May 2024
National Strategy to Improve
Maternal Mental
Health Care
TASK FORCE ON MATERNAL MENTAL HEALTH
i
Table of Contents
Executive Summary ...................................................................................................................................... 1
The National Strategy to Improve Maternal Mental Health Care: Pillars, Priorities,
and Recommendations .................................................................................................................................. 3
Background ............................................................................................................................................... 3
U.S. Maternal Mental Health .................................................................................................................... 3
Risk Factors and Disparities Addressed in the National Strategy ............................................................. 4
Barriers Related to the Lack of a Supportive Infrastructure and Environment ......................................... 5
Policies Contributing to Stigma and Fears of Parent–Child Separations .............................................. 6
Workforce Shortages and Difficulties Accessing Services ................................................................... 7
A Fragmented Health Care System ....................................................................................................... 8
Lack of Systemic Supports During Postpartum Challenges ................................................................. 9
The Perinatal Period: An Opportunity to Address Mental Health Conditions and SUDs ...................... 10
Introduction ................................................................................................................................................. 11
The Audience, Scope, and Vision for the National Strategy .................................................................. 14
Audience ............................................................................................................................................. 14
Scope ................................................................................................................................................... 14
Vision .................................................................................................................................................. 15
Call to Action ...................................................................................................................................... 15
Recommendations from the Task Force on Maternal Mental Health ......................................................... 16
Pillar 1: Build a National Infrastructure That Prioritizes Perinatal Mental Health and Well-Being ....... 16
Pillar 2: Make Care and Services Accessible, Affordable, and Equitable .............................................. 29
Pillar 3: Use Data and Research to Improve Outcomes and Accountability........................................... 42
Pillar 4: Promote Prevention and Engage, Educate, and Partner with Communities .............................. 50
Pillar 5: Lift Up Lived Experience .......................................................................................................... 55
Conclusion .................................................................................................................................................. 61
Appendix A: Acronyms and Abbreviations ............................................................................................... A-i
Appendix B: Language Used in This National Strategy ............................................................................ B-i
Appendix C: Task Force Roster ................................................................................................................. C-
i
Federal Staff Members ........................................................................................................................... C-i
Nonfederal Staff Members ................................................................................................................... C-iv
Appendix D: References ............................................................................................................................ D-i
Appendix E: Acknowledgments ................................................................................................................ E-i
Per academic and publishing standards, this document includes bibliographic citations and other attributions to printed and
digital sources and other research materials. This report has also been reviewed with industry-standard plagiarism-screening
software. All flagged instances of potential previously published material have been thoroughly researched and, where
appropriate, cited or attributed accordingly. This report incorporates information obtained from publicly solicited comments
through FR Doc. 2023-28890
and from hundreds of subject matter experts, and where possible, this document cites or attributes
this information appropriately. However, federal solicitations for public comment make possible the incorporation of information
or text from unpublished sources or other sources, which may not be cited or attributed herein.
1
Executive Summary
Maternal mental health conditions, substance use disorders (SUDs), and their co-occurrence have reached
crisis levels in the United States and are among the most common complications of pregnancy. Suicide,
drug overdose, and other incidents and conditions related to mental health and SUDs are the leading cause
of pregnancy-related deaths. The lack of sufficient U.S. infrastructure (i.e., environment, policies,
systems, and programs) and workforce capacity makes it challenging to support maternal mental health
holistically. Although best practices have been developed to address some aspects of the problem, they
have not been implemented uniformly. Because a national infrastructure and workforce capacity are
lacking, our system does not deliver the right care at the right time to all who experience maternal mental
health conditions and SUDs. The lack of a robust infrastructure is an important factor that shapes a
national landscape in which these conditions often remain undetected and untreated. This results in
negative consequences for individuals, their children, their families, and their communities and a high
cost for our nation. Moreover, these conditions and associated negative outcomes disproportionately
affect subgroups with challenging social determinants of health (e.g., economic difficulties, food and
diaper insecurity, experiences of discrimination, a lack of stable housing, a lack of access to
transportation, a lack of access to child care, and a lack of access to health care and insurance) and life
situations (e.g., having these conditions prior to pregnancy and experiencing gender-based violence and
other traumas).
Aligned with broader efforts to address women’s overall health and maternal health across the nation,
Congress directed the U.S. Department of Health and Human Services (HHS) either to form the Task
Force on Maternal Mental Health or to incorporate specified duties, public meetings, and reports into
existing relevant federal committees or workgroups (
Consolidated Appropriations Act, 2023 [Public Law
117–328, Section 1113]). The Secretary of HHS determined that these duties, public meetings, and
reports should be incorporated into SAMHSA’s Advisory Committee for Women’s Services (ACWS).
ACWS’s Task Force on Maternal Mental Health is a panel of experts from multiple complementary
disciplines—some of whom have lived experience—who represent federal and nonfederal organizations
with a bearing on care for maternal mental health conditions and SUDs. This national strategy features
the ACWS’s task force’s recommendations for a whole-government approach to build the
necessary infrastructure to improve care for maternal mental health conditions and SUDs. The
recommendations in this strategy represent the general consensus of the task force. Single
recommendations may not have the full support of the more than 100 organizations represented by the
members of the task force.
A companion report, The Task Force on Maternal Mental Health’s Report to Congress, provides a
detailed discussion of the U.S. maternal mental health crisis, the task force’s methods, best practices,
existing federal programs and coordination, and feedback from listening sessions with state and local
stakeholders.
The vision set forth by this national strategy is one in which maternal mental health (also known as
perinatal mental health) and substance use care is seamless and integrated across medical,
community, and social systems. The vision includes models of care and support that are innovative and
sensitive to individuals’ experiences, culture, and community and does not distinguish between physical
health care and mental health care. Building upon existing federal government efforts, the task force
outlines a path to achieve the vision within a framework consisting of the following five pillars, each with
supporting priorities and recommendations.
2
1. Build a national infrastructure that prioritizes perinatal mental health and well-being,
which entails establishing and enhancing federal policies that promote perinatal mental health and
well-being—with a focus on reducing disparities—and federal policies that promote care models
from multidisciplinary and interdisciplinary teams that integrate perinatal care and mental health
and SUD care with holistic support for mother–infant dyads and their families.
2. Make care and services accessible, affordable, and equitable, which will advance the
implementation of culturally relevant and trauma-informed clinical screening, improve linkages
to accessible early intervention and treatment, create accessible and integrated evidence-based
services that are affordable and reimbursable, and build capacity by training, expanding, and
diversifying the perinatal mental health workforce.
3. Use data and research to improve outcomes and accountability, which encompasses the
evidence-driven support of strategies and innovations that improve outcomes and build a
foundation for accountability in prevention, screening, intervention, and treatment.
4. Promote prevention and engage, educate, and partner with communities, which will involve
promoting and funding prevention strategies, elevating education of the public about perinatal
mental health and substance use, and engaging communities with outreach and communications.
5. Lift up lived experience, which includes listening to the perspectives and voices of people with
lived experience and prioritizing their recommendations (many of which overlap with those of the
task force) as outlined in a specially prepared report by the U.S. Digital Service and summarized
in this national strategy.
The five pillars of this national strategy highlight the cross-cutting imperatives of (1) increasing equity
and access, (2) improving federal coordination, (3) elevating culturally relevant supports, and (4) using
trauma-informed approaches to bolster maternal mental health and enhance care for perinatal mental
health conditions and SUDs. The national strategy also spotlights evidence-based, evidence-informed, and
promising practices (e.g., programs) with supporting resources and expertise that can be scaled up for
widespread implementation. Throughout, the task force points out opportunities for the federal
government to collaborate with diverse groups of partners to spearhead the implementation of the national
strategy and lift up the voices of people with lived experience (highlighted in quotation marks). Finally,
the task force notes that this national strategy is a living document that will be regularly updated. It
focuses on ways that the federal government can lead efforts, but it also calls upon many types of partners
(e.g., states, advocates, medical and professional societies, and individuals with lived experience) to help
build the necessary infrastructure to support the mental health and well-being of the nation’s mothers and
their children, families, and communities.
3
The National Strategy to Improve Maternal Mental
Health Care: Pillars, Priorities, and
Recommendations
Background
The ACWS’s Task Force on Maternal Mental Health sets forth this national strategy and the
accompanying report to Congress to address an urgent national public health crisis. As these documents
demonstrate, maternal mental health conditions are among the most common complications of pregnancy.
Currently, the United States does not have the infrastructure, systems, policies, or workforce in place to
support optimal maternal mental health for everyone. Without a supportive infrastructure and
environment, the nation will not be able to address the high prevalence and negative consequences of
maternal mental health conditions, substance use disorders
(SUDs), and their co-occurrence. This national strategy
features the task force’s recommendations for the federal
government to enhance internal, public–private, and state
collaboration and coordination to build the necessary
infrastructure to spearhead efforts to improve care for
maternal mental health conditions and SUDs.
U.S. Maternal Mental Health
Mental health conditions and SUDs during pregnancy and the postpartum period affect an estimated 1 in
5 individuals annually in the United States (American Psychiatric Association, 2023). Maternal mental
health conditions (e.g., mood disorders, anxiety disorders, trauma-related disorders, obsessive-compulsive
disorder, and postpartum psychosis) and SUDs range in type and severity (American College of
Obstetricians and Gynecologists, 2023; Clarke et al., 2023). Preexisting maternal mental health conditions
and SUDs, including serious mental illnesses such as schizophrenia and bipolar affective disorders, may
be affected by pregnancy and the postpartum period with risk of increased relapses (Taylor et al., 2019).
When left untreated, maternal mental health conditions and SUDs can have long-lasting negative effects
on individuals and families—with costs estimated to be more than $14 billion a year in the United States
(Centers for Disease Control and Prevention, n.d.-a, n.d.-f; Jahan et al., 2021; Luca et al., 2020; Lupton et
al., 2004; Mughal et al., 2019; Prince et al., 2024). For example, research links maternal perinatal
depression and anxiety with problems in children’s social–emotional, cognitive, language, motor, and
adaptive behavior development, all the way into adolescence (Rogers et al., 2020). Ongoing research is
examining the complex biological mechanisms underlying these
links (e.g., elevated maternal glucocorticoids, alteration of
placental function and perfusion, and epigenetic mechanisms)
(Lewis et al., 2015). In our current system, most individuals who
experience maternal mental health conditions and SUDs do not
receive treatment (Byatt et al., 2015; Lynch et al., 2021).
Moreover, clinical screening—one way that these conditions can
be detected—is not typically provided for the most prevalent
conditions (e.g., perinatal depression) (Britt et al., 2023).
The unmet need for treatment of maternal mental health conditions and SUDs has reached a crisis point.
From 2017 to 2019, suicide, drug overdose, and other incidents and conditions related to mental health
and SUDs were the leading cause of pregnancy-related deaths in the United States—accounting for 22.7
percent of these deaths (Trost, Beauregard, Chandra, Njie, Berry, et al., 2022). By comparison, the next
“Maternal mental health, also known
as perinatal mental health, is a
[person’s] overall emotional, social,
and mental well-being during and after
pregnancy” (Zuloaga, 2020).
“In Massachusetts, we had two
local moms who [died by suicide]
in postpartum 2 to 3 days after
birth and one after a month. It’s on
every new mom’s mind.”
- A provider who coordinates
new-mom groups
4
leading causes of pregnancy-related deaths were hemorrhage (13.7 percent), cardiac and coronary
conditions (12.8 percent), and infection (9.2 percent) (Trost, Beauregard, Chandra, Njie, Berry, et al.,
2022). Pregnancy-related deaths from suicide, drug overdose, and other causes related to mental health
conditions and SUDs are discussed in greater detail in the report to Congress. Here, the task force notes
that these deaths are often preventable, are marked by disparities, and occur up to 1 year postpartum
(Trost, Beauregard, Chandra, Njie, Berry, et al., 2022; Trost, Beauregard, Chandra, Njie, Harvey, et al.,
2022). These findings have heightened attention to the mental health of pregnant and postpartum
individuals and the care and services landscape in the United States. Concern about maternal mental
health conditions and SUDs is further amplified by broader initiatives in response to the high overall U.S.
maternal mortality rate—which is the highest among high-income countries despite our spending the most
on health care per person (Gunja et al., 2023; Hoyert, 2024).
Risk Factors and Disparities Addressed in the National Strategy
The perinatal period is a time of intense physical and emotional demands and physiological and social
changes. Although the factors underlying the risk for mental health conditions, substance use, and SUDs
are complex and multifactorial (e.g., biological factors, environmental factors, and components that entail
the interaction of biological and environmental factors), the task force highlights a number of subgroups
at high risk because they experience challenging situations and stressors. These challenges and stressors
can contribute to mental health conditions, substance use, and SUDs that occur prior to pregnancy and
precipitate onset or relapse during the perinatal period. Therefore, these subgroups are briefly mentioned
here and have been integrated throughout the recommendations of this national strategy.
Subgroups at high risk for these conditions include individuals who are members of the under-resourced
and underserved populations highlighted in “Language Used in This National Strategy,” such as under-
resourced racial and ethnic groups. Additional subgroups at high risk for these conditions include
individuals who are incarcerated; parents of children in neonatal intensive care units (NICUs); people
who have experienced pregnancy loss, forcible displacement, trafficking, or gender-based violence
(GBV); active-duty service members; veterans; and people with preexisting mental health conditions and
SUDs, including those with severe mental illness (Shah & Christophersen, 2010). As described in the
report to Congress, adverse childhood experiences (ACEs) and trauma
*
are highly prevalent and can be
associated with negative and lasting effects on the risk for mental health conditions and SUDs—
particularly if experienced during childhood, if experienced multiple times, and if treatment is not
received (Centers for Disease Control and Prevention, n.d.-g; Feriante & Sharma, 2024; Substance Abuse
and Mental Health Services Administration, 2015). The report to Congress also details the intersection of
experiencing ACEs and trauma, including GBV, with maternal mental health conditions and SUDs. The
special considerations for supporting people who experience GBV in general and intimate partner
violence (IPV) in particular are noted throughout this national strategy. For example, the discussion under
some recommendations mentions that not everyone has safe family members or personal networks to
support them during the perinatal period. Because of the high prevalence of ACEs and trauma—including
IPV and other types of GBV—the task force underscores the need for providers, programs, and
organizations to be educated about trauma-informed approaches and to implement them in health care and
services (Centers for Disease Control and Prevention, n.d.-c; D’Angelo et al., 2022; Foti et al., 2023;
Substance Abuse and Mental Health Services Administration, 2014).
*
Adverse childhood experiences (ACEs) are potentially traumatic events that occur in childhood—such as abuse or
neglect, experiencing or witnessing violence, household challenges, bullying, and parental mental health and/or
substance use problems [CDC, 2023
]. Trauma is a mental health concern that occurs among individuals who have
experienced an event or circumstance resulting in physical, emotional, and/or life-threatening harm [SAMHSA,
2022].
5
Trauma-Informed Approaches
A trauma-informed approach to care encompasses services that incorporate an understanding of trauma
and an awareness of the impact it has. It also views trauma through a cultural lens and recognizes that
context influences the perception and processing of traumatic events. Importantly, trauma-informed care
anticipates and avoids retraumatizing processes and practices (Substance Abuse and Mental Health
Services Administration, 2023).
Of note, when assessing for concerns around trauma, including GBV, traditional screening practices are
not often the best fit, because the goal is not to detect or diagnose but rather to create trauma-informed
safe spaces to enable individuals to discuss their concerns and experiences openly with their providers,
who can then offer support and resources and address any immediate safety concerns.
Challenging life situations and barriers that influence maternal mental health and the risk for maternal
mental health conditions and SUDs often considerably overlap with negative social determinants of health
(SDOH).
†
When discussing maternal mental health conditions and SUDs in the national strategy, the task
force considers SDOH—particularly along the lines of race/ethnicity, educational attainment, income
level, and geographic location, as well as their interaction—as these social drivers tend to accumulate
over the life course, be associated with risk factors, and contribute to the marked health disparities and
inequities in the United States (National Academies of Sciences, Engineering, and Medicine, 2021; Puka
et al., 2022). Maternal mental health conditions, substance use, and SUDs disproportionately affect Black
and American Indian/Alaska Native
women and other people in under-
resourced communities (Policy Center
for Maternal Mental Health, 2023a,
2023b). Negative SDOH (e.g., economic
difficulties, food and diaper insecurity,
experiences of discrimination, lack of
stable housing, lack of access to
transportation, lack of access to child
care, and lack of access to health care
and insurance) during the perinatal
period can be enormously stressful and
may contribute to maternal mental health
conditions and SUDs. Subgroups that are
at high risk for maternal mental health
conditions and SUDs also often face
challenges related to SDOH and
systemic barriers to receiving the
supports and care they need (discussed
below in “Barriers Related to the Lack of
a Supportive Infrastructure and
Environment”).
