An Overview for the General Psychiatrist Evaluating Patients With Obstetric and Neonatal Complications and Perinatal Loss

Abstract

When neonatal and obstetrical complications occur, the identification and management of mood and anxiety disorders become complex with an ever-expanding array of psychiatric needs that include the management of grief- and trauma-related disorders. With high rates of maternal morbidity and mortality in the United States and laws in many states restricting reproductive health access, psychiatrists must be proficient in managing psychiatric sequelae in this context. High-risk groups for peripartum mood and anxiety disorders, posttraumatic stress disorder, and complicated grief include those with neonatal intensive care unit (NICU) stays and those who have experienced infertility and recurrent pregnancy loss. Groups who have been historically marginalized by the medical system (e.g., Black, Indigenous, people of color) and those from LGBTQ+ communities are at similarly high risk, and more interventions are needed to support these groups. Strategies emphasizing trauma-informed care, psychotherapeutic approaches, and using patient-centered language are recommended.

Although estimates vary, up to 50% of women consider at least part of their childbirth experience to be traumatic (1, 2). Birth trauma is a personal, subjective experience and may be present regardless of technical complication (2). A sense of control throughout the delivery and support, both socially and from medical staff, is protective; absence of either is associated with a negative experience (2, 3).

Pregnancy loss is common in the United States; an estimated 10%–15% of pregnancies end in loss (4), and the 2020 fetal mortality rate for gestations of at least 20 weeks was 5.74 deaths per 1,000 (5). Preterm births are similarly common, occurring at an overall rate of 10.38% in 2022 (6). Perinatal loss is multidimensional and includes personal, prospective, and identity losses; it affects relationships and families. The traumatic nature of perinatal loss is often not circumscribed to one event but, rather, a series of experiences, including learning of the complications or circumstances leading to the loss, the birth or delivery, sharing the news with others, and trauma after the loss.

Traumatic experiences threaten a person’s well-being and can result in trauma- and stressor-related disorders. Understanding psychological responses to obstetrical trauma and perinatal loss is critical in working with women and other birthing individuals of childbearing age. Postpartum individuals may present with a range of conditions, including adjustment reactions, postpartum blues, psychological distress, or depressive disorders. Additionally, understanding normal versus pathological grief can pose additional challenges in the setting of obstetrical complications and loss. See Box 1 (7–15) for definitions of these terms.

BOX 1. Psychological responses to trauma—terms and definitions

Psychological distress: An emotional state of turmoil with symptoms of depression, anxiety, and possible somatic symptoms; it can also refer to stress (7). It is common during the perinatal period, particularly with adverse birth outcomes (8).

Postpartum blues: Also known as “baby blues,” a transient disorder featuring sadness, tearfulness, insomnia, confusion, and unstable mood for several days postpartum, for which medications and support can help (9).

Postpartum depression: A major depressive episode that occurs in the postpartum period with anhedonia; low mood; difficulty with sleep, appetite, and energy; irritability; and occasionally suicidal thoughts. It typically occurs within 4–6 weeks postpartum and is more severe than baby blues (10).

Grief: A “process of experiencing psychological, [behavioral], social and physical reactions to loss” (11). Grief is a natural phenomenon that can lead to temporary impairments, including numbness and social isolation.

Pathologic grief: Complicated grief, which is a more intense grief that interferes with daily life and can lead to self-destructive behaviors; it is more common with sudden and traumatic losses (e.g., pregnancy loss) and is a risk factor for further postpartum symptoms (12, 13).

Trauma reaction: Any number of symptoms that may occur in the immediate aftermath of a traumatic event that may include numbness, detachment, irritability, feeling jumpy, insomnia, or experiencing physical symptoms such as stomach upset or anger (14).

Acute stress disorder or posttraumatic stress disorder (PTSD): All trauma disorders can impair functioning through mood symptoms, changes in arousal, and intrusive and dissociative symptoms. Acute stress disorder occurs when symptoms last 3 days to 1 month after the trauma. PTSD involves symptoms persisting for more than 1 month and can become chronic (15).

Adjustment disorder: Adjustment disorders present within 3 months after the person encounters a stressor and lead to symptoms less severe than those of a depressive or anxiety disorder (15).

