Hsieh A. Mental health and postpartum mortality in the COVID-19 era. HPHR. 2021;34.
Mental health concerns have increased significantly over the course of the COVID-19 pandemic while disproportionately affecting young adults and females. Concerns regarding social isolation, financial and food security have contributed to this rise, further widening the gap of social disparities. Additionally, mental health disorders are now acknowledged as one of the top attributable factors in the rising maternal mortality crisis in the United States. Postpartum depression is a significant risk factor for suicidal behaviors, both of which has been climbing over the last decade with suicidal ideation doubling among pregnant women. This has led to the search for potential points of intervention, including postpartum emergency room visits as a key area to develop. Furthermore, over three quarters of maternal deaths related to mental health occur after 6 weeks postpartum, which highlights the disparity created by the short 60-days postpartum Medicaid coverage. During the pandemic, postpartum depression prevalence increased from 11% pre-pandemic to 37% in the United States. Although the true impact of COVID-19 on mental health attributable maternal mortality is still evolving, there will no doubt be a long-lasting effect. It is imperative that public health leaders advocate in this critical time to support our dying mothers.
The COVID-19 pandemic has affected countless aspects of our lives. In particular, mental health concerns increased considerably globally and across the United States.1 Various degrees of restrictions imposed in different states and countries compounded with concerns of social isolation, financial and food insecurity has had detrimental effects on mental health.2,3 Research from prior epidemics and other emerging infectious diseases have been attributed with increased mental health burdens during outbreaks including increased risk of postpartum depression.4–6 During the COVID-19 pandemic, the upsurge of mental health concerns in our population disproportionately affects young adults and females.2,3,7 Furthermore, mental health has been shown to be one of the top contributors for maternal mortality in the U.S., with the majority of those deaths among younger females.8 This raises important concerns about the impact of COVID-19 pandemic on maternal mortality through the lens of mental health.
However, prior to this pandemic, mental health was already a rising topic of importance accounting for a one trillion dollar annual global economic impact.9 In fact, the World Health Organization (WHO) created a new special initiative advocating for universal mental health coverage in 2018.9 This initiative spans a 5-year period between 2019 to 2023 covering 12 countries with over 100 million people. The goals are to improve mental health policies, quality, affordability, and accessibility.9
United States has one of the highest maternal mortality rates (MMR) among high-income countries.10 While maternal mortality decreased by 44% worldwide, the trend has been steadily increasing in the U.S. from 7.2 maternal deaths per 100,000 live births in 1987 to 17.4 deaths per 100,000 live births in 2018, creating a national maternal mortality crisis.11,12 One in three deaths within a year postpartum are caused by pregnancy-related complications and two third of these deaths contain components of care that could be improved and aid in preventing maternal deaths.13 In response to the crisis, the 115th Congress passed the Preventing Maternal Deaths Act of 2018 (H.R.1318) signed on December 21, 2018, allowing the Center of Disease Control and Prevention (CDC) to establish the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) in September 2019.14,15 This supported and enabled many states to form Maternal Mortality Review Committees (MMRC) to review deaths within a year of the end of pregnancy and provide recommendations to improve maternal health. As of October 2020, 49 states and the District of Columbia and Puerto Rico are implementing or has an established MMRC.16–18
Through the work by various MMRCs, mental health disorders have been noted as one of the leading causes of maternal mortality.8,19–21 Some studies have attributed mental health disorders as a cause in up to 36% of maternal deaths.22 In Massachusetts, over half (50.7%) of pregnancy-associated deaths had a mental health disorder diagnosis during pregnancy and 91% had mental health concerns prior to pregnancy.23 Furthermore, the majority of these deaths occur between 6 weeks and one year postpartum.20,22,24 Texas’ MMRC noted that 86% of pregnancy-related deaths due to mental disorders occurred beyond the 6-week postpartum time frame, while 90% were similarly described among substance use related deaths in Massachusetts.20,24 This is particularly significant since Medicaid, which insures approximately 48% of all births in United States, only extends coverage for pregnant individuals up to 60 days postpartum in states that opted out of the Medicaid coverage expansion under the Affordable Care Act.25,26 Due to this, many organizations and MMMRCs have pushed to extend coverage to 1 year postpartum. Globally, MMR underestimates the true effect of mental health disorders since the WHO uses ICD-10 coding which defines maternal death as “death during pregnancy or within 42 days postpartum” and does not take into account late maternal death in the MMR calculation.27,28
