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Strengthen the Evidence for Maternal and Child Health Programs

Evidence Tools
Postpartum Mental Health Screening

Introduction

This toolkit summarizes content from the Postpartum Mental Health Screening Evidence Accelerator and the MCHbest database. The peer-reviewed literature supporting this work can be found in the Established Evidence database. Use the resources below as you develop effective evidence-based/informed programs and measures.

Postpartum Mental Health Screening is related to the following topics; see these Accelerators for additional information: Postpartum Visit and Postpartum Contraception Use.

From the MCH Block Grant Guidance. Mental health conditions are common complications during the postpartum period with approximately 1 in 8 women experiencing depressive symptoms following a live birth.1 Mental health conditions are associated with several adverse health behaviors and outcomes, including poorer maternal and infant bonding, decreased breastfeeding initiation, and delayed infant development.2 They are also the leading underlying causes of pregnancy-related deaths.3 Screening for mental health conditions can identify those at risk for depression and increase the provision of treatment or referrals with the potential to reduce other adverse health consequences. Several professional and clinical organizations such as the U.S. Preventive Services Task Force, the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Pediatrics recommend screening for postpartum depression; ACOG also recommends screening for anxiety symptoms during the postpartum visit.

Goal. To increase the percent of women who receive postpartum depression or anxiety screening.

Note. Access other related measures in this Population Domain through the Toolkits page.

Overview: Read a summary of the issue related to Title V

In the United States (U.S.), mental health disorders are one of the most common medical conditions that occur during pregnancy and the postpartum period.1 The impacts of postpartum depression and anxiety disorders include withdrawal from social networks, poorer relationships with their newborns, poor self-esteem, inappropriate guilt, feeling overwhelmed, hopeless, or excessively sad, self-harm, suicidal ideation, and thoughts of harming the child.1,2 Factors contributing to the development of postpartum depression and anxiety include brain structure and functioning, genetics, and family history as well as socioeconomic and other contextual triggers.1,3

Validated screening tools should be administered both during pregnancy and at the postpartum visit.3 There are several validated screening tools that have shown to be successful in the clinical setting, all with varying question length, symptoms focus, and languages available for administration. There are several treatment recommendations for women who screen positive for postpartum depression and anxiety with equity considerations that include access to high-quality care.1,2,4

In 2018, the American College of Obstetricians and Gynecologists (ACOG) issued the ACOG Committee Opinion No. 757: Screening for Perinatal Depression, which recommends that health care providers screen patients at least once during the perinatal period for depression and anxiety as well as during the postpartum visit.5 Screening for depression and anxiety alone is not sufficient; follow-up care and support are paramount.6 It is important to assess how mothers of newborns perceive their level of support to help identify specific indicators to better support women who are transitioning to motherhood.6

It is also important to recognize that stigma and fear may prevent pregnant and postpartum women from seeking, initiating, and continuing to access mental health treatment services.7,8,9,10 In one study, women of color noted they may not disclose postpartum depression symptoms out of fear that their children would be taken away by social services.9 Some provider behaviors, use of language, attitudes, and beliefs can lead to stigmatizing interactions as well.10 To foster open conversations, clinicians need to pose questions in a non-threatening way so women are not fearful of the repercussions of truthful responses.8,9

Detail Sheet: Start with the MCH Block Grant Guidance

DEFINITION

Numerator:

Number of women who reported that a healthcare provider asked a series of questions, in person or on a form, to know if they were feeling down, depressed, anxious, or irritable since their new baby was born

Denominator:

Number of women with a recent live birth

Units: 100

Text: Percent

HEALTHY PEOPLE 2030 OBJECTIVE

Related to Pregnancy and Childbirth (MICH) Objective D01: Increase the proportion of women who get screened for postpartum depression (Developmental)

DATA SOURCES

Pregnancy Risk Assessment Monitoring System (PRAMS)

MCH POPULATION DOMAIN

Women/Maternal Health

MEASURE DOMAIN

Clinical Health Systems

Data Sources: Learn more about the issue and access the data directly

This NPM is measured through data collected from the Pregnancy Risk Assessment Monitoring System (PRAMS). Overall, in the U.S., 87.4% of women report being screened for depression during a postpartum care visit; however, this percentage varies widely by state with only about 50% of women being screened in some states and jurisdictions.11

1. Accelerate with EvidenceStart with the Science

The first step to accelerate effective, evidence-based/informed programs is ensuring that the strategies we implement are meaningful and have high potential to affect desired change. Read more about using evidence-based/informed programs and then use this section to find strategies that you can adopt or adapt for your needs.