When neonatal and obstetrical complications occur, the identification and management of mood and anxiety disorders become complex. The general psychiatrist must address an ever-expanding array of psychiatric needs in the setting of perinatal loss and obstetrical complications, potentially traumatic events in which grief is an expected response. Up to 60% of bereaved parents exhibit mood-, anxiety-, or trauma-related symptoms that can vary depending on the context and the perception of the loss (16). Within families, pregnant and nonpregnant individuals may experience the loss differently and often asynchronously (17). Cultural and political impacts may influence the experience and expression of perinatal loss, particularly with diminishing reproductive rights. Women and other birthing individuals who live in states with severe restrictions on these reproductive rights may face situations in which termination is not an option for a pregnancy with a life-threatening complication to a mother/birthing individual or in instances of fetal demise.

Here, we provide a discussion of the prevalence of depression-, anxiety-, and trauma-related disorders in populations with obstetrical complications and neonatal loss. We provide a framework for peripartum mental health conditions in this context, emphasizing clinical scenarios and settings that require management beyond postpartum depression.

Clinical Context

Screening for Psychiatric Consequences of Obstetric and Neonatal Complications and Perinatal Loss

After an obstetric complication or perinatal loss, differentiating grief from a major depressive episode becomes imperative for appropriate management. Grief is typically marked by thoughts and memories of the complication or loss and can be intense, with a slow, although not always steady, remitting of symptoms over time. A depressive episode may be more persistent, may be unremitting in nature, and may be marked by preoccupation with self-critical ruminations, feelings of worthlessness, or automatic negative thoughts. These differences may be challenging to elicit, but they can guide appropriate treatment options, including the potential use of pharmacotherapy.

Depression screening is recommended by the American College of Obstetricians and Gynecologists (1). Recent guidelines expand screening recommendations to other psychiatric disorders, including anxiety and bipolar disorders (1). The Edinburgh Postnatal Depression Scale and the nine-item Patient Health Questionnaire are well-known, validated screens for postpartum depression (18).

Other free tools allow for expansive psychiatric screening in the peripartum period and may be useful in the setting of perinatal loss and obstetrical complications. Of these, the Perinatal Anxiety Screening Scale assesses for perinatal anxiety and multiple anxiety domains, including acute anxiety, social anxiety, adjustment disorder, general worry, and specific fears (19). The City Birth Trauma Scale examines posttraumatic stress disorder (PTSD) symptoms after childbirth to assess birth-related symptoms such as avoidance and intrusions and general symptoms such as mood and hyperarousal (20). The Perinatal Obsessive-Compulsive Scale is a validated screening tool to detect perinatal obsessive-compulsive disorder (21). The Mood Disorders Questionnaire is validated in the postpartum period for identifying individuals screening positive for depression who may be at a higher risk for bipolar disorder (22). Postpartum psychosis is considered an emergency, and the patient should be assessed and treated, given risks such as suicide and infanticide (23).

Although the general psychiatrist may consider these conditions in postpartum individuals in uncomplicated circumstances, screening for these conditions may not be readily apparent in the context of obstetric and neonatal complications and perinatal loss, where the focus of the clinical encounters may be the complication or loss itself. Vigilance must be maintained to ensure adequate screening as physiological changes remain in place to put postpartum patients at risk of these postpartum syndromes.

Special Populations and Considerations With Obstetric and Neonatal Complications and Perinatal Loss

In this section, we highlight groups who are at higher risk for mental health conditions (e.g., people experiencing infertility, people whose babies require a level of care available only in the neonatal intensive care unit [NICU]) and groups at higher risk for pregnancy loss or pregnancy-related trauma (e.g., minoritized populations).

Infertility and recurrent pregnancy loss.

Infertility affects 80 million people worldwide (i.e., approximately 1 in 10 couples). Infertility can be a stressful experience for those experiencing it, and infertile persons can experience a variety of stressors, including stigma, high treatment costs, and frequent doctors’ visits and medical interventions (24). Infertility can also increase risk for relationship difficulties, sexual dysfunction, identity problems, anxiety, and depression. In previous studies, distress, anxiety, and depression were more common in people who experienced infertility (25). Often associated with infertility, recurrent pregnancy loss affects 0.5%–3% of women. Depression and emotional stress are prevalent among women with this complication (26). Higher rates of stress, anxiety, and depression have been found in those undergoing in vitro fertilization (27). A recent meta-analysis has indicated that the prevalence of depression is higher among infertile women compared with pregnant and postpartum women (24). Zurlo et al. (28) used a questionnaire to assess 250 couples with regard to demographics, fertility-related characteristics, coping, and anxiety and depression scales, and they found high rates of psychological problems in those undergoing fertility treatment. The authors advocated for the early assessment of psychological risk in patients undergoing infertility treatments and for tailored counseling interventions for this special population (28). Recurrent pregnancy loss can lead to higher rates of anxiety and depression and thus these women experiencing such loss should be screened closely (29). Assisted reproductive centers are ideal places for screening, and general psychiatrists should advocate for such screening to occur.

