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Pregnant and Postpartum Women and Behavioral Health Integration

Definition

Perinatal behavioral health conditions include mental health and substance use disorders (SUD) during pregnancy and the postpartum period (up to 12 months after delivery).

Prevalence

Perinatal mental health disorders are a common and significant complication of pregnancy and the postpartum period. An estimated 10-20 percent of women in the United States experience perinatal depression.1 Perinatal anxiety is estimated to affect 8-20 percent of women.2, 3 Other common perinatal mental health disorders include obsessive compulsive disorder, panic disorder, and post-traumatic stress disorder.4 Comorbid perinatal depression and anxiety disorders are common among pregnant and postpartum women.5, 6, 7 Postpartum psychosis, a rare and severe psychiatric emergency, is estimated to occur in 1 to 2 of every 1,000 births.4

The risk of developing SUD is highest for women ages 18 to 29 years old and increases throughout the reproductive years.8 Tobacco/nicotine is the most commonly used substance during pregnancy, followed by alcohol, marijuana/cannabis, opioids and other illicit substances. In 2019, 9.6% of pregnant women aged 15 to 44 years old in the United States reported using tobacco products in the past month, 9.5% reported using alcohol, 5.4% reported using marijuana, and 0.4% reported using opioids.9 Co-occurring SUDs are common among pregnant and postpartum women.10

Left untreated, perinatal depression, anxiety, and SUD worsen maternal mortality rates (including suicide and overdose), and are associated with severe maternal morbidity.11, 12, 13, 14, 15, 16 Between 2008 and 2017, almost 10 percent of pregnancy-related deaths were due to suicide, overdose/poisoning, and mental health-related unintentional injuries.17

Untreated perinatal depression and anxiety can lead to reduced engagement in perinatal care; increased substance use; and an increased risk of poor mother–infant attachment, stillbirth, premature birth, low birth weight, delayed cognitive and emotional development for infants, and behavioral problems in later life.4, 18, 19, 20, 21 Having an untreated mental health disorder is a major risk factor for SUD and suicide in the postpartum period.22

Substance use during pregnancy, including the use of tobacco/nicotine, alcohol, marijuana/cannabis, opioids, stimulants, or other illicit drugs, is associated with increased risk of stillbirth, premature birth, low birth weight, and birth defects.23 Use of alcohol and drugs during pregnancy can also cause neonatal abstinence syndrome (NAS), which can cause a constellation of symptoms in the infant including tremors, irritability, poor sleep and poor feeding.24

Pregnant and postpartum women who have a behavioral health condition are less likely to be receiving adequate care compared to women who are not pregnant.25, 26 OB/GYNs, family physicians, pediatricians, advanced practice nurses, nurses, midwives, doulas, and other primary care providers play a critical role in identifying pregnant and postpartum women with untreated behavioral health conditions and connecting them with care.

Implementing integrated behavioral health in all practice settings allows pregnant and postpartum women to address behavioral health issues in a place where they already have relationships and feel comfortable. Integrated behavioral health care improves the reliability of screening, increases the efficiency of referrals, reduces barriers to treatment for mental health and substance use disorders, and improves health outcomes for pregnant and postpartum women.27, 28, 29, 30, 31, 32

Key Components

Integrated health programs and systems ensure that there is no wrong door – that access to care is available at any point of entry – for pregnant and postpartum women who need behavioral health treatment. Facilitating and implementing key components of integrated behavioral healthcare can improve health outcomes for pregnant and postpartum women. 33, 34

