2023 Maternal Mental Health Roadmap

Though there are some general barriers that apply across state lines, many challenges are state-specific. It takes leaders from state healthcare professional associations, government, insurers, hospitals, and mothers with lived experience to get to the root causes of poor outcomes in states. These Commissions or task forces can be formed at the urging of the governor, by the state health and human services agency (or its delegated agency), by legislature, or through HHS/public health directly. Model legislation, model agendas, and template reports are available through the Policy Center for Maternal Mental Health. 

Legislatures and/or Governors can issue a proclamation or resolution declaring May Maternal Mental Health Month, or the first week of May Maternal Mental Health Week. State health and human service agencies, in conjunction with other agencies such as public health departments, should prioritize raising awareness and in unique ways, which could include: deploying a cross-sector social media campaign, requiring birthing facilities to utilize posters from the state or national nonprofit organizations, embedding the blue dot, the universal symbol of maternal mental health into bus stop campaigns, etc. The national Maternal Mental Health Hotline could be shared as a resource. Model proclamations and awareness materials are available through the Policy Center for Maternal Mental Health https://mchb.hrsa.gov/national-maternal-mental-health-hotlineHealth.

It has been recommended by the workgroup advising CMS that the 2025 CMS Adult “Core Set” of mandatory measures include the HEDIS postpartum depression screening measure. States can require reporting prior to 2025, and require that plans also report the depression screening during pregnancy measure. (Of note, commercial plans/insurers who obtain NCQA Accreditation are currently required to report on both the pregnancy and postpartum HEDIS measures).

Though the focus of research, and therefore programs and initiatives was postpartum depression, research now clearly illustrates that new onset of maternal depression and anxiety happens nearly as frequently in pregnancy as in the postpartum period. When untreated in pregnancy, these disorders lead to preterm birth and poor outcomes for the mother and baby. State Medicaid agencies can recognize the importance of obstetric providers (including Ob/Gyns and midwives) in detecting and treating these disorders early in pregnancy by addressing reimbursement for screening for these disorders, just as many states have addressed screening reimbursement for pediatricians.

Health plans and insurers are in a significant position to effectuate change. Quality Management programs are created by plans and insurers to monitor the delivery of care and services and create interventions to improve performance and outcomes. States can require through legislative and/or regulatory guidance and oversight development of Quality Management programs for both Medicaid and commercial plans/insurers. These programs will help plans/insurers prioritize actions to support maternal mental health. Interventions could include: (1) Providing direction to obstetric providers (Ob/Gyns, Midwives and Family Practice PCPs) regarding fee-for-service billing codes for screening and treatment outside of the global maternity care capitation; (2) Monitoring network adequacy related to the number of Perinatal Mental Health Certified (PMH-C) providers and taking strong actions to recruit/adequately reimburse such providers; (3) Creating care management programs to assist Ob/Gyns and midwives and patients with obtaining patient care. These programs could include transportation support and child care support, in addition to standard nurse/social worker outreach. Care coordination reports could be provided monthly to the treating obstetric provider.

All states now have a state-sanctioned certified peer support training, certification, and Medicaid reimbursement program.However, states which developed these programs years ago may only have addressed the use of peers for substance use disorders.In that case, programs should be expanded to address the provision of mental health services. States should recognize the value of peer support services (MH/SUD) for the maternal population and work to deploy them into clinical and community-based settings to immediately expand the behavioral health workforce and provide culturally competent and approachable services to mothers and expectant mothers in need. (The Policy Center for Maternal Mental Health is working in partnership with sister nonprofit organizations to provide an add-on maternal mental health training for state-certified peer specialists.)

Through legislative and/or agency-based services, states can support existing nonprofit community-based organizations (CBOs) and development of new CBOs through: offering grant programs and training on how to become a billing provider, hiring/supervising of certified peer support specialists, billing for certified peer support services and community-based social service, for example.

Cover through Medicaid and require commercial insurers to cover group maternity care programs such as “Centering Pregnancy,” certified doulas offering support during pregnancy and labor and delivery, certified doulas offering postpartum home care and home health nursing care.Birth doulas provide support to those who are pregnant through labor and delivery.They provide education about staying healthy and the birth process and serve as an interface between medical providers, as needed, particularly during labor and delivery. This coverage is particularly important for those who indicate they don’t have a partner or family member to support them through pregnancy and/or labor and delivery.Additionally, Medicaid and commercial plans/insurers should cover postpartum doula home visits. Postpartum doulas offer holistic care for the entire family is during the postpartum transition, including support with infant sleep, breastfeeding, and more. Finally, coverage should be provided for home health nurses for any birth where there were infant or maternal medical complications, including a c-section. In addition to requiring coverage, these benefits should be explained to beneficiaries/covered members, such providers/services should be addressed in provider directories, and benefits should be explained in writing to contracted maternity care providers, including publishing the billing codes.

Current federal maternal mental health programs include HRSA maternal mental health grants to states, and the National Maternal Mental Health Hotline.