NICU hospitalization.

A NICU hospitalization can disrupt the parent-infant relationship bidirectionally and present challenges early on to both the parent and infant (30, 31). Research has demonstrated elevated levels of emotional distress and increased rates of mental health conditions in parents of infants hospitalized in the NICU compared with their non-NICU counterparts (31). Mothers of infants hospitalized in the NICU report rates of depression at least double those of their non-NICU counterparts and higher rates of PTSD (32, 33). Morbidities for infants who require a NICU stay far exceed those of their non-NICU counterparts, with higher rates of behavioral and self-regulatory problems in early childhood and higher rates of academic, cognitive, emotional, and physical problems later in life (34).

Black, Indigenous, people of color (BIPOC) communities.

Racial disparities exist within the perinatal population. Black women have maternal mortality rates three to four times higher than those of White women. Additionally, in the first year after birth, Black babies are more than twice as likely to die as White babies. Black and Latina/x individuals have increased risks of maternal morbidity, even after accounting for other risks such as insurance and co-occurring conditions (35).

LGBTQ+ communities.

Inequities in pregnancy outcomes pose challenges for LGBTQ+ populations, who are often excluded from pregnancy studies. Achieving a pregnancy is complicated by additional medical interventions needed (36). For transgender males or nonbinary individuals seeking pregnancy, dysphoria can arise from the cessation of gender-affirming therapy (37). Additionally, evidence suggests that lesbian and bisexual women are more likely to experience a miscarriage or stillbirth (38).

Treatment Strategies and Evidence of Obstetric and Neonatal Complications and Perinatal Loss

Immediate Management: Trauma-Informed Care, Distress Management, and PTSD

Prompt intervention to address perinatal grief and trauma has been associated with lower depression rates and improved quality of life. Immediate support follows the principles of trauma-informed care and includes partner involvement in treatment discussions and continuity of staff in delivery of diagnosis. Providing proactive communication as decisions are happening can restore a sense of control to individuals experiencing obstetrical trauma.

Documentation of memories (e.g., keepsakes, photos, meaningful objects) should be considered and encouraged if clinically appropriate to do so. A general psychiatrist who is not experienced with consultation to obstetric floors may not have familiarity with recommended protocols; having this knowledge may help them to better understand experiences, even if they are meeting them after they have been discharged from their hospital stay. General psychiatrists who round in medical hospitals should encourage hospital policies that promote keeping infants in the room, when desired by the patient. This section could also include reference to immediate management during and/or after an obstetric complication, such as providing proactive communication as decisions are happening, and so forth.

Patient-led language in these instances is critical with avoidance of terms such as miscarriage if not desired by the individual experiencing loss. Utilization of patient-led terms may include use of “your baby” (i.e., as opposed to “the fetus”), and this should be explored with the patient proactively. Language such as “You will get pregnant again,” carries a high potential for patient distress and feelings of being misunderstood (39). In the case of stillbirth, studies show that contact with the deceased baby is associated with lower rates of depression and anxiety. In the immediate period after loss, pharmacological treatment can be considered in individuals at high risk of developing depression, anxiety, or PTSD or who already have a psychiatric condition, but it is not universally recommended (40).

Expanded Workforce to Support Patients During the Perinatal Period

Peer support is a low-cost, high-yield intervention with demonstrated positive outcomes in perinatal and NICU settings, including reduced depressive symptoms (41–43). Peer support groups have shown benefits such as decreased perceived loneliness and increased perceived support (44).

Doula care is a strategy to reduce racial disparities in maternal and infant health outcomes and provide comprehensive support, including emotional, physical, and informational support, during the perinatal period. Doula care has demonstrated positive benefits to maternal and infant care, including decreased rates of preterm birth, increased rates of breastfeeding, and higher satisfaction rates (45, 46).

For first-time mothers, adolescent mothers, and mothers who have experienced a traumatic delivery, home health visits, telephone-based peer support, and psychotherapy may help prevent postpartum depression (PPD) (42).