  • Protocols for screening, brief intervention, referral to treatment (SBIRT) for SUD and mental health disorders. Establish protocols to identify pregnant and postpartum women who could benefit from behavioral health services and ensure appropriate referrals and follow up to behavioral health services (e.g., group and individual SUD treatment, individual and group counseling, psychiatric care, pediatric care, hepatitis C treatment) after a positive screening.
  • Patient-provider communication. For pregnant and postpartum women to receive the greatest benefit from integrated care, they must actively communicate symptoms to their providers, remain engaged throughout their care, and ask questions about their care. This requires an established foundation of trust and compassion. It is important to educate pregnant and postpartum women and their partners about integrated care and encourage them to actively participate in their care and care planning . It is even more important to do so with language that shows compassion and care and avoids stigmatization, dehumanization, and harm .
  • Shared care plans. Electronic health records (EHRs) can be a useful communication tool if they are integrated, but are often insufficient in ensuring adequate care team collaboration. Developing a shared care plan can ease the exchange of clinical information, medication reconciliation, and other forms of coordination that engage patients as full participants in their care and allow care team members to gauge patient stability and indicate any changes in treatment.
  • Telehealth expansion . The use of telehealth technologies has helped address care disruptions and improve access for pregnant and postpartum women during the COVID-19 pandemic, especially in rural areas and areas with provider shortages. 35 Telehealth technology can be used during pregnancy and the postpartum period to provide mental health and substance use disorder screening and treatment, facilitate patient-provider communication so that women can conveniently raise issues or concerns with care team members, and remotely monitor key vital signs.
  • Expanded care team members and roles . Tailor care team roles and obtain the behavioral health expertise needed to meet the needs of pregnant and postpartum women with behavioral health conditions. Practices may be able to obtain training and support for nurses, midwives, and other obstetrics and primary care providers and practitioners to prescribe the medications for opioid use disorder (MOUD) while providing care. Practices can also incorporate psychologists, psychiatrists, social workers, substance use counselors, peer recovery support specialists, recovery coaches, and/or community health workers into care teams to meet the needs of patients.
  • Care coordination. Establish operational systems to support quick coordination and triage to respond immediately to the needs of pregnant and postpartum women with behavioral health conditions. Practices can add patient navigators and nurse care managers to care teams to assist pregnant and postpartum women with accessing care.
  • Collaborative and co-located care. There may be opportunities for practices to collaborate with other healthcare settings (e.g., an emergency department that offers MOUD initiation) to ensure 24/7 rapid access to treatment or to locate OBGYN, primary care and behavioral health care team members in the same space or in different departments/locations within the same facility. Collaborative and co-located care can be particularly useful when caring for high-risk patients who may present to care infrequently, as it allows providers to triage and treat the most urgent issues.
  • Community partnerships. Determine what behavioral health supports and services are feasible to offer in-practice and connect pregnant and postpartum women with external behavioral health providers, specialty care providers, and other community resources (e.g., methadone clinics, residential addiction treatment centers, health departments, recovery supports, intimate partner violence shelters and programs, emergency food providers, income support programs, housing support services, employment assistance, transportation, and family planning) as needed, to complement services available within the practice setting. A patient navigator or community health worker can help facilitate these linkages to care.

Models

The perinatal period is a critical time to address mental health and substance use disorders for women. There are several models of integrated care that can connect pregnant and postpartum women with the behavioral health services they need.

Programs

The following table includes a sample of integrated perinatal behavioral health programs that have blended and adapted aspects of various integrated care models.

 

MaineMOM

Moms in Recovery Program

Project RESPECT

UNC Horizons Program

Drug Free Moms and Babies

Maternal Mental Health NOW

MCPAP for Moms

SBIRT - Screening and brief intervention

X

X

X

X

X

X

X

SBIRT - Referral to treatment

X

X

X

X

X

X

X

Patient- provider communication

X

X

X

X

X

X

 

Expanded care team members and roles

X

X

X

X

X

X

X

Shared care plans

X

X

X

X

X

Not Applicable

Not Applicable

Care coordination

X

X

X

X

X

X

Not Applicable

Collaborative and co-located care

X

X

X

X

Not Applicable

X

Not Applicable

Telehealth

X

X

X

X

Not Applicable

Not Applicable

X

Community partnerships

X

X

X

X

X

Not Applicable

X

Pregnant and postpartum women with behavioral health conditions will vary widely in the types and intensity of the supports they need for treatment and recovery, and those needs may change over the course of pregnancy and after childbirth. There also are key aspects of perinatal behavioral health conditions that practices should consider when providing care, some related to patient needs and others regulatory in nature.

