Maternal depression, which includes depression before, during and after pregnancy, can have serious consequences for mothers and their children, especially infants and toddlers. Risks include preterm birth, low birth weight and cognitive and developmental delays. Postpartum depression is linked to hormonal and chemical changes in the mother’s body after giving birth and can be exacerbated by a number of factors, including economic stressors and lack access to treatment and services.
The negative effects of maternal depression on mother and child are well researched and clear. Scientific research confirms that infants need engaged, attentive and nurturing caregivers to thrive, and when mothers are unable to engage in a loving and nurturing way, their children’s health and development suffer.
Science clearly points to the need for early identification and treatment of maternal depression. While racial or ethnic minorities are less likely to be depressed, those who are depressed experience worse health outcomes and are less likely to receive care and treatment.
This brief provides an overview of maternal depression, its effects on mothers and infants, and state legislative options to address the issue.
Antepartum Depression: Depression During Pregnancy
While postpartum depression receives the lion’s share of public attention, depression during pregnancy, clinically known as antepartum depression, remains an issue for many women. Fourteen to 23 percent of women suffer from some type of depression during pregnancy, according to the American Congress of Obstetricians and Gynecologists.
Antepartum depression is the greatest predictor of postpartum depression. Nearly 73 percent of women who report antepartum depression also experience postpartum depression, compared to 38 percent of women who did not experience antepartum depression but later experienced it postpartum.
Depression during pregnancy can significantly affect mothers and developing babies. Several studies have linked antepartum depression with preterm birth and low birth weight. Preterm births (births that occur before 37 weeks) are both more costly than a full-term birth and increase the likelihood of physical and intellectual developmental delays.
The cost of preterm births, during and after delivery, is also concerning. According to the March of Dimes, caring for a preterm baby in the first year of life costs approximately $50,000, whereas care for a baby born without complications costs about $5,000. Approximately half of all births in the U.S. are paid for by Medicaid, which covers a greater share of preterm births than private insurance. Together, these facts are evidence of the effect of poverty on health and well-being.
Postpartum depression disorders range from “baby blues” to postpartum depression and, in rare cases, postpartum psychosis. An estimated 50 to 80 percent of women experience baby blues, or feelings of sadness, that last only a few weeks immediately after birth, according to the American Academy of Pediatrics. Postpartum depression lasts longer than a few weeks and occurs in approximately 10 to 12 percent of women. Postpartum depression generally occurs about six weeks after birth, but it can happen as late as one year after birth. Postpartum psychosis, the rarest of these three conditions, typically has a sudden onset within the first two weeks after birth. Symptoms include paranoia, hallucinations, delusions, hyperactivity and mood swings. Postpartum psychosis occurs in only 0.1 to 0.2 percent of all births. Women who have personal or family history of bipolar disorder or a previous psychotic episode are at highest risk.
Postpartum depression is linked to delays in cognitive, linguistic, and social and emotional development in infants and toddlers. In the first few years of life, a child’s brain develops a million new neural connections every second. These connections are influenced by many environmental factors, most significantly child-adult interactions. Scientists describe healthy interactions between infants and adults as a “serve and return” relationship. This is the give-and-take interaction between infants and adults. For example, an adult makes a silly face at the baby, the baby laughs in response to the silly face, and the adult smiles back at the baby. This back-and-forth interaction provides much-needed stimuli for babies’ developing brains and is needed for a healthy bond to form between caregiver and child. Postpartum depression can interfere with the serve and return relationship. Babies consistently deprived of this interaction can experience levels of stress that are constant to the point that it affects their developing brain. This is known as toxic stress.
State Policy Options
Coverage and Access for Depression Screenings
Some health care providers screen their patients to identify women suffering from maternal depression and use that information to connect patients with treatment. Screenings generally are written questionnaires that patients fill out or brief interviews conducted by a health care provider. The Edinburgh Postnatal Depression Scale (EPDS) and the Patient Health Questionnarie-9 (PHQ-9) are two of the most commonly used standardized and validated screening tools; however, screening for depression is neither uniform nor universal, and in fact, varies greatly.
In recent years, state legislators examined increases in coverage and access to screenings for pregnant women and new mothers. Thirty-seven states allow, require or recommend that Medicaid cover maternal depression screenings at well-child visits. At least 13 state Medicaid programs cover maternal depression screenings, including Colorado, Delaware, Iowa, Illinois, Maryland, Massachusetts, Nevada, New York, North Dakota, Ohio, South Carolina, Virginia and Washington.
Some states allow the child’s insurance to reimburse for the mother’s depression screening. The American Academy of Pediatrics (AAP) publishes the Bright Futures Guidelines for health care providers, specifically pediatricians, to improve care and address infant and toddler health care needs. The guidelines are a resource for providers and family members and include information on when children should have well-child visits and which screenings and services to provide at those appointments. In these guidelines, AAP recommends pediatricians conduct maternal depression screenings as a part of well-child visits at ages 6 months, 1, 2 and 4 because of the strong relationship between the mother’s and child’s health.
The Centers for Medicare & Medicaid Services (CMS) stressed a similar point in a 2016 report, stating that “since a maternal depression screening is for the direct benefit of the child, state Medicaid agencies may allow such screenings to be claimed as a service for the child as part of the [Early and Periodic Screening, Diagnostic and Treatment, (EPSDT)] benefit.” EPSDT is part of a federal Medicaid requirement that mandates coverage of a wide range of preventive and treatment services for children under 21 who are covered by Medicaid.