It is important to understand perinatal depression and its consequence on parental and infant health. Over 264 million people are affected by depression.29 Diagnostic criteria for major depression follows the DSM-5 criteria of a combination of depressed mood or loss of interest, cognitive and physical symptoms over a 2-week period. The prevalence of depression in United States is 8.1%, however, women are twice (10.4%) as likely to be diagnosed with depression than men (5.5%).30 Furthermore, there is evidence of differences in clinical presentation between males and females, where symptoms presented by males can be masked and diagnosed with comorbid alcohol and substance abuse.31,32
Maternal perinatal depression is well established and recognised in the DSM-5. The prevalence of maternal postpartum depression is ranges from 11% to 19%.33,34 Due to the high prevalence of maternal postpartum depression, screening in the postpartum period has been recommended by several organizations including the U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics.35–37 One of the most commonly used screening tools is the Edinburgh Postnatal Depression Scale (EPDS) which is a 10 item validated questionnaire.35,38 Fisher et al. identified 3 distinct trajectories for women with postpartum depression. These included gradual remission (50.4%), partial improvement (41.8%), and chronic severe (7.8%). Seeking early healthcare consultation was associated with a less severe trajectory which is in keeping with the screening recommendations.39
There are significant consequences and morbidity of perinatal depression. It is associated with impaired bonding with infant, early cessation of breastfeeding, preterm birth, low birth weight, and negative maternal behaviors.35 This can negatively impact the infant’s cognitive and psychological development, as well as increase the risk of behavioral problems and psychiatric disorders. The most severe morbidity involves infanticide.32,35
While maternal perinatal depression is well recognized, paternal perinatal depression (PPND) is less well studied. Nonetheless, it is important to consider the mental wellbeing of both new parents as this affects their relationship, infant bonding, and the significant other’s mental health. The data surrounding paternal perinatal depression prevalence is heterogenous and quoted around 8-10%, or about twice that of the male general population prevalence.32,40,41 Despite robust maternal screening recommendations, routine screening of the paternal partner has not yet been recommended, leading to potential underestimation or misdiagnosis.32
Studies have shown that paternal perinatal depression can be present throughout pregnancy and postpartum with the highest prevalence peaking (up to 26%) at 3-6 months postpartum. Furthermore, presence of maternal depression has been correlated as a strong predictor of paternal depression and vice versa.40 Three main profiles have been established including anhedonic, anxious-worried, and depressive.42 Paternal perinatal depression has been associated with significant morbidity including comorbid mental health disorders, sexual dysfunction, marital dissatisfaction, and negative impact on the child similar to that described above.32
Contrary to maternal mortality rates, mortality rate associated with paternal perinatal depression or in the postpartum period among the partners has not been well studied. Notably, suicide rates in United States have risen by 30% between 1999 (12.3 deaths/100,000 persons) and 2016 (15.4 deaths/100,000 persons) with firearms being the most common method (48.5%). Fatality rate of suicide attempts is significantly higher in males, and accounts for 77% of suicides in the US in 2015.43 However, it is difficult to ascertain the impact of paternal perinatal depression on suicidality. Despite the lack of screening recommendations, the EPDS has been validated in perinatal paternal population. Additional screening tools specifically for paternal perinatal depression includes the Perinatal Assessment of Paternal Affectivity (PAPA) calling to question the need to reconsider screening guidelines.32,44 While paternal morality rate and depression do not directly contribute to maternal mortality rates, it warrants further discussion and consideration of paternal needs with new perinatal depression or maternal mortality initiatives.