Barriers Related to the Lack of a Supportive Infrastructure and
Environment
This national strategy and its recommendations need to be understood in the context of the systemic
barriers that those who are pregnant and those who are postpartum face. These barriers are not the fault of
†
Social determinants of health (SDOH) are “the conditions in the environments where people are born, live, learn,
work, play, worship, and age that influence health risks and outcomes” [Healthy People 2030].
Accessing Maternity Care Can Be Difficult
• The United States has a critical and growing shortage of
obstetric care providers. More than 2.2 million people
who are of childbearing age live in a maternity care
desert, defined as “any county … without a hospital or
birth center offering obstetric care and without any
obstetric providers” (March of Dimes, 2022). More than
one-third of U.S. counties are designated as maternity
care deserts, and two-thirds of those are in rural
counties (March of Dimes, 2022).
• According to the Policy Center for Maternal Mental
Health, 96 percent of birthing-aged women in the United
States live in an area with a shortage of maternal mental
health professionals. The majority (70 percent) of U.S.
counties lack sufficient maternal mental health
resources (Britt et al., 2023).
• Women in nearly 700 counties face a high risk for
maternal mental health disorders, and more than 150
counties are “maternal mental health dark zones,” with
both high risk and large resource gaps (Britt et al., 2023).
6
the individual. Rather, they occur because the United States lacks the infrastructure and environment
needed to sufficiently support maternal mental health and well-being. An overarching barrier is that
mental health conditions and SUDs in general are seen as nonmedical and are therefore more likely to be
misunderstood, stigmatized, and perceived to be outside the purview of the health care system. Because of
this erroneous classification, mental health conditions and SUDs do not have the same research base,
reimbursement parity, and focus in the medical and health care system. They tend to be addressed in
different care systems. This overarching issue is magnified in the context of maternal mental health. Both
providers, including clinicians (Clarke et al., 2023), and community-based non-clinicians lack specific
education about these conditions. Additionally, stigmatization of people who experience perinatal mental
health conditions and SUDs can affect whether individuals seek care and how they are treated in the
health care and social service systems (Cantwell, 2021; O’Connor et al., 2022). The topic of stigma and
maternal mental health conditions and SUDs is discussed in more detail in the report to Congress.
Policies Contributing to Stigma and Fears of Parent–Child Separations
The perception that mental health conditions and SUDs are nonmedical persists, and their stigmatization
continues. Stigma toward people with SUDs manifests in punitive policies (Adams & Volkow, 2020).
Evidence indicates that family separation, criminalization, and incarceration for SUD during pregnancy is
ineffective at deterring substance use and is harmful to the health of pregnant people and their infants
(American College of Obstetricians and Gynecologists, 2020; Office of National Drug Control Policy,
2022). Yet service providers in many states are mandated to report
substance use by pregnant and postpartum individuals. Some state
statutes also have implications for mandated “test and report”
policies—i.e., urine toxicology testing for substances during the
perinatal period and reporting to child protective services. State or
county child protective service departments may take the extreme
measure of removing a child from a parent’s custody. Such policies are often applied in ways that
disproportionately affect Black women—for example, testing them even if they do not have a history of
substance use (Jarlenski et al., 2023). Punitive policies related to child removal also apply to women with
mental health conditions (such as schizophrenia, schizoaffective disorder, and other mental health
conditions involving psychosis). In the context of experiencing IPV, abusive partners may use punitive
policies as a means of continued control and coercion, as discussed in the report to Congress. Such
policies leave many individuals in understandable fear and cause them to mistrust service providers and
organizations. These factors affect treatment seeking and willingness to have honest conversations about
mental health and substance use (Alderdice & Kelly, 2019; Choi et al., 2022; Megnin-Viggars et al.,
2015; O’Connor et al., 2022). People with lived experience of maternal mental health conditions and
SUDs voice these concerns. (See “Pillar 5: Lift Up Lived Experience.”)
Federal laws (the
Child Abuse Prevention and Treatment
Act [CAPTA]) require states to create policies that
address child abuse and neglect. State policies (such as
mandatory reporting), procedures, and investigation
systems vary across many dimensions, including how
states implement
plans of safe care (POSCs), a
requirement of the Comprehensive Addiction and
Recovery Act (CARA; Public Law 114–198), which
amended CAPTA. POSCs focus on the shared
responsibility of child welfare, hospitals, service
providers, child care and early childhood education
settings, and others to promote the health and well-being
of infants and their caregivers in the context of parental
SUDs (Office of National Drug Control Policy, 2022).
“I was terrified my kids would
be taken away from me.”
- S.B., mother of two
Highlighted Resource: The National
Center on Substance Abuse and
Child Welfare Technical Assistance
The National Center on Substance Abuse
and Child Welfare offers technical
assistance (e.g., trainings, videos, and
webinars) to localities on how to
implement CAPTA POSCs. The assistance
is
designed to improve (1) the safety and
well-being of infants affected by prenatal
substance exposure and (2) the recovery
outcomes for their caregivers.
7
Typically, a designated local agency (e.g., child protection services or a public health agency) develops an
individualized POSC for a family that is designed to foster the recovery of any parent with SUD while
ensuring the safety and well-being of the child (or children). POSCs aim to keep children in their homes
with their birth parents when that can be accomplished safely (Office of National Drug Control Policy,
2022), and POSCs should enforce notification (as opposed to reporting) pathways in which maternal
substance use is noted to facilitate appropriate linkages to services and follow-up.
Society and professionals have a duty to keep children safe. In the current policy climate, providers are
concerned about children and the risk of harm and neglect, as well as losing their licenses to practice if
they do not comply with policies. However, the fear that parents with mental health conditions or SUD
have of mandatory reporting of maternal mental health symptoms and substance use to child welfare
services and the possibility of their children being removed from their homes and placed in foster care is a
barrier to their seeking SUD treatment (Office of National Drug Control Policy, 2022). In line with the
Biden–Harris administration’s report titled Substance Use Disorder in Pregnancy: Improving Outcomes
for Families, it is crucial that policies, procedures, and practices support family preservation and parental
access to treatment while keeping children safe. Additionally, the racial bias in parent–child separations
must be addressed. In addition to seeing this issue in their professional experience, members of the task
force heard this concern in listening sessions with staff members from state and local agencies and in the
public comments generated by a request for information
. The National Center on Substance Abuse and
Child Welfare offers resources to help providers understand policies and how to implement POSCs.
Ultimately, there are multilayered contributing factors to these punitive policies and practices, and
solutions need to involve greater educational investment and cross-disciplinary collaboration among
policymakers, hospital administrators, health care providers, community leaders, and people with lived
experience.
Workforce Shortages and Difficulties Accessing Services
The shortage of obstetric providers and the lack of a national infrastructure for maternal health care,
services, and supports are systemic barriers that put undue stress on pregnant and postpartum individuals
(March of Dimes, 2022). Additionally, our nation has a chronic shortage and geographic maldistribution
of mental health and SUD care providers, such that the majority of U.S. counties do not have the
resources to support pregnant and postpartum individuals with these conditions (Britt et al., 2023; Health
Resources & Services Administration, 2024a). In particular, this workforce shortage plays a significant
role in both the discomfort referring providers feel with screening and diagnosing these disorders
(because of a lack of referral pathways) and the limited access to timely and appropriate care for patients.
Systemic barriers further intersect with individual challenges, SDOH, and inequities to influence maternal
mental health conditions, substance use, and SUDs. Accessing affordable and comprehensive
reproductive care, maternity care, and care for perinatal mental health conditions and SUDs is difficult for
many individuals (Britt et al., 2023; Choi et al., 2022; Salameh et al., 2019). Difficulties accessing care
occur on many levels (e.g., problems with transportation to
appointments or lack of child care preventing attendance at perinatal
care visits). The task force recognizes those individual barriers but
generally refers to problems with access as the larger systemic
issues that make it difficult for individuals to get the right care that
meets their needs at the right time.
Lack of access is primarily driven by a significant shortage in the workforce members, both clinical and
nonclinical, who provide perinatal services—a shortage that causes widespread maternity care deserts.
Access is also affected by other factors, including the need to go to different facilities for various types of
care and a lack of reimbursement for needed services (e.g., patient education and screening). Only 32
percent of substance use treatment facilities accept pregnant women as patients, according to the 2022
National Substance Use and Mental Health Services Survey (Substance Abuse and Mental Health
“Even if we could have swung it
financially, [paying for therapy]
would have felt indulgent.”
- E.L., mother of one
8
Services Administration, 2023c). Additionally, health care and services that are culturally relevant to the
individual may not be available. Existing health care and social service systems serving this population
are highly fragmented and typically do not meet the needs of the whole person or the mother-child dyad.
For example, billing systems typically support reimbursement for services provided to an individual
patient rather than the mother–child dyad. Fragmented and non-holistic systems contribute to missed
opportunities to identify maternal mental health conditions and SUDs, link people with the appropriate
interventions, and provide the necessary continuity of care (Byatt et al., 2015; Green et al., 2024). Based
on the expertise and experience of the task force, complicated insurance systems and processes can be
difficult and stressful to navigate. The cost of care—and the trend of providers of care for mental health
conditions and SUDs not accepting insurance, causing all fees to be out-of-pocket expenses—is a
significant barrier for many.
Acknowledging the Challenges That Providers Face
Frontline providers who care for pregnant and postpartum individuals and their infants face significant
challenges when addressing maternal mental health conditions and SUDs. The task force has found that
although the nation has many providers who are experts in perinatal mental health and SUD care, topics
in perinatal mental health and SUDs are typically not covered well in education and training systems for
obstetric, pediatric, and primary care providers. Similarly, many mental health and SUD care providers
may lack sufficient training in the unique needs and considerations of pregnant and postpartum
individuals (Clarke et al., 2023). Workforce shortages affect both clinical and nonclinical providers, who
are increasingly asked to perform more services in 15- or 30-minute visits. Other provider challenges
include burnout, administrative burden, and billing issues (Herd & Moynihan, 2021). Providers also may
be unaware of (and often don’t have the staffing to help find) community resources to support people
with maternal mental health conditions, SUDs, and various life situations that affect their well-being (e.g.,
SDOH and experiences of trauma, including GBV). Providers may also have concerns about protecting
the safety and confidentiality of patients/clients experiencing IPV.
A Fragmented Health Care System
Task force discussions focused on the considerable fragmentation of the U.S. health care system and its
effects on access to maternal mental health and SUD care. In the experience of the task force, our system
does not address the holistic needs of the mother–child dyad. The major challenges include integrating
services into the workflow and electronic medical records, issues with insurance reimbursement, the
workforce shortage and need for specific training, and the lack of clinical–community partnerships. For
example, bundled payment for perinatal care often does not incorporate services for mental health
conditions and SUDs, and vice versa. Additionally, clinical facilities (including birthing hospitals) often
lack familiarity with community resources that support maternal mental health and new parents.
Moreover, these facilities are not co-located with the support services that new parents often need. In
contrast, co-located or integrated perinatal (or primary) care provided by interdisciplinary teams offers
access to evidence-based services for mental health conditions and SUDs. Integrated care reduces stigma
and reduces the burdens and negative SDOH that many people face—such as lack of access to
transportation and child care and time constraints—when they need to access these services (including
services for IPV). In areas with workforce shortages, co-located and integrated care can reduce the
number of required support staff members. Facilities that offer integrated care might be more likely to use
perinatal psychiatry access programs to address gaps in expertise rather than refusing to treat perinatal
mental health conditions and SUDs. On-site resources (e.g., team members with the time and expertise to
talk with patients about complex concerns) and established community partnerships also increase the
ability of busy providers to support people who are experiencing IPV, other GBV-related trauma, and/or
negative SDOH. Telehealth collaborations could represent another pathway to better care coordination.
9
Lack of Systemic Supports During Postpartum Challenges
Pregnancy and the postpartum period represent major life course events. The physical, mental, emotional,
and practical challenges—including sleep deprivation, costs associated with medical care and caring for a
newborn, and around-the-clock caregiving on top of other responsibilities—of caring for an infant are
considerable. Our nation lacks the federal- and state-level infrastructure needed to fully support these
major life events. Such infrastructure would include guaranteed paid family and medical leave, universal
child care, full support for parents and infants getting proper nutrition, and equitable, full access to
culturally relevant, trauma-informed medical and mental health care services. Systemic issues—including
mostly separated medical and mental health systems, complicated insurance processes, a lack of
workforce members to address perinatal mental health conditions and SUDs, a lack of knowledge about
support resources, and mandatory reporting and other punitive measures—also present challenges during
the postpartum period. Moreover, the federal government lacks the infrastructure to lead efforts to address
these systemic issues.
The lack of paid family and medical leave remains a primary concern, as well as access to affordable
healthful foods for parents and infants in all communities. Current social safety net programs (e.g., the
Special Supplemental Nutrition Program for Women, Infants, and Children [WIC
]; the Children’s Health
Insurance Program [CHIP]; Temporary Assistance for Needy Families [TANF]; and the Supplemental
Nutrition Assistance Program [SNAP]) and housing assistance significantly mitigate the impact of
poverty and food insecurity; however, given their limitations or requirements—such as insufficient
coverage for those in deep poverty, income limits/requirements, stringent work requirements, difficult
application processes, program implementation challenges, and time limitations on services—these
support programs do not sufficiently address these social problems (Marti-Castanar et al., 2022; Shaefer
et al., 2020; Giannarelli et al., 2017; Danziger, 2010 as cited in Marti-Castanar et al., 2022).
In fact, the United States is one of the few high-income nations that does not yet provide paid family and
medical leave (Livingston & Thomas, 2019). Paid family and medical leave policies allow workers to
receive compensation when taking longer periods of time away from work for qualifying reasons (e.g.,
having a new child, being ill, or having a family member who is ill) (U.S. Department of Labor, n.d.).
Currently, no federal law influences these policies for the U.S. private sector. A growing number of states
have established their own policies. Paid family and medical leave policies are important because they
permit workers to engage in employment and other economic activities rather than exit the workforce to
care for loved ones (U.S. Department of Labor, n.d.). Although the
Family and Medical Leave Act of
1993 is available, researchers have pointed out that the
law’s requirements for a minimum number of hours
worked, duration of employment, and employer size
generate inequities (Heymann et al., 2021). Some
researchers have argued that policies for national paid leave
(such as paid sick leave) could help reduce health and
socioeconomic inequities (Heymann & Sprague, 2021).
On the whole, our nation’s fragmented infrastructure and limited resources often put the burden of
managing all the challenges of the perinatal period on individuals and families, which strains parental
mental health and well-being. Moreover, some individuals have limited or no support systems to help
with the practical and emotional aspects of pregnancy and the postpartum period. People who lack in-
person and day-to-day support and resources during the initial months after delivery face many challenges
that may affect their mental health. They, in particular, would benefit from a care system that assesses the
level of support that individuals have and bolsters assistance. It is also critical that infrastructure and
systems be tailored to address the unique considerations faced by pregnant and postpartum adolescents
who have little or no support, as their needs will differ from those of adults.
“With my second [child] … I would have
done better if I had taken more time to
properly heal. [That would have been
better for] both … me and [my] baby.”
- C.S., pregnant mother of two
10
As the United States does not have a federal paid family and
medical leave policy, many people must return to work before
they are ready. This situation is compounded by a shortage of
affordable high-quality child care and may negatively affect
maternal mental health. (See “Pillar 5: Lift Up Lived
Experience”). One issue that arises during the postpartum period
as new parents return to work is infant feeding. A postpartum individual’s informed decision of whether
to breastfeed as part of their approach to infant feeding should be supported by their provider and those
they trust. The method of infant feeding is a major consideration for postpartum individuals. Although
there are many clear benefits to both the mother and the baby from breastfeeding—including
breastfeeding’s being associated with improved mental health outcomes—lactation may not always be
easy. Some evidence suggests that people who experience challenges with breastfeeding that do not
match their expectations may be likelier to experience negative mental health outcomes (Yuen et al.,
2022). The necessary supports to start and succeed at breastfeeding (e.g., high-quality breast pumps,
lactation consultants, coaches, and peer support programs) may not be available, covered by insurance, or
affordable. Lack of infrastructure in the workplace (e.g., designated rooms for lactation, refrigerators, and
time accommodation for pumping) may be a barrier. Pressure from others may play into the decision of
whether to breastfeed and its effects on mental health. Maternal conditions, including mental health
diagnoses or SUDs, may require medications, and risks and benefits must be taken into consideration
when choosing optimal infant feeding strategies. Both providers and patients need current, evidence-
based information so they can engage in shared decision-making about the risks and benefits of
breastfeeding for their individual situation and also about continuation of medications during pregnancy
and in the postpartum period. Mental health repercussions should be routinely recognized and addressed.
