By Joy Burkhard, MBA, and Sarah Johanek, MPH

On June 24th, 2022, the Biden-Harris Administration released the White House Blueprint for Addressing the Maternal Health Crisis, outlining the administration’s vision for the United States to be “considered the best country in the world to have a baby.”

The Blueprint notes: “To make the real progress that mothers in the U.S. deserve, we will continue to ensure that their voices and experiences are a guidepost. We remain focused not only on every birth that ends in mortality or morbidity—but every birth that leaves mothers and families with trauma or that otherwise leaves diminished trust in our healthcare system. We believe that our vision for the future—in which the United States will be considered the best country in the world to have a baby—is a compelling call to action, and we hope you join us in this work.”

This blueprint is the Administration’s call to action to prioritize the health of women, reduce maternal mortality and morbidity, diminish disparities in maternal health outcomes, and improve the experiences of those who are pregnant. The blueprint consists of five main goals with 50 actions that more than a dozen federal agencies will undertake to meet the administration’s goals. These agencies include the U.S. Departments of Health and Human Services (HHS), Agriculture (USDA), Defense (DoD), Housing and Urban Development (HUD), Labor (DOL), Justice (DOJ), and Veterans Affairs (VA), the Environmental Protection Agency (EPA), Office of Personnel Management (OPM), and state Medicaid and CHIP agencies.

These goals are:

Goal 1: Increase access to and coverage of comprehensive high-quality maternal health services, including behavioral health services

Goal 2: Ensure those giving birth are heard and are decision makers in accountable systems care

Goal 3: Advance data collection, standardization, transparency, research, and analysis

Goal 4: Expand and diversify the perinatal workforce

Goal 5: Strengthen economic and social supports before, during, and after pregnancy

Is Maternal Mental Health Addressed in the Plan?

The actions that directly address mental health are outlined below, along with our recommendations for how the Administration could further its maternal mental health reach concerning these goals.

Goal 1: Increase access to and coverage of comprehensive, high-quality maternal health services, including behavioral health services

Action 1.10. Strengthen supports and access to perinatal addiction services for individuals with substance use disorder [SUD] by partnering with hospitals and community-based organizations to implement evidence-based interventions.

“The Department of Health and Human Services (HHS) will work with hospitals and community-based organizations to create more support for those with substance use disorders (SUDs) and will educate individuals on milestones in pregnancy and postpartum to decrease stress and reduce the risk of drug use.”

Our thoughts:

While it’s critically important to address SUDs, the HHS Blueprint falls short in only addressing SUDs and not naming the critical importance of addressing Maternal Mental Health Disorders (MMHDs) both as standalone disorders and comorbid disorders. Further, it is a strong step in the right direction to address working with hospitals and community-based organizations (CBOs) in addressing SUDs, however, HHS failed to address obstetric settings. It’s imperative that the critical role of the primary care medical home: obstetric providers, be named and that strategies be put in place to both support OBs and hold them accountable for screening and initial treatment plan development for MMHDs and SUDs.

Action 1.12. Expand the National Maternal Mental Health Hotline for pregnant individuals and new mothers facing mental health challenges to increase access to mental health care.

“The Administration aims to decrease stigma around MMH by increasing the funding, staffing, and capacity of the National MMH Hotline launched in Spring of 2022. This hotline is confidential, toll-free and accessible 24/7 in Spanish and English via call and text. The FY 2023 budget requests $7 million, doubling the initial investment.”

Our thoughts:

We applaud HHS for effectively implementing the hotline, required by the reauthorization of funding, an effort led by the Maternal Mental Health Leadership Alliance. We also want to ensure the Administration understands a national hotline for mothers should be icing on the cake, that “the cake”, should be to ensure the health care system is working to detect and treat MMHDs in the first place, and in a culturally appropriate and welcoming way.

Action 1.13. Appoint a dedicated Associate Administrator for Women’s Services in Substance Abuse and Mental Health Services Administration (SAMHSA) to lead its efforts on promoting positive mental health during pregnancy and in the postpartum period.

“By appointing an Associate Administrator, the administration hopes to expand federal programs, like Medicaid and childcare, to integrate support for mental health and substance use disorders.”

Our thoughts:

Appointing a dedicated leader focused on Maternal Mental Health within HHS (SAMHSA) is a strong step in the right direction. This Associate Administrator could play a critical role in coordinating inter-agency programs, supporting embedding MMHD prevention and support services in all applicable existing programs, and reducing duplicative efforts between agencies, in line with what the TRIUMPH for New Moms Act will require.

Action 1.14. Expand capacity to screen, assess, treat, and refer for maternal depression and related behavioral disorders by providing real-time psychiatric consultation, care coordination support, and training to frontline health care providers.

