Consensus Bundle on Maternal Mental Health: Perinatal Depression and Anxiety

Increasing Access To Perinatal Mental Health Care: The Perinatal Psychiatry Access Program Model

Perinatal psychiatry access programs offer a scalable approach to building the capacity of perinatal professionals to identify, assess, and treat mental health conditions. Little is known about access programs' implementation and the relative merits of differing approaches. We conducted surveys and semistructured interviews with access program staff and reviewed policy and procedure documents from the fifteen access programs that had been implemented in the United States as of March 2021, when the study was conducted. Since then, the number of access programs has grown to thirty state, regional, or national programs. Access programs implemented up to five program components, including telephone consultation with a perinatal psychiatry expert, one-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, trainings for perinatal professionals, and practice-level technical assistance. Characterizing population-based intervention models, such as perinatal psychiatry access programs, that address perinatal mental health conditions is a needed step toward evaluating and improving programs' implementation, reach, and effectiveness.

Scoping Review of Racial and Ethnic Representation of Participants in Mental Health Research Conducted in the Perinatal Period During the COVID-19 Pandemic

OBJECTIVE

To identify the racial and ethnic representation of participants in mental health research conducted in the perinatal period during the COVID-19 pandemic.

DATA SOURCES

MEDLINE, CINAHL, Cochrane Library, PsycINFO, Scopus, Web of Science.

STUDY SELECTION

We included peer-reviewed research articles in which researchers reported mental health outcomes of women during the perinatal period who were living in the United States or Canada during the COVID-19 pandemic. We included 25 articles in the final review.

DATA EXTRACTION

We extracted the citation, publication date, design, aim, country of origin, participant characteristics, sampling method, method of measurement of race and ethnicity, and mental health outcome(s).

DATA SYNTHESIS

The combined racial and ethnic representation of the 16,841 participants in the included studies was White (76.5%), Black (9.8%), other/multiracial (6.2%), Asian (3.9%), Hispanic/Latina (2.6%), Indigenous or Ethnic Minority Canadian (0.9%), and Native American or Alaska Native (0.1%). Most studies were conducted in the United States, used a cross-sectional design, and incorporated social media platforms to recruit participants. Depression, anxiety, and stress were the most frequently assessed mental health outcomes.

CONCLUSION

Relatively few women of color who were pregnant or in the postpartum period during the pandemic participated in mental health research studies. Future studies should develop intentional recruitment strategies to increase participation of women of color. Researchers should use updated guidance on reporting race and ethnicity to accurately represent every participant, minimize misclassification of women of color, and report meaningful results.

Prevalence and associated factors of perinatal depression among working pregnant women: a hospital-based cross-sectional study

Perinatal depression is a major public health problem having serious negative impacts on personal, family, and child developmental outcomes. This study aimed to determine the prevalence of major depressive disorder (MDD) and its associated factors in working pregnant women. This descriptive, cross-sectional study was performed on 389 working pregnant women enrolled from four Tunisian public maternity hospitals. Data collection tools were the sociodemographic, obstetric, family relationships, and work environment questionnaire, and the Center for Epidemiologic Studies Depression Scale (CES-D). The mean score of depression was 27.39 ± 6.97 and 76.1% of women had major depressive symptoms using cutoff points on the CES-D ≥ 23. Family income, diagnosis with a chronic illness, history of depression, and employment categories were associated with major depressive symptoms. In multivariate analyses, family income and work posture were significantly associated with MDD. These results suggest an increased burden of MDD during pregnancy in Tunisian women. Prevention, early detection, and interventions are needed to reduce the prevalence of perinatal depression.

Perspectives on addressing bipolar disorder in the obstetric setting

OBJECTIVE

Perinatal Psychiatry Access Programs have emerged to help obstetric professionals meet the needs of perinatal individuals with mental health conditions, including bipolar disorder (BD). We elucidate obstetric professionals' perspectives on barriers and facilitators to managing BD in perinatal patients, and how Access Programs may affect these processes.