Stigma and Fear

Stigma and fear may keep pregnant and postpartum patients from seeking, initiating, and continuing to access substance use and mental health treatment services. Pregnant and postpartum women that are using substances fear referral to child welfare agencies, loss of parental rights, and incarceration.36, 37, 38, 39 Some common provider behaviors, use of language, attitudes, and beliefs can create stigmatizing interactions with pregnant and postpartum women and contribute to these fears.40, 41

Addressing fear and stigma is key in connecting pregnant and postpartum women with behavioral health conditions with treatment services. Discuss fears and concerns openly and compassionately and as early as possible. Speak transparently and not coercively about what impacts drug toxicology results may have on child welfare agency involvement. For example, advise patients that integrated perinatal behavioral health care is associated with maintaining legal custody of children at birth.42

Resources

Mandatory Reporting for Substance Use During Pregnancy

Many states have reporting mandates related to the disclosure of substance use and/or engagement in substance use treatment by pregnant women. Informed consent should be obtained prior to screening, testing, and treatment of pregnant patients for substance use disorder.43, 44 Informed consent includes a non-coercive and supportive discussion with the patient about the benefits and potential implications of mandatory state reporting laws (e.g., loss of parental rights, custody, or incarceration).

Resources

Policy Listings:

Example Algorithms and Workflows:

Universal Screening for Mental Health and Substance Use Disorders

Using empirically validated approaches and tools for universal screening is essential for integrated perinatal behavioral healthcare. Screening for mental health and substance use disorders at least once during the perinatal period – at the first prenatal visit for substance use and SUD and at the postpartum checkup for mental health disorders – using a validated instrument has been recommended for all pregnant and postpartum women to identify those women that need to be connected with perinatal behavioral health treatment and appropriate follow-up.45, 46, 47, 48, 49, 50, 51, 52, 53, 54

Resources

Example Algorithms and Workflows:

Mental Health Screening Tools:

  • PHQ–9 (Patient Health Questionnaire 9) for depression [PDF - 39.9 KB]
  • EPDS (Edinburgh Postnatal Depression Scale) [PDF - 1.59 MB]
  • PASS (Perinatal Anxiety Screening Scale)
  • GAD-7 (Generalized Anxiety Disorder 7)
  • MDQ (Mood Disorder Questionnaire) for bipolar disorder

Substance Use Screening Tools:

  • 4 Ps (Parents, Partner, Past and Pregnancy) [PDF - 10.2 KB]
  • T-ACE (Tolerance, Annoyed, Cut Down, Eye-opener) for alcohol use during pregnancy
  • TAPS (Tobacco, Alcohol, Prescription Medication, and Other Substance Use)
  • CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) for adolescent substance abuse

Universal Screening for Social Determinants of Health

In addition to universal screening of pregnant and postpartum women for mental health and substance use disorders, it is imperative to identify women at increased risk for other perinatal behavioral health conditions. Women experiencing intimate partner violence (IPV) are at increased risk of substance use. IPV often begins or escalates during pregnancy and the postpartum period, and is also associated with an increased risk of adverse maternal and neonatal outcomes.55, 56, 57, 58 Additionally, history of adverse childhood experiences (ACEs) increases risk of perinatal anxiety and/or depression.59, 60 Other social determinants of health (SDOH) risk factors, including disparate access to care, transportation barriers, food and housing insecurity, and lack of social support also increase susceptibility to perinatal behavioral health conditions.61, 62, 63

Universal screening for IPV, ACEs, and other SDOH risk factors is essential for identifying pregnant and postpartum women at increased risk for perinatal behavioral health conditions and providing care that is trauma-informed.64 Like screening for mental health and substance use disorders, it is critical that these screenings are completed periodically – commonly recommended at annual exams, initial prenatal visits, and postpartum checkups – with validated tools in a setting that is conducive to potentially difficult conversations and one that ensures privacy and confidentiality.65, 66, 67, 68, 69

Resources

Example Algorithms and Workflows:

IPV Screening Tools:

  • HITS (Hurt, Insult, Threaten, Scream) [PDF - 1,752 KB]
  • OVAT (Ongoing Violence Assessment Tool) [PDF - 1,752 KB]
  • STaT (Slapped, Things and Threaten) [PDF - 1,752 KB]
  • WAST (Woman Abuse Screen Tool) [PDF - 1,752 KB]
  • HARK (Humiliation, Afraid, Rape, Kick)
  • AAS (Abuse Assessment Screen)
  • PVS (Partner Violence Screen)
  • SAFE-T (Secure, Acceptance, Family, Even, Talk Measure)
  • PSQ (Parent Screening Questionnaire)
  • OAS (Ongoing Abuse Screen)

ACEs Screening Tools:

  • ACE Questionnaire [PDF - 268 KB]
  • CTQ–SF (Modified Childhood Trauma Questionnaire–Short Form)
  • PEARLS (The Pediatric ACEs and Related Life Events Screener) [PDF - 266 KB]

SDOH Screening Tools:

  • SEEK PQ-R (A Safe Environment for Every Kid Parent Questionnaire-R) [PDF - 104 KB]
  • WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education) Survey
  • PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences)
  • ACH HRSN (Accountable Health Communities Health-Related Social Needs) Screening Tool [PDF - 328 KB]
  • The EveryONE Project Social Needs Screening Tool [PDF - 764 KB]
  • IHELP (Income, Insurance, Hunger, Housing, Homeless, Education, Safety, Legal Status, Power of Attorney) Pediatric Social History Tool

Universal Screening for Infectious Diseases

Sexually transmitted diseases (STIs) are common among pregnant women, and those with SUD are at increased risk for contracting STIs and hepatitis C.70, 71, 72 If left untreated, these infectious diseases can be transmitted to the fetus and lead to adverse pregnancy outcomes and development outcomes in the child.7374 Universal testing for HIV, hepatitis B, hepatitis C, gonorrhea, chlamydia, and syphilis has been recommended for all pregnant women.75, 76, 77, 78

Resources

Polysubstance Use

Polysubstance use (using more than one substance at a time) during pregnancy is common, is highest during early pregnancy, and is often associated with comorbid perinatal depression and other psychiatric conditions.79, 80, 81, 82, 83, 10 Pregnant and postpartum women who use multiple substances are at the greatest risk for depression and anxiety.83 Identifying and understanding how pregnant and postpartum women are using substances is key for treatment planning.

Resources

Co-occurring Mental and Substance Use Disorders

Co-occurring mental and substance use disorders affected 4.6 million women aged 18 or older in the United States in 2019.84 From 2005-2014, pregnant women with perinatal depression and anxiety were more likely to have at least one SUD, compared to other pregnant women hospitalized for delivery.85 It is often difficult to distinguish between the two conditions as exacerbations in mental health disorders may contribute to relapses/return to substance use in pregnant or postpartum women. Similarly, symptoms associated with ongoing substance use or withdrawal may mimic common mental health disorders, such as irritability, agitation, and insomnia. Careful attention to both conditions is essential in providing optimal and patient-centered care.

Resources

Initiation or Continuation of Medications

Decisions around the initiation and continuation of medications for perinatal mental health and substance use disorders should be based on assessment, diagnoses, patient needs, and patient consent. It is not uncommon for providers or patients to abruptly discontinue medications for mental health and substance use disorders after discovering pregnancy, causing an exacerbation of symptoms and relapse of an SUD.86, 45, 87, 88 Several professional organizations and regulatory bodies advise against abruptly stopping medications, and treatment with buprenorphine or methadone throughout the pregnancy is considered the standard of care.44, 45, 89, 90 Stabilizing with medication can be less risky and do less harm (see the “What Works” section below) than leaving perinatal behavioral health conditions sub-optimally treated.

Perinatal, primary care, behavioral health providers, and other subspecialty providers on the care team can coordinate and collaborate to determine maternal and fetal risks and benefits, discuss those benefits and risks with pregnant and postpartum women, and engage in shared decision-making to determine the best treatment plan.

Resources

A mix of pharmacological and nonpharmacological interventions may be used for treating pregnant and postpartum women with mental health and substance use disorders. Primary care providers will need to coordinate and collaborate with perinatal, primary care, behavioral health providers, and other subspecialty providers on the care team to determine maternal and fetal risks and benefits, create an individualized, patient-centered treatment plan, make clinical decisions, and manage care for pregnant and postpartum patients across various care settings.

