Report: Workshop on maternal mental health, February 11–12, 2024, cosponsored by the American College of Obstetricians and Gynecologists

Abstract

The Society for Maternal‐Fetal Medicine 2024 President's Workshop on maternal mental health, cosponsored by the American College of Obstetricians and Gynecologists, will be comprehensively described in this article. Workshop leaders and speakers represented the fields of obstetrics and gynecology (OBGYN), maternal‐fetal medicine (MFM), complex family planning, psychology, psychiatry, and pediatric neuroscience. In addition to clinical expertise, participants had experience in research, policy and advocacy, workforce development, medical education, and community‐based programming. Medical societies, government agencies, nonprofit organizations, and philanthropic foundations were represented. The goals of the workshop were as follows: (1) Expand OBGYN and MFM mental health treatment capacity through discussion of perinatal psychiatric disorders and identification of pertinent educational resources. (2) Leverage two‐generation prenatal brain plasticity science for clinical and research opportunities. (3) Promote access to mental health treatment and prevention during pregnancy and postpartum through identification of effective, scalable health services, interventions, and community‐based programs.

1. INTRODUCTION

Up to one in five childbearing people experience mental health conditions as a complication of pregnancy [1, 2]. Mental health conditions, including suicide and overdose, are the leading causes of death in the first postpartum year in the United States and are 100% preventable [3]. Most people who experience perinatal mental health conditions do not get the care they need, which negatively affects their own health and the wellness of their partner, fetus, child, and family [4]. One study estimated that perinatal mood and anxiety disorders cost the United States $4.7 billion in productivity losses, $3.3 billion in preterm births, $2.9 billion in maternal health expenditures, and $1.6 billion in child behavioral and developmental disorders, among other costs [5]. Gaps in mental health screening and treatment access disproportionately affect historically marginalized people, those who live in low‐income neighborhoods, and those who lack access to maternity care [6, 7].

Recent research on brain plasticity demonstrates that perinatal mental health affects not just the well‐being of the birthing parent but also fetal development and infant behavior—that is, two generations. Pregnancy and postpartum are opportune times to address mental health and set parents and children up for a healthy future. The data clearly show that perinatal mental health is a critical component of overall health for parents and children. Although tools are available to identify and treat perinatal mental health conditions, effective implementation requires better translation into clinical practice and sustainable funding through improved coverage for mental health services. Across the country and in every clinical setting, people experiencing mental health conditions need better access to mental health care and coordinated approaches to help them navigate and continue treatment. Moreover, the health system should acknowledge that good mental health is not simply the absence of a disorder; it includes emotional well‐being, resilience, and the capacity to cope with the unique stresses of the perinatal period. Advancing this broader vision of perinatal mental health requires coordinated action across all sectors—medical systems, industry, academia, government, and communities—with each stakeholder recognizing their specific role and potential contributions to develop comprehensive solutions.

2. BRAIN PLASTICITY AND MENTAL HEALTH

2.1. Brain plasticity

Maternal brain plasticity increases during the perinatal period [8]. Morphometric changes during pregnancy resemble those occurring during adolescence (e.g., pruning of synapses, which improves brain efficiency) [9]. The term “matrescence” has emerged to describe the transition to motherhood [10]. High levels of stress (including stress associated with poverty such as unstable or crowded living arrangements or material deprivation) [11] during the perinatal period are associated with dampened brain response to infant cries and less sensitive parenting behaviors during interactions with one's own infant [12]. Similarly, substance use is associated with dampened brain responses to infant cues [13]. Beyond these external stressors, the cognitive demands of parenting also warrant consideration. Among birthing parents, cognitive functioning often declines during the first postpartum year, though recovery and improvement are typically observed over time [14].

In this context, fostering resilience in new parents and supporting sensitive caregiving behaviors could be critical for enhancing their neural responsiveness to infant cues. For example, adopting active coping skills (e.g., emotional support, mental reframing, and planning) is associated with increased brain response to infant cry sounds compared with passive coping techniques (e.g., denial, disengaging, and self‐blame) [14].