Evidence-based/Informed Strategies: MCHbest Database

The following strategies have emerged from studies in the scientific literature as being effective in advancing the measure. Use the links below to read more about each strategy or access the MCHbest database to find additional strategies.

Chart of Evidence-Linked Strategies and Tools

Evidence-Informed

Evidence-Based

Mixed Evidence

Emerging Evidence

Expert Opinion

Moderate Evidence

Scientifically Rigorous

 

Field-Based Strategies: Find promising programs from AMCHP’s Innovation Hub

Key Findings and Emerging Issues: Read more from the literature

KEY FINDINGS

The following are key findings emerging from the literature:

  1. Integrating screening into multidisciplinary care such as during prenatal visits, pediatric well visits, and pediatric emergency department visits has been shown to not only be successful, but also decrease logistical barriers associated with screening including cost, transportation, and childcare issues.20-24
  2. Mothers caring for infants in the neonatal intensive care unit (NICU) are at a higher risk of screening positive for postpartum depression. Strategies that employ routine screening for mothers of babies in the NICU have shown to be successful in identifying individuals in an at-risk population. A referral resource packet can also be given to mothers in the NICU to help facilitate treatment and follow-up care.25-27
  3. Technology-based screening approaches such as text-message based strategies, smartphone app strategies, and machine learning strategies are particularly successful in identifying positive screens for individuals who are often difficult to reach during the postpartum period.28-30
  4. Strategies integrating screening into routine care for populations at a higher risk for developing postpartum mental health disorders such as women with pre-existing mental health conditions, mothers eligible for the Women, Infants, and Children program and incarcerated mothers have shown to be effective.30,31,32

RESEARCH

Multiple strategies are emerging as potential approaches to advance this NPM, but haven’t been studied with enough rigor to be included in the evidence-based continuum. Additional research is needed to verify outcomes, but initial studies have shown promise of these strategies in MCH settings:

  • Partnering with Medicaid to promote expansion of Medicaid benefits and reduce barriers to Medicaid enrollment.33,34
  • Promoting partner involvement to assist new parents in identifying the signs and symptoms of postpartum mental health disorders.35
  • Engaging with community leaders to promote postpartum mental health screening.36
  • Establishing peer support programs to decrease stigma attached to postpartum depression.37

Research Gaps: Learn where more study is needed

Specific Intervention Research Gaps. Lack of studies on:

  • Standardizing clinical screening procedures using validated screening tools for maternal depression.
  • improving  postpartum visit attendance to enhance population-based screening efforts. 
  • Recognizing the need for interventions that go beyond screening for depression and anxiety and address specific  symptoms, initiation of care-seeking services, provider education, and system-level support.
  • Partnering with Medicaid to promote expansion of Medicaid benefits and reduce barriers to Medicaid enrollment.
  • Promoting partner involvement to assist new parents in identifying the signs and symptoms of postpartum mental health disorders.
  • Engaging with community leaders to promote postpartum mental health screening.
  • Establishing peer support programs to decrease stigma attached to postpartum depression. 

Strategy Video: Watch a summary of evidence-based/informed strategies

Watch a short video discussing state-of-the-art, evidence-based/informed strategies that can be used or adapted as ESMs. Experts in the field discuss approaches, the science, and specific ways that Title V agencies can implement and measure these approaches.

2. Think Upstream with Planning ToolsLead with the Need

The second step in developing effective, evidence-based/informed programs challenges us to plan upstream to ensure that our work addresses issues early and is measurable in “turning the curve” on big issues that face MCH populations. Read more about moving from root causes to responsive programs and then use this section to align your work with the data and needs of your populations.

A. Move from Need to Strategy

Use Root-Cause Analysis (RCA) and Results-Based Accountability (RBA) tools to build upon the science to determine how to address needs.

Planning Tools: Use these tools to move from data to action

B. Align with the Needs of the Population

Consider the following findings related to this performance measure.