METHODS

We conducted three focus groups with obstetric professionals, two with- and one without-exposure to an Access Program, the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms. Focus groups discussed experiences, barriers, facilitators, and solutions to caring for perinatal individuals with BD. Qualitative data were coded and analyzed by two independent coders; emergent themes were examined across exposure groups.

RESULTS

Thirty-one obstetric professionals (7 without-exposure, 24 with-exposure) participated. Identified themes included: (1) gaps in perinatal BD education; (2) challenges in patient assessment; (3) MCPAP for Moms as a facilitator for addressing BD; and (4) importance of continued outreach and destigmaization to increase care collaboration.

CONCLUSIONS

Barriers to obstetric professionals accessing adequate mental healthcare for their patients with BD abound. With psychiatric supports in place, it is possible to build obstetric professionals' capacity to address BD. Perinatal Psychiatry Access Programs can facilitate obstetric professionals bridging these gaps in mental health care.

Adaptation of the Edinburgh Postnatal Depression Scale in the Indonesian Version: Self-reported Anxiety and Depression Symptoms in Pregnant WomenAdaptation of the Edinburgh Postnatal Depression Scale in the Indonesian Version: Self-reported Anxiety and Depression Symptoms in Pregnant Women

BACKGROUND: Anxiety and depression disorders in pregnant women are often not identified so that early treatment is not optimal. Indonesia already has comprehensive integrated antenatal care, including services for pregnant women with mental disorders, but until now Indonesia does not yet have a standardized instrument that is valid and suitable as a screening tool to assess symptoms of anxiety and depression in pregnant women. The Edinburgh Postnatal Depression Scale (EPDS) is a screening instrument with high sensitivity and specificity, has been translated into Indonesian, but until now, the Indonesian version of the EPDS instrument has not been evaluated for validity and reliability in the population of pregnant women. AIM: this study aimed to adapt the Indonesian version of the EPDS instrument, including testing the validity and reliability of the instrument when used on pregnant women in Indonesia. METHODS: This research is a cross sectional study. The number of pregnant women who participated were 125 samples. Data were collected randomly, and the assessment of symptoms of anxiety and depression was self-reported via online. Content validity was assessed with a content validity index from 5 experts, construct validation was analyzed by Explanatory Factor Analysis and Confirmatory Factor Analysis and Convergent Validity. The reliability of the EPDS instrument was assessed by construct reliability and Cronbach's Alpha. RESULTS: Content validity index shows expert agreement with a value of .98. The Indonesian version of the EPDS shows assessing three factors, namely: Depression (5 items), Anxiety (3 items), and Anhedonia (2 items). The reliability of the Indonesian version of the EPDS instrument is good with Cronbach's Alpha .80 and the internal reliability of the 10 items (Cronbach's Alpha .767-.812). CONCLUSION: The Indonesian version of the EPDS instrument is valid and reliable to be used to assess symptoms of anxiety and depression in pregnant women in antenatal care in Indonesia.   Keywords: pregnant women, EPDS, validity, reliability

Building Obstetric Provider Capacity to Address Perinatal Depression Through Online Training

Background: Perinatal depression is common, underdiagnosed, and undertreated. Obstetric providers often do not receive training in perinatal depression, despite being the frontline providers for perinatal individuals. The objective of this study was to develop and pilot test an online training module to assess feasibility, efficacy, and acceptance in improving obstetric providers' knowledge, skills, and practices regarding perinatal depression. Materials and Methods: We designed, developed, and implemented an online, asynchronous, interactive educational module that trains obstetric providers to: (1) know the prevalence and impact of perinatal depression; (2) use validated tools for depression screening; (3) assess for depression; and (4) start and/or refer for treatment. Formative evaluation with five providers, iterative module and question refinement, and a pilot test with pre- and post-test knowledge and self-efficacy questions were conducted. Results: Sixteen obstetric providers averaged a 32% improvement in their pre- to post-test scores (p < 0.01). The average pretest score was 49% (range 20%-70%), and the average post-test score was 81% (range 70%-95%). Provider beliefs (p = 0.01), self-efficacy (p < 0.01), and confidence (p < 0.01) in treating perinatal depression were also significantly increased between pre- and post-test. Average Likert scores on overall training satisfaction were very high post-training completion (4.44 out of 5, with 5 being most positive). Conclusions: The module was feasible and effective at improving provider knowledge of perinatal depression, self-rated confidence, and self-efficacy. Improving the knowledge and skills of obstetric providers regarding depression is a critical part of any intervention aimed to close gaps in care and help ensure that patients receive optimal treatment.