2.2. Prenatal programming: The two‐generation concept

Maternal mental health matters for two generations. Decades of research show that when pregnant individuals experience stress, anxiety, and depression, it affects their offspring in utero and beyond. Through biological pathways, prenatal maternal distress programs the fetal brain, potentially contributing to the risk of future mental health problems. Thus, there is a third pathway that increases inherited risk for psychiatric illness beyond shared genes and the quality of parental care: the impact of pregnant people's distress on fetal and infant brain behavior development [15]. In a 2014 study, elevated maternal anxiety (defined as the top 15% of self‐reported scores) was associated with a twofold increase in risk of probable childhood mental health disorders [16]. A 2022 study using objective observations found that higher maternal prenatal stress and depression led to lower levels of inhibitory control and sustained attention in offspring (primarily male children) at ages 4–7 years [17]. The recognition of this two‐generation impact underscores the urgent need for prompt identification of mental health symptoms and timely, evidence‐based treatment and support during the perinatal period to improve outcomes for both the birthing person and their child.

3. SELECT FACTORS AFFECTING PERINATAL MENTAL HEALTH

3.1. Racism and health disparities

Black and Hispanic mothers who experience depression are less likely to receive services and more likely to experience poverty, separation or divorce, unemployment, and financial difficulties than White mothers with depression [18]. Efforts to improve perinatal mental health must prioritize racial equity and center the experiences of members of the communities most affected. Some steps can be taken to mitigate disparities in clinical practice as follows:

• Integrate culturally specific healing practices: Incorporate traditional healing methods alongside conventional treatments to build trust, improve engagement, and honor cultural perspectives on mental well‐being. This approach may include collaboration with cultural healers, spiritual leaders, or community elders when appropriate and desired by patients.

• Develop care models collaboratively with community members: Establish partnerships with community members to design services that reflect their needs, preferences, and contexts. Involve community representatives in program development, implementation, and evaluation to ensure relevance and accessibility.

• Enhance clinician training: Implement comprehensive training for clinicians that addresses both cultural competency and the specific manifestations of perinatal mental health conditions within diverse populations. Training should include recognition of how cultural factors influence symptom presentation, help‐seeking behaviors, and treatment preferences.

• Build community capacity: Develop sustainable programs that educate community members about perinatal mental health, reduce stigma, and create networks of support. Examples include training community health workers, establishing peer support programs, and creating accessible educational resources.

Each strategy should be implemented with clear metrics for evaluation, sustainable funding mechanisms, and ongoing community feedback to ensure effectiveness and accountability.

Effective models of community‐engaged care for mental health include peer‐led support groups, peer‐to‐peer support groups, shared decision‐making, structured support groups, and reliance on community health workers [19, 20, 21, 22, 23]. The community is often the missing link in programmatic development. Embodying the principle “Nothing about us without us” is imperative [24]. Representatives from the affected community should be actively involved in the conversation whenever decisions are being made about service design, implementation, or evaluation. This approach not only enhances cultural relevance and accessibility but also builds trust, fosters community ownership, and ultimately improves health outcomes through solutions that address the authentic needs of those they serve [25].

The Elevating Voices, Addressing Depression, Toxic Stress, and Equity (EleVATE) program is a group prenatal care model that embodies community‐engaged participatory research, demonstrating core principles of effective community‐centered interventions. It involves engaging program stakeholders in co‐creation, collaborating with patients as partners, designating a program staff member to serve as a trusted broker, adopting shared governance structures, establishing protocols for presenting communal work, and practicing budget transparency [26, 27, 28].

3.2. Stillbirth

Stillbirth and perinatal loss are life‐changing traumas. Stillbirth increases the risks for depression, anxiety, substance use disorders (SUDs), posttraumatic stress disorder, and suicide [29, 30, 31]. Observational studies have reported a variety of factors that contribute to mental health conditions after perinatal loss (see Box 1) [32, 33, 34]. Stigma and misconceptions about grief worsen outcomes for parents experiencing stillbirth, while support and patient‐led remembrance and acknowledgement about the baby who died facilitate coping with the loss [35, 36].

BOX 1: Factors associated with mental health after stillbirth [32, 33, 34, 35, 36]

Generally associated with better mental health outcomes

• Supportive partner.

• Social support.

• Memory making.

• Talking about the loss.

• Passage of time.

• Having a previous living child.

Generally associated with risk for worse mental health outcomes

• Unmarried or unpartnered.

• Dissatisfaction with emotional support.

• Negative thinking about oneself.

• Less time than desired with the deceased child.

• Societal pressure to “move on.”

• Secondary infertility.