The Role of Title V: Get ideas on how to implement strategies

Title V has a role to play in improving rates of screening for postpartum depression and anxiety including:

  • Partnering with community-led organizations to dismantle stigma surrounding mental health screening and provide educational opportunities for women about the importance of postpartum depression and anxiety screening.  
  • Partnering with Home Visiting and other programs to address social isolation and create support groups for new mothers.
  • Supporting the expanded use of telehealth and/or community health workers to increase access to mental health services in maternity care deserts.
  • Establishing statewide or regional networks that provide real-time psychiatric consultation to improve providers’ capacity to screen, assess, treat, and refer for maternal mental health issues.
  • Participating in interagency collaboration to ensure perinatal women are being cared for in a system that is effective in detecting and treating postpartum depression and anxiety.1,12,18,19

SDOH and Health Equity Considerations: Identify ways to advance health for all

Social Determinants of Health (SDOH)

ACOG stresses the influence that social risk factors have on the health of pregnant and postpartum women, along with the role obstetricians-gynecologists have in improving them. Strategies affecting social risk that have demonstrated effectiveness include:

  • Addressing SDOH triggers of postpartum depression and anxiety, such as cultural stigmas, socioeconomic stressors, lack of paid leave, and gender discrimination.
  • Screening for individual-level social risk factors that impact mental health at prenatal and postpartum visits, such as stable housing, enough food for mom and baby, enough diapers, and a safe place for baby to sleep.
  • Addressing barriers, such as lack of clinician time or awareness of resources, that prevent postpartum women from accessing timely, affordable, and high-quality mental health care.
  • Establishing interdisciplinary teams to support postpartum women and screen for postpartum depression and anxiety.1,2,4

HEALTH EQUITY

While postpartum anxiety and depression impact women of all backgrounds, traditionally marginalized individuals are impacted at a higher rate. Postpartum women from low socioeconomic status or of racial/ethnic minorities (especially Black, Latina, Native American and Alaska Native or Indigenous individuals) have a higher likelihood of not only developing postpartum anxiety and depression, but are also less likely to receive adequate or culturally-competent care.12,13 Women from these groups also have lower rates of follow up and continued mental health care.13 Overall, compared to white women, identification of postpartum depression and anxiety remains lower in non-white women.2,14

Health equity can be improved for postpartum depression and anxiety by:

  • Focusing on systems-level, institutional, and community-level strategies that build on culturally-appropriate strengths for the identification and treatment of postpartum depression and anxiety. 
  • Educating practitioners, including doctors, nurses, midwives, doulas, and lactation consultants, to treat the whole patient – this includes principles of integrated behavioral care.
  • Valuing and investing in the community voice – centering on the opinion and expertise of the women being cared for.15

Special Considerations: Tease out ways to zoom in on populations of focus

Impact of Postpartum Depression and Anxiety on Newborns and Children

There are numerous negative outcomes that postpartum depression and anxiety could potentially impact the health and well-being of infants and children such as poor cognitive motor and language development, behavioral disorders and poor academic performance, higher risk of preterm birth, low birth weight, and poor physical growth.1,16 Research also indicates that infants of mothers with postpartum depression and/or anxiety were less likely to be placed in the recommended back-to-sleep position.16 These impacts highlight the importance of resources for screening and follow-up care.1

3. Work Together with Implementation ToolsMove from Planning to Practice

The third step in developing effective, evidence-based/informed programs calls us to work together to ensure that programs are movable within the realities of Title V programs and lead to health equity for all people. Read more about implementation tools designed for MCH population change and then use this section to develop responsive strategies to bring about change that is responsive to the needs of your populations.

Additional MCH Evidence Center Resources: Access supplemental materials from the literature

Implementation Resources: Use these field-generated resources to affect change

PRACTICE

The following tools can be used to translate evidence to action to advance this NPM:

  • The National Maternal Mental Health Hotline | MCHB provides 24/7, free, confidential support before, during and after pregnancy. The Blue Dot Project raises awareness on maternal mental health disorders and aims to combat stigma around mental health. Clinician training/education, patient education, and collaboration between care providers are strategies shown to be effective in increasing screening rates.12 Although universal mental health screening might be beneficial, ethical factors such as the presence, or lack of, a systematic referral process should be considered.4,16,17
  • Postpartum Depression Toolkit (AAFP). This toolkit includes materials to assist in the identification/care of postpartum depression.
  • Maternal Depression-Making a Difference Through Community Action: A Planning Guide (MHA). This guide strengthens the capacity of communities to mobilize around postpartum depression.

