In Montana, stigma and shame around mental illness can be so profound that many pregnant women and mothers struggling with anxiety and depression choose to suffer in silence rather than seek help.
Brie MacLaurin understands what they go through because she has walked in their shoes.
“I was trained in this stuff, or at least I thought I had been,” MacLaurin, a public health nurse, says of the stress, anxiety and depression she felt after giving birth. “It was horrible. I didn’t say anything because of my pride. I was super ashamed of what was happening. You don’t want to admit you can’t take care of your baby.”
As executive director of the nonprofit organization Montana Coalition of Healthy Mothers, Healthy Babies, MacLaurin focuses on improving the health of Montana’s mothers and babies.
Nationwide, as many as 1 in 5 women experience depression or anxiety during or after pregnancy, and research indicates these issues can lead to adverse pregnancy outcomes for mothers and their babies. Yet, many don’t receive referrals for mental health screenings and education because of lack of access to providers or health care coverage.
“Women will see a front-line health care provider 20 to 25 times during a routine pregnancy and first year of baby’s life, providing ample opportunity for these providers to detect and address perinatal health conditions,” says MacLaurin, whose organization is supported by a grant from Blue Cross and Blue Shield of Montana. “That’s a good time to raise the issue.”
She and other health care experts believe the demand for mental health care access revealed by the novel coronavirus outbreak could lead to permanent improvements in care delivery to all Americans, including Montana mothers. Increased use of telemedicine to access mental health care could substantially boost outcomes for Montana women during and after childbirth.
MacLaurin wants to seize the opportunity and integrate mental health screenings into maternal/infant care and establish a state directory of experts to whom doctors could refer mothers for mental health care and support.
“Maternal/child health is the foundation of a healthy society,” she says. “There’s so much more we can do to better coordinate care and build mental health care into the maternal health care model.”
The United States has the highest rate of maternal deaths in the industrialized world, with about 700 women dying every year because of pregnancy-related problems, according to the Centers for Disease Control and Prevention. A third of those deaths happen after delivery, when many women lose health coverage.
"Depression is a fatal illness. Judging it is not contributing to a solution.”
Meantime, mental health issues such as postpartum depression can take several months to appear and months to resolve.
“There have been big gaps in continuity of care for woman after delivery because all of the focus is on the baby,” says Dr. David Lechner, BCBSMT’s chief medical officer and vice president of health care delivery. “Progress starts by recognizing that problems, including behavioral health issues, occur more frequently than we think and building treatment options for resolving those issues.”
Telemedicine shows promise in making health care delivery changes that could save the lives of more women in Montana, says Lechner, a family practice doctor who pioneered integration of maternal behavioral and physical health care services 30 years ago in his office. In the months after the novel coronavirus shut down the country, telemedicine was used more often for behavioral health services than for medical care, according to a RAND Corporation study.
“Part of the secret to the success of telemedicine is the ability to reduce the stigma of going to a psychiatrist’s office,” Lechner says. “Patients don’t have to hide the fact they are going for behavioral health issue.”
He believes telemedicine services would be most useful to Montanans if they include local and regional providers who could direct residents to appropriate resources.
“I am optimistic these solutions can lead to real change,” Lechner says. “Business as usual is unacceptable. Depression is a fatal illness. Judging it is not contributing to a solution.”
The COVID-19 crisis has yielded another opportunity to improve maternal health. The federal stimulus law enacted in March gives states the option to extend maternal health care benefits for low-income mothers for 12 months after delivery.
Medicaid pays for about 40% of all U.S. births but currently provides only 60 days of postpartum coverage, even though research shows pregnancy-related conditions can kill women up to a year after giving birth.
Now it’s up to state governments to seek a federal waiver for the longer coverage, beginning in April 2022 and available for five years under the American Rescue Plan Act. Illinois became the first state to gain approval in April.
“I think framing the discussion around how such an investment would save costs later is super timely and important,” says MacLaurin, who hopes Montana chooses to extend coverage. “The impact could be huge.”