Stillbirth remains subject to social stigma, even from obstetric clinicians, whether intentionally or not [37]. For clinicians, being aware of the nature of trauma, practicing trauma‐informed care, acknowledging triggers, and providing anticipatory guidance can be helpful. It is difficult but necessary to distinguish grief following stillbirth or perinatal loss from mental health pathology. Standardizing a grief scale for use after perinatal loss may be helpful in studying effective interventions for support in the future.

3.3. Infertility

People undergoing infertility care experience increased rates of anxiety and depression, with 28%–44% of individuals affected [38]. A systematic review of qualitative studies revealed three main themes around the experience of infertility and its treatment: the personal reproductive trauma, the impact of infertility on relationships, and a sense of being failed by health care and society [39]. Study subjects described stress about fertility, grief about lost reproductive plans, insomnia, a sense of isolation, relational conflict, and sexual dysfunction.

A 2023 meta‐analysis including 58 randomized controlled trials of psychological interventions for infertility found small reductions in participant distress and modest improvements in pregnancy rates, but the quality of evidence was low [40]. Social drivers of health (SDOH), such as income and health insurance, are associated with the severity of infertility‐associated mental health disorders, highlighting a need for comprehensive support strategies in this population [41]. Future research should be informed by patients’ perspectives on infertility and mental health [42].

3.4. Abortion bans and restrictions

Recent cross‐sectional studies have documented population‐level increases in symptoms of anxiety and depression after the 2022 Dobbs v. Jackson Women's Health Supreme Court decision overturned the constitutional right to abortion [43, 44]. These findings align with studies that show an association between restrictive state abortion laws and mental distress in reproductive‐aged females [45, 46]. Additionally, previous research has established that being denied a wanted abortion is associated with elevated anxiety and that abortion restrictions disproportionately affect historically marginalized populations [47, 48].

4. CLINICAL CONSIDERATIONS IN ADDRESSING MATERNAL MENTAL HEALTH

4.1. Clinical practice guidelines and resources

Assessing maternal mental health symptoms is the first step in mental health care provision. More than 50% of birthing parents with antenatal or postpartum depression go undiagnosed, approximately 85% do not receive treatment, and 95%–97% are not treated to remission [49]. The American College of Obstetricians and Gynecologists (ACOG) recommends screening for perinatal depression and anxiety using standardized, validated instruments at the initial prenatal visit, later in pregnancy, and at postpartum visits [50]. Clinicians should also screen for bipolar disorder, particularly before starting pharmacotherapy for suspected perinatal depression, because individuals with bipolar disorder often do not respond to antidepressant therapy, and unopposed antidepressant treatment in people with bipolar disorder can precipitate mania and increase the risk of other negative outcomes [51]. Because bipolar disorder is associated with an increased risk of psychosis, suicide, infanticide, and homicide, consultation with a mental health professional should be considered if this diagnosis is suspected.

Screening should be implemented with systems in place to ensure timely access to treatment. Psychotherapy remains the first‐line treatment for individuals with mild to moderate depression or anxiety, yet it is often not accessible—in large part due to a shortage of psychotherapists who offer affordable treatment covered by insurance—or not acceptable to some patients. Discussing and initiating psychopharmacotherapy for depression or anxiety is within the scope of practice of an obstetrician‐gynecologist (OBGYN) [52]. ACOG recommends that a validated screening tool (e.g., the Patient Health Questionnaire‐9 or Edinburgh Postnatal Depression Scale for depression or the General Anxiety Disorder‐7 for anxiety) be used to monitor for response to treatment and adjust medication dosages as needed, with the goal of remission of depressive and anxiety symptoms.

Perinatal psychiatric access programs (PPAPs) are a helpful resource for management and treatment guidance. Such programs provide training and toolkits, clinician‐to‐clinician telephone psychiatric consultation (and, in some cases, face‐to‐face consultation with patients), links to community‐based mental health resources, and technical assistance to help practices integrate mental health care into obstetric practice workflow. The United States has 28 state or county PPAPs and two national programs: Postpartum Support International's Perinatal Psychiatric Consult Line [53] and the Department of Veterans Affairs’ Reproductive Mental Health Consultation Program [54].