Development of the Practice Readiness to Evaluate and address Perinatal Depression (PREPD) assessment

OBJECTIVE

Perinatal depression is a common pregnancy complication and universal screening is recommended. The Practice Readiness to Evaluate and address Perinatal Depression (PREPD) was developed to measure obstetric practice readiness to integrate depression care into workflows. Objectives were to describe: (1) the PREPD; (2) associated characteristics by readiness level; and (3) use of the assessment to measure change.

METHOD

The PREPD has four components, each scored to a 16-point maximum: (1) Environmental Scan (10% of PREPD); (2) Depression Detection, Assessment, and Treatment Questionnaire (30%); (3) Depression-related Policies Questionnaire (10%); and (4) Chart Abstraction (50%). Components were weighted and summed for an overall score. Summary and component scores were calculated by patient, practice, and provider.

RESULTS

Average overall PREPD score was 7.3/16 (range: 4.8-9.9); scores varied between practices. The Environmental Scan averaged 2.0/16 (range: 0-5.2); Detection, Assessment, and Treatment averaged 8.3/16 (range: 3.0-11.5); Chart Abstraction averaged 7.2/16 (range: 5.1-9.6); and Depression-related Policies averaged 10.4/16 (range: 7.5-15).

CONCLUSION

We found wide variation in obstetric practices' readiness to implement interventions for depression; most were minimally prepared. These data may be used to tailor practice intervention goals and as benchmarks with which to measure changes in integration of depression care over time.

Is There an Association Between Oxytocin Levels in Plasma and Pregnant Women's Mental Health?

BACKGROUND: Mood and anxiety disorders are prevalent in women during peripartum. AIMS: Purpose of the present article was to study the relationship between oxytocin (OT) plasma levels and affective symptoms in women during the third trimester of pregnancy. METHODS: Thirty-four pregnant women (13 with an affective disorder, 9 with preeclampsia, and 12 controls) were evaluated through the Edinburgh Postnatal Depression Scale (EPDS), the State/Trait Anxiety Inventory Form Y (STAI-Y), and the Prenatal Attachment Inventory (PAI). A blood sample was collected from all participants, and OT plasma levels have been compared between diagnostic groups. The total sample has been divided into two groups, according to OT median plasma levels, and compared using (a) χ² tests for qualitative variables and (b) a multivariate analysis of covariance for quantitative ones. RESULTS: No statistically significant difference was found among the diagnostic groups in terms of OT plasma levels (F = 0.49, p = .62). Women with lower OT plasma levels, independent from the presence of preeclampsia or an affective disorder, showed worse EPDS and STAI-S total scores than individuals with higher hormone levels (F = 5.93, p = .02 and F = 7.57, p = .01, respectively). CONCLUSIONS: OT may play a role in the etiology of anxious/depressive symptoms during perinatal period independent from a medical or psychiatric diagnosis. This result has a clear effect on the quality of the relationship of patients with mental health professionals, including nurses, and higher levels of this hormone, in the light of its anxiolytic and antidepressive effect, may make easier medical and nursing procedures.

