By Lauren Gimbel, MD, Brenda Gulliver, MS, Ryoko Kausler, PhD, Gwen Latendresse, PhD
In this multi-part blog series, researchers at the University of Utah College of Nursing share new insights that are expanding our understanding of women's health. This third installment discusses web-based interventions for screening women at risk for perinatal depression and accessing support and prevention resources.
What really goes through a new mother's mind when the house finally goes quiet? For many, it's a mental to-do list-the dishes, the laundry, the nap she keeps meaning to take. But for far too many others, the silence brings something much darker, and much harder to talk about.
Twenty percent of women experience perinatal depression, yet only a fraction receive treatment. Perinatal depression occurs during pregnancy (prenatal period), or during the first 12 months after delivery (postpartum period).
Without intervention, perinatal depression can lead to adverse outcomes. Some women have trouble bonding with their babies. Others neglect their older children, partners, household responsibilities, or self-care. Still others experience suicidal ideation or attempt suicide.
Although perinatal depression is treatable, 80% of women diagnosed with the condition do not follow through on treatment recommendations. We are trying to change this by providing at-risk women with education and access to resources and treatment.
Why Women Don't Follow Through on Care
About 15 years ago, researchers at the College of Nursing began offering women in-person programs for perinatal depression treatment and prevention. Although many patients were interested, the events were poorly attended. We had an increase in participation when we moved to telehealth about 12 years ago.
Because of our success, we thought women would participate via telehealth during the COVID-19 pandemic, but that wasn't the case. Pregnant and postpartum women, like everyone else at the start of the pandemic, were too stressed and overwhelmed to commit to something new.
There are many reasons why four out of five women with perinatal depression don't do anything about it. Common barriers to care include:
- Time constraints. New moms are overwhelmed by how much they have to do. Some women who shared feedback with us said they want to participate in our intervention, but they couldn't, even for an hour a week. For some, the idea of focusing on themselves made them feel guilty or selfish.
- Stigma. Women may worry about negative attitudes associated with mental health care, particularly in rural communities, where everyone knows everyone else. They might hesitate to seek care if people could see their car parked at the doctor's office.
- Medication-related fear. Pregnant and breastfeeding women are hesitant to take medication for any reason, including depression, out of fear of harming the baby. There's evidence to support that these medications are relatively safe, but women don't want to take risks.
People in rural areas typically have limited access to care, especially mental health care. When we provide mental health care via telehealth, some rural women have said they felt less alone.
Mental Health Screening for Perinatal Patients
When women see their doctor for prenatal care, the focus is on their physical health, not mental health. Is the baby growing well? Is the mom's blood pressure too high? Providers have only a few minutes with patients during clinic visits, and they often don't ask about depression. We've taken steps to change this.
Just before the pandemic, around the time that the American College of Obstetricians and Gynecologists recommended that all pregnant women should be screened for perinatal depression, we started to screen all University of Utah Health obstetric patients using validated screening tools.
When at-risk women were identified, we recommended Bump2Baby360, an online patient education portal offered by U of U Health as part of our MaMa (Maternal Mental Health Access) study.
Bump2Baby360 provides well-vetted, accurate information and evidence-based patient education tailored specifically for pregnant and postpartum women. The MaMa study introduced perinatal mental health education and resources on Bump2Baby360. It includes strategies for reducing perinatal depression risk, including mindfulness-based practices and cognitive-behavioral therapy.
We evaluated the implementation of the mental health screening and online portal into our academic health center, as well as six rural health districts across the state.
It can be challenging to integrate new evidence-based treatments into health care systems. Nationwide, it takes an average of 17 years to implement new or improved treatments. Our research team wanted to identify barriers and facilitators that impacted the ability to screen for perinatal depression and to direct those at risk to resources and prevention.
One barrier was red tape: It took a year to get approval to add the perinatal depression screening and Bump2Baby360 access to U of Health's EPIC MyChart system. Once it was in place, patients and providers began receiving automated messages. But some patients don't complete the screening, and some providers don't look at their alerts. These are barriers that still need to be addressed.
Expanding Perinatal Depression Screening
After we integrated our screening tool and online portal into six rural health districts across Utah, the Utah Department of Health and Human Services (DHHS) expanded our program statewide.
In Utah, suicide is the number one cause of maternal mortality. To lower the risk, the Utah DHHS uses resources developed by the MaMa study team and Utah's Women and Newborn Quality Collaborative to provide any woman in Utah with free perinatal mental health screening-even if they aren't part of a health care system. They'll contact at-risk individuals and provide resources for care. These resources are also distributed in U of U Health women's health clinics to patients in need.
DHHS also offers clinicians patient safety bundles about perinatal depression prevention. These resources offer information about evidence-based practices that can be implemented at academic centers or community hospitals.
We've been expanding our perinatal mental health initiative into Idaho for the past three years. Idaho doesn't have an academic-associated health care system, so the program is being implemented differently than at U of U Health. We've developed a relationship with a community health organization focused on rural health to help us reach women across Idaho.
Access to Perinatal Depression Screening and Education
Now that the MaMa study is over, we've made the perinatal mental health prevention program and resources available in Bump2Baby360, and they're open to all U of U Health patients at no cost. Nearly 93% of our patients with new obstetric appointments have MyChart. Not everyone engages with the platform, but among active MyChart users, 40-50% use Bump2Baby360.
Open access to perinatal mental health screening and the Bump2Baby portal ensures that more people learn about perinatal depression and strategies to decrease risk. That's our goal: Helping women maximize mental wellness during and after pregnancy, so that moms and babies have better outcomes.
Lauren Gimbel, MD, MSCI
Lauren Gimbel is an obstetrics and gynecology provider at University of Utah Health. She provides full spectrum women's health care through all stages of life. Her clinical interests include women's mental health, minimally invasive gynecologic surgery, rural and global health, and teaching students and residents. Gimbel received an MD at Rush University Medical Center in Chicago and completed residency in obstetrics and gynecology at the University of Utah.
Brenda Gulliver, MS
Brenda Gulliver is operations manager for clinical programs and ambulatory women's health at University of Utah Health. Her work focuses on health care quality and process improvement. Gulliver received an MS in nursing at the University of Utah.
Ryoko Kausler, PhD, FNP-BC, MN, RN
Ryoko Kausler is a board-certified family nurse practitioner and assistant professor of nursing in the School of Nursing at Boise State University. Her research focuses on maternal mental health, particularly perinatal depression/anxiety and substance use in rural health care settings. She leads a NIH/NIGMS pilot study examining telehealth interventions for perinatal mental health and substance use risk, while collaborating on an NIH/NINR grant developing web-based interventions for perinatal depression prevention. Through partnerships with health care institutions and local communities, she explores technology-based interventions to enhance access to perinatal mental health care, particularly addressing comorbid psychiatric illnesses and prevention. Kausler received a PhD in nursing science at the University of Utah and a master's in population health nursing at Boise State University.
Gwen Latendresse, PhD, CNM, FACNM, FAAN
Gwen Latendresse is a professor in the College of Nursing at the University of Utah. Her research interests in adverse pregnancy outcomes led her to biobehavioral investigations of chronic maternal stress, perinatal depression and anxiety, potential interventions, and community-engaged implementation science. Latendresse is the PI for an NIH/NINR R01 project that focuses on prevention of perinatal depression through integration of multimedia, web-based intervention. She also directs a HRSA Advanced Nursing Education Workforce (ANEW) grant to increase the number of graduate DNP students trained to provide health care services to rural and underserved communities after graduation. She received a PhD and MS in nursing at the University of Utah.