PARTNERSHIP

The following organizations focus efforts on Postpartum Depression Screening:


References

Introductory References: From the MCH Block Grant Guidance

1 Bauman BL, Ko JY, Cox S, et al. Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression - United States, 2018. MMWR Morb Mortal Wkly Rep. 2020;69(19):575-581. Published 2020 May 15. doi:10.15585/mmwr.mm6919a2.

2 Slomian J, Honvo G, Emonts P, Reginster JY, Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes [published correction appears in Womens Health (Lond). 2019 Jan-Dec;15:1745506519854864]. Womens Health (Lond). 2019;15:1745506519844044. doi:10.1177/1745506519844044

3 Trost SL, Beauregard J, Njie F, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2022. https://www.cdc.gov/reproductivehealth/maternal- mortality/docs/pdf/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf

Toolkit References: From the Evidence Accelerator

  1. Waqas A, Koukab A, Meraj H, et al. Screening programs for common maternal mental health disorders among perinatal women: report of the systematic review of evidence. BMC Psychiatry. Jan 24 2022;22(1):54. doi:10.1186/s12888-022-03694-9
  2. Garthus-Niegel S, Radoš SN, Horsch A. Perinatal Depression and Beyond—Implications for Research Design and Clinical Management. JAMA Network Open. 2022;5(6):e2218978-e2218978. doi:10.1001/jamanetworkopen.2022.18978
  3. The American College of Obstetricians and Gynecologists. Perinatal Mental Health Toolkit. https://www.acog.org/programs/perinatal-mental-health
  4. Cedars-Sinai. Moms With Postpartum Depression Benefit From Improved Screening. https://www.cedars-sinai.org/newsroom/moms-with-postpartum-depression-benefit-from-improved-screening/
  5. American College of Obstetricians Gynecologists. ACOG Committee Opinion No. 757: screening for perinatal depression. Obstet Gynecol. 2018;132(5):e208-e212.
  6. Corrigan, C. P., Kwasky, A. N., & Groh, C. J. (2015). Social Support, Postpartum Depression, and Professional Assistance: A Survey of Mothers in the Midwestern United States. The Journal of perinatal education24(1), 48–60. https://doi.org/10.1891/1058-1243.24.1.48
  7. Corrigan, P. W., Druss, B. G., & Perlick, D. A. (2014). The impact of mental illness stigma on seeking and participating in mental health care. Psychological Science in the Public Interest15(2), 37-70.
  8. Modak, A., Ronghe, V., Gomase, K. P., Mahakalkar, M. G., & Taksande, V. (2023). A Comprehensive Review of Motherhood and Mental Health: Postpartum Mood Disorders in Focus. Cureus15(9), e46209. https://doi.org/10.7759/cureus.46209
  9. Tully, K. P., Stuebe, A. M., & Verbiest, S. B. (2017). The fourth trimester: a critical transition period with unmet maternal health needs. American journal of obstetrics and gynecology217(1), 37-41.
  10. Agency for Healthcare Research and Quality. Pregnant and Postpartum Women and Behavioral Health Integration. https://integrationacademy.ahrq.gov/products/topic-briefs/pregnant-postpartum-women
  11. Kuehn BM. Postpartum Depression Screening Needs More Consistency. JAMA. 2020;323(24):2454-2454. doi:10.1001/jama.2020.9737
  12. O’Connor E, Senger CA, Henninger M, Gaynes BN, Coppola E, Weyrich MS. Interventions to Prevent Perinatal Depression: A Systematic Evidence Review for the US Preventive Services Task Force [Internet]. 2019;
  13. Maternal Health Technology Transfer Center Network. Perinatal Mental Health.
  14. Iturralde E, Hsiao CA, Nkemere L, et al. Engagement in perinatal depression treatment: a qualitative study of barriers across and within racial/ethnic groups. BMC Pregnancy and Childbirth. 2021/07/16 2021;21(1):512. doi:10.1186/s12884-021-03969-1
  15. Matthews K, Morgan I, Davis K, Estriplet T, Perez S, Crear-Perry JA. Pathways To Equitable And Antiracist Maternal Mental Health Care: Insights From Black Women Stakeholders. Health Affairs. 2021;40(10):1597-1604. doi:10.1377/hlthaff.2021.00808
  16. Slomian J, Honvo G, Emonts P, Reginster JY, Bruyère O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes. Womens Health (Lond). Jan-Dec 2019;15:1745506519844044. doi:10.1177/1745506519844044