4.2. Reimbursement and coding

Administering mental health screening, reviewing screening results, and discussing SDOH with patients require additional time and effort from physicians and office staff. The International Classification of Diseases, 10th Revision, codes for SDOH and mental health screening [55] should be used for documentation and reimbursement purposes. Clinical practices should adopt a screening tool, preferably embedded into the electronic health record, that can be administered by staff or self‐administered by patients. Notably, the billing codes for addressing the impact of SDOH and coordinating care under the collaborative care model (CCM) are time‐based, so reimbursement is higher when the situation demands more time. However, willingness to pay for such care varies by insurance provider, underscoring the importance of partnership with and education of payors to optimize clinicians’ ability to provide comprehensive and coordinated care that includes mental health care.

4.3. Workforce capacity

Better preparing OBGYNs, psychiatrists, psychologists, and other mental health professionals to recognize and treat perinatal mental health conditions requires systems‐level interventions. The Accreditation Council for Graduate Medical Education does not require psychiatrists to have any training related to pregnancy or reproductive health. It does not require OBGYNs to have any training on perinatal mental health other than the diagnosis and initial pharmacological management of postpartum depression. Most OBGYNs agree that mental health conditions fall within their responsibilities, and ACOG's Clinical Practice Guidelines on perinatal mental health affirm that this care with pharmacology falls within the scope of OBGYNs [50, 52]. However, most OBGYNs feel that they lack the training to address or treat such conditions. Mental health providers are not required to have specialized training in maternal mental health.

4.4. Perinatal psychopharmacology

Depression during pregnancy is the strongest predictor of postpartum depression, and discontinuation of antidepressant treatment is associated with relapse of major depression [56]. While findings are often heterogeneous due to methodologic challenges associated with confounding by indication, data show that, when adequately adjusted for the underlying mental health condition, selective serotonin reuptake inhibitor (SSRI) exposure in pregnancy is likely not associated with congenital anomalies, fetal growth problems, preterm birth, or long‐term developmental abnormalities [57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67]. SSRI exposure is associated with an increase in the odds of persistent pulmonary hypertension in the newborn (adjusted odds ratio [OR], 1.28; 95% confidence interval [CI], 1.01–1.64 [60]) with absolute risk still very low, and neonatal adaptation syndrome, which could result in admission to the neonatal intensive care unit (OR, 2.64; 95% CI, 1.58–4.40) [59]. Clinical providers, including OBGYNs and maternal‐fetal medicine subspecialists, should be aware of best practices regarding counseling about SSRI exposure and how to initiate and optimize medication management. Barriers to counseling about SSRIs should be explored to help more clinicians feel comfortable prescribing them.

4.5. Prevention

Counseling interventions can prevent perinatal depression [68]. The United States Preventive Services Task Force (USPSTF) recommends the Mothers and Babies Program and the Reach Out, Stay Strong, Essentials intervention for primary prevention of perinatal depression [69]. Practical Resources for Effective Postpartum Parenting is an emerging intervention for the prevention of perinatal depression [70]. It is worth noting that counseling is moderately effective at preventing perinatal depression, but most of the evidence comes from studies of people at increased risk for perinatal depression [68]; it is unclear whether all populations benefit equally from these prevention interventions.

Sizable gaps remain in the implementation of counseling interventions aimed at prevention. Barriers to mental health care in general include the lack of screening, lack of access to mental health care, stigma around mental health care, systemic and structural racism, SDOH, lack of integration of mental health and maternal care, the siloed nature of specialized services, and lack of culturally adapted evidence‐based interventions [71, 72]. For maternal mental health preventive services in particular, evidence‐based interventions have been slow to scale up, and clinicians may not be aware that they can be reimbursed for providing mental health services [73, 74]. Effective interventions incorporate the voices of the community, particularly those with relevant lived experience.

4.6. Health services initiatives

The chasm between the need to address perinatal mental health disorders and the provision of services underscores the importance of evidence‐based health services interventions to improve perinatal mental health outcomes. The CCM integrates mental health care into primary care settings. Evidence from multiple studies has shown that the CCM significantly improves screening for mental health conditions, initiation and adequacy of treatment, and mental health outcomes, making it a preferred model over standard primary care [75, 76].

Several adaptations to the CCM have been made to optimize its impact in the context of perinatal care. For example, the Collaborative Care Model for Perinatal Depression Support Services (COMPASS) addresses the differences between primary care and perinatal care that exist at the patient, clinician, and system levels. Data from COMPASS demonstrate that it results in improvements in screening for perinatal depression, increased OBGYN clinician recommendations for treatment for those with identified perinatal depression symptoms, and reductions in disparities in each of these process measures [77].