Feasibility, Acceptability, and Preliminary Effects of "Mindful Moms": A Mindful Physical Activity Intervention for Pregnant Women with Depression

BACKGROUND

Nonpharmacological and accessible therapies that engage individuals in self-management are needed to address depressive symptoms in pregnancy. The 12-week "Mindful Moms" intervention was designed to empower pregnant women with depressive symptomatology to create personal goals and engage in mindful physical activity using prenatal yoga.

OBJECTIVES

This longitudinal pilot study evaluated the feasibility, acceptability, and preliminary effects of the "Mindful Moms" intervention in pregnant women with depressive symptoms.

METHODS

We evaluated enrollment and retention data (feasibility) and conducted semistructured interviews (acceptability). We evaluated the intervention's effects over time on participants' depressive symptoms, anxiety, perceived stress, self-efficacy, and maternal-child attachment, and we compared findings to an archival comparison group, also assessed longitudinally.

RESULTS

Enrollment and retention rates and positive feedback from participants support the intervention's acceptability and feasibility. "Mindful Moms" participants experienced decreases in depressive symptoms, perceived stress, anxiety, ruminations, and maternal-child attachment and no change in physical activity self-efficacy from baseline to postintervention. Comparisons of the "Mindful Moms" intervention to the comparison groups over time indicated differences in depressive symptoms between all groups and a trend in differences in perceived stress.

DISCUSSION

Results support the feasibility and acceptability of "Mindful Moms" for pregnant women with depressive symptoms and suggest that further research is warranted to evaluate this intervention for reducing depressive and related symptoms. Lack of a concurrent control group, with equivalent attention from study staff, and no randomization limit the generalizability of this study; yet, these preliminary findings support future large-scale randomized controlled trials to further evaluate this promising intervention.

Women's Experiences of the Effect of Financial Strain on Parenting and Mental Health

OBJECTIVE

To develop a conceptual theory to describe how financial strain affects women with young children to inform clinical care and research.

DESIGN

Qualitative, grounded theory.

SETTING

Participants were recruited from the waiting area of a pediatric clinic and an office of the Special Supplemental Nutrition Program for Women, Infants, and Children embedded within the largest safety-net academic medical center in New England. Participants were interviewed privately at the medical center or in the community.

PARTICIPANTS

Twenty-six English-speaking women, mostly single and African American/Black, with at least one child 5 years old or younger, were sampled until thematic saturation was met.

METHODS

We used grounded theory methodology to conduct in-depth, semistructured interviews with participants who indicated that they experienced financial strain. We analyzed the interview data using constant comparative analysis, revised the interview guide based on emerging themes, and developed a theoretical model.

RESULTS

Five interrelated themes emerged and were developed into a theoretical model: Financial Strain Has Specific Characteristics and Common Triggers, Financial Strain Is Exacerbated by Inadequate Assistance and Results in Tradeoffs, Financial Strain Forces Parenting Modifications, Women Experience Self-Blame, and Women Experience Mental Health Effects.

CONCLUSION

For women with young children, financial strain results in forced tradeoffs, compromised parenting practices, and self-blame, which contribute to significant mental health problems. These findings can inform woman-centered clinical practice and advocacy interventions. Women's health care providers should identify families experiencing financial strain, provide referrals to financial services, and join advocacy efforts to advance social policies that address the structural causes of poverty, such as increased minimum wage and paid family leave.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Care for Women With Opioid Use Disorder

The opioid epidemic is a public health crisis, and pregnancy-associated morbidity and mortality due to substance use highlights the need to prioritize substance use as a major patient safety issue. To assist health care providers with this process and mitigate the effect of substance use on maternal and fetal safety, the National Partnership for Maternal Safety within the Council on Patient Safety in Women's Health Care has created a patient safety bundle to reduce adverse maternal and neonatal health outcomes associated with substance use. The Consensus Bundle on Obstetric Care for Women with Opioid Use Disorder provides a series of evidence-based recommendations to standardize and improve the quality of health care services for pregnant and postpartum women with opioid use disorder, which should be implemented in every maternity care setting. A series of implementation resources have been created to help providers, hospitals, and health systems translate guidelines into clinical practice, and multiple state-level Perinatal Quality Collaboratives are developing quality improvement initiatives to facilitate the bundle-adoption process. Structure, process, and outcome metrics have also been developed to monitor the adoption of evidence-based practices and ensure consistency in clinical care.

