When Risks Collide: Maternal Mortality and Mental Health

Alarmingly, the maternal mortality rate in the U.S. is more than double the rate of 10 other high-income countries, according to a 2020 report from The Commonwealth Fund. The rate for non-Hispanic Black women is even worse — more than double that of non-Hispanic white women and nearly triple that of Hispanic women.

These grim statistics are not news for healthcare organizations. The obstetrics community has focused on addressing high-risk areas such as maternal sepsis, postpartum hemorrhage, hypertensive disorders of pregnancy, fetal heart monitoring, non-medically indicated Cesarean births, and shoulder dystocia emergencies. Hospitals and health systems have targeted their approaches to these issues and others to help reduce complications through adherence to evidence-based clinical protocols and reducing variation in care.

One area of increasing focus that hasn’t received as much attention is the intersection of maternal mortality and maternal mental health. Yet pregnancy-related deaths due to mental health comprised over 10% of maternal deaths in 2020.

Looking at how maternal care and mental health intersect requires the collaboration of obstetrics and behavioral health care teams. They also need to recognize how social determinants play a role — to make sure risks are not overlooked during pregnancy and follow-up care is in place after the mother is discharged after the delivery of her baby.

A Personal Story of Maternal Mental Health

Lora Sparkman, MHA, RN, BSN, Partner, Patient Safety and Quality at Relias, has worked in healthcare for over 35 years, serving in bedside nursing roles at the beginning of her career and then working with clinical and patient safety leaders to help improve delivery of care and patient outcomes, increase reliability, and reduce risk for healthcare organizations.

With the knowledge that maternal mental health needs more attention, Sparkman took the courageous step of telling her personal story about the loss of her niece Brianne to complications from peripartum depression and anxiety after childbirth.

Her segment, Motherhood and Mental Health in the BBC’s Caring with Courage StoryWorks series, raises awareness about spotting the signs, breaking the silence, and caring for new mothers that have identified risk factors for maternal mental health concerns.

Sparkman hadn’t planned on speaking about her niece but decided to come forward knowing how important it is to associate real people with the data. “Telling stories really personalizes the statistics — that’s one of the ways that patient safety leaders keep the issue at the forefront. You have to keep talking about it and sharing stories, whether it’s a story with an adverse event or a near miss.”

Since researching the prevalence of postpartum depression after the passing of her niece, Sparkman has worked to elevate the importance of behavioral and mental health in maternity care. “It becomes easier to talk about — and with passion and urgency — when you know so many women and their families are negatively affected by not being diagnosed and treated.”

She continues to use her platform to be proactive and make an impact and was named one of the Top 25 Women Leaders in Healthcare Software in 2022 by The Healthcare Technology Report.

Maternal Risk Factors: Social Determinants and Mental Health

Sparkman’s professional emphasis has been on leveraging principles of high reliability to improve patient safety in healthcare organizations. She focuses on organizational culture, process, and structure to improve health outcomes.

But she also educates about social determinants of health — which include race, bias, discrimination, access to resources, and other social factors. Care teams should assess patients for these preexisting risks just as they assess for clinical reasons for maternal mortality and severe morbidity.

Sparkman drew parallels between the way healthcare organizations have worked to improve care for physical health factors such as hypertension and obstetrical hemorrhage and the way we should approach social factors that affect maternal mental health.

She advocates creating standard evaluation protocols that include using evidence-based guidelines, practices, and data as a routine practice to help improve outcomes.

Screening Can Lead to Life-Saving Care

Nurses have an important role in recognizing risks stemming from social factors, and by doing so, can provide potentially life-saving care. Screening for risks and knowing the exact protocol for managing and treating behavioral or mental health issues is critical throughout the ante, peri, and postpartum periods.

For example, a provider might clear a new mother to go home without consideration of social factors such as low socioeconomic status, lack of family support, or unfamiliarity with healthcare processes, which could lead to difficulties in the postpartum period.

Mothers could also have mental health postpartum risk factors, such as a history of anxiety, depression, interpersonal violence, or struggles with substance use.

When both social and mental health issues are present, risks multiply. Life stressors caused by social determinants such as unstable housing, lack of social support, unemployment, medication instability, domestic violence, and other factors can exacerbate mental health conditions.

Awareness of and assessment of both sets of factors must become the new standard of care for all mothers.

“We should proactively identify maternal mental health risk factors using evidence-based tools like the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire (PHQ-9) so that patients can get the appropriate diagnosis and treatment they may critically need,” Sparkman said.

Tackling Maternal Mental Health Issues at the System Level

Healthcare organizations must improve communication and coordination at the system level. Providers must direct patient care by connecting with other providers and caregivers. They should ensure that appropriate interventions are in place — whether they include community behavioral health resources, social workers, or other types of case management — to reduce the gap between acute care and when the patient goes home.

In places where resources may be scarce, providers may need to use innovative approaches. For example, mobile medicine or online services like telemedicine and teletherapy can provide care when in-person care is not an option.

“If Medicaid, the nation’s largest insurer, and other commercial insurance payers expanded benefits to include mental health and mom/baby wellness home checks for new mothers, imagine the impact this would have on improving outcomes for new mothers that are most vulnerable,” Sparkman observed.

Policy change and legislation would lead to greater change nationwide, but we can start right now with awareness and early steps. As an example, CMS has proposed a “birthing friendly” designation for hospitals as part of its 1,786-page proposal to improve maternal mortality and care.

Part of the designation involves reporting data that will reveal how social determinants such as race, ethnicity, sex, and location affect maternal safety. Hospitals must also report on their responses to maternal health cases to reveal how equitable and effective they are.

Above all, awareness and education are crucial for providers, nurses, healthcare organizations, and the public to improve maternal health outcomes for those who have social and/or behavioral risk factors.