“The Full Year (FY) 2023 Budget requests $10 million to allow HHS to expand to seven more states and increase access to treatment and recovery support services. Additionally, the Department of Defense’s Military Health System will implement a reproductive behavioral health consultation service, adapted from the VA, to allow providers to access behavioral health support on reproductive mental health issues related to pregnancy and postpartum.”

Our thoughts:

A study conducted by Mathematica predicted the cost of untreated MMH disorders to be over $14 billion in 2017 and that cost likely increased substantially during the pandemic. Increasing the capacity of screening and treatment services will strengthen our, healthcare system, and better support mothers and other birthing people.

Access to a Telepsychiatry Access line is vital to supporting obstetric medical homes in effectively implementing screening, intervention, and treatment programs. We encourage HHS (and Congress if necessary) to consider developing a national Maternal Mental Health consultation line, to more quickly provide these critical services to obstetric providers in all states, similar to the CDC’s provider consultation line for HIV services. Grants could continue to be provided to states as well as educational institutions and non-profit organizations to educate obstetric providers about maternal mental health disorders and how and when to use the national consultation program.

Further, It is critical to integrate screening for MMH disorders in obstetric provider settings, as promoted in the SAMHSA guide “Essential Elements of Integrated Primary Care and Behavioral Health Teams.”

Action 1.15. Integrate behavioral health supports in community settings by training navigators and community health workers to identify behavioral health needs and link families to local resources, such as medical homes, school-based and other community health centers, community-based organizations, and local community social supports.

“The FY 2023 Budget requests $50 million to train navigators and community health workers to identify behavioral health needs and connect families to community and school resources.”

Our thoughts:

We applaud the Administration for identifying the importance of community-based mental health services in the Strategy to Address the Nation’s Mental Health Crisis and encourage HHS (and Congress as needed) to create/identify a National Mental Health Peer Support Center of Excellence (CoE), to propel the use of state certified peer support specialists who are equipped to provide interventions and care navigation in community-based settings and beyond. All 50 states have state-sanctioned training and certification programs and most states reimburse for these services through their Medicaid programs. Pilots have illustrated the use of state-certified maternal mental health peer support specialists provides an opportune pathway to addressing workforce shortages. The CoE could provide community-based organizations (and health care agencies) with support on how to bill for these services, and more.

Further, HHS should consider not just providing this support through community-based organizations, but also through existing federal programs, like Women Infants and Children (WIC) and Healthy Start whose populations served are less likely to have protective factors in place.

Goal 2: Ensure those giving birth are heard and are decision makers in accountable systems care

Action 2.6. Train providers on implicit biases, culturally and linguistically appropriate care and behavioral health needs of pregnant and postpartum women, including screening and referral for abuse and maltreatment.

“By training providers and students in the program Culturally and Linguistically Appropriate Services (CLAS) in Maternal Health Care, they can better provide culturally competent, patient-centered care while combatting their implicit biases. Additionally, the Agency for Healthcare Research and Quality (AHRQ) Safety Program in Perinatal Care will train providers on trusting and listening to their patients and empowering them to advocate for themselves.”

Our thoughts:

Providers should be trained in implicit bias and implement patient complaint systems. Such processes could be put in place by individual state health care provider boards, however, this could take 15-20+ years with no guarantee all states would adopt such a protocol. Alternatively, the Centers for Medicaid and Medicare Services (CMS) could explore implementing training and complaint monitoring programs through hospitals via admitting rights agreements.

Action 2.12. Reduce the stigma of postpartum depression and other behavioral health conditions through a media campaign to raise awareness about postpartum depression.

“In the spring of 2023, the HHS will launch an awareness campaign for the general public on postpartum depression and how to support families and improve maternal mental health outcomes. This campaign will use evidence-based practices, such as first-person narrative videos, to destigmatize reporting MMH concerns.”

Our thoughts:

As stated in our response to the U.S. Government’s plan to improve maternal health in 2020:

”The Office of Women’s Health should think about partnering with those behind the current U.S. maternal mental health week, awareness campaign (TheBlueDotProject.org), where an audience of perinatal women has already been developed on social media.

It’s also important that mothers’ stories illustrate the process of receiving treatment is mostly fragmented and imperfect, and that no one size fits all experience occurs in the U.S.

Finally and most importantly, I’d like the government to seriously consider that most doctors, nurses, and midwives still are not adequately educated to be responsive (i.e. helpful and not hurtful) when a woman reports symptoms of maternal mental health disorders. All too often, when mothers speak up, they are not taken seriously, they aren’t screened with a screening tool, or worse they are reported to child protective services when they share symptoms of intrusive thoughts or rage, or are sent to the ER only to be placed on a watch for 48 hours, unable to nurse her baby, often shamed and sent home without a treatment plan.”

