What We're Reading
By Joy Burkhard, MBA
Founder and Executive Director, 2020 Mom
In this edition, we share the latest articles on maternal health, telehealth, and reproductive access (including new labeling of the morning after pill). The articles that most excited and saddened me were an article addressing the role a bachelor’s level psychologist can play in conducting assessments to pinpoint diagnoses, and a new study that highlighted the pandemic had an outsized impact on maternal overdoses – an 81% increase from 2017-2021.
PREVENTING PREGNANCY
Their Mothers Were Teenagers. They Didn’t Want That for Themselves.
Teen pregnancies have plummeted, as has child poverty. The result is a profound change in the forces that bring opportunity between generations.
MATERNAL MORTALITY / SUICIDE
Viewpoint: Texas Falls Short on Maternal Care
Of the pregnancy-related deaths, 90 percent had at least some chance of being preventable, the committee found. All told, the 118 maternal deaths resulted in an estimated 184 children who were left without a mother. The study also found obesity, mental health and discrimination were leading contributors for pregnancy-related deaths.
It also found six underlying causes accounted for 79 percent of the reviewed 2019 pregnancy-related deaths: obstetric hemorrhage (25 percent), mental health conditions (17 percent), noncerebral thrombotic embolism (12 percent) and injury (10 percent) were the leading four. Cardiovascular conditions and infection (8 percent) tied for fifth.
Maternal Deaths in the U.S. Are Staggeringly Common. Personal Nurses Could Help
"It was a little scary. But, being that I had the nursing group, I had my whole team at the hospital, I really felt like ... my pregnancy was very smooth," she says.
That model, first studied in a randomized controlled trial more than 40 years ago, pairs low-income, first-time parents with a personal nurse from pregnancy through their child's second birthday.
Progress Is Slow as America Tackles Maternal Mortality Crisis
Chiquita Brooks-LaSure, the head of the Centers for Medicare & Medicaid Services, said there that most states expanded Medicaid postpartum coverage from 60 days to 1 year, with help from the American Rescue Plan Act of 2021. She also unveiled a birthing-friendly hospital designation — essentially a badge awarded to hospitals that have demonstrated a commitment to maternity care quality, safety and equity. More than 25 healthcare plans have agreed to display the icon in their hospital directories.
But despite the federal push, attention to this issue at the state level still varies.
TREATMENTS
Pharmacological Treatment for Postpartum Depression: A Comprehensive Review
This summary provides a run down of drug therapies and non-drug therapies for PDD that women has expressed interest in.
Selective serotonin reuptake inhibitors (SSRIs) like sertraline are effective in acute management. Venlafaxine and desvenlafaxine are serotonin-norepinephrine reuptake inhibitors used for the relief of symptoms. The SSRI and tricyclic antidepressants (TCA) used in combination have a prophylactic role in PPD. Women prefer psychological therapies, complementary health practices, and neuromodulatory interventions like electroconvulsive therapy more than previous pharmacological treatments of depression. Allopregnanolone drug made into sterile solution brexanolone leads to a rapid decline of PPD symptoms.
Vitamin D Status Should Be Explored to Reduce Anxiety, Improve Mental Health
Limited dietary intake of vitamin D and minimal sun exposure increases the risk of clinically significant anxiety symptoms in young women.
Art vs. Angst: Brussels Offers a New Way to Beat Depression
Museums and doctors in the Belgian capital are teaming up on an initiative that uses cultural outings as an antidote to depression.
A 2019 World Health Organization report cites more than 3,000 studies identifying a "major role for the arts in the prevention of ill health, promotion of health, and management and treatment of illness across the lifespan."
Doula Care and Maternal Health: An Evidence Review
Though improving access to doula services would not singlehandedly address the ongoing need to improve access to clinical care services in some communities across the U.S., coverage for doula services is one option to improve the maternity care experience for patients and provide supports that can contribute to improved maternal health outcomes as described later this report.
COVID
Mental Health of Working Parents During the COVID-19 Pandemic: Can Resilience Buffer the Impact of Psychosocial Work Stress on Depressive Symptoms?
A result research study’s results highlight the need for measures to reduce psychosocial work stressors on parents and to promote resilience, partially supporting the potential protective role of resilience buffering.
A subsample of working mothers and fathers completed the subscale for work-privacy conflict (WPC) of the Copenhagen Psychosocial Questionnaire, the Effort-Reward Imbalance (ERI) Questionnaire, the Connor-Davidson Resilience Scale (CD-RISC), and the Edinburgh Postnatal Depression Scale (EPDS).
Dramatic Pandemic Changes Led to Increased Stress for Mothers: Study
Mothers who reported greater disruption in daily life during the COVID-19 pandemic were more likely to experience symptoms of traumatic stress.