The Perinatal Period: An Opportunity to Address Mental Health
Conditions and SUDs
The perinatal period offers a unique opportunity to engage pregnant and postpartum individuals in
discussions about mental health and substance use and to intervene with those who have mental health
conditions and SUDs. It also provides opportunities to address issues that affect maternal mental health
and well-being, such as negative SDOH and experiences of GBV and other trauma. Generally, pregnant
and postpartum individuals are actively engaged in the health care
system. A person with an uncomplicated pregnancy has an average
of 25 interactions with health care providers during the perinatal
period. But some experiences, such as NICU hospitalization of the
infant or prolonged hospitalization of the mother, may disrupt
screening opportunities for perinatal mental health conditions and
SUDs. System supports could help ensure that opportunities for
detecting these conditions are not missed. Additionally, pregnant
and postpartum individuals often interact with nonmedical community-based providers—such as doulas,
childbirth educators, lactation consultants, home visitors, and community health workers. These
nonmedical community-based providers often have strong and trusted relationships with their clients and
are well situated to provide education about maternal mental health conditions, SUDs, and other issues, as
well as sharing resources. The perinatal period also offers a unique opportunity to have a two-generation
approach by addressing these issues that, if left untreated, can have long-term negative effects on the life
course of the parent and the life course of the child.
“I felt like I had to do it all, like
Superwoman. I didn’t disclose
that I was sad or crying.”
- J.S., mother of one
“Being asked about my mental
health made me feel that
mental health and emotions
were a legitimate concern.”
- S.B., mother of two
11
Introduction
Congress’s authorization of the task force’s meeting and reporting requirements aims to address the crisis
of maternal mental health by calling for greater collaboration within the federal government, emphasizing
best practices related to maternal mental health conditions and substance use disorders (SUDs), and
requiring the Task Force on Maternal Mental Health to develop a national strategy to serve as a blueprint
for improving maternal mental health and SUD care. Congressional action was prompted by the
individual and societal consequences of these conditions when left untreated, as well as advocacy efforts.
HHS formed the Task Force on Maternal Mental Health as a subcommittee of SAMHSA’s ACWS in
response to a directive from Congress to address this public health crisis (
Consolidated Appropriations
Act, 2023 [Public Law 117–328, Section 1113]). The members of the task force developed the
recommendations in this national strategy based on their collective expertise and discussions, review of
the relevant literature, listening sessions with state- and local-level stakeholders, and public comments.
The task force also considered input from people who have direct knowledge and experience of these
conditions (including providers). (See “Pillar 5: Lift Up Lived Experience.”) Given the urgency of the
maternal mental health crisis, the publication of this document and the complementary Task Force on
Maternal Mental Health’s Report to Congress was expedited to accelerate implementation of the task
force’s recommendations. The report to Congress details the committee’s methods.
The task force is a subcommittee of SAMHSA’s ACWS and falls under the Federal Advisory Committee
Act (FACA). The lead agencies are the HHS Office of the Assistance Secretary for Health’s (OASH)
Office on Women’s Health (OWH) and the Substance Abuse and Mental Health Services Administration
(SAMHSA).
12
At a Glance: Task Force Members and Methods
Task Force Members
• Experts in obstetrics and gynecology, maternal and child health, clinical and research psychology,
psychiatry, counseling, gender-based violence (GBV), strategic policy, community behavioral
health, federal–community partnerships, and other relevant areas
• More than 100 members from diverse backgrounds
• Both federal and nonfederal members
• Federal members leading departments and agencies (or the designees of leaders) with purviews
that include maternal and child health and health care, services for mental health conditions and
SUDs, and surveillance efforts and data collection
• Nonfederal members with expertise in maternal mental health, recruited through multiple notices
in the Federal Register, including advocates, representatives from nonprofit entities,
representatives from policy centers, providers, representatives from medical and professional
societies, industry representatives, and those with lived experience
• Individuals with lived experience of maternal mental health conditions and SUDs (including as
providers of care)
Task Force Methods
• The task force consulted federal and national program reviews, consulted a literature review, held
four 1-hour virtual listening sessions for state- and local-level input from representatives of key
national groups of stakeholders, obtained public comments through a request for information
(RFI), and consulted the report titled Maternal Mental Health: Lived Experience, completed by the
U.S. Digital Service (USDS).
• Five task force workgroups met virtually about 40 times (1–2 hours each time) between November
2023 and April 2024 to generate the findings and write recommendations for this national strategy.
• There were 10 workgroup co-chair check-in meetings between November 2023 and April 2024.
• There were five meetings of the entire task force and two meetings of federal task force members
to refine drafts of the national strategy in March and April 2024.
• There were two meetings with the ACWS to approve the national strategy and its
recommendations (the first meeting was for approval in principle, and the second meeting was for
approval of the final language) in April 2024.
• There is ongoing work to update and supplement the report to Congress and national strategy
regularly, with a sunset date of September 30, 2027.
Participating Federal Agencies
• Administration for Children and Families (ACF)
• Administration for Community Living (ACL)
• Agency for Healthcare Research and Quality (AHRQ)
• Centers for Disease Control and Prevention (CDC)
• Center for Faith-based and Neighborhood Partnerships (Partnership Center)
• Centers for Medicare & Medicaid Services (CMS)
• Food and Drug Administration (FDA)
• Health Resources and Services Administration (HRSA)
• HHS Office of the Assistant Secretary for Health (OASH)
• HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE)
• HHS Office of Intergovernmental and External Affairs (IEA)
• Indian Health Service (IHS)
• National Institutes of Health (NIH)
• Office of Management and Budget (OMB)
13
At a Glance: Task Force Members and Methods
• Substance Abuse and Mental Health Services Administration (SAMHSA)
• U.S. Department of Homeland Security (DHS)
• U.S. Department of Defense (DOD)
• U.S. Department of Labor (DOL)
• U.S. Department of Veterans Affairs (VA)
• U.S. Digital Service (USDS)
The Task Force on Maternal Mental Health’s national strategy and report to Congress are an important
part of broader federal efforts to address women’s overall health (including their mental health) and
maternal health in particular across the nation. The task force’s documents are aligned with multiple
ongoing initiatives, including the following:
• The White House Initiative on Women’s Health Research
;
• White House Blueprint for Addressing the Maternal Health Crisis;
o The task force notes that the White House Blueprint for Addressing the Maternal Health
Crisis makes recommendations that address maternal mental health, including:
improving data collection
focusing on veterans
expanding the National Maternal Mental Health Hotline
integrating supports for mental health conditions and SUDs in community
settings
o To accompany the blueprint,
Substance Use Disorder in Pregnancy: Improving
Outcomes for Families was developed by the Office of National Drug Control Policy
with input from other federal agencies, including SAMHSA.
• The HHS Secretary’s Postpartum Maternal Health Collaborative with six states (Iowa,
Massachusetts, Maryland, Michigan, Minnesota, and New Mexico);
• The Hear Her (with resources for American Indian/Alaska Native individuals) campaign (CDC);
• The Maternity Care Action Plan (CMS);
• The Transforming Maternal Health Model (CMS);
• The Enhancing Maternal Health Initiative (HRSA);
• The National Maternal Mental Health Hotline (HRSA);
• The Talking Postpartum Depression campaign (OWH); and
• The State Technical Assistance Maternal Mental Health Learning Communities (SAMHSA).
Coordination among federal agencies, along with collaboration with the federal government’s many
partners, is essential to maximize the impact of these efforts. With the release of this national strategy, the
Task Force on Maternal Mental Health indicates a path forward for the whole federal government to
coordinate its many ongoing activities, initiatives, and programs with the goal of addressing the barriers
discussed. Individual federal agencies provided information on federal programs discussed for the
recommendations, and some of the text quotes or paraphrases their websites and agencies’ other
publications and materials. The federal government’s work must include ongoing partnerships with states,
U.S. territories, local jurisdictions, and tribes. Although the report to Congress and this national strategy
discuss recommendations and potential partnerships with states, the task force will also develop a report
to all governors in the U.S. that details further opportunities for local- and state-level partnerships and
recommendations specific to states. Federal government collaborations also must include public–private
entities, industry, advocates, medical and professional societies, communities, and individuals with lived
experience and their families. Throughout this national strategy, there is a focus on leveraging and
expanding federal programs, resources, and expertise—as well as evidence-based practices.
14
Implementation of the national strategy will provide a blueprint for building the necessary infrastructure
to support the mental health and well-being of all pregnant and postpartum individuals, their children,
their families, and communities across the nation.
The Audience, Scope, and Vision for the National Strategy
Audience
The primary target audience for this national strategy is the federal government—namely, Congress and
the executive branch, including the many federal departments and agencies that spearhead the provision
of health care and services in communities. Note that at times the recommendations specify a particular
entity within the federal government and that at other times no particular agency or entity is specified
because it is implied that a whole-government approach is needed.
However, the federal government’s work cannot be carried out without collaborations and partnerships
with states, public–private entities, industry, advocates, medical and professional societies, communities,
and individuals with lived experience and their families. Therefore, this national strategy also speaks to
those collaborators and partners and identifies opportunities for them to come together to change the
national landscape of perinatal mental health and substance use care.
Scope
Congress charged the task force with lifting up best practices and improving federal coordination to
address perinatal mental health, substance use, and their co-occurrence (Consolidated Appropriations Act,
2023). Per the authorizing legislation, the scope of the national strategy is to describe how the Task Force
on Maternal Mental Health (as well as those federal departments and agencies represented on the task
force) “may improve coordination with respect to addressing maternal mental health conditions, including
by:
• Increasing the prevention, screening, diagnosis, intervention, treatment, and access to maternal
mental health care, including clinical care and non-clinical care—such as those provided by peer-
support and community health workers, through the public and private sectors;
• Providing support relating to the prevention, screening, diagnosis, intervention, and treatment of
perinatal mental health conditions, including families, as appropriate;
• Reducing racial, ethnic, geographic, and other health disparities related to prevention, diagnosis,
intervention, treatment, and access to maternal mental health care;
• Identifying opportunities to modify, strengthen, and better coordinate existing federal infant and
maternal health programs to improve perinatal mental health and SUD screening, diagnosis,
research, prevention, identification, intervention, and treatment with respect to maternal mental
health; and
• Improving planning, coordination, and collaboration across Federal departments, agencies,
offices, and programs.”
The task force highlights the following cross-cutting imperatives throughout this national strategy:
• The need to improve equity and access to perinatal care and services by directing resources to
the individuals, families, and communities that disproportionately experience these maternal
mental health conditions, substance use, and SUDs;
• The important role of federal coordination in building an infrastructure and an environment that
support maternal mental health and families;
• The essential contribution of culturally relevant support and care provided by workforce
members who understand the role of perspectives of mothers from under-resourced communities
in bolstering maternal mental health; and
• The need for trauma-informed approaches to care and services and the importance of training
and education in this area among providers, programs, and organizations.
15
Vision
The task force expects that its work—this national strategy, the report to Congress, and subsequent
reports and updates—will improve maternal mental health and well-being for all individuals and
communities across the nation. The task force envisions that perinatal mental health and substance
use care in our nation will be seamless and integrated across medical, community, and social
systems, such that there will no longer be a distinction between physical and mental health care and
that models of care and support will be innovative and sensitive to individuals’ experiences, culture,
and community.
Call to Action
The task force summarizes the current national landscape for maternal mental health conditions and
SUDs:
• There is a high prevalence of pregnancy-related deaths, and maternal mental health conditions
and SUDs are significant contributors to that.
• Disparities disproportionately affect individuals at higher risk for perinatal mental health
conditions and SUDs.
• GBV and social determinants of health (SDOH) are contributing factors.
• There is a lack of cohesive policies, programs, and systems; and
• There have been many missed opportunities to engage pregnant and postpartum individuals.
Given this landscape, the task force calls for the following in order to achieve the aforementioned vision:
• Regular and respectful education about, discussion of, and screening for maternal mental health
conditions and SUDs (along with consideration of SDOH and GBV) for all individuals during the
perinatal period;
• Clear pathways to connect individuals affected by maternal mental health conditions and SUDs
with care that is holistic, equitable, affordable, trauma-informed, patient-centered, and culturally
and linguistically relevant; and
• Adequately staffed care that focuses on the mother–infant dyad with two-generational approaches
and ensures that the right treatment is available at the right time.
As described in the report to Congress, federal programs, as well as and state and local efforts, are
ongoing to realize this vision. These efforts employ evidence-based, evidence-informed, and promising
practices (see definitions in “Language Used in This National Strategy”), many of which are also detailed
in the report to Congress. Throughout this national strategy, the task force highlights some federal
programs, state and local efforts, models, and best practices—suggesting ways that federal coordination
could scale up these effective measures. The task force also outlines what the federal government could
do—in collaboration with its diverse array of public and private partners—to promote maternal mental
health and prevent SUDs for all pregnant and postpartum individuals.
Some of the recommendations described in this national strategy are actionable in the short term, whereas
others represent aspirational goals to work toward over many years. The national strategy is framed
around five pillars, each of which is supported by priorities and recommendations to improve care and
services for maternal mental health conditions and SUDs. The voices of people with lived experience are
uplifted throughout this national strategy, including in quotations from Maternal Mental Health: Lived
Experience. The Task Force on Maternal Mental Health will regularly update the national strategy—a
living document that will inform Congress of the federal government’s efforts and describe the current
status of this crucial area of public health in the United States.
16
Recommendations from the Task Force on
Maternal Mental Health
As a subcommittee of the ACWS, the Task Force on Maternal Mental Health developed
recommendations to coordinate and improve federal activities related to addressing maternal mental
health conditions and SUDs. Its parent FACA committee approved all of the recommendations, which are
presented within the framework of five pillars (with priorities under each). The recommendations do not
necessarily reflect the views, opinions, or positions of any of the participating departments or agencies.
The organizational framework for the recommendations is shown in the figure below. Although the
background section of this national strategy provides the overarching reasons for the recommendations as
a whole, each recommendation is supported by a brief rationale (“Why?”) and suggested federal
government implementation activities (“How?”). The activities are broad and ambitious and will depend
on federal collaboration with multiple partners—including state, local, tribal, and territorial governments;
industry; professional and scientific associations; community-based organizations; and communities
across the country—to change the national landscape of perinatal mental health and substance use care
and ultimately improve the lives of people with these conditions.
Pillar 1: Build a National Infrastructure That Prioritizes Perinatal
Mental Health and Well-Being
Our nation currently lacks the infrastructure and environment to sufficiently support maternal mental
health and well-being. There is a lack of federal laws and policy to support parental leave and child care;
activities at the federal level require better coordination; systems of care are often fragmented and do not
meet the needs of the mother–infant dyad; and some policies are stigmatizing and punitive, especially
17
around maternal substance use disorders (SUDs). Recommendations supporting Pillar 1 include
establishing relevant federal laws, policies, programs, and mechanisms to prioritize and destigmatize
perinatal mental health and SUD care; improving disparities; integrating physical and mental health care;
and implementing universal education, prevention, screening, treatment, and recovery support for
maternal mental health conditions and SUDs.
Priority 1.1: Establish and Enhance Federal Policies That Promote Integrated
Perinatal and Mental Health/SUD Care Models with Holistic Support for Mother–Infant
Dyads and Families from Multidisciplinary and Interdisciplinary Teams
Recommendation 1.1.1
Enact federal laws and align incentives for states, the District of Columbia (D.C.), and territories to
mirror the expansion, funding, and enhancement of federal- and state-level integrated perinatal
and mental health/SUD care models involving multidisciplinary and interdisciplinary teams that
extend from pregnancy through at least 1 year postpartum—including two-generation (maternal
and pediatric care) practices, evidence-based screening and prevention, provision of treatment, and
linkages to follow-up and support services.
Why?
In integrated health care, teams of multidisciplinary health professionals collaborate to provide patient
care. This approach features a high degree of collaboration and communication among members of the
health care team. All health professionals on the team share patient care information so an individualized
comprehensive treatment plan can be developed (American Psychological Association, 2013). In the
experience of the task force, integrated perinatal care is holistic and considers the effects of life situations
(e.g., social determinants of health [SDOH] and intimate partner violence [IPV]) on health and the ability
to engage in care. Integrated care models do not separate physical and mental health, and they focus on
health promotion and prevention rather than treatment. This recommendation also builds on a strategic
priority outlined in the
HHS Roadmap for Behavioral Health Integration.