Depression and Anxiety

Pregnant and postpartum women with perinatal depression may experience feelings of extreme sadness, anxiety, loss of interest in usual activities, and fatigue that may make it difficult for them to function and care for themselves or others.91 Pregnant and postpartum women with perinatal anxiety may experience feelings of excessive worry, fear, tension, and doom; restless sleep, panic attacks, hyperventilation, and other physical symptoms of worry; and obtrusive, obsessive, and repeated thoughts or images of scary things happening to the baby that may start to interfere with daily functioning, relationships, or job performance.4, 92 Untreated perinatal depression or anxiety may increase the risk of preterm birth and is associated with low birth weight, small for gestational age, stillbirth, and maternal morbidity.4, 18, 19, 93

For mild to moderate perinatal depression or anxiety, nonpharmacologic therapy is the first-line treatment. Cognitive behavioral therapy (CBT), mental health counseling, mindfulness, yoga, relaxation interventions, supportive and educational based interventions (e.g., sleep hygiene), acupressure, acupuncture, and diet and exercise are common nonpharmacological interventions that are effective for pregnant and postpartum women with perinatal depression and anxiety.94, 95, 96, 97

For moderate to severe perinatal depression or anxiety, pharmacotherapy in conjunction with nonpharmacologic therapy is the first-line treatment. Practice recommendations for the use of medications for depression or anxiety during pregnancy vary but consistently advise the use of monotherapy (as opposed to combination therapies) at the lowest effective dose, when possible.98, 99 For pregnant and postpartum women with psychosis or complex co-occurring mental health disorders, a combination of medication may be required.

The priority for treatment is stability in the mother's mood throughout pregnancy. Dosage adjustments should be made on a clinical basis. Abruptly stopping pharmacological treatments, such as antidepressants, can lead to relapse of depression and anxiety symptoms.100 Providers should engage in shared decision making with the patient regarding the risks and benefits of medications for maternal mental health disorders during pregnancy.101

Resources

Alcohol Use

There is no known safe amount of alcohol use during pregnancy or while trying to become pregnant. Alcohol use during pregnancy can cause miscarriage, stillbirth, preterm birth, low birth weight, and fetal alcohol spectrum disorders (FASDs), a range of lifelong birth defects and behavioral and intellectual disabilities.102, 103, 104, 105

Practice recommendations for screening for alcohol use during pregnancy include brief intervention to discuss the risks of alcohol use as well as resources available to assist in reducing alcohol use.106, 107 Motivational interviewing counseling sessions and brief interventions consisting of knowledge assessment with feedback, contracting and goal setting, behavioral modification, and a summary are common nonpharmacological interventions that are effective for pregnant women using alcohol.108, 109, 110

Medications for alcohol use disorder (MAUD) have not been proven completely safe during pregnancy or breastfeeding and have not been approved by the U.S. Food and Drug Administration (FDA) for use in adolescents younger than 18 years old. Practice recommendations advise weighing the benefits and risks of using MAUD (naltrexone or acamprosate) for the treatment of alcohol use disorder (AUD) during pregnancy versus risks of ongoing alcohol use.111, 112, 113

Resources

Opioid Use

Opioid use during pregnancy has been linked to maternal mortality, poor fetal growth, preterm birth, stillbirth, and neonatal opioid withdrawal syndrome (NOWS), a withdrawal syndrome caused by in utero exposure to opioids.114, 115, 116

Practice recommendations for screening for opioid use during pregnancy include brief intervention to discuss risks of ongoing opioid use as well as resources available for treatment.44

Practice recommendations advise against opioid detoxification during pregnancy, which is associated with high rates of relapse.117 Opioid agonist pharmacotherapy using medication for opioid use disorders (MOUD) plays an important role in reducing complications and risks, stabilizing maternal craving and withdrawal symptoms, reducing repeated periods of intoxication and withdrawal, and improving neonatal and maternal outcomes.118, 119 Practice recommendations advise using MOUD (methadone, buprenorphine, or buprenorphine/naloxone) in conjunction with counseling and behavioral therapy to treat opioid use disorder (OUD) in pregnant and postpartum women.44,87,118 For opioid agonist pharmacotherapy using buprenorphine, buprenorphine/naloxone therapy is becoming the standard of care for pregnant and postpartum women as it reduces the risks of diversion and misuse associated with monotherapy.120