Utilization of Health Care Among Perinatal Women in the United States: The Role of Depression

Background: Individuals with depression have increased nonpsychiatric health care utilization. Associations between depression and utilization have not been studied in perinatal women, despite their heightened depression risk. We examined patterns of nonpsychiatric health care utilization by symptoms of perinatal depression, expecting more frequent use of acute services while being less likely to have routine medical care. Materials and Methods: We identified 1,103 perinatal participants from the 2005 to 2016 National Health and Nutrition Examination Surveys. The Patient Health Questionnaire was used to identify depression (score ≥10). We evaluated associations between perinatal depressive symptoms and health care utilization using logistic models and relative excess risk due to interaction (RERI) using adjusted models with appropriate weighting to provide national estimates. Results: Among perinatal U.S. women, 7.3% had depressive symptoms. Relative to those without these symptoms, women experiencing depressive symptoms were younger, more impoverished, and uninsured (p < 0.05). Women with depressive symptoms, compared with those without them, had twice the odds of being without routine medical care (21.6% vs. 12.5%, adjusted odds ratio [aOR]: 2.1, 95% confidence interval [CI]: 1.1 to 4.1) and of using urgent care more frequently (26.5% vs. 15.1%, aOR: 1.9, 95% CI: 1.0 to 3.9). Depressive symptoms combined with lack of insurance generally increased the odds of not having routine care (RERI: 8.4, 95% CI: -0.5 to 17.3) and more frequent use of urgent care (RERI: 7.1, 95% CI: -2.7 to 17.0). Conclusions: Perinatal depression is a prevalent, high-risk illness that requires more nonpsychiatric services and increased psychiatric care. Approaches that facilitate establishing a place for routine care and decreasing acute care use are necessary.

The role and competence of midwives in supporting women with mental health concerns during the perinatal period: A scoping review

Perinatal mental health problems are linked to poor outcomes for mothers, babies and families. Despite a recognition of the significance of this issue, women often do not receive the care they need and fall between the gap of maternity and mental health services. To address this, there is a call for reform in the way in which perinatal mental healthcare is delivered. This paper responds to this by exploring the role and competence of midwives in delivering mental healthcare. Using a scoping review methodology, quantitative and qualitative evidence were considered to answer the research question 'what is the nature of the evidence relevant to the provision of mental health interventions by midwives?' To identify studies, the databases PubMed, Maternity and Infant Care, Science Citation Index, Social Sciences Citation Index, Medline, Science Direct and CINAHL were searched from 2011 to 2018, and reference lists of included studies were examined. Studies relevant to the role of midwives in the management and treatment of perinatal mental health issues were included; studies focussed on screening and referral were excluded. Thirty papers met inclusion criteria, including studies about the knowledge, skills, and attitudes of midwives and student midwives; the effectiveness of educational interventions in improving knowledge and skills; the delivery of counselling or psychosocial interventions by midwives; and barriers and enablers to embedding midwife-led mental healthcare in practice. Synthesis of the included studies indicates that midwives are interested in providing mental health support, but lack the confidence, knowledge and training to do so. This deficit can be addressed with appropriate training and organisational support, and there is some evidence that midwife-led counselling interventions are effective. Further research is needed to test midwife-led interventions for women with perinatal mental health problems , and to develop and evaluate models of integrated perinatal mental healthcare.

Implementation of a Perinatal Depression Care Bundle in a Nurse-Managed Midwifery Practice

OBJECTIVE

To implement a perinatal depression care bundle at a midwifery practice to help certified nurse-midwives (CNMs) educate women about perinatal depression and direct those affected to mental health services.