In the experience of the task force, integrated care models facilitate universal screening of perinatal health
conditions and SUDs—a practice that reduces stigma and offers opportunities to provide patient
education and resources (e.g., brochures, videos, mobile apps, and websites). Existing evidence-based
integrated care models are effective and could be enhanced and expanded, with the potential for a
significant increase in positive outcomes. For example, Seattle and King County’s public health system’s
implementation of MOMCare for pregnant women with major depressive disorder or dysthymia led to a
reduction in depression severity. This program—which was found to be cost-effective—improved rates of
adherence to care and depression remission (Grote et al., 2015). As described in the task force’s report to
Congress, federal programs that offer integrated care include the Maternal Opioid Misuse (MOM) Model
and Perinatal Reproductive Education Planning and Resources (PREPARe).
Research supports extending coverage for pregnancy care for up to 1 year postpartum. Among pregnancy-
related deaths from suicide, drug overdoses, and other causes associated with mental health conditions
and SUDs analyzed between 2008 and 2017, nearly two-thirds (63 percent) occurred 43–365 days
postpartum (compared with 18 percent of deaths from other causes) (Trost et al., 2021). Among women
who reported postpartum depressive symptoms at 9 to 10 months, 57.4 percent did not report these
experiences at 2 to 6 months—a finding that underscores the importance of attending to maternal mental
health throughout the year after giving birth (Robbins et al., 2023). Extending pregnancy coverage
ensures continuity of care, warm handoffs, and referrals and linkages to primary care or mental health
support systems.
18
How?
• This recommendation calls for the integration of mental health care and substance use care across
all relevant perinatal settings, such as obstetricians’ offices, primary care offices, pediatric
outpatient settings, emergency rooms, inpatient settings (including medical units), labor and
delivery settings, postpartum units, and neonatal intensive care units (NICUs).
• Services embedded in these integrated care models should include evidence-based screening,
prevention, assessment, treatment, referral, and follow-up services; evidence-based dyadic
(parent–child) treatment services to address both the parental mental health conditions and SUDs
and associated early childhood mental health concerns when they are present; nonclinical support
personnel—such as community health workers, doulas, and peer support specialists—to facilitate
culturally responsive linkages to services in the community and assist with screening and
providing resources to address SDOH; guidance on how atypical locations for care and services
(such as jails, prisons, and Special Supplemental Nutrition Program for Women, Infants, and
Children [WIC] offices) can integrate mental health and SUD treatment into their service
provision; screening, patient education, and services for gender-based violence [GBV] and other
trauma; and coordination with community-based organizations to provide at least 1 year of
follow-up support in the community.
• All components of the integrated care models should be embedded in a practice’s electronic
health records or equivalent documentation systems and be accounted for when billing.
• There should be incentives established and support provided to states for offering increased
reimbursement for screening and treatment services related to perinatal mental health and
substance use conditions (Agency for Healthcare Research and Quality, n.d.).
• Established guidelines on integration—such as those in the American College of Obstetricians
and Gynecologists’ (ACOG) Guide for Integrating Mental Health Care into Obstetric Practice,
the World Health Organization’s (WHO) Guide for Integration of Perinatal Mental Health in
Maternal and Child Health Services, and the Agency for Healthcare Research and Quality’s
(AHRQ) information on behavioral health integration for pregnant and postpartum women—
should be followed.
• Federal policies and incentives should be established and expanded to encourage all states to
promote and sustain permanency of pregnancy-related Medicaid coverage.
• Congress and the executive branch should enact laws that do the following:
o Require (versus only offer an option to) all states, all territories, and D.C. to expand
Medicaid and Children’s Health Insurance Program (CHIP) coverage from 60 days to 1
year after pregnancy, as well as providing information on how to use these benefits to
providers, patients, and communities (MOMMIES Act, 2023).
o Require all states, D.C., and all territories to provide Medicaid coverage of nonclinical
support staff members, such as community health workers, doulas, health navigators,
peer support specialists, lactation consultants, and GBV counselors/specialists.
o Require all states, D.C., and all territories to provide Medicaid coverage for dyadic
family mental health and SUD services. Ensure that providers can bill for services
provided to both the mother and the baby during the same visit (i.e., not having just one
of them be the identified patient).
• There should be incentives and support for states and private payers to implement the same
coverage as outlined above.
• In the absence of federal law, federal agencies should encourage more states to opt in to Medicaid
benefits for services provided by nonclinical support personnel, such as community health
workers, doulas, and peer support specialists. As of July 1, 2022, 29 states that had responded to
KFF’s 22nd annual Medicaid Budget Survey reported allowing Medicaid payment for the
services of community health workers (Haldar & Hinton, 2023).
19
• Models that have worked, including the following, should be funded, scaled up, and
disseminated:
o The Integrated Maternal Health Services (IMHS) program fosters the development and
demonstration of integrated maternal health service models, such as the Maternity
Medical Home, with a focus on advancing equity and supporting comprehensive care for
pregnant and postpartum people from under-resourced communities.
o The AIMS Center at the University of Washington offers a comprehensive
implementation guide for the Collaborative Care Model, which is an evidence-based
model demonstrating positive outcomes in the primary care setting (Melek et al., 2018)
and has also been shown to reduce racial disparities in care (American Psychiatric
Association Committee on Integrated Care, n.d.). The behavioral care manager serves as
the linchpin of the Collaborative Care Model. Care managers (often clinical social
workers, psychologists, or nurses by training) act as the primary point of contact for both
patients and obstetricians.
o The Integrated Behavioral Health Academy at Denver Health uses existing mental health
and substance use treatment systems and staffing to create a universal screen-to-treat
process for perinatal mood and anxiety disorders in obstetric clinics (Lomonaco-Haycraft
et al., 2019).
o The New Jersey Birth Equity Funders Alliance has an effective model for providing
grants to community-based organizations that focus on reducing disparities.
• Training should be incorporated into federal technical assistance programs, and training programs
that have been effective should be disseminated (e.g., the training programs for integrated care
managers identified by Miller and colleagues [2020]).
• Maternity care centers (MCCs) could be created to address the problems of having a limited
workforce and maternity care deserts and provide integrated care (modeled on certified
community behavioral health clinics [CCBHCs] and federally qualified health centers [FQHCs]),
which includes psychiatry access programs, peer navigators, doulas, community health workers,
and licensed substance use and mental health care providers. This should include a robust
program and process for workforce projection, monitoring, development, and deployment.
Recommendation 1.1.2
Enact federal laws that require the implementation of 6 months of paid family and medical leave
and universal child care in all states, the District of Columbia, and all U.S. territories.
Why?
Federal paid family and medical leave. The benefits that federal paid family and medical leave would
have on perinatal mental health emerged as an overarching theme of task force discussions, listening
sessions, and public comments. Countries that provide paid family and medical leave by law have better
maternal and infant health and well-being outcomes (National Partnership for Women and Families,
2021). Among 41 countries examined in one analysis, the United States was alone in offering no national
paid family or medical leave of any kind (Livingston & Thomas, 2019). Without a federal paid family and
medical leave policy, about a quarter of new mothers return to work within 2 weeks of giving birth.
Research suggests that state-level policies that make it easier for people to extend paid family and medical
leave may improve maternal mental health outcomes
(Coombs et al., 2022). As of February 2024, federal
employees are offered 12 weeks of paid family and medical
leave. The U.S. Department of Defense has also extended
paid family and medical leave to 12 weeks for service
members and offers convalescent leave for recovery from
pregnancy and birth (Vergun, 2023). Only 13 states plus the
“I didn’t want to go back to work, but
America isn’t really set up for moms to
stay at home and live on one income,
so that wasn’t something we could do.”
- K.L., mother of two
20
District of Columbia have mandatory paid family and medical leave systems. In states with paid family
and medical leave, many parents need education and assistance around completing documentation for the
leave. Additionally, the lag time in receiving the initial payment can be a challenge for those with low
incomes.
Paid family and medical leave can have a direct and lasting positive impact on the mental health and well-
being of both parents and children (Herrick, 2023). For example, parental leave can help alleviate mental
health symptoms by preventing or reducing stress associated with childbirth and infancy and increase
bonding time between parent and child. There is some evidence that paid family and medical leave
reduces household financial instability—decreasing poverty and stress that could lead to mental health
symptoms and other negative outcomes, such as family violence (Bullinger et al., 2024).
Universal child care. Affordable high-quality child care can offer tremendous benefits to families and the
overall economy (Herrick, 2023). Currently, more than 3 million families lack access to child care, and
most families are challenged by the cost of child care (Herrick, 2023). Additionally, individuals in the
child care workforce are often paid substandard wages. It is crucial for our nation to build the
infrastructure for a robust child care system—including increasing wages for child care workers—to
support the mental health and well-being of parents, children, and families.
How?
Paid family and medical leave.
• The federal government should identify ways to support the House Bipartisan Paid Family Leave
Working Group (launched in January 2023).
o The task force suggests a duration for paid family and medical leave of at least 6 months
(Earle & Heymann, 2019).
• For states where it may prove challenging to implement this legislation in a timely manner, the
federal government should offer support and technical assistance around implementation.
Universal child care.
• Congress and the executive branch should implement a series of actions, including the following:
o Expansion of relevant tax credits, such as child tax credits and employer tax credits for
providing child care. (For example, the Internal Revenue Service’s Employer-Provided
Child Care Credit “offers employers a tax credit up to $150,000 per year to offset 25
percent of qualified child care facility expenditures and 10 percent of qualified child care
resource and referral expenditures” [26 U.S. Code 45F
].)
o Establishing policies that provide child care subsidies and expanding current federal child
care subsidy programs.
o Consideration of universal federal incomes during the postpartum period.
o Enacting laws that mandate a universal minimum wage and health benefits for all child
care workers.
• The federal government should establish incentives and support for state and local governments
to leverage a variety of different funding sources to increase early childhood education (ECE)
workforce wages and benefits.
• The federal government should work with state and local governments to improve consumer
education efforts so they are culturally and linguistically responsive to reach more families and
improve their access to early care and education programs and services.
• The federal government should facilitate partnerships among state and local governments and
institutions of higher education to improve professional pathways and professional development
opportunities for the ECE workforce.
21
Administration for Children and Families (ACF) Resources That Support
Increased Wages for Child Care Workers and Support the Mental Health
and Well-Being of Parents and Children
• The Office of Child Care released sub-regulatory guidance that supports lead agencies in using the
Child Care and Development Fund to improve compensation for the child care workforce.
• ACF hosted a webinar titled “Helping Early Childhood Educators Thrive: Promoting ECE Staff Mental
Health and Well-Being.” Slides for the webinar are available here.
• The Office of Early Childhood Development released a “dear colleagues” letter titled “Dear Colleague
on New Federal Opportunities to Bolster the Early Care and Education Workforce.” The letter outlines
new federal opportunities for states, local programs, and communities to sustain and build on their
efforts to strengthen the ECE workforce.
• The Office of Early Childhood Development regularly updates the Resources to Support Early Care and
Education Workforce Strategies webpage. The resources address compensation and benefits,
pathways for career advancement, and information about working conditions that demonstrate the
value of the early childhood workforce.
• The Office of Early Childhood Development also regularly updates the Behavioral Health Resources for
Children and Families webpage. This page includes resources related to supporting the mental health
and well-being of parents, other caregivers, and the ECE workforce.
• The National Early Care & Education Workforce Center is a joint research and technical assistance
center. “This center builds on broader efforts of [ACF] to support the early childhood workforce by
identifying effective policies and strategies through research and evaluation, translating lessons from
research for practice, and supporting innovations in states and communities through technical
assistance.”
Recommendation 1.1.3
Establish policies that support non-stigmatizing and non-punitive approaches to screening for
SUDs, mental health conditions, and suicide in pregnant and postpartum individuals and ensure
access to culturally responsive, evidence-based, trauma-informed, family-centered care.
Why?
Stigma and punitive approaches against people with mental health conditions and SUDs have negative
effects on perinatal well-being and can be strong deterrents to seeking help. Substance use is considered
child abuse under civil child-welfare statutes of 24 states and the District of Columbia (Weber et al.,
2021). In 25 states and the District of Columbia, health care professionals are mandated to report
suspected prenatal drug use, with eight states requiring the testing of infants for prenatal drug exposure
when maternal substance use is suspected (Weber et al., 2021). These policies are often implemented in
discriminatory ways (Jarlenski et al., 2023).
Women are understandably concerned about mandatory referrals to child welfare services and the
possibility of their children being removed from their homes by child protective services and placed in
foster care, and this concern is a barrier to their seeking SUD treatment (Office of National Drug Control
Policy, 2022). In addition to seeing this issue in their professional experience, members of the task force
heard this concern in state and local listening sessions and the public comments. Evidence indicates that
the criminalization of SUD during pregnancy is ineffective at deterring substance use and may actually
lead to worse maternal and child health outcomes (American College of Obstetricians and Gynecologists,
2020; Office of National Drug Control Policy, 2022). These fears can be further amplified in the context
of IPV, in which abusive partners threaten to leverage punitive policies as a tactic of control (Office of the
Assistant Secretary for Planning and Evaluation & Family & Youth Services Bureau, 2020; Phillips et al.,
2021; Warshaw & Tinnon, 2018). In addition to the Office of National Drug Control Policy (ONDCP),
major medical and professional societies have supported non-punitive approaches to screening and care,
including the American Medical Association (AMA), ACOG (the American College of Obstetricians and
22
Gynecologists), and the American Society of Addiction Medicine (ASAM). ASAM “strongly supports
reforms to reverse the punitive approach taken to substance use and SUD during and after pregnancy and
respond to the shared interests of the parent-newborn dyad by providing ethical, equitable, and accessible,
evidence-based care” (American Society of Addiction Medicine, 2022).
Women with mental health conditions may also be concerned about the removal of their children,
especially if they experience intrusive thoughts about harming their babies, which can occur with
perinatal obsessive-compulsive disorder (Byatt et al., 2019). As noted in the task force’s report to
Congress, women experiencing perinatal mental health problems in the United Kingdom reported that
stigma and fear (including losing custody of children) were significant barriers to seeking treatment (Ford
et al., 2019). Other qualitative research on individuals with perinatal mental health conditions indicated
their need for nonjudgmental and compassionate support, their unmet need for information, and their
desire to be involved in treatment decisions (Megnin-Viggars et al., 2015).
How?
• The federal government should work with states, D.C., and U.S. territories to implement
guidelines, recommendations, and actions from:
o ASAM’s
Public Policy Statement on Substance Use and Substance Use Disorder Among
Pregnant and Postpartum People, in the section titled “Federal and State Policy Changes
and Reimagining Support”;
o ONDCP’s report titled Substance Use Disorder in Pregnancy: Improving Outcomes for
Families;
o ACOG’s policy statement titled “Opposition to Criminalization of Individuals During
Pregnancy and the Postpartum Period”;
o AMA’s report titled Improving Access to Care for Pregnant and Postpartum People with
Opioid Use Disorder: Recommendations for Policymakers; and
o The National Center on Domestic Violence, Trauma, and Mental Health’s research and
policy brief titled “Saving Lives: Meeting the Needs of Intimate Partner Violence
Survivors Who Use Opioids,” specifically sections that make recommendations for
federal and state policymakers.
• Training and technical assistance activities should be developed for the field to reduce
overreporting, and other incentives should be established that support implementation of the
above recommendations on non-stigmatizing and non-punitive approaches to maternal substance
use, SUDs, and mental health conditions (Roberts et al., 2024).
• The federal government should work with states, hospitals, licensing bodies, professional
societies, and training programs to establish notification pathways to resources without reporting
pathways.
• The federal government should scale up, enhance, and fund successful models that promote non-
punitive approaches and offer medications for opioid use disorder (MOUD) and medications for
alcohol use disorder (MAUD).
o The Maternal Opioid Misuse (MOM) Model
, funded through the Center for Medicare
and Medicaid Innovation, offers states the ability to integrate maternal health, mental
health, and SUD treatment to help alleviate psychosocial stressors and stigma around
seeking help.
o The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Services
Program for Residential Treatment for Pregnant and Postpartum Women and State Pilot
Program for Treatment for Pregnant and Postpartum Women support comprehensive
family-centered and dyadic care for mothers with primary diagnoses of SUDs and their
infants.
23
• The federal government should ensure states are in compliance with the SUPPORT for Patients
and Communities Act (Public Law 115–271), which requires state Medicaid programs to cover
all Food and Drug Administration–approved forms of MOUD, as well as counseling.
Recommendation 1.1.4
Invest federal funding into creating trauma-informed, accessible, and equitable family-friendly
health care facilities across the spectrums of inpatient, residential, and outpatient care by ensuring
free embedded child care.
Why?
