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870 Market Street, Suite 928, San Francisco, CA 94102
Phone: (415) 421-2926 Ÿ Fax: (415) 421-2928 Ÿ www.mentalhealthsf.org
MATERNAL MENTAL HEALTH POLICY BRIEF
by Erin Huie, MSW
Special Projects Manager, The Center for Dignity, Recovery and Empowerment
February 2015
Copyright reserved, Center for Dignity, Recovery and Empowerment 2015. All rights, reproduction,
and usage is limited and prohibited without expressed consent of the Center.
The Center for Dignity, Recovery & Empowerment at the Mental Health Association of San Francisco was established to advance effective
mental health supports grounded in hope and human dignity through integration of policy, research and community-based practices.

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STATEMENT OF ISSUE
Maternal mental health conditions such as depression and anxiety are the most common
complications of childbirth, impacting approximately 15-20% of pregnant and postpartum
women.1
When untreated, these conditions can have severely adverse long-term effects on the
health of the whole family, including the mother, partner, and child2
and potentially lead to
eventual self-harm and suicidal ideation. Women experiencing symptoms of maternal depression
and anxiety face significant challenges in adequately caring for the needs of their infants as well
as themselves,3
and may have difficulty functioning in the workplace and among social peers.4
They are also likely to engage in high-risk behaviors including alcohol and substance abuse.5 6
Fetal and neonatal outcomes of perinatally depressed mothers can be significantly adverse and
include increased risk for premature delivery, low gestational and birthweight, and unhealthy
fetal activity and behavior.7 8
Infants and young children of women with postpartum conditions
are at high risk for experiencing serious cognitive, developmental, and emotional delays or
impairments up to adolescence.9
Women across age groups, socioeconomic status, educational levels, races, cultures, and
ethnicities are at risk for developing maternal mental health conditions. Certain risk factors
strongly contribute to the likelihood of developing maternal depression and anxiety, including:
history of psychopathology and psychosocial adversities, history of abuse, low levels of social
support, experiencing stressful life events, substance misuse, and negative cognitive style.10 11
The prevalence of depression and anxiety is nearly twice as high in vulnerable groups;12
low-
income and minority mothers experience stressors that increase their likelihood of becoming
depressed and face greater barriers to having symptoms detected and accessing treatment than
1
Postpartum
Support
International
(2014).
Perinatal
Mood
&
Anxiety
Disorders
Overview.
Retrieved
from
http://www.postpartum.net/Get-the-Facts.aspx
2
Xu,
F,
Austin,
M,
Reilly,
N.,
Hilder,
L.,
Sullivan,
E.A.
(2012).
Major
depressive
disorder
in
the
perinatal
period:
using
data
linkage
to
inform
perinatal
mental
health
policy.
Archives
of
Women’s
Mental
Health,
15(5).
Retrieved
from
http://link.springer.com/article/10.1007/s00737-012-0289-8#
3
Oregon
Health
Authority
(n.d.).
Maternal
Mental
Health.
Retrieved
from
https://public.health.oregon.gov/HealthyPeopleFamilies/Women/MaternalMentalHealth/Pages/index.aspx
4
Maternal
and
Child
Public
Health
Leadership
Training
Program
(2007).
Preventing
Perinatal
Depression.
Northwest
Bulletin,
21(2).
Retrieved
from
http://depts.washington.edu/nwbfch/PDFs/NWBv21n2.pdf
5
Chapman,
S.L.C.,
Wu,
L.
(2013).
Postpartum
substance
use
and
depressive
symptoms:
a
review.
Women’s
Health,
53(5).
Retrieved
from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3742364/
6
National
Institute
for
Health
Care
Management
Foundation
(2010).
Identifying
and
treating
maternal
depression:
strategies
&
considerations
for
health
plans.
NIHCM
Foundation
Issue
Brief.
Retrieved
from
http://www.nihcm.org/pdf/FINAL_MaternalDepression6-
7.pdf
7
Kinsella,
M.T.,
Monk,
C.
(2009).
Impact
of
maternal
stress,
depression,
and
anxiety
on
fetal
neurobehavioral
development.
Clinical
Obstetrics
and
Gynecology,
52(3).
Retrieved
from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3710585/
8
Muzik,
M.,
Borovska,
S.
(2010).