Care Delivered in the NICU Setting

Recommendations for psychiatric professionals in the NICU include screening both parents for depression within the first week of NICU admission and rescreening within 48 hours of discharge for stays longer than 7 days. Screening should only be implemented if resources are available either within the NICU or through outside referral (47).

Developmental interventions that are widely utilized in NICUs include strategies to manage the environment and individualize preterm infant care to promote parent-infant attachment. Kangaroo care promotes skin-to-skin contact, thereby increasing coregulation between parent and infant, conferring long-term benefits for the motor and perceptual-cognitive processes of preterm infants, and providing positive effects on maternal depression and sensitivity (48). Family-centered care increases the involvement of parents in the infant’s care plan through daily bedside medical team rounding, bedside parental sleep chairs, and breastfeeding consultants, and it has demonstrated a reduction in maternal stress and depression, decreased anxiety, increased self-esteem, and improvement in parent-infant feeding (49).

Parents experiencing NICU care of their infants are usually facing an array of challenges that may include balancing being present at the bedside with limited family medical leave from their employers, procuring care for any older children in the home, and recovering from what may have been a complicated delivery. Provision of care in this setting reduces barriers to care for parents at a high risk of developing depression, anxiety, and/or PTSD.

Screening Parents From BIPOC Communities

The Patient-Reported Experience Measure of Obstetric Racism Scale is a validated survey tool that measures Black birthing parents’ experiences of medical racism within obstetrics through factors such as safety, autonomy, communication, neglect, mistreatment, and kinship, centering patients’ lived experiences and helping hospitals combat medical racism (50). Few studies investigate interventions designed to support BIPOC birthing parents through high-risk pregnancies, despite racial disparities in pregnancy outcomes (51–54).

Screening Parents From LGBTQ+ Communities

Although LGBTQ+ populations are underrepresented in reproductive health research, one recent study developed a survey tool to capture the broad range of pregnancy experiences in the LGBTQ+ community, including different pregnancy roles, outcomes, and biases that they might face (55). Utilization of these scales, although not yet studied, may help identify individuals at higher risk of postpartum mood and anxiety disorders or trauma and guide targeted interventions. Physicians and other health care providers should explore individual patients’ values with respect to LGBTQ+ community access and connection as a source of support (56).

Preventive Interventions and Proactive Consultation

The U.S. Preventive Services Task Force (57) published a recommendation in 2019 in favor of referral to counseling for those at risk for perinatal depression and included obstetrical complications on their list of risk factors (57). A proactive approach to treating peripartum mood and anxiety disorders in high-risk groups, such as those with obstetrical complications and perinatal loss, may guide appropriate management. Birth trauma, intimate partner violence, birthing parent history of adverse childhood experiences, and newborn admission to the NICU are associated with increased risk of peripartum depression, anxiety, and/or trauma disorders, all of which have overlapping symptomatology and are highly comorbid (58–60).

Studies that have examined the relationship between gestational age and grief severity after pregnancy loss have not shown a consistent correlation, and a broad range of grief reactions can be experienced after pregnancy loss, regardless of gestational age (61). The provision of increased support for at-risk parents must be balanced with the acknowledgment of grief as part of an expected and healthy response to loss. Care must be taken to avoid retraumatization. Given the prevalence of trauma disorders after childbirth and the difficulty of predicting birth conditions that might be perceived as traumatic, a reliable screening tool for posttraumatic symptoms can be utilized, such as the City Birth Trauma Scale, which assesses posttraumatic symptoms after birth trauma (62).

Pharmacologic Considerations

Although grief and posttraumatic sequelae may be expected after an obstetrical complication or perinatal loss, conditions such as depression, anxiety, and PTSD may require medication management. Medication similarly may be indicated to address symptoms (e.g., insomnia) that may impair a healthy recovery or grief process or increase the risk for mood or anxiety disorders.

Few studies investigate the use of antidepressants and other classes of medications exclusively in the context of obstetrical complications and peripartum loss. Medications such as selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors to target specific symptoms, including depression and anxiety, may be used in this population with consideration to the risk of untreated illness on the fetus and the risk of adverse effects. Among the potential adverse effects of antidepressants, the risk of postpartum hemorrhage as a potential obstetrical complication is important in this population, although discontinuation of medications is not recommended, as additional studies are warranted to investigate confounders (63). Pharmacological treatment, such as prazosin, for trauma-associated nightmares have, to date, limited data related to pregnancy (64). A full review of pharmacology is outside the scope of this review.

