Bringing Postpartum Depression Out of the Shadows Act
Women are expected to be happy after the birth of their child. What happens when they feel the opposite instead? Most women experience baby blues after giving birth, which is very common and typically lasts for about two weeks. However, some women experience more intense feelings of sadness and hopelessness; they become withdrawn from family and friends and lose the ability to do daily life activities. When women start having these symptoms, they are going through postpartum depression (PPD), which may occur up to a year after birth. PPD does not go away on its own, unlike baby blues. It can turn to postpartum psychosis if not treated, and women can ultimately harm themselves or their baby (Centers for Disease Control and Prevention [CDC], 2020).
PPD as a condition itself is nothing new. It has been around since women have been giving birth. Since it used to be stigmatized, women did not receive proper treatment. Women suffered through PPD by themselves because they feared of being placed in psychiatric hospitals and being away from the child and family (Rysavy, 2013). Hippocrates, in the 4th century BC, first hypothesized that women could experience delirium and mania from uterine bleeding that was not fully expelled and instead went to the women’s brain (Rysavy, 2013). Hippocrates’ hypothesis was supported by Louis-Victor Marcé in 1858 when he hypothesized that PPD is associated with physiological and hormonal reproductive changes after birth. According to Marcé, PPD should be considered its own diagnosis since the combination of symptoms during PPD is distinctive from other mental health conditions (Rysavy, 2013). Despite research indicating PPD as its own diagnosis, the Diagnostic and Statistical Manual of Mental Disorders (DSM) IV in 1994 added PPD under the Major Depressive Disorder category with peripartum onset occurring during pregnancy or in the four weeks postpartum (Shortsleeve, 2020).
An estimated 15% of women experience PPD, which is much higher than the 10% of women being diagnosed with gestational diabetes (Penn Medicine’s Department of Communications, 2016). The US Preventive Services Task Force (USPSTF) made a recommendation for OB providers (physicians, midwives, nurse practitioners) to screen and provide counseling to pregnant women with one or more risk factors: personal or family history of depression, history of physical or sexual abuse, having an unplanned pregnancy, current stressful life events, low socioeconomic status, lack of social or financial support, and adolescent parenthood. Through cognitive behavioral and interpersonal therapies initiated during the 2nd trimester, women will benefit from the prevention of developing PPD (USPSTF, 2019). However, since there is no standardized screening tool, depression questions vary from state to state. In fact, about 1 in 5 women were not asked during a prenatal visit, and 1 in 8 were not asked during a postpartum visit (CDC, 2020).
Maternal mental health (MMH), including PPD, can cause higher work absenteeism and an increased risk of maternal health morbidity and mortality on the mother. It can cause an increased risk of sudden infant death syndrome, behavioral and developmental disorders, and chronic health conditions (asthma, obesity) on the child. The societal cost of untreated MMH in 2017 was 14.2 billion for all births when following conception to age five. A mother and child pair cost $32,000 each over six years. Because of its societal cost, stakeholders, including the government, employers, and health insurance companies, should support programs that help lower MMH incidence (Luca et al., 2019).
To address PPD and its effects on women and children, Representative Katherine Clark of Massachusetts developed the Bringing Postpartum Depression of the Shadows Act. Rep. Clark was inspired by the Massachusetts Child Psychiatry Access Project (MCPAP) for Moms (Bologna, 2016). It was first introduced in the House of Representatives in July 2015. It was then introduced in the Senate by Senator Dean Heller in November 2015. It was incorporated into the 21st Century Cures Act, and after winning the House and Senate votes, President Obama signed it into law on December 13, 2016 (Burkhard, 2017). Congress is required to allocate $5 million per year from 2018-2022 to fund a minimum of three states (Burkhard, 2017). “For the purpose of screening, assessing, and treating PPD, the grants would allow states to create, improve, or maintain programs around maternal mental health and help women who are pregnant or recently gave birth” (Bologna, 2016, para. 4). Before the passage of Rep. Clark’s act, a similar bill, the MOTHER’S Act, was passed by Congress in 2010 as part of the Affordable Care Act. It was also developed to provide research about PPD screening benefits and the best treatments for PPD. While it was not funded, it introduced PPD into the federal legislative record (Maternal Mental Health Leadership Alliance [MMHLA], n.d.). To ensure the success of the Bringing Postpartum Depression Out of the Shadows Act, specialized interest groups and stakeholders formed the National Coalition for Maternal Mental Health. The alliance includes both national and local organizations, including National Institute for Health Care Management, Healthy Mothers Healthy Babies, March of Dimes, American College of Obstetrics and Gynecology, Postpartum Support International, 2020 Mom, Jenny’s Light, Junior League of San Francisco, Maternal Mental Health Now, Motherwoman, and Postpartum Health Alliance (2020 Mom, n.d.a).
Through a competitive grant process, only seven states- Florida, Kansas, Louisiana, Montana, North Carolina, Rhode Island, and Vermont were chosen among 31 states and DC that applied (MMHLA, n.d.). Like MCPAP for Moms, the goal of the funding is to establish or expand programs directed towards screening and treating MMH. MCPAP for Moms includes a patient-centered, multidisciplinary team. It provides training sessions and a toolkit for OB providers to identify MMH symptoms. If the patient screens positive for MMH, like PPD, the OB provider calls a helpline to get in touch with a psychiatrist for a faster referral. The psychiatrist does a phone consultation with the patient within 30 minutes and arranges a face-to-face consultation within a week or two. A resource and referral specialist also works with the patient to find therapy session support groups tailored to her needs (Chatterjee, 2020).
California has developed MMH laws that 2020 Mom supports. AB 3032 (Hospital Maternal Mental Health), effective since January 2020, requires hospitals to train OB providers to assess and teach pregnant women for MMH symptoms and how to seek help if they have these symptoms. AB 2193 (Obstetric Provider Screening and Insurance Company MMH Program Development), effective since July 2019, requires OB providers to screen pregnant or postpartum women at least once using the Edinburgh Postnatal Depression Scale to aid them in developing a diagnosis and a treatment plan. It also urges insurance companies to develop an MMH program to help women receive timely treatment (2020 Mom, n.d.b).
Screening, identifying, and treating MMH has been proven to be cost-effective (Camacho & Shields, 2018). Unfortunately, funds directed towards MMH are limited. If Congress allocated an additional $5 million, five more states would receive funding to improve, maintain, or establish MMH programs. Moreover, it would take $2 million to fund a national hotline in all states with access to a 24-hour voice and text support (MMHLA, 2021).
COVID-19 has increased the rates of MMH by 3-4 times (MMHLA, 2021). The US has not perfected the way it deals with MMH. The Bringing Postpartum Depression Out of the Shadows Act has opened more ways to help pregnant and postpartum women deal with MMH, like PPD. Providing OB providers tools on screening patients and working with psychiatrists is beneficial in treating women on time. Screening patients also destigmatize MMH conditions and encourage them to open up and receive treatment. As nurse practitioners, we must support programs that train us to screen and assess patients for MMH symptoms, so when we encounter a pregnant or postpartum patient, we know what initial steps to do, who to call for referrals, and what local resources patients can use. We must be vigilant to provide counseling and treatment to our patients as early as possible before they can harm themselves or their families.
Bringing Postpartum Depression Out of the Shadows Act