In December 2021, President Joe Biden signed Executive Order 14058, focused on improving customer
experience when it comes to interacting with federal services—including maternity care and the WIC
program. Parents who visit a health care facility, mental health care setting, or SUD treatment program in
person often need to bring their children with them because they lack other options for child care (Waters
et al., 2022). It can be stressful for parents to manage long wait times, filling out forms, and consultations
with young children in tow. The lack of child care is a key reason many people are unable to attend office
visits and do not complete their treatment programs during the postpartum period (Choi et al., 2022).
Specialized inpatient care in the form of psychiatric mother–baby units is considered the gold standard of
care in other countries, and some have argued for expansion of these facilities in the United States
(Dembosky, 2021; Posmontier et al., 2022). The low number of residential SUD treatment programs that
include child care or restrictions on the children that mothers can bring with them is considered a
structural barrier (Substance Abuse and Mental Health Services Administration, 2009). Therefore,
provision of child care is considered one way to engage women in SUD treatment (Substance Abuse and
Mental Health Services Administration, 2009).
How?
• The federal government should establish incentives and support for states, hospitals, and
outpatient clinics to create family-friendly spaces and free embedded child care in facilities that
include outpatient SUD treatment, mother–baby mental health units, SUD residential treatment
centers, maternal/perinatal intensive outpatient programs, and partial hospitalization programs.
• Federal health care facilities, physical health and mental health care service programs, and SUD
treatment programs should be required to establish a designated child-friendly play area
(equipped with toys and age-appropriate activities) with supervision from dedicated staff
members or volunteers on-site.
• The federal government should scale up, enhance, and increase funding for model programs:
o SAMHSA’s State Pilot Program for Treatment for Pregnant and Postpartum Women and
Services Program for Residential Treatment for Pregnant and Postpartum Women make
child care services at the treatment centers mandatory as part of wraparound and recovery
support services.
• The federal government should provide technical assistance support for establishing family-
friendly spaces—such as sample plans, budget templates, and volunteer schedules.
Recommendation 1.1.5
Increase the implementation of well-deliberated, clinically sound recommendations, practice
guidelines, and evidence-based interventions related to the treatment and support of individuals
and mother–infant dyads with perinatal mental health conditions, substance use, and SUDs in all
relevant health care systems, with universal implementation as a target.
24
Why?
The American Academy of Family Physicians defines clinical practice guidelines as “statements that
include recommendations intended to optimize patient care that are informed by a systematic review of
evidence and an assessment of the benefits and harms of alternative care options” (American Academy of
Family Physicians, 2017). Clinical practice guidelines help practitioners understand the risks, benefits,
and potential harms of a treatment so that they can engage in shared decision-making with patients
(American Academy of Family Physicians, 2017). Although best practices and resources that could
improve maternal mental health exist, providers may not be unaware of them, may not have the time and
resources to learn and implement them, or may not be implementing them because of systemic barriers,
which can lead to suboptimal care and in some cases cause harm to patients.
Selected Recommendations and Practice Guidelines
Various medical and professional societies have released well-deliberated, clinically sound
recommendations and practice guidelines relevant to providing care for maternal mental health and
SUDs, including the following:
• ACOG’s guidelines for screening and diagnosis;
• ACOG’s guidelines for treatment;
• The American Society of Addiction Medicine’s guidelines for opioid use disorder treatment;
• The Society for Maternal-Fetal Medicine’s guidelines;
• The American Psychiatric Association’s Perinatal Mental Health Toolkit;
• The U.S. departments of Veterans Affairs and Defense’s Clinical Practice Guidelines for the
Management of Pregnancy;
• SAMHSA’s Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use
Disorder and Their Infants;
• The ACCESS Mental Health for Moms Perinatal Mental Health Toolkit;
• The HRSA-Supported Women’s Preventive Services Guidelines;
• The Agency for Healthcare Research and Quality’s Safety Program in Perinatal Care; and
• The Alliance for Innovation on Maternal Health’s (AIM) patient safety bundles (discussed below).
o Perinatal mental health conditions
o Pregnant/postpartum SUD
o Institute for Healthcare Improvement (IHI)–AIM change packages
AIM has developed patient safety bundles—collections of evidence-informed best practices that address
specific conditions in pregnant people and postpartum individuals. The bundles offer a structured way to
improve the processes of care and patient outcomes. Each one includes actionable steps that can be
adapted to a variety of facilities and resource levels. AIM has produced perinatal mental health and SUD
safety bundles, along with IHI–AIM change packages. AIM patient safety bundles include
multidisciplinary resources and implementable changes for organizations, as well as trainings and drills.
Additionally, clinical providers can extend their capacity in the area of maternal mental health conditions
and SUDs by linking with community-based services. These efforts are related to the work of perinatal
quality collaboratives (PQCs)—state or multistate
networks of teams working to improve the quality of
maternal and infant care—which are addressed in a
separate recommendation (3.2.2) of this national
strategy (Centers for Disease Control and
Prevention, 2023a).
“The hardest part is finding someone who
takes Medicaid. I can call all the therapists in
the area, but not everyone takes Medicaid.”
- F.P., pregnant mother of one
25
How?
• The federal government should leverage existing expertise, evidence, teamwork, and
communication science to increase the access to and implementation of evidence-based practices
and clinical practice guidelines for the treatment of perinatal mental health conditions and SUDs
through training and technical assistance to the workforce.
o Examples of existing federal programs include HRSA’s portfolio of
activities that
support AIM—the AIM Technical Assistance Center, AIM’s state capacity grants, and
AIM’s Community Care Initiative.
o Grantees, contractors, hospitals, and community organizations need programmatic
support in choosing and implementing evidence-based practices and the most up-to-date
clinical guidelines.
• Providers in federally funded programs should be required to adhere to guidelines, and the
requirements should be added to relevant notices of funding opportunities and contracts, along
with guidance for contracting officers’ representatives (CORs) and government program officers
(GPOs) on how to oversee compliance.
• The federal government should work with ACOG and The Joint Commission to ensure that
mental health and SUD care is incorporated into their Advanced Certification in Perinatal Care,
which requires that hospitals rely on evidence-based literature and practice guidelines to design
and implement their policies and improve clinical outcomes (The Joint Commission, n.d.). This
could be the gold standard by which federal programs look at hospitals, inpatient care settings,
and their delivery of care.
• The National Committee for Quality Assurance (NCQA) might consider how Healthcare
Effectiveness Data and Information Set (HEDIS) and Medicaid measures, which are addressing
implementation to a degree, could be further leveraged.
• Federal agencies should use incentives, quality measures, and quality improvement measures
(e.g., measures from HEDIS and the Medicaid Core Set) to increase adherence.
• The federal government should create a national technical assistance center for perinatal mental
health and SUD that provides consultation for the health workforce and focuses on
implementation strategies for evidence-based practices related to maternal mental health
conditions and SUDs. It should also assist with dissemination of research findings and
communicating them in plain language. Finally, it should have an advisory board with members
representing various communities, cultures, practice settings, types of practitioners, and types of
researchers.
• Federal agencies should partner with appropriate medical societies or other relevant organizations
to create AIM patient safety bundles on addressing GBV in perinatal populations, as well as
bundles that focus on maternal mental health in special settings, such as NICUs.
• The federal government should consult an evidence review for additional information on policy
and programmatic changes needed to improve maternal mental health (Wisner et al., 2024).
Priority 1.2: Establish and Enhance Federal Policies That Promote Perinatal Mental
Health and Well-Being with a Focus on Reducing Disparities
Recommendation 1.2.1
Expand, enhance, and increase funding for federal programs serving perinatal populations to
ensure that mental health, SUD, and GBV screening and preventive services, linkages to timely
holistic treatment, and resources and referrals to community-based recovery support services for
mental health conditions and SUDs are included.
26
Why?
SAMHSA, HRSA, AHRQ, and other federal agencies engage populations at high risk for maternal mental
health conditions and SUDs in services through existing programs. However, these programs are not
always required to incorporate care for maternal mental health conditions and SUDs. Agencies could
readily expand them to include maternal mental health screening and linkage to intervention. Such
programs (e.g., Healthy Start) are discussed in the “Existing Federal Programs and Coordination” chapter
of the report to Congress. Community-based programs include evidence- and research-based models,
some of which are discussed in the “Best Practices” chapter of the report to Congress (e.g.,
CenteringPregnancy, Expect With Me, MAMA’s Neighborhood, Mothers and Babies, the ROSE
Program, the CUB Clinic, Practical Resources for Effective Postpartum Parenting [PREPP], Family
Spirit, Healthy Families America, the Nurse-Family Partnership, HealthySteps, and Parents as Teachers).
How?
• The relevant federal programs for which to consider expansion include—but are not limited to—
the following:
o CCBHCs;
o Healthy Start;
o FQHCs and HRSA-funded health centers;
o Maternal Infant and Early Childhood Home Visiting (MIECHV) and Tribal MIECHV;
o The Services Program for Residential Treatment for Pregnant and Postpartum Women;
o The Maternal Opioid Misuse (MOM) Model;
o The Continuum of Care Program;
o State, local, territorial, and tribal partnership programs to reduce the number of maternal
deaths caused by violence; and
o The Rural Maternity and Obstetrics Management Strategies (RMOMS) program.
• Federal agencies should make training in perinatal mental health, SUD, and GBV screening,
assessment, treatment, and recovery supports mandatory for relevant federal programs, ensuring a
focus on trauma-informed, culturally relevant approaches.
• The federal government should work with private payers and offer incentives to enhance
coverage of maternal mental health services and SUD screening and intervention.
• Congress and the executive branch should enact laws to add a specific set-aside requirement to
enhance perinatal mental health training, screening, intervention, and treatment services, as well
as the perinatal mental health workforce, within existing state block grant funding for maternal
and child health, SUD, and mental health. Additionally, these funds should cover partnerships
with community-based services for GBV, substance use treatment, housing, and legal assistance.
Recommendation 1.2.2
Recognize the effects that structural racism and historical trauma have on creating and worsening
mental health conditions and SUDs and prioritize solutions for improving racial equity, addressing
trauma, and resolving disparities in care.
Why?
The task force’s report to Congress discusses the intersection of SDOH—e.g., race, ethnicity, educational
attainment, income level, and geographic location—as well as their relationships with the marked health
disparities and inequities in our country (Puka et al., 2022). Data indicate that Black, Hispanic, and
American Indian/Alaska Native (AI/AN) individuals, as well as people with less than a high school
diploma (or an equivalent diploma) and rural residents, generally are exposed to less favorable SDOH,
bringing about worse health outcomes and less access to high-quality health care (Hill et al., 2023; Singh
et al., 2017). The report to Congress also describes how negative SDOH (e.g., experiences of racism and
discrimination and food insecurity) are stressors that are associated with a higher likelihood of maternal
mental health conditions and SUDs (Linares et al., 2020; Weeks et al., 2022). These research findings are
27
aligned with the broad understanding of SDOH as reflected in the definition from CDC. This definition
says SDOH encompass “the wider set of forces and systems shaping the conditions of daily life” and adds
that those forces “include economic policies and systems, development agendas, social norms, social
policies, racism, climate change, and political systems” (Centers for Disease Control and Prevention, n.d.-
h).
Crear-Perry and colleagues (2021) applied a theoretical framework that focuses on “structural
determinants of health” to analyze the higher overall maternal mortality rate among Black women in the
United States. Their analysis outlines how structural determinants of health—such as slavery, the Jim
Crow era, and residential segregation—have influenced interacting SDOH (e.g., income, housing,
educational opportunities, and access to care) (Crear-Perry et al., 2021). Those SDOH in turn affect the
higher rate of maternal mortality among Black women (Hoyert, 2024). The theoretical framework applied
by Crear-Perry and colleagues (2021) contributes to the identification of the “root causes of inequities”
and extends the understanding of how social and political structures and policies have influenced the
distribution of unfavorable SDOH for particular U.S. subgroups (Crear-Perry et al., 2021). The authors
also suggest how practice and policies might be changed to reduce inequities in maternal health.
Access to high-quality maternity care is uneven in the United States and intersects with multiple health,
societal, and economic factors that contribute to higher rates of maternal and infant health complications
(March of Dimes, 2023). Multiple disparities related to maternal mental health and substance use
outcomes persist among demographic subpopulations (e.g., those related to race, ethnicity, age,
socioeconomic status, educational achievement, and geographic location)—with Black and AI/AN people
disproportionately affected (Policy Center for Maternal Mental Health, 2023a, 2023b). The ongoing
effects of structural racism influence inequities in access to diagnostic and treatment services for maternal
mental health conditions and SUDs (Matthews et al., 2021). Qualitative research suggests the need to
center equity in the education and training of practitioners, mental health workforce investments, and
funding of community-based organizations. Additionally, this research highlights the importance of
investing in all communities, recognizing traditional healing practices, promoting integrated care, and
supporting shared decision-making (Matthews et al., 2021).
How?
• Federal agencies should include best practices for screening and treating mental health
conditions, substance use, and SUDs as domains in respectful care guidelines (Cantor et al., 2024)
and incorporate them into trainings for nonclinical and clinical providers and others who work
with pregnant and postpartum individuals.
• The federal government should increase funding and focus for research in this area, such as new
funding opportunities, notices of special interest, and inclusion of this topic in special research
initiatives, such as the Office of the Secretary Patient-Centered Outcomes Research Trust Fund
.
• Federal agencies should develop metrics and enhance collection of data on racial disparities. For
example, the government should incentivize health plans and hospitals across the country to
report disaggregated data on maternal mental health to their states, ensuring a focus on these
outcomes and allowing for tailored approaches for improvement.
• There should be federal advisories with guidance to the nation’s health care centers and providers
on how to address structural racism in practice and improve patient outcomes.
• Trainings on implicit bias and structural racism should be incorporated into federal technical
assistance programs.
• The federal government should follow the HHS Office of Minority Health’s
National Standards
for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint
for Advancing and Sustaining CLAS Policy and Practice and make the implementation of the
National CLAS Standards mandatory in all relevant federal programs serving perinatal
populations and their families.
28
Recommendation 1.2.3
Appropriate sufficient funds to maintain and federally administer the work of the current Task
Force on Maternal Mental Health to enhance, coordinate, and sustain efforts and partnerships on
perinatal mental health and substance use. Establish in future legislation with funding—before the
2027 sunset of the task force—an ongoing coordinating committee on maternal mental health that
includes federal and nonfederal representatives.
Why?
As described in The Task Force on Maternal Mental
Health’s Report to Congress, the federal government
supports many programs, initiatives, and activities related
to promoting maternal mental health and addressing
maternal mental health conditions and SUDs. Continuing
the work of this task force would provide the coordination
needed to implement this national strategy.
How?
• Congress should consider changing the name of the group from a “task force” to a “coordinating
committee.”
• Congress should consider replicating the Advisory Committee on Immunization Practices
(ACIP), a highly influential FACA committee whose recommendations are reviewed directly by
the CDC Director and, if approved, published as official HHS recommendations in the Morbidity
and Mortality Weekly Report (MMWR) (Centers for Disease Control and Prevention, 2022).
• Congress should identify the federal agencies that should be represented on the permanent
Coordinating Committee on Maternal Mental Health. This might include HRSA, SAMHSA,
CDC, NIH, VA, DOD, DHS, ACF (including the Office of Family Violence Prevention and
Services), ASPE, CMS, IHS, DOJ, AHRQ, OASH, and DOL (including the Employee Benefits
Security Administration).
• Congress should identify nonfederal organizations and stakeholders to be represented on the
permanent Coordinating Committee on Maternal Mental Health. This might include providers,
medical/professional societies, people with lived experience, industry representatives, payers,
advocates and nonprofit groups, states, local agencies, and private groups.
• The federal government should call for the implementation of this national strategy and update it
regularly.
• Federal agencies might create a consortium of key stakeholders to help guide and support
implementation of this national strategy so it is aligned with the
U.S. National Plan to End
Gender-Based Violence: Strategies for Action.
• Congress should consider modeling the Health in All Policies (HiAP) approach in future
legislation for this work.
• The HHS Office of Disease Prevention and Health Promotion should bolster the Healthy People
2030 goals related to pregnancy and the postpartum period by including all perinatal mood and
anxiety disorders (PMADs) and SUDs, as well as their treatment (i.e., go beyond screening).
Similarly, the government should review the U.S. Preventive Services Task Force’s (USPSTF)
recommendations on prevention for perinatal depression and consider expanding them to all
PMADs and SUDs and including a mechanism for enforcement and monitoring. The government
should use the Healthy People 2030 goals, USPSTF’s recommendations, the CMS “Birthing-
Friendly” designation, and the Child and Adult Core Sets to guide an interagency approach to
effecting change.
