“I look at my baby and I don’t feel a thing,” the patient whispers as she cradles her 3-week-old baby. “I feel so much guilt … sometimes I don’t want to be here at all.” And yet, she is not alone. Her words echo the silent yet growing public health crisis of perinatal mental health.
Approximately 1 in 5 women are affected by mental health conditions during the perinatal period. According to the Centers for Disease Control, perinatal mental health conditions are now the leading cause of maternal mortality in the U.S., accounting for 23 percent of pregnancy-related deaths. Specific causes of death from mental health conditions include suicide and overdose/poisoning related to substance use disorder. Furthermore, perinatal mental health conditions not only impact maternal morbidity and mortality, but also infant outcomes through lower rates of breastfeeding initiation, impaired maternal-infant bonding, and higher risk of developmental delay.
Despite the well-established burden of perinatal mental health, significant barriers persist in access to care, screening, and management of these conditions. Despite the 2021 Medicaid expansion of postpartum coverage to 12 months, gaps in mental health access persist and vary by state. In a nationally representative study of pregnant individuals, nearly 65 percent of those with a major depressive episode did not receive a diagnosis and half did not receive treatment. Common barriers to receiving treatment included cost, personal reluctance, and stigmatization of mental health conditions. Furthermore, the Policy Center for Maternal Mental Health found that 84 percent of the perinatal population reside in areas with shortages of mental health providers, emphasizing the inequitable distribution of mental health resources in our country.
The American College of Obstetricians and Gynecologists (ACOG) recommends screening for depression and anxiety at least once during the perinatal period. Despite guidelines, screening remains inconsistent across clinical settings, contributing to delayed diagnosis and lack of appropriate management of perinatal mental health conditions. According to data from the Pregnancy Risk Assessment Monitoring System (PRAMS), 1 in 5 women denied being asked about depression during prenatal visits and 1 in 8 denied being asked during postpartum visits. Another study of obstetricians and primary care providers identified uncertainty in addressing perinatal mental health conditions, as well as significant variance in symptom recognition. This gap may be explained by the lack of formal training in perinatal mental health among providers, as the Accreditation Council for Graduate Medical Education (ACGME) currently does not mandate dedicated mental health training for Obstetrics and Gynecology (OB/GYN) residency programs.
Addressing this public health crisis demands systemic reform. First, screening for perinatal mental health conditions should be universal and consistent across providers. Additionally, coordinated and multi-disciplinary care between obstetricians, primary care providers, and behavioral health specialists should begin at the hospital bedside and extend throughout the postpartum period. Moreover, the Accreditation Council for Graduate Medical Education (ACGME) should require dedicated mental health training for OB/GYN residents to ensure they are equipped to identify, treat, and support patients. Telehealth services should also be distributed to limited resource areas to foster equitable access to mental health care. Finally, we must decrease stigma surrounding perinatal mental health conditions through education and compassionate, patient-centered care.
We can no longer overlook the fact that mental health conditions are the leading cause of maternal mortality in the U.S. This alarming reality demands a shift in our perception of and approach to mental health during and after pregnancy. Mental health should be considered a core component of the care we provide to pregnant and postpartum individuals. We must call on the health systems, policymakers, and the ACGME to take urgent action and create a reality where no mother’s life is lost to a treatable perinatal mental health condition.
Sheila Lytle is a medical student.