Perinatal
depression:
implications
for
child
mental
health.
Mental
Health
Family
Medicine,
7(4).
Retrieved
from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083253/
9
Stein,
A.,
et
al.
(2014).
Effects
of
perinatal
mental
disorders
on
the
fetus
and
child.
The
Lancet,
384(9956).
Retrieved
from
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61277-0/fulltext#article_upsell
10
Howard,
L.,
et
al.
(2014).
Non-­‐psychotic
mental
disorders
in
the
perinatal
period.
The
Lancet,
384(9956).
Retrieved
from
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961276-9/abstract
11
Leigh,
B.,
Milgrom,
J.
(2008).
Risk
factors
for
antenatal
depression,
postnatal
depression
and
parenting
stress.
BMC
Psychiatry,
8(24).
Retrieved
from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2375874/
12
Chaudron,
L.,
et
al.
(2010).
Accuracy
of
depression
screening
tools
for
identifying
postpartum
depression
among
urban
mothers.
Pediatrics,
125(3).
Retrieved
from
http://www.ncbi.nlm.nih.gov/pubmed/20156899

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the general population.13
Despite the high prevalence of maternal depression and anxiety across the US, only 15-20% of
mothers eventually receive treatment. Among low-income women, this rate is considerably
lower.14
Women experiencing symptoms of perinatal/postpartum depression and anxiety often
remain undiagnosed and untreated due to ‘practical barriers’ to care (not knowing where and
how to access services, family responsibilities, lack of time, lack of knowledge on issues) and
‘social barriers’ to care (shame, fear of stigma, fear of stereotypes on what motherhood should
include or look like).15 16
While women with fewer resources are especially affected by practical
barriers, a majority of women across economic means report the following significant
challenges: difficulty in accessing screening services, lack of flexibility of treatment location and
treatment options, and lack of overall awareness, support, and education which lead to fear and
doubt about treatment effectiveness.17
Low-income women tend to face additional logistical,
structural, and personal barriers, including: lack of routine and systematic screening-and-referral
mechanisms in primary care or other settings, finding affordable services and childcare,
misunderstanding of treatment options, and cultural preferences.18
BACKGROUND
Since 2000, maternal mental health conditions have received increased attention from federal
and state agencies. Federal support for screening, early identification, and treatment of perinatal
depression rose in the early 2000s until, in 2003, the first federal legislation on perinatal
depression was introduced in response to the suicide of Melanie Blocker-Stokes, who suffered
from postpartum psychosis to her death. The Melanie Blocker Stokes MOTHERS Act or “Moms
Opportunity To access Health, Education, Research and Support” finally became incorporated
into the Patient Protection and Affordable Care Act, which passed in 2010. This Act includes
research provisions and includes additional provisions on directing the future actions of the
National Institute of Mental Health, authorizing grants to support the establishment, operation,
and delivery of effective and cost-efficient systems for providing clinical services to women
with, or at risk for, postpartum depression or psychosis, and appropriates money to study the
benefits of screening. However, due to federal budget issues and a challenging political climate
surrounding the Affordable Care Act, no funds have been allocated toward the Act by Congress
since its passage.
13
Boyd,
R.
Mogul,
M.,
et
al.
(2011).
Screening
and
referral
for
postpartum
depression
among
low-­‐income
women:
a
qualitative
perspective
from
community
health
workers.
Depression
Research
and
Treatment,
Article
ID
320605.
Retrieved
from
http://www.hindawi.com/journals/drt/2011/320605/cta/
14
Retrieved
from
http://opinionator.blogs.nytimes.com/2014/10/16/treating-­‐depression-­‐before-­‐it-­‐becomes-­‐postpartum
15
Muzik,
M.,
Borovska,
S.
(2010).
Perinatal
depression:
implications
for
child
mental
health.
Mental
Health
Family
Medicine,
7(4).
Retrieved
from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083253/
16
Barnes-­‐Higgs,
K.
(2012).
Behavioral
health
care
for
maternal
mental
health
in
Philadelphia.
Maternity
Care
Coalition.
Retrieved
from
http://maternitycarecoalition.org/wp-content/uploads/2012/02/Perinatal-Depression-Barriers-and-Recommendations.pdf
17
Muzik,
M.,
Borovska,
S.
(2010).
Perinatal
depression:
implications
for
child
mental
health.
