding of the scope of perinatal mental health conditions and identify whether additional treatment or resources are needed. It is essential to understand how perinatal mood disorders can affect the parental dyad and the infant in the long term to enhance our understanding of the full impact of mental health on both the mother and infant.9
Patient safety considerations for perinatal mental health require a comprehensive approach that includes screening, follow-up care, and a variety of treatment options. By considering education, communication, and care coordination when implementing and providing care, healthcare workers can provide safer care. Healthcare providers can help ensure that patients receive the appropriate care and support they need for optimal mental health during pregnancy and postpartum. Providing appropriate care can reduce the risk of adverse outcomes.
- Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry. 2020;19(3):313-327. doi:10.1002/wps.20769
- Bruce FC, Berg CJ, Hornbrook MC, et al. Maternal morbidity rates in a managed care population. Obstet Gynecol. 2008;111(5):1089-1095. doi:10.1097/AOG.0b013e31816c441a
- Kendig S, Keats JP, Hoffman MC, et al. Consensus bundle on maternal mental health: perinatal depression and anxiety. J Obstet Gynecol Neonatal Nurs. 2017;46(2):272-281. doi:10.1016/j.jogn.2017.01.001
- Chin K, Wendt A, Bennett IM, et al. Suicide and maternal mortality. Curr Psychiatry Rep. 2022;24(4):239-275. doi:10.1007/s11920-022-01334-3
- Meltzer-Brody S. Treating perinatal depression: risks and stigma. Obstet Gynecol. 2014;124(4):653-654. doi:10.1097/AOG.0000000000000498
- Carter EB, EleVATE Women Collaborative, Mazzoni SE. A paradigm shift to address racial inequities in perinatal healthcare. Am J Obstet Gynecol. 2021;224(4):359-361. doi:10.1016/j.ajog.2020.11.040
- Chinn JJ, Martin IK, Redmond N. Health equity among Black women in the United States. J Womens Health (Larchmt). 2021;30(2):212-219. doi:10.1089/jwh.2020.8868
- Smythe KL, Petersen I, Schartau P. Prevalence of perinatal depression and anxiety in both parents: a systematic review and meta-analysis. JAMA Netw Open. 2022;5(6):e2218969. doi:10.1001/jamanetworkopen.2022.18969
- Glazer KB, Zeitlin J, Howell EA. Intertwined disparities: applying the maternal-infant dyad lens to advance perinatal health equity. Semin Perinatol. 2021;45(4):151410. doi:10.1016/j.semperi.2021.151410