Baby2Home is a digital health intervention designed to extend postpartum support beyond traditional postpartum visits. Baby2Home integrates holistic family support, including parenting education, self‐management tools, and infant care communication support, building on the core foundations of the CCM. Moreover, Baby2Home actively engages the nonbirthing co‐parent in mental health and parenting processes, emphasizing the importance of care for the family unit during the transition to new parenthood. Baby2Home is currently being evaluated in a clinical trial [78]; the model may offer an innovative path to expand mental health services during the first year postpartum.

The Collaborative Care Model for Perinatal Wellness Support Services—Population‐Level Equity‐Centered Solutions (COMPASS‐PLUS) was codesigned with the community to address ongoing barriers to perinatal mental health care [79]. Informed by a community action and advisory board, COMPASS‐PLUS builds on the core tenets of the CCM but embeds comprehensive and community‐driven approaches to addressing health‐related social needs. It also provides training materials for the perinatal collaborative care team that strive to heighten awareness about birth equity [79]. The COMPASS‐PLUS approach centers partnerships with community‐based organizations to ensure all birthing people have mental health support that is accessible and acceptable.

Several resources have emerged to support OBGYN clinicians and health systems in expanding knowledge about perinatal mental health and building models of care. These resources include ACOG Clinical Practice Guidelines [50, 52]; the Alliance for Innovation on Maternal Health Patient Safety Bundle, Perinatal Mental Health Conditions [80]; Postpartum Support International's resources [53]; the National Curriculum on Reproductive Psychiatry [81, 82]; and state‐based PPAPs. The National Maternal Mental Health Hotline [83] also offers support, and clinicians should give obstetric patients the information for this valuable resource.

5. KEY FINDINGS AND RECOMMENDATIONS

5.1. Overcoming healthcare system barriers to detecting and treating maternal mental health conditions

5.1.1. Increase reimbursement rates for mental health care

The US healthcare system has historically underinvested in mental health services, creating significant gaps in access to care. Although comprehensive solutions would require substantial policy and funding changes, targeted reimbursement reforms could produce meaningful improvements in the near term. Key reforms should include (1) enforcing mental health parity mandates with insurance providers, (2) establishing equal reimbursement rates for in‐person and telehealth mental health services, (3) mandating coverage for evidence‐based models of care (e.g., CCM) and digital health interventions, and (4) addressing the compensation disparities between fee‐for‐service/direct pay and insurance‐based care. Attention to compensation disparities is particularly critical, as the current approach has resulted in a two‐tiered system in which adequate mental health care is more readily available to those who can pay out of pocket, and those relying on insurance face significant barriers to timely, appropriate care. In particular, adjusting reimbursement rates could increase access to care by encouraging more mental health clinicians to accept insurance. Similarly, fair compensation for the time OBGYNs spend managing mental health concerns would help integrate this care into routine practice.

5.1.2. Improve dissemination and awareness of existing clinical tools

A key barrier to preventing perinatal mental health conditions is clinicians’ lack of awareness and familiarity with evidence‐based interventions. Many OBGYN clinicians are unaware of existing clinical training resources and recommendations such as those from the National Curriculum on Reproductive Psychiatry and the USPSTF [69, 81]. Better dissemination of these resources is essential to drive implementation of prevention, screening, and treatment practices in routine care.

An online clearinghouse should be developed to host clinical and logistical educational resources covering topics such as screening protocols, billing strategies, care models, and treatment decision‐making. Embedding mental health resources into smartphone applications already used in clinical settings may be another effective dissemination strategy. Additionally, patient portals offer a promising platform for delivering targeted, educational mental health content to pregnant and postpartum individuals.

5.1.3. Improve clinician and trainee education about maternal mental health

To meet the growing demand for perinatal mental health care, comprehensive education in mental health screening and psychopharmacology must begin in training and extend throughout clinical practice. Improving trainee education in screening and the principles of psychopharmacology could be achieved through additional emphasis on mental health conditions in the Council on Resident Education in Obstetrics and Gynecology's educational objectives (which should be clearly aligned with ACOG's Clinical Practice Guidelines) [84], the Society for Academic Specialists in General Obstetrics and Gynecology Pearls of Exxcellence [85], and the American Board of Obstetrics and Gynecology's qualifying and certifying examinations. Another approach would be to require psychiatry rotations as part of OBGYN residencies, particularly rotations within PPAPs. Similar strategies should be carried out to ensure better education about reproductive health in psychiatric residency training.

