UCLA

Background: Perinatal depression and anxiety are common in the U.S., affecting between 10-30% and 15-25% of patients, respectively. Those with perinatal depression and anxiety have an increased risk of adverse maternal and infant outcomes compared to those without these conditions. Mental healthcare can alleviate symptoms of perinatal depression and anxiety and mitigate subsequent adverse outcomes. In order to facilitate access to mental healthcare, healthcare providers must screen perinatal patients for mental health symptoms. Perinatal mental health screening is recommended by the American College of Obstetricians and Gynecologists (ACOG) and is required by law in four states, including California as of 2019. However, studies suggest that one-third or more of perinatal patients are not screened for mental health. Further, nearly one-quarter of all pregnancy-related deaths are attributed to mental health conditions, and over half of all pregnancy-related deaths occur postpartum. As such, healthcare visits in the postpartum period are essential to address perinatal mental health conditions and ultimately prevent maternal mortality. However, studies suggest that patients with depression may be at high risk of not attending postpartum care.

Objective: The overall objective of this dissertation is to investigate perinatal mental health screening, including healthcare provider screening practices, rates of screening, and factors associated with screening, as well as the association between depression and anxiety symptoms indicated on screenings during pregnancy and use of postpartum care, focusing on one academic health system in Southern California. Aim 1 of the dissertation qualitatively explores healthcare provider practices for perinatal mental health screening, challenges faced in perinatal mental health screening, and the experiences of healthcare providers after a California law mandating perinatal mental health screening. Aim 2 of the dissertation quantitatively assesses rates of perinatal mental health screening in pregnancy and postpartum and the sociodemographic characteristics, healthcare utilization, and health factors associated with perinatal mental health screening. Aim 3 of the dissertation quantitatively investigates the association between symptoms of depression and anxiety indicated on screenings during pregnancy and use of postpartum care.

Methods: This multi-method dissertation leveraged expert interviews conducted with obstetricians and gynecologists (OBGYNs) and staff in OBGYN clinics in one academic health system in Southern California, alongside de-identified electronic medical records (EMR) data from patients who delivered singleton infants at the same academic health system in Southern California between 2021-2023. Aim 1 analyzed expert interviews conducted with 10 OBGYNs, two OBGYN clinic managers, and two OBGYN clinic nurse managers in 2023. Qualitative expert interviews were coded using a dual inductive/deductive approach and themes were identified through thematic analysis. Aims 2 analyzed EMR data from nearly 7,000 patients who delivered singleton infants in the health system between 2021-2023. Aim 2 included all patients in this population (N=6791), while Aim 3 focused on the subgroup of this population who completed at least one mental health screening during pregnancy (N=4539). Quantitative EMR data were analyzed using univariate frequencies and means, bivariate chi-square tests and t-tests, and multivariable logistic regression models.

Results: In Aim 1, healthcare providers indicated that all perinatal patients are screened for mental health during both pregnancy and postpartum using the 10-item self-administered Edinburgh Postnatal Depression Scale (EPDS-10), though providers described some administrative issues that may result in some patients not being screened. Additionally, providers identified two main challenges to perinatal mental health screening: limited time for mental health screening during perinatal appointments and lack of mental healthcare resources and treatment options to offer patients after screening. Overall, healthcare providers believed that the California law mandating perinatal mental health screening resulted in higher rates of screening, but did not increase patients’ access to mental healthcare, due to the lack of available mental healthcare providers. Aim 2 demonstrated that, in contrast to healthcare provider perceptions discussed in Aim 1, about 66% of patients were screened for mental health at least once during pregnancy and 55% of those who received postpartum care were screened for mental health at least once during postpartum. Overall, only 40% of patients who received postpartum care were screened for mental health at least once during both pregnancy and postpartum. In particular, patients who were White, non-English speakers, multiparous, privately insured, began prenatal care in the third trimester, and did not have medical complications during pregnancy or delivery had higher odds of not being screened for mental health compared to their counterparts. Aim 3 found that, among patients who completed screenings in pregnancy, 14% of patients did not complete postpartum care and 8% had EPDS-10 scores indicating likely perinatal depression. Moreover, higher EPDS-10 scores were associated with lower odds of completing postpartum care. In supplementary analyses, scores on the EPDS-3 anxiety subscale alone were not significantly associated with postpartum care.

Conclusions and Implications: This dissertation adds to existing evidence on perinatal mental health screening practices, rates of screening, factors associated with screening during pregnancy and postpartum, and the association between mental health symptoms during pregnancy and use of postpartum care. The findings of this dissertation suggest that the California state law mandating perinatal mental health screening is not sufficient to result in consistent screening of all perinatal patients. Additional policies and/or interventions are necessary both to ensure that all patients are screened during both prenatal and postpartum care, and to facilitate access to mental healthcare for those who indicate perinatal mental health concerns on screenings. Healthcare institutions can help improve consistency of screening by implementing and enforcing clear policies for the appropriate timing and frequency of screening with mechanisms to confirm all patients are screened, and by providing standardized referrals to mental healthcare following screening. In order both to alleviate the burden on OBGYNs to address mental health during perinatal appointments and to provide a more in-depth screening process for patients, healthcare institutions could hire social workers to meet with all perinatal patients for mental health screening and to make appropriate referrals to mental healthcare based on patients’ needs and preferences. Particular attention should be paid to the groups of patients who have the lowest rates of completing screenings to ensure these populations are screened for mental health. Additionally, given the inverse association found in this dissertation between depression symptoms indicated on screenings during pregnancy and use of postpartum care, healthcare providers should take additional steps to ensure that patients with mental health conditions during pregnancy return for postpartum care, such as offering flexibility in scheduling postpartum care or hiring patient navigators to work closely with postpartum patients. Future research should build upon this dissertation by further investigating mental health screening practices among perinatal healthcare providers, identifying rates of screening and factors associated with screening in population-based datasets, assessing screening rates before and after state laws mandating screening, and working toward disentangling the associations between depression and anxiety and completion of postpartum care. Given the high rates of maternal morbidity and pregnancy-related deaths in the U.S., more research is needed on postpartum healthcare access and quality, ideally across the entire first year following delivery.