Expand primary care provider and obstetric provider (including Ob/Gyns and Midwives) capacity to screen and effectively treat depression and anxiety disorders by creating a “988 for Providers.” More specifically, creating a national consultation line for primary care and obstetric providers to obtain real-time support from a psychiatrist to discuss a patient’s mental health with behavioral health professionals, including psychiatrists. Research shows PCPs are de facto mental health care providers and are treating depression but are not treating depression according to clinical guidelines, resulting in inefficient and often ineffective mental health treatment. A consultation program could address this. Such a service exists in many states for pediatricians. Still, it is a fundamental gap for PCPs who are being called on to provide mental health screening, preliminary diagnosis, and treatment plan development for depression and anxiety. This service could be modeled after the Health Resource and Services Administration (HRSA) - AIDS, National Clinical Consultation Center: https://www.hrsa.gov/grants/find-funding/HRSA-20-072

Implement the TRIUMPH for New Moms Act, which calls for the formation of a national task force for maternal mental health to improve coordination of maternal mental health among existing maternal, infant, and mental health federal programs, in addition to the creation of a national strategic plan including detailing additional strategies for Congressional and state actions to improve maternal mental health outcomes. Federal programs where additional support for maternal mental health could be noted include: improved maternal suicide tracking; behavioral health and primary care/obstetric care integration; expansion of the SAMHSA residential treatment for pregnant and postpartum women (“PPW”) program to address severe depression and serious mental illness in addition to substance use disorders, development of a national center of excellence (CoE) technical assistance program to provide Certified Community Behavioral Health Clinics (CCBHCs), Federally Qualified Health Centers (FQHCs), hospitals, and other clinical programs with assistance implementing screening and treatment programs for maternal mental health; development of a national maternal mental health peer support and lay professional center of excellence (CoE) to provide maternal mental health lay professional/peer and supervisor training, and provide clinical and community-based organization employers with technical support surrounding employing personnel and billing for these services.

According to the Health Resource and Services Administration (HRSA) as of May 2023, 163 million Americans live in areas with a shortage of mental health professionals and there is a need for 8,200 additional mental health providers. The Federal Government can take timely action by providing funding for education/training to individuals who spend a minimum number of years working in shortage areas. Further, funding should be prioritized to diversify the mental health workforce and support high-need populations like children and mothers.

Department of Labor’s Employee Benefits Security Administration (EBSA) has the authority to ensure all Americans have access to mental health and substance use disorder benefits however, actions are not being taken quickly enough to require America’s health plans and insurers to comply with the Federal Mental Health Parity and Addiction Act (MHPAEA) in part because plans/insurers believe their hands are tied. However, creative solutions are available, including solutions like contributing to a federal fund to build the mental health workforce. Learn more about additional solutions.

As the U.S. Preventive Services Task Force recommendations are under threat, the Health Resource and Services Administration (HRSA) Women’s Preventive Services Guidelines should be updated to account for maternal depression screening to determine if a person is at risk and cover interventions, including talk therapy and other preventive interventions like group mindfulness treatments. Insurers and health plans should not only cover these services but be required to inform network providers in writing about these benefits, where to find information about delivering these covered intervention services, and the applicable billing codes. 

Congress should pass a paid parental leave program. Paid parental leave has been associated with improved maternal mental health and improved maternal health. Providing these benefits on a federal basis ensures that small to mid-size businesses can compete with large employers for the best talent and that benefits are available to all American families regardless of where they live and who they work for.

Through traditional and non-traditional platforms, including: 

• Federally Qualified Health Care Centers (FQHCs) and Community Health Clinics (CHCs) 

• Further investing in family planning providers under Title X (the Federal Family Planning Program)

• The Women Infants and Children (WIC) program 

• FDA making contraception available over the counter (and at no cost through the Affordable Care Act) 

• Require coverage of all FDA approved contraception, without insurer/plan limits or requirements

• Define roles of these providers in providing robust family planning counseling using the Person-Centered Contraception Counseling (PCCC) framework. 

• Address reimbursement and billing pathways through Medicaid and Private Insurance (Commercial/ERISA) coverage.

Support men in learning about and obtaining likely new FDA approved male contraception. Consider novel incentives for distribution, marketing and uptake. 

Similar to federal mental health parity oversight, identify a Federal agency, such as the Department of Labor, to oversee insurance coverage of contraception, with enforcement capabilities. 

For those couples who have babies, prioritizing low-income and single-parent families, provide: 

• Child tax credits, 

• Paid parental leave (see above),  

• Free childcare to allow and empower parents to work,

• Free diapers and formula for those unable or choose not to breastfeed, 

• Coverage for postpartum in-home support so mothers can rest, heal, attend appointments, have support caring for sick infants and children, etc.

Suggested Citation:
The Policy Center for Maternal Mental Health. (2023, May). 2023 Maternal Mental Health Roadmap. https://www.2020mom.org/2023-maternal-mental-health-roadmap