Within the maternal mortality crisis, up to 36% of maternal deaths in the US can be attributed to mental health disorders.22 The majority of deaths unfortunately occur beyond the usual Medicaid coverage period. However, research shows that there are many points of potential intervention that are important areas to highlight for future public health initiatives and policies.
Suicide or suicidal ideation is one such topic. A Canadian population-based study showed a perinatal suicide rate of 2.58 per 100,000 live births (5.3%) with the highest risks among rural regions and in the last quarter of the first postpartum year.45 Suicidal ideation among pregnant women in the US has doubled from 47.5 to 115.0 per 100,000 pregnancy- and delivery-related hospitalizations. Yet over 30% of those patients with suicidal behaviours were not diagnosed with depression.46 Another study by Admon et al. looked at the trends of suicidal ideation and attempts a year prior to and after pregnancy. They noted a significant increase from 2006 to 2017 in both ideation (100/100,000 vs 500/100,000 individuals, p<0.001) and attempts (100/100,000 vs. 200/100,000 individuals, p<0.001). Concomitant diagnosis with depression or anxiety increased the prevalence from 1.2% per 100 individuals in 2006 to 2.6% per 100 individuals in 2017.47 This intersection between suicidal ideation or attempt, and concomitant mental health disorders emphasizes a critical opportunity for prevention of suicidal completion.
The urgent care is another common touch point. Among women with perinatal depression, they were found to be using the urgent care more frequently than those without symptoms (26% vs 15.1%). Furthermore, they were more likely to be younger, of lower socioeconomic status, and uninsured.48 Another study similarly demonstrated an association between postpartum mental health disorders and emergency department use in the first 30 days postpartum (aOR 1.74, p<0.001).49 The California MMRC identified that the majority of drug-related or suicide deceased women made at least one emergency department or hospital visit between their delivery and death date. This indicates that these visits are important points of intervention to be further explored.21
Many treatment options for individuals with perinatal depression includes counselling and therapy sessions. However, the COVID-19 pandemic has severely restricted in-person access to many resources including counseling and crisis management.50 In addition to social isolation, many hospitals are limiting visitor and support persons access during visits, labour, and postpartum.51 Furthermore, pregnant women are at higher risk of severe illness with COVID-19 compared to their non-pregnant counterparts.52
Multiple studies have investigated the effect of COVID-19 on maternal mental health given the current stressors. These studies demonstrated the prevalence of perinatal depressive symptoms to range from 25% to 37%, and anxiety symptoms between 29% to 57%.53–57 This is a large increase compared to before the pandemic with maternal postpartum depression prevalence between 11% to 19%.33,34 Studies are currently underway to better understand protective and risk factors to perinatal mental health in the COVID-19 pandemic as to provide policy recommendations and intervention strategies.58 Although data is not available yet to determine the impact this has on mental health attributable maternal mortality, it highlights a critical need to improve maternal mental health support.
In December 2020, the U.S. Surgeon General made a call to action to improve maternal health.59,60 The emergence of mental health as a top cause of maternal mortality, particularly in light of the rising concerns among this population during the pandemic, forces us to highlight the importance of this matter as public health advocates. United States is in the midst of a maternal mortality and mental health crisis. We must educate the public population and engage the stakeholders and policymakers to change the structure of our healthcare system to better support our dying mothers. This starts with recognizing the various touch points for intervention and implementing resources and support. It also means underlining the role of partners and ensuring mental wellbeing among all new parents, not just the women. Most importantly is to provide quality and timely access to mental health resources and health coverage. Leveraging these crises to increase national Medicaid coverage to at least a year postpartum is a critical first step. Prioritizing mental health and maternal mortality cannot wait.
Dr. Ada Hsieh is a Canadian medical resident in Obstetrics and Gynaecology and is passionate about the intersectionality of public health and women’s health. She is a women’s health advocate who promotes preventative medicine for maternal health and gynaecological cancers.