Mental
Health
Family
Medicine,
7(4).
Retrieved
from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083253/
18
Pooler, J. (2013). Postpartum depression, low-income women, and WIC: examples of integrated screening and referral efforts. Altarum
Institute. Retrieved from http://altarum.org/health-policy-blog/postpartum-depression-low-income-women-and-wic-examples-of-integrated-
screening-and-referral-efforts

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Several states have passed laws mandating screening and education, but a number of these
mandates have not been strictly enforced. In 2006, New Jersey became the first U.S. state to pass
a law mandating universal screening, education and referral for postpartum depression. In 2007,
Illinois passed a law requiring that licensed health care professionals provide education about
perinatal mental health disorders as part of prenatal education and invite women to complete a
screening questionnaire. Many states including California, Virginia, Texas, and Pennsylvania
have launched innovative statewide training, campaign, and systemic treatment access programs.
Outreach, screening, education, and treatment practices have vastly improved in recent years
across various settings of care. Despite improvements, however, outreach and screening practices
remain inconsistent, especially for low-income women. Providers present inadequate or no
education to women due to limited training. Finally, while treatment addressing maternal mental
health conditions is largely effective, women who do receive referrals for treatment face
significant barriers in accessing treatment. This is largely due to the fact that providers are
typically not co-located with location of treatment access and/or do not have strengthened
mechanisms in place to ensure follow-up of services.
POLICY RECOMMENDATIONS
PROVIDER SETTING
• Mental health professionals trained in the area of treating maternal depression and
anxiety should be co-located in settings where women undergo screening and
evaluation. Improved coordination of care and co-location of treatment access at
obstetrics clinics or gynecology clinics have been shown to enable treatment-seeking
behavior and ensure follow-up and obtainment of appropriate services.
• Early screening and secondary prevention mandates are imperative to preventing the
potential onset of additional symptoms and/or providing women with an additional net
of preventive support to build sustained resiliency against possible development of new
conditions. Additionally, it is recommended that women who present 1) a previous
history of psychopathology and psychosocial challenges and/or 2) one or more risk
factors for developing depression or anxiety should be offered opportunities for close
monitoring and evaluation throughout the perinatal and postpartum periods.
• To better address barriers to detection and treatment of maternal mental health
conditions for low-income women, community-based health workers should be actively
engaged in mandated, routine screening and warm handoff referral processes to
culturally and linguistically sensitive treatment services, ideally co-located at local
clinics, agencies, and health centers.
• Primary care physicians and staff working with pregnant and postpartum women should
complete comprehensive trainings on best practices in the delivery of destigmatizing
and culturally sensitive education, screenings, and treatment knowledge to reach the
need at scale.

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• Diagnostic evaluation must be mandated to follow all positive screenings to confirm
diagnoses, as screenings can produce a high rate of false positives and existing
screening instruments vary in overall efficacy, sensitivity, and specificity, and to-date
are not culturally sensitive.
SYSTEMS SETTING
• Workplace policies and occupational health programs should be revised to promote
ongoing wellness and recovery for mothers with mental health conditions and provide
supports for successful continuation or re-entry to work. This can include provision of
prevention, support, flexibility, and referral measures for prenatal, perinatal, and
postpartum women.
• Local and state agencies must allocate substantial funding and resources toward the
development and sustained support of stigma-reducing public information and
awareness campaigns with the goal of shifting culture and societal expectations
surrounding motherhood. Agencies should work closely with a diverse range of
community-based organizations and field leaders to develop sensitive, destigmatizing
messaging and advance evidence-based stigma reduction activities.
• Local and state public health agencies must collaborate with community partners –
such as workplaces, hospitals, wellness centers, childcare centers, and clinics – and
existing programs such as Maternal, Infant, and Early Childhood Home Visiting
Programs, WIC, and Early Head Start to ensure extensive access to culturally and
linguistically sensitive maternal mental health education and resources.
• Continued advocacy for funding allocation toward the Affordable Care Act-approved
Melanie Blocker Stokes MOTHERS Act is imperative to the ongoing development of
innovation and research in this field. This Act, which was passed in 2010 to establish a
federal commitment to expand research efforts, public awareness, and education
initiatives on postpartum depression, has remained stagnant due to Congress’ lack of
financial commitment.