Mental health education should be a requirement for licensure and should be evaluated through quality measures. Education and resources should be delivered at practice locations, including providing physical materials to patients (e.g., magnets or stickers for the National Maternal Mental Health Hotline [83]) and establishing on‐site training sessions for staff by experts in reproductive psychiatry. Systemic efforts to inform clinicians about psychotherapy and increase patient access to psychotherapy should be accompanied by efforts to expand the provision of psychopharmacologic treatment by OBGYNs.

Both trainee and clinician education must include content on effective communication strategies for discussing mental health conditions as common and treatable, avoiding stigmatizing language, and supporting shared decision‐making.

5.1.4. Encourage integrated care models that promote mental health

Clinicians should prioritize team‐based care, although they would benefit from more guidance on how to implement integrated care models such as the CCM. Collaborative care and other integrated behavioral health models can reduce clinician burden and improve access to care, but they require implementation support, training across the entire care team (including medical assistants, nurses, and front‐desk staff), and financial models that support sustainability. Ideally, integration should also involve community‐based partnerships, with the recognition that a purely medical model is insufficient. Collaborating with community organizations can help address SDOH and provide culturally responsive support. Finally, coordination between mental health and SUD programs can maximize resources and reduce care silos. Successful models from either domain could be adapted to serve both populations more effectively.

5.1.5. Strive for equity in mental health care

Racial and ethnic disparities persist across the perinatal mental health continuum. Universal mental health screening can help mitigate clinicians’ implicit biases around whom to screen and when. However, to be effective, screening tools must be culturally sensitive, and the care pathways they trigger must be culturally responsive. Currently, there is a shortage of resources that reflect the cultural values, languages, and lived experiences of diverse populations.

Efforts to address disparities must also tackle the underlying SDOH that prevent individuals from accessing timely mental health care. While many initiatives rightly center the needs of Black birthing people, other underserved groups—including Indigenous and immigrant communities and lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender minorities—also require focused attention.

In some jurisdictions, mental health conditions in the perinatal period are criminalized, leading to fear and avoidance of care. Policies are urgently needed to ensure that pregnant and postpartum individuals can seek help without fear of punitive consequences such as involvement of child protective services. Decriminalizing perinatal SUDs is a critical policy priority to reduce barriers to care and promote equitable access to mental health services [86].

5.2. Increasing public awareness of mental health and access to resources

5.2.1. Consider technological methods to increase access to care

Hotlines and telehealth have the potential to improve access to mental health services. However, individuals vary in their preferences for and comfort with telehealth services. State requirements around telehealth vary; policies should be revised to allow clinicians to provide telehealth across state lines.

Delivering digital mental health services yields opportunities and challenges. The heterogeneity of electronic medical records limits the implementation of digital interventions and the types of evaluation data that can be collected. Additionally, some existing digital mental health applications have unclear profit models and lack data to support efficacy or effectiveness. Efforts to increase the uptake of digital mental health services should account for barriers at the patient and clinician levels.

Leveraging social media to raise public awareness about perinatal mental health, especially with assistance from celebrities and influencers, would improve patient education and could help to reduce stigma. Campaigns that engage trusted public figures and influencers can normalize conversations about perinatal mental health and drive demand for care. One key message to communicate is the safety of pharmacologic treatment for mental health during pregnancy—specifically, that people should not stop taking medications for mental health disorders during pregnancy without first talking with a clinician familiar with the psychological and obstetric consequences of discontinuation.

5.2.2. Build capacity to assess and address mental health

Expanding the care team by engaging advanced practice professionals, doulas, and community health workers is crucial to meeting the needs of patients at risk for and experiencing perinatal mental health conditions. Building therapeutic capacity by training more people in mental health care can increase access. All providers should be prepared to respond to and address mental health needs with links to care and follow‐up to ensure adequate treatment.

Perinatal mental health initiatives could include more entities that interact with people during the perinatal period such as programs that provide food assistance. In such cases, more communication among clinical, social service, and other providers is needed to ensure people receive adequate links to care.