Colorado, Illinois, North Dakota and Virginia cover maternal depression screenings under the child’s insurance when they are covered by the Children’s Health Insurance Program (CHIP). Each state provides this coverage in slightly different ways, but most stipulate that screenings be billed under the child’s Medicaid coverage when the parent is not otherwise insured.
Illinois, Massachusetts, New Jersey and West Virginia went further by mandating that providers screen all women for prenatal and postpartum depression. West Virginia enacted legislation in 2008 that requires women receiving prenatal care be screened to evaluate risk of depression. New Jersey enacted legislation in 2006, making it the first state to require health care providers to administer postpartum depression screenings to all new mothers.
Home visiting programs are another tool to screen for maternal depression. Not all home visitors are trained to address maternal depression, but most can identify a depressed mother and provide a referral. Maryland developed a statewide training and certification program to train home visitors to identify signs of maternal depression, substance abuse, domestic violence and child behavior issues. All home visitors funded through Maryland’s Maternal, Infant and Early Childhood Home Visiting (MIECHV) program must complete the training.
Coverage and Access for Treatment
While screenings can indicate a woman’s risk of depression, additional services are needed to treat maternal depression. Many states are working to increase access and coverage for treatment related to behavioral health overall, and in some states, this includes treatment for women during pregnancy and in the postpartum period.
New York became the first state to enact legislation to recognize pregnancy as a “life qualifying event” in 2015, triggering a special opportunity for people to enroll in state health exchanges.
States also are looking at ways to extend coverage after pregnancy. Missouri enacted legislation in 2018 that supports the governor’s plan to apply for a Medicaid 1115 demonstration waiver that, if accepted by the Centers for Medicare and Medicaid Services (CMS), will cover behavioral health services for women up to one year postpartum. Without this waiver, women not otherwise covered by insurance will lose access to behavioral health services 60 days postpartum. With increasing rates of maternal mortality across the country, sometimes due to untreated behavioral health conditions, states are examining ways to provide continued coverage and care for this population.
Along with ensuring coverage of maternal depression treatment, states continue to make efforts to increase access to treatment. Massachusetts created the Massachusetts Child Psychiatry Access Program (MCPAP) to address severe shortages of child psychiatrists in the state. MCPAP offers a phone number that a child’s primary care provider can call to connect with a behavioral health professional who can provide information and referrals for the patient. The MCPAP model was so successful in increasing access for children in Massachusetts that more than 30 other states created programs based on this model. In recent years, MCPAP expanded to include consultations for maternal depression and postpartum depression.
States also have passed legislation that requires increased access to information on postpartum depression and treatment options. Virginia enacted legislation in 2003 that requires hospital staff to provide information on postpartum depression to women and their families. It also requires hospital staff to discuss postpartum depression with maternity patients before discharge. In a similar effort to increase access to treatment and services, New York enacted AB 8953 in 2018, which requires its department of mental health to provide information on its website regarding how to locate behavioral health providers who treat maternal depression.
State-Federal Partnership on Data Collection
States are using data to track, analyze and assess maternal depression; however, information limited to prevalence and severity is incomplete.
The Pregnancy Risk Assessment Monitoring System (PRAMS) is a project run by the CDC in conjunction with state health departments. PRAMS is the only database that tracks the number of women screened for postpartum depression across states. It tracks state-specific information on pregnancies and babies through a questionnaire sent randomly to women who have recently given birth. All information is confidential and is used to track and analyze health patterns over time and across states. PRAMS tracks maternal drug and alcohol use, breastfeeding, mental health, obesity, preconception health, pregnancy history, prenatal care, sleep behavior, tobacco use and other health-related topics.
Almost 83 percent of all U.S. births are tracked in the database; however, PRAMS provides an incomplete picture in several important ways. First, not all states use it, and second, PRAMS tracks only the occurrence of screenings, not screening results, referrals or treatment. Acknowledging these limitation, PRAMS has the best available data on rates of maternal and postpartum depression screenings.
Public Education and Awareness
Public education and awareness campaigns can serve a variety of functions, including educating the population as a whole, educating people in a specific population, and raising awareness and attention among lawmakers.
States have increased awareness and understanding of maternal depression in various ways. California passed a resolution in 2010 declaring May “Perinatal Depression Awareness Month.” Several states, including Colorado, created public awareness campaigns about postpartum depression.
Other states more narrowly target their education efforts. For example, Minnesota enacted legislation in 2005 that required its state health commissioner to work with health care stakeholders to create and disseminate information on postpartum depression. The state further required health care professionals who provide prenatal care to make this information available to women and their families.
Depression before, during and after pregnancy can have lasting negative effects on new mothers and their young children. A mother’s ability to care for and form an attachment with her young child can affect the child’s long-term social, emotional, physical and cognitive development. Access to maternal depression screening, services and treatment is important to a healthy start for infants and toddlers. State legislators play a critical role in determining policies and funding options related to maternal depression screening and treatment, improved data tracking, and public awareness and education. While there is no silver bullet for maternal depression, many states are ensuring better health and developmental outcomes for infants and toddlers by supporting their mothers’ emotional well-being.