“My midwife checked in with me
periodically. She was one of my
providers. She was support for me. And I
was honest with her about where I was
mentally, but there was only so much
support she could provide me.”
- F.P., pregnant mother of one
29
Pillar 2: Make Care and Services Accessible, Affordable, and
Equitable
Individuals experiencing maternal mental health conditions and SUDs face many barriers in accessing
care that is equitable and affordable. Many factors contribute to these challenges, including workforce
shortages (both clinical and nonclinical), the fact that systems of care can be fragmented and non-holistic,
challenges with reimbursement and payment, and the fact that care is not always linguistically and
culturally relevant. As a result, the majority (up to 75 percent) of individuals experiencing maternal
mental health conditions and SUDs do not get the care they need, potentially leading to long-term
negative effects on mothers, infants, and families (Byatt et al., 2015; Mughal et al., 2019).
Recommendations supporting Pillar 2 include addressing issues of diagnosis, reimbursement, access,
continuity of care, and workforce shortages.
Priority 2.1: Implement culturally relevant and trauma-informed clinical screening
and diagnosis, and improve linkages to accessible timely intervention and treatment.
Recommendation 2.1.1
Establish comprehensive pathways to improve routine culturally relevant and trauma-informed
screening for the presence of and assessment of risk factors related to developing perinatal mental
health conditions, substance use, and SUDs, along with GBV, other trauma, and SDOH—with the
provision of appropriate preventive services, resources, referrals, and linkages to timely
intervention in all relevant care settings.
Why?
Despite the high prevalence of maternal mental health conditions and SUDs, screening rates remain low.
For example, only about 20 percent of individuals are screened for perinatal depression, according to data
from HEDIS (Burkhard & Britt, 2022). Without screening and appropriate follow-up, women
experiencing these conditions do not receive the care they need. Although many validated screening tools
exist (these are noted in the task force’s report to Congress), they are not universally implemented. In the
case of perinatal depression, researchers have shown that a
collaborative care model improves rates of screening and
treatment recommendations (Miller et al., 2021). Health care
systems should support asking patients questions about their
histories of maternal mental health conditions and SUDs as
much as they support the consideration of gestational diabetes
and preeclampsia in previous pregnancies. Screening is not the
sole responsibility of the provider; health care systems and
infrastructure often leave little support, resources, and time for providers to screen in a culturally relevant,
trauma-informed way. Nor is there typically support for providers to engage subsequently in dialogue
with patients to provide education regarding the screening results and provide linkages to follow-up
resources and care. Other barriers to screening include a lack of reimbursement and a lack of support for
the provision of holistic care coordination and referral resources. In order for this recommendation to
come to fruition, providers need the adequate support, infrastructure, and practice personnel.
“[I experienced] anxiety around the
birth, feeling uncertain, nervous,
trying to do the right thing to keep
myself and my family healthy.”
- R.R., mother
30
IPV and Screening for Perinatal Mental Health Conditions and SUDs
It is important to understand the links among IPV, maternal mental health conditions, and SUDs when
screening for these conditions. Experiencing IPV has a significant impact on maternal mental health and
substance use and is a major contributor to maternal mortality, suicide, overdose, and homicide. People
who experience IPV often face additional barriers to care by abusive partners who prevent them from
accessing treatment, control their medications, sabotage their recovery efforts, and then leverage stigma-
related policies against them (e.g., child custody loss) as part of broader patterns of abuse and control
(Phillips et al., 2021; Warshaw et al., 2014). Women who experience IPV are 7.5 times likelier to have a
partner interfere with their care than those who do not experience this form of violence (McCloskey et al.,
2007). Despite the finding in one study that 3.5 percent of the women studied had experienced perinatal
IPV, many reported that they had not been asked about IPV before (58.7 percent), during (26.9 percent), or
after pregnancy (48.3 percent) (Kozhimannil et al., 2023).
How?
The federal government should expand training and implementation of education, screening, and
preventive services for all health systems and providers.
• Training:
o Federal agencies should provide technical assistance and training on issues such as (1)
reducing stigma, creating safe spaces, and implementing screening tools with fidelity and
in culturally relevant, trauma-informed manners, including how to raise and discuss
sensitive issues (e.g., GBV and other trauma); (2) clinical workflow and reducing
provider burden; and (3) communication of screening results (including for those with
disabilities).
o Federal agencies should encourage the provision of patient education as part of a broader
continuum of care that begins with screening. Approaches to educating pregnant and
postpartum individuals and their providers, promoting maternal mental health, and
preventing SUDs should attempt to eliminate stigma and shame, ensure knowledge about
these complications of pregnancy and childbirth and empower people to access services,
and create safe opportunities for people to discuss experiences of violence or other life
circumstances that affect their mental health, well-being, and access to care. Education
and screening approaches also should provide information and resources as early in
pregnancy as possible, thereby potentially preventing and/or mitigating negative effects.
o Federal agencies should provide training on trauma-informed responses to people
experiencing GBV and other trauma, including incorporation of conversations about IPV
and other trauma into routine assessments and clinical care; information, resources, and
ongoing support; warm handoffs and/or on-site GBV services; access to trauma
treatment; and attention to issues of safety, confidentiality, and coercive control (e.g.,
treatment interference, recovery sabotage, telehealth and electronic medical record safety,
and custody-related threats).
o Federal agencies should offer training and technical assistance on the identification of
military/veteran status, screening for these individuals, and the resources and treatment
needed to best support service members and veterans.
• Implementation:
o The federal government should work with states and health systems to embed screening
for mental health conditions, substance use, and SDOH into provider electronic medical
record platforms, along with prompts for asking and responding appropriately and
addressing safety.
o Evidence-based recommendations about preventive services (such as screening) for
pregnant people, postpartum people, and all women of reproductive age (including
adolescents) should be incorporated into all federal maternal, pediatric, and primary care
31
programs and recommendations serving perinatal populations, such as recommendations
from the U.S. Preventive Services Task Force (USPSTF) and the Maternal Mental Health
Leadership Alliance’s framework that has an equal emphasis on patient education and
screening (the Perinatal Mental Health Education and Screening Project).
o The federal government should fund, model, and scale up interventions that work well—
for example:
SAMHSA’s community-based provider education on screening, brief
intervention, and referral to treatment (SBIRT) and the expansion of SBIRT
implementation (Substance Abuse and Mental Health Services Administration,
2022). This should include ways to incorporate assessment of GBV, other
trauma, and SDOH into SBIRT.
o Federal agencies should support task-shifted workforce practices for implementing
screening and assessments related to GBV and SDOH. Interdisciplinary teams should
include members (clinical or nonclinical) who have the time to talk with patients about
sensitive issues.
The VA’s national maternity care coordination program
includes trained care
coordinators who contact patients via phone and administer some screenings
(e.g., for trauma and SDOH) and refer patients to care as appropriate. This
removes the burden from direct clinical care providers while ensuring that
patients are supported.
• Federal agencies should consider incentives, partnerships, and technical assistance to facilitate
state oversight to ensure that laws and regulations around screening are carried out—for example:
o The Women’s Preventive Services Guidelines (supported by HRSA), which require that
the following preventive services be covered in most health plans for patients without
their having to pay a copayment, coinsurance, or deductible:
Screening for anxiety in adolescent and adult women, including those who are
pregnant or postpartum; and
Screening adolescents and women for interpersonal and domestic violence at
least annually and, when needed, providing or referring them for initial
intervention services.
o California’s legislation mandating maternal mental health screening
in the prenatal,
birthing, and postpartum periods (California A.B. 2193, 2018).
• Federal agencies should work with experts, communities, and research bodies to lead efforts to
adapt and validate screening tools for perinatal mental health conditions, substance use, and
SUDs for various cultures, various languages, and people with various disabilities.
Recommendation 2.1.2
Clarify, modify, and adopt universal diagnostic criteria (e.g., language and definitions) that reflect
more accurate symptom presentation, range, timing, frequency, and severity of perinatal mental
health disorders and that improve reimbursement for screening, assessment, and intervention.
Why?
Research indicates that for about 75 percent of
women who screen positive for maternal mental
health conditions, symptoms emerge during
pregnancy or the postpartum period (Moore Simas et
al., 2023; Wisner et al., 2013). The clinical nuances of
these conditions require perinatal specifiers at a
minimum, if not a new category for perinatal mental
illness. Clarification or standardization of language in
“Make me feel like I am actually being listened
to. Ask about me as a person. I am still a
person. I am still a female, a woman.
Sometimes you get that feeling of the doctor
doesn’t really want to hear you.”
- J.N., pregnant mother of one
32
the field is needed for diagnostic and coding purposes and to improve research and surveillance (e.g.,
have more accurate prevalence rates). Currently, studies use different definitions of “maternal,”
“perinatal,” and “postpartum.” As a result of these different definitions, estimates of mortality and
morbidity and their causes vary considerably (Nguyen & Wilcox, 2005). This national strategy represents
an opportunity for the federal government, in partnership with the American Psychiatric Association and
other relevant professional societies, to encourage the development of a universal set of criteria that may,
in turn, support payer–provider policies related to coverage and reimbursement.
How?
• The federal government should facilitate convenings, discussions, and partnerships among
relevant stakeholders—such as medical, mental health, and research organizations and
professional societies, as well as payers, health care providers, and people with lived experience.
• Federal agencies should align definitions and diagnostic criteria through partnerships and/or
research support to build an evidence base that could be incorporated into diagnostic criteria
development.
• Federal agencies should collaborate with such relevant stakeholders to survey the literature in
order to:
o Identify perinatal-specific conditions that have large evidence bases and are currently not
included in diagnostic criteria;
o Determine a standardized time period that captures the majority of adverse outcomes
related to maternal morbidity and mortality;
o Standardize the definitions of relevant terminology—such as “maternal,” “perinatal,” and
“postpartum”—across health and research disciplines; and
o Propose perinatal specifiers with unique perinatal presentations supported by the
literature.
Priority 2.2: Create Accessible and Integrated Evidence-Based Services That Are
Affordable and Reimbursable
Recommendation 2.2.1
Create federal mechanisms to fund and develop infrastructure that supports innovation in care
delivery models for mental health conditions, substance use, SUDs, and GBV during the perinatal
period to reduce barriers to more accessible, holistic, and multigenerational dyadic care.
Why?
Traditional models of care by appointment and other barriers related to SODH (e.g., lack of access to
transportation and child care) discussed in the Background section of this national strategy contribute to
missed appointments and difficulties accessing perinatal care. Improving flexibility in how pregnant and
postpartum individuals access services (e.g., expanding
hours, home visiting, community outreach, and innovative
technology options such as telehealth) is essential to
improving equitable access to care (Burak & Wachino,
2023; Goldfeld et al., 2021; Hanach et al., 2021; Stentzel et
al., 2023).
Research suggests that mobile health (mHealth)—including mobile applications and text messaging—has
promise as a cost-effective means of providing patient education, facilitating the management of health
conditions, and supporting self-care (Rathbone & Prescott, 2017). Apps related to pregnancy are
increasingly popular and might offer opportunities for outreach and engagement. There are more than 250
apps related to pregnancy, according to a systematic review published in 2024. These apps provide
“It was going to take 3 to 6 months to
find someone, and I ended up just
giving up.”
- C.S., pregnant mother of two
33
entertainment, information, and maternal health monitoring (Mazaheri Habibi et al., 2024). Their use
could be expanded to provide education, awareness, and connections with mental health services. Some
apps are used in clinical care. For example, the VA’s National Center for PTSD has developed a suite of
free evidence-informed apps to help people live with post-traumatic stress disorder. Research on training
VA providers—both those in mental health and those from other areas of care—suggests the feasibility of
introducing these resources during visits (McGee-Vincent et al., 2023).
How?
• The federal government should establish (and bolster existing) programs that include/strengthen
the following:
o Requirements to incorporate innovative patient-centered care delivery, including flexible
scheduling; culturally relevant services, such as the inclusion of promotoras de salud,
community health workers, or cultural brokers; coordinated appointments (e.g., therapy
and medication treatment visits); integrated and co-located care for the mother and baby
(as well as elementary-age children); and the creation of mobile mental health teams;
o Home visiting programs that can provide home-based care in the perinatal period—for
example, leveraging the HRSA-funded
Maternal, Infant, and Early Childhood Home
Visiting (MIECHV) program, which provides evidence-based voluntary home visiting
services to pregnant people and parents of young children to improve their health and
well-being and focuses on enhancing early childhood development, preventing child
abuse and neglect, increasing children’s readiness for school, and connecting families to
community resources to address SDOH (e.g., WIC, Medicaid, and housing support);
o Access to technology and telecommunications, such as affordable and accessible
broadband and government-subsidized data plans that allow for video-based health visits
;
infrastructure support, including improving and funding telehealth access; innovative
methods to reach and support people during the perinatal period, particularly in medically
underserved areas; sustained support for telehealth reimbursement (including telephone
care); and telehealth options with protections for the safety of individuals experiencing
IPV;
o Co-created app content with maternal mental health experts, individuals with lived
experience, storytellers, and other stakeholders;
o The use of text messaging among community-based organizations to enhance
engagement and tailor the content of interventions/support;
o Digital solutions within community-based settings to help in closing the access gap to
support services, such as Health Evolve
; and
o Training and technical assistance support on how to implement, monitor, and sustain all
of the above interventions.
Recommendation 2.2.2
Improve federal funding and support for implementation of integrated crisis intervention services
for perinatal populations and their families, training of the workforce on crisis care provision that
is trauma-informed and culturally relevant, and development of infrastructure that leverages the
support of state and local crisis systems.
Why?
Pregnant and postpartum people experiencing a mental health crisis need integrated intervention services
to prevent self-harm. The task force’s report to Congress provides detailed information on pregnancy-
related deaths from suicide. An analysis of pregnancy-related deaths in 14 states found that 63 percent of
deaths determined by a maternal mortality review committee (MMRC) to be related to a mental health
34
condition were by suicide (Trost et al., 2021). Among people with pregnancy-related mental health deaths
(i.e., deaths from suicide, deaths from overdose or poisoning related to SUD, and other deaths that an
MMRC deemed related to a mental health condition or SUD), more than a fifth (22 percent) had a
documented previous suicide attempt or attempts, and 72 percent had a history of depression (Trost et al.,
2021). This study also found that nearly two-thirds (63 percent) of pregnancy-related deaths from causes
associated with mental health occurred 43–365 days postpartum (Trost et al., 2021). This finding aligns
with the results of research from the Canadian province of Ontario between 1994 and 2008, which found
that these deaths most often occurred after 6 months postpartum (Grigoriadis et al., 2017). Other research
has found that both depression and suicidal ideation during the year prior to pregnancy increased between
2008 and 2018—with the sharpest rises occurring among Black women (Tabb et al., 2023).
In the context of these and other findings on perinatal suicidal behavior, researchers have pointed out the
lack of studies to inform evidence-based strategies for prevention and emphasized the need to elevate it as
a public health imperative (Kobylski et al., 2023). The task force adds that currently, there are no
thorough, comprehensive evidence-based guidelines for emergency department providers on care for
individuals experiencing a mental health crisis during the perinatal period (Pluym et al., 2021). The task
force’s report to Congress discusses the intersection of GBV, particularly trauma from IPV, with perinatal
mental health conditions, SUDs, and pregnancy-related deaths. The task force asserts that the integrated
crisis intervention services for perinatal populations should take a trauma-informed approach and provide
culturally relevant support.
How?
• The federal government should establish programs that will implement crisis intervention
services, training, and infrastructure support for addressing mental health, SUD, and GBV-related
crises in perinatal populations, and it should incorporate that type of support into existing
integrated service programs.
• All crisis intervention should be paired with program-specific technical assistance and training on
how to implement best practices in crisis support for perinatal populations. Examples of ways to
accomplish that include the following:
o Expanding current technical assistance grants, such as SAMHSA’s Crisis Systems
Response Training and Technical Assistance Center and Suicide Prevention Resource
Center, to incorporate technical assistance on this topic;
o Working with SAMHSA’s 988 team and HRSA’s National Maternal Mental Health
Hotline team to ensure that content specific to maternal mental health conditions and
SUDs (such as suicidality risk and postpartum psychosis) is incorporated into all crisis
and mental health response team trainings; and
o Providing training and technical assistance for first responders in the community on how
to manage perinatal crises.
• The federal government should fund the development and dissemination of evidence-based
guidelines for emergency room providers on how to assess, provisionally diagnose, and treat
perinatal mental health crises.
Recommendation 2.2.3
Work with states and all payers to help establish financial incentives, including increased
reimbursement, and support for perinatal mental health and SUD interventions that demonstrate
positive outcomes.
Why?
