- A new study reveals 1 in 5 birthing individuals experience maternal mental health (MMH) conditions.
- MMH conditions extend beyond depression to anxiety, OCD, psychosis, substance abuse, and bipolar disorder.
- MMH State Report Cards provide a comprehensive view of maternal mental health in the U.S.
- MMH is the responsibility of policymakers, healthcare providers, hospitals, insurers, and communities.
The journey of motherhood is often romanticized, but beneath the surface lies a complex landscape of challenges that can significantly impact a woman’s mental health.
Up to 20 percent of pregnant individuals and new mothers are affected by maternal mental health (MMH) conditions, including anxiety, depression, and obsessive-compulsive disorder (1).
Approximately 75 percent of MMH conditions experienced by birthing individuals go untreated (2). Recently, the Policy Center for Maternal Mental Health provided the first-ever comprehensive view into the state of maternal mental health in the U.S.
With only one state receiving the highest grade, a B-, and dozens receiving Ds and Fs, the U.S. is facing a crisis in maternal mental health.
Moreover, when we critically examine the disproportionate burden borne by birthing individuals due to systemic factors such as race and disability, we further see the necessity of targeted interventions. Stigma, systemic forces, and uneven progress across states underscore the urgency for collaborative efforts toward comprehensive maternal mental health care, ensuring the well-being of mothers and families across the United States.
A Complex Landscape
The PPD (postpartum depression) questionnaire is a common one for new birthing individuals, who see this survey at the pediatrician’s office and/or the ob-gyn. The Edinburgh Postnatal Depression Scale 1 (EPDS) asks the individual to respond to questions about their experience in the past week with statements including: “I have been able to laugh and see the funny side of things;” “I have been anxious or worried for no good reason;” and “I have been so unhappy that I have been crying.”
According to the Maternal Mental Health Leadership Alliance (MMHLA), however, maternal mental health conditions can range beyond depression, encompassing a range of conditions including postpartum anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, substance use disorders, bipolar disorder, and postpartum psychosis (3).
Research suggests that mothers may be more at risk of experiencing mental health concerns if they lack social support, especially from their partner or family; experienced a traumatic birth or previous trauma in their lives; have a personal existing mental health concern; or have a baby in the neonatal intensive care unit (4).
Postpartum refers to one year from a child’s birth. According to a 2013 study of birthing individuals who experienced postpartum anxiety or depression, 40 percent developed symptoms following childbirth, 33 percent developed symptoms during pregnancy, and 27 percent entered pregnancy with anxiety or depression (5). Research suggests that women with untreated MMH conditions are more likely to:
- not manage their own health
- experience physical, emotional, or sexual abuse
- question their competence as mothers
- experience breastfeeding challenges
- be less responsive to a baby’s cues (6)
Uneven Progress
The inaugural Maternal Mental Health Report Card provides the first-ever comprehensive view into the state of maternal mental health in the U.S. The 2023 State Report Cards serve as an evaluation of each state’s policies and initiatives concerning maternal mental health care, shedding light on the progress made and the challenges that persist.
The main objective of the State Report Cards is to assess the accessibility and quality of maternal mental health care services provided by each state. The report card grades states in three domains:
- Providers and Programs
- Screening and Screening Reimbursement
- Insurance Coverage and Payment
Up to three points are provided for each of the 17 measures within these domains. Readers can find more about the Policy Center’s methodology and assessment here.
The evaluations reveal a diverse landscape across the nation. While some states have made commendable strides in addressing maternal mental health issues by implementing comprehensive policies and frameworks, others continue to lag behind.
California scored, for example, the highest with a B-, broken down more specifically as:
- Providers and Programs, score C
- Screening and Screening Reimbursement, score C
- Insurance Coverage and Treatment Payment, score B
Pennsylvania, from where I write, scored, overall, a C with that further broken down as:
- Providers and Programs, score D
- Screening and Screening Reimbursement, score D
- Insurance Coverage and Treatment Payment, score C
Forty states, along with Washington D.C., scored an overall D or F.