The Failed Promise of Online Mental-Health Treatment
Heavy advertising and other strategies from Silicon Valley’s playbook boost providers’ growth but not the quality of care
Remote treatment of mental-health problems surged in the pandemic, as in-person treatment became difficult while pandemic-driven isolation increased anxiety and depression.
Digital mental-health companies plunged in, promising to provide millions with access to high-quality care by video, phone, and messaging. Hiring consultants rather than employees is one of the problems.
Consider What Happens When We Don't Care for NICU Parents
— Here's how hospitals can support parental mental health
As the National Perinatal Association outlines mental health initiatives can be implemented with families via universal distress screening; "layered levels of support" through education, especially peer support groups; and employment of mental health professionals. Here are my recommendations for how these may be best incorporated into standard care.
COVERAGE AND ACCESS
New Draft Law in Romania Gives Mothers Free Psychological Counseling Before and After Giving Birth
Romania's Chamber of Deputies recently approved a draft law that would have women who have recently given birth benefit from psychological counseling in state maternity hospitals. Until now, mothers could receive counseling only during the time they were hospitalized.
Amid Dire Maternal Mortality Rates, Congress Falls Short on Medicaid Postpartum Care
The stunted legislative language now reflects the Helping MOMS Act rather than the MOMMA’s Act, which would have required all states to provide coverage. It comes amid staggering maternal mortality rates — the worst in the developed world — that have only further deteriorated during the pandemic. While 33 states opted into a Biden administration offering this April to extend Medicaid postpartum care for a year, most of the resistant states are in the Midwest. Several of those states have among the country’s worst maternal mortality rates, and many have implemented stringent abortion restrictions in the wake of Roe v. Wade’s upheaval. Texas is one of them.
Telehealth May Reduce Racial Disparities in Postpartum Visit Attendance
Availability of telehealth significantly reduced disparities in postpartum visit attendance between Black and non-Black patients, researchers reported in the American Journal of Obstetrics & Gynecology Maternal-Fetal Medicine.
HEALTH DELIVERY REFORM
Primary Care Physicians Try to Give Their All — Until They Can’t. It’s Time to Flip the Archetype to Teamwork
Six months before the Covid-19 pandemic emerged, Skip died by suicide. At his memorial service, a friend described Skip’s dedication to his patients: he would overhear Skip tell his wife he’d be home to cook dinner, only to get into a series of telephone calls with patients and miss dinner altogether. Patients described how when they were ill, Skip would double book them into his schedule or go see them at home.
HHS Assistant Secretary: Action Plan For Primary Health Care Is ‘Proceeding Really Well’
WASHINGTON — HHS officials are working on an action plan that will improve access to primary care and support the integration of behavioral, environmental, oral and reproductive health care services.
During the Primary Care Collaborative’s annual conference, Admiral Rachel L. Levine, MD, assistant secretary for health at HHS, said the action plan builds on a report from the National Academies of Sciences, Engineering and Medicine (NASEM) that outlines recommendations for rebuilding the foundation of primary health care.
Lessons From Ecuador on Responding to the Mental Health Crisis in the U.S. And Around the World
Though many countries have implemented policies…the pace of spending on behavioral health and getting mental health services into primary care settings has been slow.
To provide more access to mental health services…a mental health test model includes…10 clinics that feed into a local hospital.
The program aims to increase the capacity of clinics to identify, diagnose, and treat people with mental illness. Clinic staff learn how to implement simple tools to identify individuals with possible depression, anxiety, and other conditions such as bipolar disorder or schizophrenia. Bachelors-level psychologists are trained to screen and assess patients, provide evidence-based psychoeducation for depression and anxiety based on cognitive behavioral therapy principles, and refer those with more complex problems to psychiatrists.
Opportunities to Improve Maternal Health Through Value-Based Payments
Paying differently for high-value versus low-value care and tying reimbursement to maternal and infant quality outcomes as well as total costs can help address challenges in maternal care. Value-based models can encourage evidence-based care throughout a pregnancy and post-partum periods,6 such as: • Screening for health risks during pregnancy, such as hypertension or depression.
REPRODUCTIVE CARE
Abortion Access Tied to Suicide Rates Among Young Women
Enforcing restrictions on reproductive care linked with nearly 6% rise in suicide rate
In a Doctor’s Suspicion After a Miscarriage, a Glimpse of Expanding Medical Mistrust
She’d had a miscarriage, the doctor said, once she was dressed. That was why she’d been in pain, why there was no fetus visible on the ultrasound. He was sorry for her loss. She felt a surge of relief, and teared up. The doctor mistook that for devastation. Gently, he began asking questions, his voice soothing.