5.3. Advancing clinical and research opportunities related to the two‐generation brain plasticity framework

5.3.1. Improve the quality of mental health research

Research on two‐generation brain plasticity is complicated by the heterogeneity of the US population (e.g., race, socioeconomic status, gender identity, and religion). Further, there are inherent challenges to engaging participants with perinatal depression in research, which may skew study populations toward milder depression. A robust study must consider these limitations. An intersectional approach seeks to understand participants in their personal contexts (including work and life stressors). Expertise from multiple disciplines—including pediatrics, psychiatry, biology and other basic science, obstetrics, and neuroscience—improves the quality of research design, methodology, findings, dissemination, and implementation. Study rigor is also enhanced by engaging community partners, integrating qualitative methods, and learning from lived experiences.

5.3.2. Explore innovative approaches to perinatal health research

Investigators should reconsider traditional clinical settings for maternal mental health research and instead design studies that bring care and interventions to places where families already are. For example, embedding screening and intervention efforts in high‐traffic, accessible environments—such as big box retail stores—could expand reach and reduce barriers to participation. These settings offer a unique opportunity to engage a broad cross‐section of the population, including those who may not regularly access traditional health care. Follow‐up could be facilitated through telehealth, supplemented by in‐person visits for imaging, specimen collection, or other research needs. This approach would promote equity, convenience, and real‐world applicability of maternal mental health interventions.

Researchers should take advantage of data collected during the COVID‐19 pandemic to better understand the effects of stress on maternal mental health and the relationship between maternal immune activity and fetal development. This global event can serve as a natural experiment for understanding moderators and mediators of depression in a more broadly representative sample.

Researchers should seek out large data sets that may provide novel insights. For example, the Centers for Disease Control and Prevention's Maternal and Infant Clinical Network (MAT‐LINK) gathers data [87] from 11 clinical sites across the nation to monitor key exposures and outcomes that impact pregnant women and their infants. Although MAT‐LINK primarily collects information on medication for SUDs, there is substantial overlap between SUDs and mental health disorders.

5.4. Develop and use better research tools and methods

Researchers should consider including both biological and psychological indicators in maternal mental health studies. For example, incorporating allostatic load—a cumulative measure of psychological stress—may provide a more accurate assessment of stress and its impact on perinatal mental health and the offspring. Additionally, there remains a notable gap in positive measures of maternal mental health such as well‐being, social support, resilience, or quality of life. These outcomes are critical for capturing the full impact of interventions.

Promising developments in mental health research include the identification of biomarkers for postpartum depression. In addition, other efforts are underway to predict depression using risk factors detected in the electronic medical record. Some researchers and clinicians perceive such tools as more sensitive than self‐reported questionnaires used for screening; thus, these approaches may expand the reach of mental health services.

Studies of perinatal depression treatment should include child outcomes to evaluate the full impact of maternal mental health interventions. However, this shift will require changes to the existing framework of federal grant funding to support longitudinal follow‐up. These additional data would allow for testing of the two‐generation scientific model and provide evidence on how treating maternal depression affects child and maternal health.

5.5. Better communicate research findings

Thoughtful messaging is critical to communicating about study findings. Research in the field is often characterized as investigating the damage done by stress or mental health conditions, but positive framing and messaging about protective factors and wellness could be more helpful to the public. For example, clinicians can explain that maintaining wellness and mental health during pregnancy benefits the fetus and helps with the transition to parenthood, leveraging the desire of parents to do whatever they can to achieve a successful outcome. Successful messaging will help the public and policymakers better understand the link between mental and physical health.

5.6. Support future research

Additional areas for research include the following:

• Impact of abortion bans on maternal mental health.

• Assessment of chronicity versus severity of stressors.

• Effects of limited workplace parental leave and childcare policies on maternal mental health.

• Optimal methods of medical education in maternal mental health, including the timing (e.g., during residency) and format (e.g., clinical rotations) of effective training.

• Perinatal mental health conditions in nonbirthing partners.

• Protective and strengthening factors in maternal mental health.

• Effective mental health screening tools and approaches to screening for diverse populations.

• Effectiveness of maternal mental health applications currently on the marketplace and in development.

5.7. Identify new funding sources for research

New and expanded clinician and patient education efforts require new funding. Funding for mental health research should support partnerships with community groups, pilot studies, and the collection of long‐term outcomes. Generating more and better evidence of the effectiveness of perinatal mental health interventions through community‐based and community‐led projects will increase dissemination and uptake. Researchers would benefit from better coordination and bridging among different funding sources (e.g., government and philanthropic), as well as a centralized resource on perinatal mental health research and grants. Additionally, funders can convene diverse groups working on perinatal mental health to facilitate coordination and collaboration.