When seeking mental health care, many people have difficulty finding in-network mental health providers
that accept new patients (U.S. Government Accountability Office, 2022). Limited access to in-network
providers and low reimbursement for Medicaid patients drive this problem. Low provider reimbursement
35
rates for psychological, psychiatric, and substance use
treatment also contribute to this problem. Mental health
parity laws require that health plans and insurers offer mental
health and SUD benefits that are comparable to their
coverage for general medical and surgical care.
Preauthorization and referral requirements for services
related to perinatal mental health conditions and SUDs are
barriers to treatment. Removing these barriers would support
maternal mental health and facilitate timely treatment access. Incentivizing states to increase
reimbursement for their Medicaid programs represents another way that the federal government could
support enhanced access and equity in maternal mental health. More than two-fifths (41 percent) of
women who gave birth in the United States in 2021 were covered by Medicaid (Valenzuela & Osterman,
2023).
States might benefit from assistance with encouraging insurance companies to improve reimbursement for
and coverage of midwives and other perinatal supports, as well as services provided by community-based
workers (The White House, 2022). The number of state Medicaid programs that reimburse the services of
peer support specialists, community health workers, and doulas is growing. Community-based workforce
roles provide meaningful career pathways for people with lived experience; such workers understand the
people they serve. The Policy Center for Maternal Mental Health (2023c) and others have argued that
peer support specialists are well positioned to address maternal mental health, as their services are
reimbursed by most state Medicaid programs (Fallin-Bennett et al., 2020; McLeish et al., 2023). Reforms
should strive for a system in which all in-network providers who care for perinatal patients can bill for the
services of certified peer support specialists.
Alternative payment models (APMs) are another way to
incentivize states in ways that align with positive outcomes in
perinatal mental health and substance use care. According to
CMS, an APM “is a payment approach that gives added
incentive payments to provide high-quality and cost-efficient
care. APMs can apply to a specific clinical condition, a care
episode, or a population” (Centers for Medicare & Medicaid
Services, n.d.). APMs can serve as a vehicle to provide more flexible prevention, early intervention, or
care that is not traditionally viewed as medical (e.g., linkage to a housing provider or support for people
experiencing IPV) that reduces the risk for negative maternal and child outcomes. APMs might
specifically address equitable access to care during the perinatal period (Stone et al., 2023).
How?
• The federal government should work with states and private payers to increase financial
incentives and reimbursement for services that demonstrate positive outcomes. The following are
some ways to do this:
o CMS could support states with creative proposals to change maternal health payment
methodologies, including APMs—especially those that incentivize upstream care and
support to prevent substance use and health and family crises.
o CMS could increase awareness of its new regulation
that requires states to compare their
fee-for-service payment rates for primary care, obstetric and gynecological care, and
outpatient mental health and SUD services with Medicare rates and publish their analyses
every two years.
o The U.S. Department of Labor's Employee Benefits Security Administration could be
involved in conversations about reimbursement of perinatal maternal mental health and
“I joined the Black women’s center.
They have a doula on staff to help. She
makes me appointments, has child
care. That’s how I kept it together.”
- J.N., pregnant mother of one
“The financial cost of paying someone
[for mental health counseling] out of
pocket is not in the budget.”
- F.P., pregnant mother of one who
didn’t have a therapist after 6
months
36
SUD services in Employee Retirement Income Security Act of 1974 (ERISA)– and
employer-provided insurance.
o The federal government could incentivize public–private partnerships in efforts to reduce
administrative burden and encourage insurance companies to remove preauthorization
and referral requirements for services related to perinatal mental health conditions and
SUDs.
o The federal government could work with all payers to encourage increasing
reimbursement rates for the following:
State Medicaid programs. For example, the government should consider
providing funding to state Medicaid programs for a maternity care and/or mental
health/SUD incentive payment that could supplement current rates. This would
help to increase the number of patients with Medicaid who are accepted into
mental health and SUD care. The government should call attention to the need to
factor reimbursement and billing administration into the direct and indirect work
of service providers.
Nonclinical support personnel, such as community health workers, doulas, and
peer support specialists. The government should encourage more states to opt in
to the community health worker Medicaid benefit (currently available in 29
states) (Haldar & Hinton, 2023).
Developing and scaling perinatal collaborative care models in settings such as
OB-GYN, pediatrics, and primary care (Miller et al., 2020). Collaborative care
models are evidence-based, patient-centered models of care that traditionally
integrate primary care and mental health care and have been shown to
reduce
stigma (American Psychiatric Association, n.d.)and reduce disparities (American
Psychiatric Association Committee on Integrated Care, n.d.). These models can
provide many lessons that apply to perinatal populations. Specific attention to
reimbursement in perinatal collaborative care is vital, as reimbursement and
insurance coverage vary across disciplines and providers.
Note: This might entail creating forums—such as learning communities, policy academies, or technical
expert panels—to encourage peer learning of successful models and discuss the benefits of increased
reimbursement, including cost savings, improved patient outcomes and engagement, expansion of the
workforce, and support for clinical providers that are often overburdened and understaffed.
• The federal government should implement and sustain APMs for Medicaid perinatal care that
account for integrated mental health and substance use screening and treatment.
o One example is the new CMS Transforming Maternal Health (TMaH) Model. The TMaH
Model will include an APM for participating states. It is a new 10-year payment and care
delivery model with a goal of improving maternal health and birth outcomes for women
and their infants. The TMaH Model focuses on improving maternal health care for people
enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).
Recommendation 2.2.4
Strengthen the continuity of care in the community by encouraging federal agencies to add
requirements to their notices of funding opportunities that direct recipients to collaborate with
other federally funded programs and develop partnerships with community-based organizations
and regional/state programs to expand access and referral to treatment and recovery support
services.
37
Why?
Efforts to enhance community-based perinatal services, supports, and resources should ensure that they
are culturally responsive. In the experience of task force members and participants in listening sessions,
strengthening links to community-based services is particularly important for under-resourced populations
because those populations are less likely to seek care in health care systems. Public comments and
feedback from listening sessions mentioned the need to adapt evidence-based practices to ensure cultural
sensitivity. These comments highlighted issues with trust, stigma, and systemic racism as challenges that
might be addressed by integrating community-based workers—including peer support specialists, doulas,
community health workers, navigators, and lactation consultants—into perinatal services. As described in
the task force’s report to Congress, these workers typically serve people in their communities, have
similar lived experience, and are familiar with local resources. They are well positioned to provide
culturally relevant multigenerational support for mothers, infants, and families. Throughout the task force
discussions, listening sessions, and public comments, participants emphasized the important roles
community-based services and workers play in supporting maternal mental health.
How?
• There should be collaboration among federally funded programs that support mental and
behavioral health, including the National Maternal Mental Health Hotline, the Community
Mental Health Centers Grant Program, the VA’s mental health services, the Family Violence
Prevention and Services Act program, and the Pediatric Mental Health Care Access Program.
• Federally funded programs should develop and enhance partnerships to expand treatment and
recovery support service options and coordinate services and activities to achieve program goals.
That should be completed by doing the following:
o Developing partnerships across a state, tribe, or region and then connecting these partners
to a broad range of community-based mental health and substance use treatment and
recovery providers;
o Ensuring that partnerships increase access to such services for pregnant and postpartum
people and their families; and
o Ensuring that partnerships are established with entities that receive funding for other
federal programs to facilitate referrals for comprehensive services for pregnant and
postpartum individuals.
• Federally funded programs (e.g., FQHCs, CCBHCs, Healthy Start, the MOM Model, MIECHV,
and HRSA home visiting) should specify the categories of partnerships that they require in
funding opportunities as a condition of funding to ensure community linkages.
Priority 2.3: Build Capacity by Training, Expanding, and Diversifying the Perinatal
Mental Health Workforce
Recommendation 2.3.1
Require all relevant federally funded training, curricula, and technical assistance programs to
incorporate how to prevent, screen, assess, and treat perinatal mental health conditions, inclusive of
SUD and GBV.
Why?
Providers are at the heart of the envisioned maternal mental health infrastructure but must be supported
themselves. For example, both clinical and nonclinical providers require the appropriate training and
education on maternal mental health conditions, substance use, and SUDs (including non-stigmatizing,
respectful, and culturally appropriate care). Appropriate provider training helps build trust with pregnant
and postpartum individuals. Task force discussions, listening sessions, and public comments all pointed to
the need for specific training in the area of maternal mental health. Frontline providers—including
38
nonphysician providers (e.g., midwives, doulas,
community health workers, and consultants)—need
specific training on how to address perinatal mental
health conditions and SUDs. In the experience of the
task force, specific training on perinatal mental
health conditions and SUDs is needed among health
care providers (e.g., in obstetrics, pediatrics, and
family medicine) of all levels (e.g., advanced practice
nurses, other nurses, physicians, and physician assistants). Mental health care providers (e.g.,
psychiatrists, psychologists, social workers, counselors, and therapists) and SUD treatment specialists
also need specific training in perinatal conditions. Part of provider training should cover the risk factors
for and subgroups most affected by perinatal mental health conditions and SUDs. Providers also need
ongoing support and supervision.
The field needs increased opportunities for training in interdisciplinary care (including mental health care)
and requirements for cultural competence and knowledge of SDOH. Medical school and residency
training for obstetrician-gynecologists (ob-gyns) in maternal mental health is insufficient. Major
transformations in provider trainings—such as requirements, certifications/accreditations, and changes to
curricula—may require alterations to laws, policies, regulations, and standards set by medical and
educational bodies. A specific training need relates to the reluctance among many health care providers to
prescribe (or continue) medications for mental health conditions and SUDs to patients during the perinatal
period (American Psychiatric Association, 2022; Kalfoglou, 2016). Continuing education and training
and technical assistance initiatives have the potential to increase providers’ knowledge about that.
Although difficult to implement, these changes would most likely have a high impact on overall access to
services and individual care encounters.
How?
• In order to effect this recommendation, federal agencies should:
o Incorporate implementation of specialty training efforts by federal agencies and experts
in the field of perinatal mental health and SUD, such as those below, into all relevant
federal training and technical assistance programs:
The National Curriculum in Reproductive Psychiatry
, which provides
reproductive mental health information to both mental health and maternal–child
health providers and includes the 5-Hour Essentials Mini-Curriculum, designed
for students who have limited time to devote to reproductive psychiatry;
Programs supported by HRSA’s Maternal and Child Health Bureau (e.g., the
Maternal and Child Environmental Health Network: MotherToBaby);
SAMHSA’s Providers Clinical Support System (PCSS) and SMI Advisor; and
Postpartum Support International’s training opportunities.
o Partner with professional associations, societies, providers, and national technical
assistance centers to enhance training and technical assistance, including the creation of
guidance through publications and advisories;
o Include opportunities for clinicians to access free training toward the Postpartum Support
International Certification in Perinatal Mental Health;
o Ensure that training and technical assistance are targeting all health care disciplines,
including pediatrics, internal medicine, family medicine, emergency medicine, obstetrics
and gynecology, mental health and SUD care, and nursing; and
o Incentivize and offer technical assistance to support anti-stigmatizing and
nondiscriminatory patient interaction training for health care providers and all personnel
(e.g., assistants, front desk staff members, and others).
“I didn’t go [to therapy] for months. There were
wait lists. The other piece was, I was starting to
go back to work and find a day care. [Making a
mental health care] appointment … felt [like]
too much, another thing [for me to do].”
- S.B., mother of two
39
Recommendation 2.3.2
Educate future and current clinical providers in perinatal mental health conditions, substance use,
SUDs, and GBV by ensuring that these topics are included in the curricula for both health care and
mental health care providers (e.g., in medical and nursing school, mental health and substance use
training programs, and allied health and mental health programs) and in continuing education
requirements.
Why?
As discussed above, there is insufficient training and education provided for perinatal mental health,
SUDs, and GBV, and more collaborative and comprehensive efforts need to be made to improve curricula
in school and in continuing education for practicing providers. Workforce shortages must be offset by
increasing the number of new providers entering fields who are trained from the outset to provide care for
patients with maternal mental health conditions and SUDs (including those who have experienced GBV).
How?
• Federal agencies should work with medical professional societies, clinical training programs, and
other relevant institutions to help support the adjustment of training and educational curricula and
certification to include perinatal mental health conditions, substance use, SUDs, GBV, and SDOH
and ensure that assessments reflect current practice guidelines for pregnant and postpartum
individuals. Agencies should encourage inclusion and expansion of these topics in all
examinations required for relevant professional licensure, such as the United States Medical
Licensing Examination (USMLE) for physicians, the American Board of Psychiatry and
Neurology’s (ABPN) certification exam for psychiatrists, and the American Board of Obstetrics
& Gynecology’s (ABOG) qualifying exam.
• Federal training and technical assistance programs should provide continuing education units
(CEUs) and continuing medical education (CME) for clinicians.
• Federal agencies should work with licensing bodies to create a requirement to complete a
minimum number of education credits on perinatal mental health, SUDs, and GBV for initial
license approval and subsequent license renewals in all professions serving pregnant and
postpartum individuals.
Recommendation 2.3.3
Allocate long-term funding to establish, expand, and sustain perinatal mental health, substance use,
and GBV consultation programs for medical, mental health and substance use, nursing, allied
health, and nonclinical community-based workers.
Why?
Given the shortage of obstetricians and psychiatrists who specialize in treating mental health conditions
during pregnancy and the postpartum period, perinatal psychiatry access programs can help meet the need
for care. Perinatal psychiatry access programs (which include professional consultation lines) are
typically state-based resources that support ob-gyns in improving access to high-quality mental health
care. These programs also help mental health care providers who would like to enhance their training or
competency in reproductive health care. Providing consultations with perinatal mental health specialists
(e.g., reproductive psychiatrists and perinatal psychiatrists)
via telehealth can increase access to services, such as the
diagnosis of mental health conditions and SUDs. Perinatal
psychiatry access programs also can serve as a means of
training and education for providers—particularly in rural
areas and other medically underserved areas. Scaling up
these programs emerged as an important way to increase
“I was looking for a Latina [provider],
someone who has had a home birth
experience, an experience they could
share with me.”
- F.P., pregnant mother of one
40
access and address the workforce shortage in task force deliberations, listening sessions, and public
comments. In the experience of the task force, scale-up will require increasing the number of specialists
who are knowledgeable about perinatal mental health conditions and SUDs to staff these programs.
How?
• The HRSA-funded State Perinatal Psychiatry Access Programs, provided through the Screening
and Treatment for Maternal Mental Health and Substance Use Disorders program, should be
expanded to cover all states, D.C., and all territories. These programs should provide specific
culturally appropriate supports for tribes and territories.
• The federal government should encourage states to adopt recent Medicaid guidance on
interprofessional consultation, which allows for reimbursement of interprofessional consultation.
This would enable obstetric care providers to be reimbursed for their services when they consult
with a specialist but do not have a face-to-face interaction with the patient.
• Federal agencies should develop and scale up consultation-based technical assistance programs,
such as SMI Adviser, the Refugee and Migrant Behavioral Health Technical Assistance Center
(both of which include addressing perinatal mental health, SUDs, or GBV), and the VA
Reproductive Mental Health Consultation program.
• Federal agencies should increase the awareness of and engagement with these psychiatry access
programs among perinatal care providers—including primary care, mental health/SUD clinicians,
and allied health providers.
• The federal government should clarify messaging on the purpose and target population for each
consultation line.
• Federal agencies should consider ways to engage relevant clinical and nonclinical providers
directly to increase use of consultation lines.
• Support programs such as Lifeline for Moms
, which provides training and technical assistance for
providers that want to implement perinatal psychiatry access lines, should be scaled up and
modeled.
Recommendation 2.3.4
Fund, incentivize, and bolster recruitment and training efforts to expand and diversify the
perinatal clinical and nonclinical mental health and substance use workforce, particularly in under-
resourced areas.
Why?
Drastic workforce shortages and under-resourcing drive the lack of access to services for perinatal mental
health conditions and SUDs, as well as general support for pregnant women, postpartum people, and
parents. This is particularly true in maternal health care deserts. The workforce shortage—as well as a
lack of representation among communities most affected by maternal mental health conditions and
SUDs—was a major theme of task force discussions, listening sessions, and public comments. Our nation
faces a shortage of obstetricians, licensed midwives, family physicians, and mental health care and SUD
treatment providers (Counts, 2023; Health Resources & Services Administration, 2024a; The White
House, 2022). These professions lack diversity and have limited pathways for people from
underrepresented communities to enter these roles, which contributes to gaps in culturally appropriate
care (Counts, 2023; The White House, 2022). Nonclinical community-based professionals who provide
perinatal services and support for mental health and SUD recovery are also in short supply—a problem
that is integrally related to low reimbursement rates and lack of coverage from insurers (Counts, 2023;
The White House, 2022). States need guidance on how they might expand access to licensed midwives,
doulas, peer support workers, community health workers, and freestanding birth centers.