NOWS is an expected and treatable condition that can follow exposure to MOUD. Maternal dose of MOUD is not related to the severity of NOWS, and reducing medication dose in an attempt to prevent NOWS may destabilize OUD and increase substance use, resulting in greater risk to the fetus.121, 122 Dosage adjustments during pregnancy should be made on a clinical basis. Practice recommendations encourage postpartum women to breastfeed while using MOUD, as it may reduce clinical signs of NOWS, provided no other breastfeeding contraindications exist (e.g., HIV or ongoing substance use).123

Resources

Tobacco and Nicotine Use

Cigarette smoking during pregnancy increases the risk of stillbirth, preterm birth, low birth weight, birth defects of the mouth and lip, and sudden infant death syndrome (SIDS).124, 125, 126, 127 E-cigarettes and tobacco products containing nicotine can cause damage to fetal brain and lung tissue.128, 129

Practice recommendations for screening for tobacco or nicotine use during pregnancy include brief intervention to discuss risks as well as resources available to reduce use.130, 131 Motivational interviewing; individual, group, and telephone counseling; mobile phone-based interventions; and contingency management are common nonpharmacological interventions that are effective for pregnant women using tobacco and nicotine.132, 133, 134

There is insufficient evidence available to assess the balance of benefits and harms of e-cigarettes, nicotine replacement products, and other pharmaceuticals for tobacco cessation during pregnancy, and e-cigarettes are not approved by the FDA to help people quit smoking.131, 135 Shared decision making around the use of pharmaceuticals for tobacco cessation should be made in collaboration with the patient.130

Resources

Marijuana and Cannabis Use

While the health effects of using cannabidiol (CBD) products during pregnancy are currently unknown, there is some evidence that marijuana use during pregnancy may increase risk of stillbirth and may cause low birth weight, preterm birth, abnormal fetal brain development, and long-term brain development issues linked to increased anxiety, aggression, and hyperactivity.136, 137, 138, 139, 140, 141 FDA strongly advises against the use of all forms of CBD, tetrahydrocannabinol (THC), and marijuana during pregnancy or while breastfeeding.142

Practice recommendations for screening for marijuana and cannabis use during pregnancy and lactation include brief intervention to discuss risks and available resources for reducing use.143, 144 Pregnant women may be unaware that ongoing cannabis use is unsafe, particularly in states where medical cannabis has been legalized and where dispensaries recommend its use during pregnancy.145 It can be useful to discuss with a pregnant patient why she is using cannabis (e.g., to self-treat anxiety, insomnia, nausea) so that safer alternative remedies can be discussed.

There are currently no FDA approved pharmacological interventions for marijuana and cannabis use.

Resources

Stimulant Use

Use of methamphetamine or cocaine during pregnancy increases the risk of preterm birth, low birth weight, and smaller head circumference.146, 147

Practice recommendations for screening for methamphetamine or cocaine use during pregnancy include brief intervention to discuss risks and available resources for reducing use.148, 149, 150 Contingency management, community reinforcement approach, CBT, motivational interviewing, are common nonpharmacological interventions that are effective for methamphetamine or cocaine use in women of reproductive age.151, 152, 153, 154, 155, 156

There are currently no FDA approved pharmacological interventions for stimulant use.

Resources

Several calls to action and recommendations have been issued for policy-related changes to support integrated perinatal behavioral healthcare.33,34, 157, 158, 159, 160, 161 Federal and State policy changes and payment reforms could incentivize integrated perinatal behavioral healthcare by allowing billing and reimbursement of services that are key to the integrated care models.

  • Offering provider incentives to complete perinatal behavioral health screenings
  • Increasing reimbursement for perinatal behavioral health-related services
  • Expanding Medicaid coverage for postpartum women

References

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