Novel treatments, such as brexanolone and zuranolone, in the postpartum period similarly have largely focused on postpartum depression and have not been studied in PTSD treatment or in the context of obstetrical trauma and perinatal loss (65, 66). Post hoc analyses with brexanolone have demonstrated a sustained reduction in anxiety symptoms and insomnia compared with placebo (66). Caution must be taken in treating individuals who have experienced obstetrical complications or perinatal loss, as brexanolone is administered in obstetrical hospital settings, which may be a challenging environment.

Questions and Controversy Related to Obstetric and Neonatal Complications and Perinatal Loss

Maternal Mortality, the Opioid Epidemic, and Maternal Mental Health

A recent report from the Centers for Disease Control and Prevention (67) evaluating causes of maternal death occurring from 2017 through 2019 indicated issues related to mental health, such as depression, anxiety, death by suicide, and substance use disorders, as the most frequent underlying cause, followed by clinical conditions. Almost 23% of the deaths were related to mental health conditions (22.7%), and a majority of these were determined to be preventable deaths. Most pregnancy-related suicide deaths occur in the postpartum period, with 62% occurring between 43 and 365 days postpartum, followed by 24% during pregnancy and 14% within 42 days postpartum (67). Along with these maternal mortality statistics, the country faces a crisis in maternal morbidity, and individuals with psychiatric disorders face 50% higher rates of severe maternal morbidity compared with people without psychiatric disorders, indicating higher obstetrical complications among these high-risk groups (68).

These alarming findings stress the need for health care organizations to develop systems to screen all pregnant patients for risk factors using evidence-based tools so that appropriate interventions are instituted in a timely and ongoing manner. Screening for depression or other psychiatric disorders should occur with frequency for the first year postpartum and allow for treatment and control of symptoms that may help prevent self-harm and negative family outcomes, such as impaired infant bonding, or neglect. Pregnant and postpartum patients who have had obstetrical complications may have more contact with health care providers postdelivery, increasing the opportunities for screening and referral for appropriate treatment. Health care systems should create more streamlined access to behavioral health care for women with obstetrical complications during pregnancy and the postpartum period, along with systematic screening after perinatal loss.

Impact of Changes in Reproductive Rights on Management of Perinatal Complications, Loss, and Reproductive Decision Making

On June 24, 2022, Roe v Wade was overturned by the Supreme Court of the United States (SCOTUS), allowing states to set their own abortion laws and resulting in the loss of reproductive rights for millions, disproportionally affecting people of color, LGBTQ+ persons, adolescents, people with disabilities, immigrants, people with low incomes, and survivors of domestic and sexual violence, all of whom face barriers in accessing affordable and safe reproductive health care (69–71). BIPOC communities already have unprecedented pregnancy and childbirth mortality rates because of the disparities in health care access, and those living in states that ban abortions will face even higher risks for pregnancy-related complications, necessitating close screening and monitoring for postpartum psychiatric sequelae by the general psychiatrist (67, 72).

Although data are not yet available on the psychiatric consequences of the SCOTUS ruling, it is reasonable to anticipate increases in delivery complications and traumatic loss, as more individuals will carry unplanned pregnancies to term. Restrictions on reproductive health care can also be expected to decrease an individual’s sense of control, leading to a more negative birth experience (2, 3). The loss of reproductive freedom has been found to have both psychiatric and physical sequelae, with a report by the Institute for Women’s Policy Research finding that the ability to control one’s own fertility had positive effects on the ability to learn, work, and escape poverty (69). General psychiatrists practicing in states with more restrictions on reproductive health must be vigilant about exploring these issues and assessing for postpartum mood, anxiety, and posttraumatic stress disorders.

Even before the overturning of Roe v Wade, many states had legislation requiring preprocedure counseling and/or waiting periods largely on the basis of the assumption that abortion leads to adverse psychological outcomes such as severe depression or loss of self-esteem (71). However, the Turnaway Study showed that being denied an abortion may be more harmful to psychological well-being than being able to obtain a wanted abortion and can lead to economic hardship, greater likelihood of continued contact with a violent partner, and poorer child development outcomes for existing children (69). Conversely, women enrolled in the Turnaway Study who received a wanted abortion were no more likely to experience depression, anxiety, decreased self-esteem, or lower life satisfaction than those who were denied the procedure (70). These data indicate that general psychiatrists who work in states with more restrictive abortion access should maintain a lower threshold for screening for psychiatric sequelae of these restrictions.