  17. O’Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016;315(4):388-406. doi:10.1001/jama.2015.18948
  18. Bauman BL, Ko JY, Cox S, et al. Vital signs: postpartum depressive symptoms and provider discussions about perinatal depression—United States, 2018. Morbidity and Mortality Weekly Report. 2020;69(19):575.
  19. March of Dimes. Maternity Care Deserts Report. Nowhere to go: Maternity care deserts across the U.S. (2022 Report) https://www.marchofdimes.org/maternity-care-deserts-report 
  20. James SJ. Maternal Postpartum Depression Screening in a Federally Qualified Health Care Center: An Evidence-Based Pilot Project. Pediatric Nursing. 2023;49(2):59-63.
  21. Puryear LJ, Nong YH, Correa NP, Cox K, Greeley CS. Outcomes of implementing routine screening and referrals for perinatal mood disorders in an integrated multi-site pediatric and obstetric setting. Maternal and child health journal. 2019;23:1292-1298.
  22. Jarvis LR, Breslin KA, Badolato GM, Chamberlain JM, Goyal MK. Postpartum depression screening and referral in a pediatric emergency department. Pediatric Emergency Care. 2020;36(11):e626-e631.
  23. Coffman MJ, Scott VC, Schuch C, et al. Postpartum depression screening and referrals in special supplemental nutrition program for women, infants, and children clinics. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2020;49(1):27-40.
  24. Russomagno S, Waldrop J. Improving postpartum depression screening and referral in pediatric primary care. Journal of Pediatric Health Care. 2019;33(4):e19-e27.
  25. Berns HM, Drake D. Postpartum depression screening for mothers of babies in the neonatal intensive care unit. MCN: The American Journal of Maternal/Child Nursing. 2021;46(6):323-329.
  26. Brownlee MH. Screening for postpartum depression in a neonatal intensive care unit. Advances in Neonatal Care. 2022;22(3):E102-E110.
  27. Vaughn AT, Hooper GL. Development and implementation of a postpartum depression screening program in the NICU. Neonatal Network. 2020;39(2):75-82.
  28. Lawson A, Dalfen A, Murphy KE, Milligan N, Lancee W. Use of text messaging for postpartum depression screening and information provision. Psychiatric services. 2019;70(5):389-395.
  29. Vanderkruik R, Raffi E, Freeman MP, Wales R, Cohen L. Perinatal depression screening using smartphone technology: Exploring uptake, engagement and future directions for the MGH Perinatal Depression Scale (MGHPDS). Plos one. 2021;16(9):e0257065.
  30. Zhang Y, Wang S, Hermann A, Joly R, Pathak J. Development and validation of a machine learning algorithm for predicting the risk of postpartum depression among pregnant women. Journal of affective disorders. 2021;279:1-8.
  31. Giron K, Noe S, Saiki L, Kuchler E, Rao S. Implementation of Postpartum Depression Screening for Women Participating in the WIC Program. Journal of the American Psychiatric Nurses Association. 2021;27(6):443-449.
  32. Meine K. Pregnancy unshackled: Increasing equity through implementation of perinatal depression screening, shared decision making, and treatment for incarcerated women. Wiley Online Library; 2018:437-447.
  33. Burak EW, Dwyer A, Mondestin T, Guest. State Medicaid Opportunities to Support Mental Health of Mothers and Babies During the 12-Month Postpartum Period. 2024.
  34. Sidebottom A, Vacquier M, LaRusso E, Erickson D, Hardeman R. Perinatal depression screening practices in a large health system: identifying current state and assessing opportunities to provide more equitable care. Archives of women's mental health. 2021;24:133-144.
  35. Sampson M, Villarreal Y, Padilla Y. Association between support and maternal stress at one year postpartum: Does type matter? Social Work Research. 2015;39(1):49-60.
  36. Lewis Johnson TE, Clare CA, Johnson JE, Simon MA. Preventing perinatal depression now: a call to action. Journal of Women's Health. 2020;29(9):1143-1147.
  37. Dennis C-L. The process of developing and implementing a telephone-based peer support program for postpartum depression: evidence from two randomized controlled trials. Trials. 2014;15:1-8.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.