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Spotlight on Programs That Incorporate Doulas
Doulas are at the heart of Hummingbird Indigenous BirthKeepers, a program that integrates evidence-
based care, culturally appropriate care, and social connections. Indigenous BirthKeepers provide holistic
support during the perinatal period. This Seattle Indian Health Board program received a maternal health
grant from the HHS Quality Improvement Fund. Oregon was the first state to launch Medicaid
reimbursement for “traditional health workers,” such as doulas, in 2012 (Oregon State Legislature House
Bill 3311, 2012). Oregon’s Community Doula Program has cross-trained doulas as peer wellness
specialists. The training allows peer support doulas to assist pregnant women affected by substance use
during pregnancy and up to 3 years postpartum. Collaboration between the Oregon Community Doula
Program and a peer support program for individuals working toward recovery has enabled 90 percent of
clients to retain custody of their children (Institute for Medicaid Innovation, 2023).
How?
• The federal government should invest in and bolster existing initiatives that train and certify
nonclinical community-based workers—such as peer support specialists, doulas, community
health workers, promotoras de salud, navigators, and lactation consultants—to expand and
diversify the perinatal workforce and improve perinatal mental health, particularly in under-
resourced areas.
o For example, Healthy Start includes support for training and supporting doulas as part of
the care team for pregnant and postpartum individuals (Health Resources & Services
Administration, 2024b).
• Federal agencies should require training in maternal mental health and SUD care as part of the
certification of peer support specialists, doulas, and community health workers.
• Federal agencies should facilitate the implementation of the “care extender” model—which
expands the health care workforce, builds capacity for maternal health teams, and offers
culturally congruent care—with peer navigators. In the short term, the government should publish
and disseminate guidance on how to recruit, train, and implement models that include peer
navigators as part of a holistic care team. In the long term, it should change payment policies and
models to incorporate peer navigator services as part of payment bundles or fee-for-service
schedules.
• Federal agencies should apply lessons learned from the Accountable Health Communities Model
,
developed by CMS, to bridge the gap between clinical care and community services. This model
used screening, referral, and community navigation services to address SDOH needs. The
development of trainings might be based on this model, which was evaluated in May 2023.
• The government should expand funding for and incorporate mandatory training around perinatal
mental health and SUD care in federal workforce programs, including but not limited to the
following:
o SAMHSA’s Minority Fellowship Program
;
o SAMHSA’s Historically Black Colleges and Universities Center of Excellence in
Behavioral Health program; and
o The Bureau of Health Workforce’s (BHW) more than 60 programs aimed at
strengthening the health workforce and bolstering the maternal health workforce by
increasing the supply, distribution, and quality of clinicians who can advance maternal
health, including family medicine and OB-GYN providers, nurses, and certified nurse
midwives. Relevant investments include the following:
The Maternity Care Nursing Workforce Expansion (MatCare) program, which is
focused on the training of nurse-midwives and has a goal of enhancing maternal
health training to better address maternal mental health, maternal mortality, and
morbidity risk factors;
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The Primary Care Training and Enhancement-Community Prevention and
Maternal Health program, which trains primary care physicians to provide
maternal health care, with a focus on improving outcomes for the perinatal
population;
Integrated behavioral health programs that expand the number of providers who
are trained to provide integrated services for SUDs in community-based settings,
including programs such as the Addiction Medicine Fellowship, the Integrated
Substance Use Disorder Training Program, and the Opioid-Impacted Family
Support Program; and
The Behavioral Health Workforce Education and Training Program for
Paraprofessionals grants, which aim to increase the number and enhance the
quality of mental health and SUD professionals.
• SAMHSA, HRSA, and related agencies should fund clinical and nonclinical internships in
federally funded programs serving perinatal populations to increase recruitment into the field.
• Federal agencies should incentivize students and trainees in high school, college, and graduate
education to choose careers in areas of need through pipeline development programs that spark
interest and develop knowledge about mental health care professions. Opportunities include
internships, summer programs, and education for high school career counselors.
Pillar 3: Use Data and Research to Improve Outcomes and
Accountability
Gathering, evaluating, and disseminating data is necessary to ensure that policies and programs are
effective. As noted in the task force’s report to Congress, our nation currently faces many challenges
related to maternal health data overall, including data related to maternal mental health conditions and
SUDs. Recommendations supporting Pillar 3 address ways that the United States could enhance the
quality of data collection, interpretation, measurement, analysis, and dissemination—including ensuring
that maternal mortality review committees and perinatal quality collaboratives are in place nationwide.
The task force also identified two primary areas in which data and research could drive positive change in
maternal mental health. First, data and research could be leveraged to support strategies and spur
innovations in care across the spectrum of care—prevention, screening, diagnosis, intervention, and
treatment—to improve outcomes for individuals with perinatal mental health conditions and SUDs.
Second, data and research are foundational for helping health systems and providers improve the quality
of care across the spectrum of services and increase access and equity.
Priority 3.1: Use Data and Research to Support Strategies and Innovations That
Improve Outcomes
Recommendation 3.1.1
Establish an interdisciplinary, interagency expert panel to determine high-priority areas of
research, surveillance, and implementation science that will directly affect national improvements
in perinatal mental health conditions and SUDs. The expert panel would be charged with ensuring
coordination across the federal government, translating data to action, and monitoring and
sustaining research and surveillance in this area.
Why?
Research and data collection are lacking in some areas relevant to perinatal mental health (e.g., effects of
medications and other treatments on under-resourced populations of pregnant people, children, partners,
and families). Federal agencies support research and data collection on many different topics, and a
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coordinating expert panel could help prioritize these efforts to ensure maximum impact. Dedicated
funding and a long-term strategic plan are needed.
How?
• The expert panel would help in carrying out this national research agenda and promote research
that supports the development, implementation, and evaluation of an array of comprehensive
holistic approaches to improving maternal mental health, including the approaches recommended
in this strategy. The research agenda would:
o Support perinatal longitudinal research, surveillance, and data collection (including the
qualitative lived experiences of families) to examine the effects of mental health
conditions, substance use, and SUDs and the need for ongoing support for women,
children, partners, and other family members.
o Examine the interplay between maternal mental health conditions, SUDs, and
comorbidities (e.g., hypertension, cardiac disease, renal disease, and birth defects) to
ensure that these topics are embedded in the research, surveillance, and care models.
o Augment research on modifiable and nonmodifiable risk factors (e.g., genetics, sleep
deprivation, social supports, and ACEs, as well as their effects on neuroplasticity), GBV,
and SDOH (e.g., the built and social environment, food access, education access and
quality, employment and economic stability, and health care access and quality) that
affect maternal mental health conditions and SUDs.
o Support studies that include greater engagement of pregnant, postpartum, and parenting
individuals across the research life cycle (e.g., development, implementation, and
dissemination) to inform policy, practice, and person-centered care across the lifespan, as
opposed to studies that focus on specific time periods (e.g., the postpartum period).
o Fund dedicated research to investigate sex-based differences and ensure the
representation of under-resourced groups and mother–child dyads.
o Support the systematic analysis of value-based payment and new delivery models (e.g.,
collaborative care) to assess the cost-effectiveness of investing in these types of care for
maternal mental health conditions and SUDs.
o Promote ongoing systematic data capture efforts to assess unmet needs for perinatal
mental health and SUD care at multiple levels (e.g., national, state, jurisdictional, county,
local, and health system). Focus on reducing pregnancy-related deaths by suicide.
o Enhance perinatal mental health and substance use research to investigate maternal and
infant outcomes associated with specific treatment approaches and models of care,
including implementation research. In addition, examine maternal and infant outcomes
associated with infant feeding.
o Support research on ways to prevent treatment from being punitive, especially for under-
resourced communities.
Recommendation 3.1.2
Invest in ways to build the trust of under-resourced communities that have experienced abuses
when participating in research and data collection efforts. Rebuild safety by engaging
communities—namely, pregnant and postpartum people with higher risk—in partnerships (e.g.,
through community-based participatory research) to ensure that research, data collection, analysis,
and reporting on perinatal mental health and substance use are equity-focused, are representative,
are culturally relevant, are trauma-informed, and maintain necessary confidentiality protections
with the highest ethical regard for vulnerable and under-resourced populations.
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Why?
Research on maternal health that includes the subpopulations most affected is crucial to advancing
knowledge, as well as equity and access. Furthermore, the exclusion of pregnant people in studies and
surveillance efforts results in an extremely limited evidence base, which curtails the ability to provide
tailored research-supported interventions for maternal mental health conditions and SUDs. Currently,
individuals from under-resourced communities are often not represented in data collection (2022).
Investments in building trust and partnerships that support the participation of under-resourced
communities would facilitate translational research and the implementation of interventions in
community-based settings. Greater inclusion of individuals from under-resourced communities in
research would help advance implementation and dissemination research to improve outcomes related to
maternal mental health conditions and SUDs.
Members of under-resourced communities that have experienced historical abuses may lack trust in the
health and medical research enterprise. Understanding their perspectives requires an appreciation of some
abusive experiences related to race, ethnicity, socioeconomic status, and other factors in the context of
medical research. Historically, some have used the pretext of scientific research to perpetuate racist
beliefs (e.g., eugenics) and to support ongoing disparities without evidence (Bergeron, 2021). Under-
resourced groups have historically not been represented in the taxpayer-funded evidence base, nor have
findings always been applied to improve the lives of people from these communities (Bergeron, 2021).
Here are examples of historical research abuses:
• Cells from Henrietta Lacks, an impoverished Black woman who sought treatment at an
academically affiliated hospital in the 1950s, were used for research purposes without informed
consent. Ms. Lacks received treatment for her symptoms but ultimately died from cervical cancer
at the age of 31. Use of her cell line has been widespread in research and continues, yet her
descendants have not received compensation despite legal action (Baptiste et al., 2022).
• In the 1930s, researchers in Tuskegee, Alabama, began a study of untreated syphilis with Black
men without informed consent. These men did not receive the treatment researchers promised,
but the study continued into the 1960s despite multiple opportunities for government agencies to
stop it. Some men in the study became infected during the research project but remained
untreated and died from syphilis. The wives of these men also developed this sexually transmitted
infection, and some of their children acquired congenital syphilis (McVean, 2019).
• The Havasupai Tribe took legal action against a research university in 2004 for using DNA
samples in studies for which members of the tribe had not provided informed consent. Members
of the tribe had participated in a study on Type 2 diabetes, providing blood samples for genetic
analysis, but had not consented for their use in other investigations (Garrison, 2013). The
university paid financial compensation to settle legal claims in 2010 (Mello & Wolf, 2010).
Current health research initiatives—such as NIH’s All of Us Research Program
—emphasize wide
participation that is representative of the diversity of the United States. Still, the trauma of past events
reverberates today and contributes to a reluctance to participate in health research among people from
under-resourced groups.
Currently, data collection is not standardized across all of the domains relevant to maternal mental health.
This limits our understanding of the impact of mental health conditions and SUDs on the lives of
individuals and subpopulations. The field must go beyond the medical model to address the impact of
these conditions on all aspects of life—for both parents and children. Data collection should encompass
the risk factors and SDOH (e.g., food insecurity, stress, and housing insecurity) associated with these
conditions. Thorough data collection helps build intervention strategies that take into consideration a
community’s lived experience and socioeconomic conditions. These factors affect access and health-
seeking behaviors, as well as maternal mental health outcomes. Data are lacking on some emergent
maternal mental health issues that warrant investigation (e.g., safe sleep environments, opioid use during
pregnancy, and rates of postpartum depression screening). To promote health equity, data collection—
45
both quantitative and qualitative—should focus on understanding and meeting the needs of underserved
communities. Although data are routinely collected in the provision of care to women and their infants
(e.g., birth and death certificates and hospital billing data) and many public programs (e.g., the Special
Supplemental Nutrition Program for Women, Infants, and Children [WIC]), this information is
infrequently combined for evaluation or research. Improved linkage of existing data systems and
leveraging the data could reduce the burden on researchers and provide a more holistic evaluation of
maternal and infant outcomes. Ultimately, policymakers and community leaders must be able to use the
data to create intervention strategies that improve health outcomes and equity.
How?
• The National Vaccine Injury Compensation Program should be a model for the inclusion of
pregnant and postpartum individuals in research related to the use of pharmaceutical or device-
based treatments.
• The federal government should work with tribal epidemiology centers across the country to
support the collection, analysis, and reporting of data on maternal mental health. For example, the
Albuquerque Area Southwest Tribal Epidemiology Center conducted a tribal Pregnancy Risk
Assessment Monitoring System (PRAMS) survey. However, this was for a limited time, and the
survey was not able to be continued because of a lack of funding. PRAMS has collaborated with
10 jurisdictions that include tribal populations to promote maternal and child health priorities and
activities (e.g., mental health, prenatal care, breastfeeding, and nutrition). Dedicated funding
could ensure routine inclusion of tribal communities in the PRAMS survey.
• The federal government should disseminate and implement the recommendations from the
Task
Force on Research Specific to Pregnant Women and Lactating Women (PRGLAC), which has
advocated for the inclusion of pregnant people in research and clinical trials and advises the HHS
Secretary on research gaps regarding whether therapies are safe and effective for use among
pregnant women and lactating women.
• Federal agencies should support community-based participatory research, which engages the
subpopulations of interest. Examples include:
o The NIH Community Engagement Alliance
;
o The Eugene Washington PCORI Engagement Award Program; and
o The National Institute on Disability, Independent Living, and Rehabilitation Research’s
2024–2028 Long-Range Plan.
• Federal agencies should encourage use of the GAP-REACH checklist, which provides guidance
on standard reporting of race and ethnicity for research.
• There should be a federally sponsored series of facilitated focus groups with people who have
lived experience of perinatal mental health conditions and SUDs and are representative of the
populations most affected by these problems, and their feedback should be incorporated into the
national research agenda mentioned above.
• Federal agencies should review case studies of research efforts that have built the trust of under-
resourced communities that have experienced abuses in the past.
Recommendation 3.1.3
Support and fund integrated data systems by sharing data across health care and community-based
services while preserving patient confidentiality. Use data to inform and drive the development of
more equitable policies, effective practices, innovative interventions and approaches to treatment,
and improved outcomes.
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Why?
There are two primary reasons for data sharing. One is for clinicians to be able to coordinate care, which
in many cases can be lifesaving; the second is for analysis of systems-level innovations with an eye to
improvement and equity. As the nation modernizes data collection and linkages across data repositories, it
is crucial to invest in data standards, data linkages, data architecture and infrastructure, and data sharing
agreements. These elements are needed
to permit the combination, comparison,
and analysis of medical data and other
data at the national, jurisdictional, and
local levels. The task force recognizes
that the federal government controls
only particular data systems and that
integration of these systems may be
limited. The task force also
acknowledges the different barriers for
sharing and linking health record
systems. In all data system linkage
efforts, best practices for coordination
of data and developing standards for
allowing research should be followed.
How?
• The federal government should invest in systems that integrate data from municipalities, counties,
states, U.S. territories, U.S.-affiliated Pacific islands, and federal agencies.
• Federal agencies should seek legal and ethical guidance on how to integrate data systems in a way
that respects patient privacy and confidentiality. They should include patients’ rights groups (e.g.,
the National Alliance on Mental Illness and Mental Health America) as co-collaborators in this
process.
• It should be determined which federal data systems require linkages.
• Contextual language should be developed to indicate the standard for which all surveillance data
sharing will be used, noting the intent is to improve the health and well-being of birthing parents.
• Any current linkages at the federal level should be leveraged and strengthened.
• Experts in data modernization should be engaged to develop the necessary data standards and
pipelines, create data warehouses and repositories, and link data. Suggested models include:
o The Trusted Exchange Framework and Common Agreement (TEFCA)
, which establishes
an agreement on technical matters that support nationwide interoperability, makes it
easier for health and social service agencies to improve care, and allows patients to
access their own health care information (HealthIT.gov, n.d.).
o The Observational Medical Outcomes Partnership (OMOP), which was designed to
provide a standardized structure for observational data and analysis to produce high-
quality medical and health evidence.
CDC’s MAT-LINK team (with the assistance of an implementation partner team
at Johns Hopkins University) is focusing on data modernization in its clinical-
focused surveillance model to improve data quality and completeness before the
data arrive at CDC. The team is working to map variables to OMOP at the
clinical sites to increase interoperability, introduce more data quality tools, and
standardize extraction of data from electronic health records. The team is also
working to increase efficiencies in gathering abstracted data into the