The Center highlights what is at the root of this failure:
- States do not have enough therapists and psychiatrists with specialties in MMH disorders
- States lack MMH treatment programs and community-based MMH resources
- States do not require providers to screen for MMH disorders
- States do not hold health plans to quality standards regarding MMH services
The report cards provide a clear picture of the gaps in maternal mental health care services and the need for a more uniform and equitable approach to maternal mental health care.
The Effects of Stigma, Silence, and Systemic Disadvantage
A pervasive challenge that impedes overall progress in maternal mental health is the stigma attached to mental health issues in general. The Maternal Mental Health Leadership Alliance (MMHLA) emphasizes that the stigma surrounding mental health often prevents women from seeking help, leading to underdiagnosis and untreated conditions. This silence can perpetuate the cycle of suffering and prevent women from accessing the support they desperately need during a vulnerable phase of their lives.
More specifically, one of the striking revelations is the disproportionate impact of maternal mental health issues on Black women and birthing individuals. Research by the MMHLA highlights startling facts:
- almost 50 percent of Black mothers will experience MMH conditions
- Black women are twice as likely as white women to experience MMH conditions but half as likely to get care
- single Black mothers are six times more likely than the general population to experience depressive symptoms (7).
Black women face a higher risk of maternal mental health disorders due to systemic factors like racial discrimination, socioeconomic disparities, medical insurance gaps, and inadequate access to quality healthcare. Their experiences of depression may differ from stereotypical symptoms of depression—often involving irritability and somatic symptoms, instead of hopelessness or depressed mood–—and a lack of attention to this difference of manifestation can cause the depression to go overlooked or mistreated. The Superwoman Schema, which involves cultural expectations of strength, compounds stress.
Removing barriers requires culturally competent care, diverse care teams, improved screening, and dismantling systemic racism.
Women with disabilities also face heightened risks of MMH conditions, being twice as likely as women without disabilities. Inadequate healthcare access during pregnancy increases pregnancy complications and exacerbates MMH concerns.
Socioeconomic disparities, coupled with misconceptions and limited awareness among healthcare professionals, contribute to these challenges. Negative stereotypes, misconceptions, and lack of disability-specific knowledge affect care quality.
Non-medically necessary C-sections, inaccessible screening tools, and fear of child protective services further strain their experiences. Tailored strategies, including cultural humility training for clinicians, accessible spaces, and specialized screening tools, are essential for improving perinatal care and addressing MMH conditions among women with disabilities (8).
While the Policy Center for MMH evaluated states based on their support for birthing individuals’ MMH conditions, 2021 research conducted by the MMHLA encourages us to not leave out fathers and non-birthing spouses.
The MMHLA states that approximately 10 percent of fathers will experience postpartum depression, with a peak most commonly observed between 3 to 6 months after childbirth. For fathers, this may manifest as elevated levels of irritability and anger, reduced affection, and increased criticism, both towards and from their partner.
Risk factors can include a lack of social support and networks, a lack of good role models, feeling excluded from infant bonding, the stress of having a new baby in the household, and the presence of a partner’s MMH (9). Recognizing and addressing the mental health challenges faced by fathers and non-birthing partners during the postpartum period is essential for fostering healthy family dynamics and ensuring the well-being of both parents as they embark on the journey of parenthood.
Conclusion
Maternal mental health remains urgent in the U.S., shaped by intertwined factors of race, socioeconomic status, disability, and stigma. To achieve comprehensive care, a collective push from federal and state policymakers, healthcare providers, hospitals, insurers, and communities is vital. Tackling systemic disparities, offering accessible aid, and promoting mental health discourse will propel the nation toward safeguarding mothers and families.
If you are U.S.-based, check out how your current state is doing here: 2023 U.S. Maternal Mental Health State Report Cards.