It is also vital that the awareness campaign does not solely mention postpartum depression as the only MMH disorder, which can do harm, as there is a range of maternal mental health disorders that women, providers, and the general public must be made aware of.

Goal 3: Advance data collection, standardization, transparency, research, and analysis

Action 3.1. Improve data collection by enhancing MMRC data to inform maternal health interventions, supporting PRAMS data collection improvements, working with hospitals in the Maternal Morbidity and Mortality Data and Analysis Initiative to identify drivers of poor outcomes, coordinating with Health Center Program participants to report de-identified data that will help address disparities, working with FEHB carriers to capture race and ethnicity data, requiring reporting of perinatal, behavioral health, and child health measures under Medicaid/CHIP, and including maternity metrics in the public Medicaid and CHIP Scorecard.

The Maternity Core Set is a group of perinatal quality measures that can be voluntarily reported through CMS. In 2024, CMS will mandate reporting by all states of the measures from the Child Core Set, the perinatal measures in the Maternity Core set, and all behavioral health measures.

Our thoughts:

We applaud the Administration’s action plan around the use of data. We also wish to share the following feedback:

The Pregnancy Risk Assessment and Monitoring System (PRAMS) is a robust survey program administered by the CDC. It addresses maternal mental health by asking women if they experienced depressive symptoms and if a provider asked them about depression during the perinatal period. This data has been instrumental as the only national/federal data set for maternal mental health. We are aware that the CDC is expanding the survey to include anxiety for future collection years, which we applaud.

The natural progression is to move from asking women to report whether they were asked by a provider about maternal depression to looking at whether health care providers are screening, with a validated questionnaire (specifically within the perinatal primary medical home, the obstetric provider). 2020 Mom helped champion the development of a maternal depression HEDIS measure which was recently tested by the National Committee for Quality Assurance and for which data will be reported this Fall, for accredited private insurers/plans and participating state Medicaid agencies. We applaud the Centers for Medicaid and Medicare Services (CMS) for requiring this measure to be adopted/reported by all Medicaid plans, via the Maternity Core Set in 2024.

Further, we applaud HHS for working with hospitals (and we presume Perinatal Quality Collaboratives) to analyze maternal mortality and morbidity data, including evaluating data about maternal suicide to identify drivers of poor outcomes. We encourage those leading such efforts to review the hospital “Whole Mom” standards, identified as easy action steps for hospitals to address maternal mental health. We also applaud the Administration for other efforts, like the National Institute of Health’s IMPROVE initiative to directly address disparities.

We also agree that the Federal government as the nation’s largest employer should review its own benefits packages through the Federal Employees Health Benefits (FEHB) Program. In addition to having FEHB collect race and ethnicity data of providers, the FEHB should consider providing employees/spouses/domestic partners with benefits like coverage of pregnancy, delivery, and postpartum certified doulas and state-certified peer support specialists. The FEHB Program should also ensure that there are adequate numbers of reproductive psychiatrists and perinatal mental health-certified behavioral health therapists in their provider networks as well as midwives, obstetricians, and birth centers/hospitals. Further, the FEHB Program has a significant influence to require health insurers to find creative solutions to addressing facility and workforce shortages, like requiring these plans/insurers to pay into a pool to train providers and develop new facilities for example.

We are also excited and eager to learn more about how HHS and HRSA may support non-profit and public patient-directed “Health Centers” (HRSA) in providing maternal mental health services through providers like behavioral health therapists and certified peer support services using “sliding-scale” fee approach as noted on the HRSA website linked above.

Finally, we applaud the Administration for also looking at the role of Federally Qualified Healthcare Centers (FQHCs). We encourage HHS/HRSA to create a system for monitoring the rollout of the HEDIS/Core Set measure as well as the U.S. Preventive Service Task Force’s recommendations for screening for those who are at risk as well as for the adoption of the Forthcoming Alliance for Innovation in Maternal Health (AIM) endorsed, Maternal Mental Health standard of care, “Bundle.”

Our closing thoughts:

The Administration is clearly very committed and concerned about the state of maternal health and the rising rates of preventable maternal mortality in the U.S. We urge the White House and HHS to ensure that maternal mental health barriers and opportunities are examined as closely as they have for medical-related maternal health challenges and Substance Use Disorder. Maternal Mental Health sits at the intersection of maternal health, substance use, and racial disparities and it’s time to invest time, resources, and a laser focus on the disturbing growing rates of maternal mental health disorders - for the future of mothers and babies.