6. CONCLUSION

Changes to clinical practice must be realistic and sustainable, and they should recognize the limitations of the traditional medical model. Rebuilding trust between clinicians and historically marginalized patient groups is crucial to address maternal mental health. Clinical practices should be responsive to current gaps in the care cascade (e.g., by embedding links to care into screening processes), have systems in place to address barriers related to SDOH (e.g., by providing transportation), and incorporate community groups in planning and implementing initiatives. Integrating mental health care across settings and partnering across disciplines are paramount to improving perinatal mental health.

This workshop was intended to catalyze continued improvements in maternal mental health. Box 2 highlights some initiatives that followed the February 2024 workshop.

BOX 2: Maternal mental health initiatives since February 2024

Federal steps

• US Department of Health and Human Services (HHS) Best Practice Guides: Telehealth for Maternal Health Services [88].

• HHS Office of Women's Health: Talking Postpartum Depression [89].

• HHS Substance Use and Mental Health Services Administration: Task Force on Maternal Mental Health: National Strategy to Improve Maternal Mental Health Care [90].

• Maintaining our Obligation to Moms Who Serve (MOMS) Act of 2024 [91].

• National Institutes of Health Women's Health Roundtable Series special session: Elevating Women's Voices to Improve Maternal Mental Health [92].

• HHS, Department of Labor, and Department of Treasury Final Rule on the Mental Health Parity and Addiction Equity Act [93].

Tools and resources

• Association of Women's Health, Obstetric and Neonatal Nurses: Perinatal Bereavement Certificate Program [94].

• American Heart Association statement: Optimizing Psychological Health Across the Perinatal Period: An Update on Maternal Cardiovascular Health [95].

• Maternal Mental Health Leadership Alliance:

  • Fact Sheet: Maternal Mental Health Overview [96].

  • Fact Sheet: Advocating for Maternal Mental Health [97].

  • Perinatal Mental Health Education and Screening Project Phase I Final Report (includes landscape analysis on insurance reimbursement for providing patient education and screening for perinatal mental health conditions) [98].

  • Perinatal Mental Health Training Database: An online searchable database for aspiring and current health care professionals seeking perinatal mental health training to better support their patients and clients [99].

  • Perinatal Psychiatry Access Programs [100].

• National Curriculum in Reproductive Psychiatry: It provides online education modules and links to other resources [81].

• Perinatal Collaborative Care Collective [101]: It offers implementation support for the collaborative care model.

• Center for the Transition to Parenthood [102]: A virtual hub providing a blueprint for enhanced whole‐person, two‐generation prenatal care, and nationwide resources for those involved in perinatal care and the people they serve.

Conferences

• Maternal Mental Health Forum at the Intersection of Policy, Payment, and Practice, hosted by the Policy Center for Maternal Mental Health (March 2025).

• Inaugural Perinatal Mental Health Summit 2025 (April 2025).

• Mission: Motherhood Maternal Mental Health Conference (May 2025).

• Perinatal Mental Health, hosted by the Royal College of Obstetricians and Gynaecologists (May 2025).

• Postpartum Support International Annual Conference (July 2025).

• Black Maternal Mental Health Summit, Hosted by the Shades of Blue Project (July 2025).

• Marcé of North America Biannual Conference (November 2025).

• National Curriculum in Reproductive Psychiatry Intensive (February 2026). This annual 3‐day course takes a practical, case‐based approach and provides continuing medical education credit [103].

International initiatives

• An international team published “Maternal mental health matters: Indicators for perinatal mental health—A scoping review” in the journal PLoS One [104]. The team condensed 25 indicators for perinatal mental health aligned with the Global Perinatal Mental Health Theory of Change to form a core set of nine indicators, with the goal of developing a global monitoring framework to monitor progress toward universal high‐quality perinatal mental health care.

• Health Canada: The Clinical Practice Guideline for the Management of Perinatal Mood, Anxiety and Related Disorders and Seeds of Hope: A Patient and Family Guide [105].

• European Union and EU4Health launched the Mind the Mum [106] project on perinatal mental health to deepen the understanding of postpartum mental health and create tools for identification and support.

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