Some states have enacted policies requiring physicians and other health care providers to counsel those seeking abortion that the procedure may put them at risk for developing a substance use disorder. These policies are not evidence based; having a wanted abortion does not increase the risk of alcohol, tobacco, or other drug use (72). Most people who are pregnant, even those with unwanted pregnancies, reduce or cease substance use upon learning that they are pregnant (72).

As of this writing, 14 states have near-total abortion bans in effect, and six states have implemented abortion bans with other limits (73), placing patients in these states at higher risk of obstetrical complications and perinatal loss. Those carrying fetuses with lethal anomalies may be forced to carry the pregnancy to term, and pregnant people with significant chronic health issues will no longer be able to choose to end a pregnancy and may have to carry an unsafe pregnancy to term. In some states, individuals who are forcefully impregnated by incest or rape may have additional distress from being required to move forward with an unwanted pregnancy. General psychiatrists working in these settings must screen carefully for grief and trauma in these clinical contexts.

Recommendations for General Psychiatrists When Caring for Individuals With Obstetric and Neonatal Complications and Perinatal Loss

When supporting individuals with perinatal loss, building a therapeutic alliance is critical and can be achieved through the five tenets of the Swanson theory of caring: knowing, being with, doing for, enabling the other, and believing that the individual has the capacity for psychological adjustment and posttraumatic growth (i.e., the idea of transformative positive changes after traumatic events) (74). Physicians and other health care providers should strive to both understand common features of bereavement shared across individuals and recognize each person’s distinct clinical and cultural experience.

In addition, screening for the presence of depression, anxiety, and PTSD is essential to identifying patients who require further treatment. Because of the limited number of peripartum PTSD treatment studies, guidelines for the general population are extrapolated, with trauma-focused cognitive-behavioral therapy as the first-line intervention (75, 76). Preliminary data have shown that written exposure therapy and short-term brief therapy for perinatal PTSD are feasible treatment strategies (77, 78). In patients with severe symptomatology or insufficient response to therapy, pharmacological treatment should be considered. To date, there are no pharmacological studies specific to psychiatric illness stemming from obstetrical complications or perinatal loss (79).

Being with a patient requires their care team to be present with and attentive to the individual’s emotions. As it relates to “doing for” and “enabling the other,” supporting patients may include formal interventions, yet psychoeducation surrounding the stages and frameworks of grief can ground and validate an individual’s experience (80). When and if the person is ready, resources such as counseling and support groups should be provided. Understanding state laws regarding reproductive access allows the clinician to appreciate the challenges that their patients may face in terms of obstetrical health. Last, documentation of memories as well as meaning-making activities and rituals can support posttraumatic growth (74). Clinical care teams should trust that individuals have the capacity for such after perinatal loss. Table 1 lists specific recommendations for the psychiatric approach to patients experiencing perinatal loss or obstetrical complications.

TABLE 1.

Recommendations for the general psychiatrist when seeing patients who have experienced obstetrical and neonatal complications and perinatal loss

Do	Don’t
Utilize validated screening tools to identify anxiety, depression, posttraumatic stress disorder	Pathologize normal grief
Utilize individual’s preferred language	Automatically refer to delivery as abortion or termination or refer to the baby as demise or fetus
Listen to the individual to determine where they are in the grief process	Assume that grieving will follow an expected timeline
Have basic knowledge about the grief process after perinatal loss	Offer platitudes such as: “It wasn’t meant to be,” “You’ll get pregnant again,” “At least it was early,” and “I know how you feel.”
Have knowledge about state laws and local resources and offer these to patients when appropriate	Attempt to problem solve before the patient is ready; attempt to “fix” the grief
Review details related to the perinatal loss before the visit	See the patient without knowledge of the events surrounding the loss
Encourage meaning-making activities and rituals when appropriate (letter writing, reproductive narrative, bereavement box, memorial garden, etc.)	Avoid discussion of or processing the loss

Conclusions

Public health studies aimed at investigating the long-term psychiatric effects of the recent maternal morbidity and mortality increases, as well as the effects of the restrictions on reproductive rights, are desperately needed to inform clinical practice. For now, general psychiatrists should incorporate PPD screening into their practice and expand this to other conditions, particularly for patients who have experienced obstetrical complications, perinatal loss, or both. A nuanced and multifactorial approach to care that goes beyond standard depression management is required in this population.