DESIGN

Quality improvement project to implement a perinatal depression care bundle for care of pregnant women between 24 and 29 weeks gestation.

SETTING/LOCAL PROBLEM

CNMs practicing in a nurse-managed midwifery practice systematically screen all women for perinatal depression during pregnancy and the postpartum period but do not have a consistent method of providing anticipatory guidance about perinatal depression.

PARTICIPANTS

All CNMs in the midwifery practice providing prenatal care (n = 16) participated in implementation.

INTERVENTION/MEASUREMENTS

The perinatal depression care bundle included three elements: (a) an educational handout; (b) a brief, provider-initiated discussion about perinatal depression; and (c) lists of local and online mental health resources. Four weeks after the care bundle was implemented, we conducted a retrospective chart review to assess CNMs' adherence to the new bundle.

RESULTS

Over 4 weeks, 51 prenatal visits met eligibility criteria for participation. CNMs implemented the perinatal depression care bundle for 22 (43.1%) eligible visits. CNM feedback indicated that the care bundle was brief, easy to incorporate into routine care, and well received by women.

CONCLUSION

This project incorporated the use of a perinatal depression care bundle for women seen during routine prenatal care. Using a systematic approach to deliver perinatal depression education and resources reduces process variability and may destigmatize the illness, allowing women to feel empowered to seek help before depression symptoms become severe.

A Systematic Review of Integrated Care Interventions Addressing Perinatal Depression Care in Ambulatory Obstetric Care Settings

This systematic review searched 4 databases (PubMed/MEDLINE, Scopus, CINAHL, and PsychINFO) and identified 21 articles eligible to evaluate the extent to which interventions that integrate depression care into outpatient obstetric practice are feasible, effective, acceptable, and sustainable. Despite limitations among the available studies including marked heterogeneity, there is evidence supporting feasibility, effectiveness, and acceptability. In general, this is an emerging field with promise that requires additional research. Critical to its real-world success will be consideration for practice workflow and logistics, and sustainability through novel reimbursement mechanisms.

A Project to Improve Postpartum Depression Screening Practices Among Providers in a Community Women's Health Care Clinic

OBJECTIVE

The purpose of this project was to improve health care providers' postpartum depression (PPD) knowledge and screening practices with the implementation of a standardized screening tool.

DESIGN

The plan-do-study-act model was used as a framework to measure and implement a practice change aimed at universal screening for PPD.

SETTING/LOCAL PROBLEM

Health care providers' screening practices for PPD were inconsistent and lacked use of a standardized screening tool at a southwestern U.S. community women's health care clinic serving minority women of lower socioeconomic status.

PARTICIPANTS

Health care providers at a community women's health care clinic.

INTERVENTION/MEASUREMENTS

A single educational in-service was presented to health care providers regarding preventive PPD screening practices and documentation recommendations. Measurements included pre- and post-education questionnaire results and electronic health record chart reviews.

RESULTS

PPD screening documentation rates increased from 56% to 92.7% (p < .5).

CONCLUSION

PPD screening education for health care providers and the addition of EPDS criteria to the electronic health record were associated with increased screening rates for PPD at a community women's health care clinic.

Positive screening rates for bipolar disorder in pregnant and postpartum women and associated risk factors

OBJECTIVE

Bipolar disorder affects 2-8% of pregnant and postpartum women; untreated illness is associated with poor outcomes. This study aimed to describe bipolar disorder screening rates in obstetric settings and associated characteristics.

METHOD

Women were recruited during pregnancy through three months postpartum from 14 obstetric clinics in Massachusetts. The Mood Disorder Questionnaire (MDQ) was used to screen for bipolar disorder; a subset previously diagnosed with bipolar was also examined. Differences in characteristics by screening outcome were tested using chi-square and t-tests.