Had she been trying to get pregnant? No. Did her partner know? No. Had she been pregnant before? Yes. How many kids did she have? None. Miscarriage? No, she said, an abortion, when she was 19 — and suddenly, something in the doctor changed.
FDA Updates Plan B Product Labeling, Clarifies It Is Not an Abortion Pill
The Food and Drug Administration (FDA) on Friday announced it had approved a request by the makers of Plan B to update how information about the drug is presented.
Along with several changes, the agency specified that Plan B does not cause abortions.
“Plan B One-Step prevents pregnancy by acting on ovulation, which occurs well before implantation. Evidence does not support that the drug affects implantation or maintenance of a pregnancy after implantation, therefore it does not terminate a pregnancy,” the FDA said.
Levonorgestrel, better known under the brand name Plan B One-Step or colloquially as the "morning after" pill, is an over-the-counter medication used to prevent the chance of pregnancy following unprotected sex or when contraceptive methods failed or were not used.
SUD
US Trends in Drug Overdose Mortality Among Pregnant and Postpartum Persons
This newly published study suggested the COVID-19 pandemic has an outsized effect on overdoses among pregnant and postpartum people. In 2020, pregnancy-associated over deaths saw a 46% spike in one year and an 81% increase since 2017, largely attributed to fentanyl and polysubstance use. This research highlights the urgent need for increased access to stigma-free treatment and non-punitive systems of support.
EQUITY
Centering Equity in the Nation’s Public Health System
Considerations for the U.S. Centers for Disease Control and Prevention and Its State, Local, Territorial, and Tribal Public Health Partners
ACES
The Legacy of Trauma in Parent-Child Relationships
Childhood trauma can have long-term effects on physical and psychological health, for mothers as well as children.
Women who have had more childhood trauma may experience more stress and negative life events while pregnant.
This stress predisposes mothers to experience postpartum depression, which makes connecting with infants more difficult.
Tracing this path allows researchers to understand how childhood trauma can have negative influences on the next generation.
RESEARCH
New Support for a Serotonin Deficit in Depression
Since the 1960s, researchers have postulated that major depression stems from disruptions in the serotonin neurotransmitter system, but the evidence for that idea, though plentiful, was indirect. In fact, a recent comprehensive analysis of existing studies concluded that there was not strong evidence to support the 'serotonin hypothesis.' In its wake, some in the field have called for a reexamination of the hypothesis. Not so fast, says a new study that provides direct evidence of disrupted serotonin release in the brains of individuals with depression.
Stress During Pregnancy Linked to Shorter Telomeres for White, Not Black, Children
Maternal stress during pregnancy was associated with shorter telomeres among the offspring of white mothers, but not those born to Black mothers, according to prospective data published in Psychological Medicine. Shorter telomeres have been associated with increased incidence of diseases and poor survival.
Babies, Parenthood and the Brain: What Do We Know?
Early in life, interactions between babies and their parents or caregivers help to cultivate the infant’s growing brain. The brain’s basic architecture is mostly present at age two, and selective “pruning” of the neural connections formed during this period continues to adulthood. As a result, these structures are formed through interaction with their early life environment.
Not only can a child’s brain be influenced by their parents, but there is also neurological evidence that parents’ brains can be rewired to nurture and protect their newborns. Changes in the maternal brain are well studied, and hormones such as oxytocin, prolactin and estradiol all influence maternal behavior in rats and other mammals. However, although changes to paternal brains do occur, these are less well understood.
Postpartum Depression Crisis Since the Second Lockdown and ‘Screening Paradox’: Many Women Identified, Very Few Treated
Increased severity of depression and anxiety symptoms during the pandemic indicates the need for additional psychological support for postpartum women. However, very few women are diagnosed in health facilities in the first year postpartum and thus are rarely referred for further treatment. The study shows that the availability of services and the focus on social and individual barriers may be critical factors in implementing perinatal mental health programs and practices. This may be especially needed in a country where the screening obligation is new. In case of a further pandemic, policymakers and health care professionals should be aware that the duration of the restrictions and the repetition of lockdowns are associated with the aggravation of symptoms. The online screening without the possibility to discuss the results is only partially effective in increasing referrals for possibly affected women.
Children Who Grow Up Around Domestic Abuse Have Poorer Social Development
Children who grow up seeing their mothers experience intimate partner violence (IPV) or depressive symptoms have poorer socioemotional development, according to a new study published in JAMA Network Open.
Almost 1 in 4 women experiences IPV during their lifetimes. Researchers note that mothers exposed to IPV are more likely to suffer from depression and administer harsh discipline to their children, which in turn may negatively impact child socioemotional development.