RESULTS

Of 574 participating women, 18.8% screened positive for bipolar disorder. Compared to those with negative, those with positive bipolar screens had 18.5-times the prevalence of positive substance use screens (11.1% vs. 0.6%, p < 0.001) and 3.4-times reported feeling they were not receiving adequate psychiatric help (24.0 vs. 7.0%, p < 0.001). Less than half of those with positive bipolar screens (42.0%) and 61.3% with pre-existing bipolar reported receiving current psychiatric care.

CONCLUSIONS

Almost one in five perinatal women screened positive for bipolar disorder. Positive screenings were associated with comorbid substance use and low treatment rates. This study highlights the importance of screening for bipolar disorder during the perinatal period and the need for systematic approaches to ensure adequate assessment and follow-up.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov identifier: NCT02760004.

Is There a Relationship Between Gestational Diabetes and Perinatal Depression?

Perinatal depression (PND) is one of the leading complications associated with childbirth. Early detection and treatment of depression, particularly during the perinatal period, is essential for the promotion of positive maternal-child outcomes. Gestational diabetes mellitus (GDM) has been suggested as a confounding factor associated with PND. Concerns associated with PND include interference with maternal-newborn bonding and long-term effects of neurobehavioral consequences. An exemplar case describing one woman's experience with GDM and her subsequent complications associated with PND is presented to discuss maternal depression and its plausible association with GDM. Recommendations include universal screening with the validated Edinburgh Postnatal Depression Scale screening tool during the early perinatal period to reduce incidence of maternal-newborn complications associated with PND and promote underpinnings for best practice.

Integrated perinatal mental health care: a national model of perinatal primary care in vulnerable populations

INTRODUCTION

Perinatal mood and anxiety disorders (PMADs) are the most common complication of pregnancy and have been found to have long-term implications for both mother and child. In vulnerable patient populations such as those served at Denver Health, a federally qualified health center the prevalence of PMADs is nearly double the nationally reported rate of 15-20%. Nearly 17% of women will be diagnosed with major depression at some point in their lives and those numbers are twice as high in women who live in poverty. Women also appear to be at higher risk for depression in the child-bearing years. In order to better address these issues, an Integrated Perinatal Mental Health program was created to screen, assess, and treat PMADs in alignment with national recommendations to improve maternal-child health and wellness. This program was built upon a national model of Integrated Behavioral Health already in place at Denver Health.

METHODS

A multidisciplinary team of physicians, behavioral health providers, public health, and administrators was assembled at Denver Health, an integrated hospital and community health care system that serves as the safety net hospital to the city and county of Denver, CO. This team was brought together to create a universal screen-to-treat process for PMAD's in perinatal clinics and to adapt the existing Integrated Behavioral Health (IBH) model into a program better suited to the health system's obstetric population. Universal prenatal and postnatal depression screening was implemented at the obstetric intake visit, a third trimester prenatal care visit, and at the postpartum visit across the clinical system. At the same time, IBH services were implemented across our health system's perinatal care system in a stepwise fashion. This included our women's care clinics as well as the family medicine and pediatric clinics. These efforts occurred in tandem to support all patients and staff enabling a specially trained behavioral health provider (psychologists and L.C.S.W.'s) to respond immediately to any positive screen during or after pregnancy.

RESULTS

In August 2014 behavioral health providers were integrated into the women's care clinics. In January 2015 universal screening for PMADs was implemented throughout the perinatal care system. Screening has improved from 0% of women screened at the obstetric care intake visit in August 2014 to >75% of women screened in August 2016. IBH coverage by a licensed psychologist or licensed clinical social worker exists in 100% of perinatal clinics as of January 2016. As well, in order to gain sustainability, the ability to bill same day visits as well as to bill, and be reimbursed for screening and assessment visits, continues to improve and provide for a model that is self-sustaining for the future.

CONCLUSION

Implementation of a universal screening process for PMADs alongside the development of an IBH model in perinatal care has led to the creation of a program that is feasible and has the capacity to serve as a national model for improving perinatal mental health in vulnerable populations.