Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth, with suicide a leading cause of postpartum deaths. PMADs are associated with poor maternal, infant, and family outcomes. Identification and early intervention are imperative for successful treatment. This case study describes the implementation and outcomes of a multidisciplinary Perinatal Mental Health Task Force (“Task Force”) at one urban academic children’s hospital that was created to promote systems change and health care policy solutions for improved identification and treatment of PMADs. Using the social ecological model as a framework, the Task Force addressed care at the individual, interpersonal, organizational, community, and policy levels. The Task Force applied lessons learned from division-specific screening initiatives to create best practices and make hospital-wide recommendations. This foundational work enabled us to build community bridges and break down internal barriers to shift our pediatric hospital toward prioritizing perinatal mental health. As a result, screening expanded to multiple hospital locations and became a hospital corporate goal, the Perinatal Mental Health Screening Tool Kit was created and disseminated within the community, Task Force members testified in governmental hearings and joined national organizations to inform policy, and Task Force and community collaborations resulted in significant grant funding. Lessons learned have been disseminated nationally. Moving forward, we aim to expand our program and partnerships to ensure that caregivers of infants receive appropriate mental health support to strengthen family well-being. The Task Force can serve as a model for advocates looking to expand and integrate PMAD care.
Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth in the United States and are associated with poor maternal, infant, and family outcomes.1–4 They occur during pregnancy or in the first year after childbirth, with postpartum depression being the most common.1–4 PMADs contribute to maternal mortality, and suicide accounts for up to 20% of postpartum deaths.5 Fathers can also suffer, with depression rates of up to 10%.6 Identification and early intervention are imperative for improving health outcomes and to prevent adverse sequelae for children and families.1,7–9 Professional societies, such as the American Academy of Pediatrics, have recommended universal screening for perinatal mental health concerns.10–14
Children’s National Hospital (CNH) is a freestanding children’s hospital in the District of Columbia with a level 1 trauma center, a level IV NICU, and a vast network of community-based primary care practices. In the District of Columbia, ∼13% of women with a recent birth reported experiencing depressive symptoms.15 Starting in 2015, providers across several divisions, including primary care, the NICU, and the emergency department (ED), recognized the importance of screening and began implementing such practices into their clinical workflow, piloting various screening tools for postpartum depression, training clinical staff, and building community connections to assist with linking caregivers to support and treatment. To unify and expand on these siloed efforts, the multidisciplinary and interdepartmental Perinatal Mental Health Task Force (hereinafter “Task Force”) was formed.
This advocacy case study describes the creation of the Task Force to formalize collaboration between hospital divisions, promote systems-level change, and advocate for health care policy solutions. The case study further describes how the social ecological model was adapted to organize and describe the breadth of work from an individual clinician’s role all the way through to policy-level considerations.16–18
Methods and Process
Initial Landscape and Stakeholders
PMAD intervention and prevention requires changes at multiple levels within our health systems and communities. Our stakeholders included the families of our patients, medical providers, support staff, social workers, psychologists, divisional and hospital leadership, community advocates, policy makers, and philanthropic organizations. The initial phases of the work started in silos at a divisional level. Each division had a different style of implementation, including different screening tools.
In 2014, the primary care division focused on implementing routine mental health screening for all ages, which included PMAD screening.19 Routine screening with the Edinburgh Postnatal Depression Scale (EPDS) formally began in 2015, although it took several years for the practice to become universal in all clinics.
Starting in 2015, the ED and NICU performed screening as part of independent research studies. Staff in the ED implemented a pilot study using the EPDS to screen a convenience sample of mothers of infants ≤6 months in age.20 Simultaneously, parental depression screening (including fathers) was conducted in the NICU by using the Center for Epidemiologic Studies Depression Scale as part of a randomized controlled trial comparing the effect of peer-to-peer support on parental mental health and infant outcomes.21 Results of these studies suggested extremely high rates of positive depression screen results (27% screening positive for depression or anxiety in the ED and 45% screening positive for depression in the NICU), which warranted the development of a universal screening protocol. None of the divisions were truly aware of the work being done elsewhere despite having similar goals.
Task Force Programmatic Development
Core staff from the ED and NICU independently reached out to the hospital’s Child Health Advocacy Institute and primary care to learn from their experiences with launching universal PMAD screening. Subsequently, in May 2017, these key stakeholders came together to discuss screening initiatives and formed the Task Force. The goal was to create a forum to discuss best practices and apply lessons learned from division-specific screening initiatives as well as to make hospital-wide recommendations to better support infants and parents across the institution. Because we recognized that not only mothers and fathers were affected by PMADs, adoptive parents, grandparents, and other caregivers were also included in screening. The Task Force created a work plan with specific goal areas, including information sharing, improved communication, and advocacy for a perinatal mental health policy, based on the social ecological model. A time line of major Task Force events between 2015 and 2020, including legislative efforts, is shown in Fig 1.
Time line of major Task Force events. CES-D, Center for Epidemiologic Studies Depression Scale; DC, District of Columbia; PCORI, Patient-Centered Outcomes Research Institute.
Time line of major Task Force events. CES-D, Center for Epidemiologic Studies Depression Scale; DC, District of Columbia; PCORI, Patient-Centered Outcomes Research Institute.
Two main challenges emerged. The first was finding a team leader to gather additional stakeholders from across the hospital system, develop a formal work plan, and hold members accountable for achieving milestones. The second was finding financial support for the programmatic and policy work. We benefited from having a program lead who had public health expertise and could dedicate time and attention to the work of Task Force as well as in-kind institutional support to fund the policy focus. Although the Task Force could have been sustained without funding, staffing this program lead position increased our success and efficiency. Previous philanthropic connections were used to provide ongoing funding for this position, including seed funding from a donor who was committed to improving perinatal mental health. Most of our funds were for dedicated personnel time.
Consistent engagement from clinical leaders in primary care, the ED, and the NICU was also imperative for the development and expansion of the Task Force. The program lead, in collaboration with core staff from these divisions, drafted a one-page summary of the proposed goals and objectives. This document was circulated across the hospital system, and staff members who were involved in existing parental mental health screening projects and others interested in the topic were invited to join the effort.
Social Ecological Model
The social ecological model recognizes that behavior is a function of individuals and of the physical, social, and organizational environments in which individuals live.16–18 Our overall goal was to identify caregivers who screened positive for PMADs and refer them for appropriate interventions. Acknowledging that this would require both behavior changes at the provider level and systemic changes, we applied the social ecological model to frame our desired impact at the individual, interpersonal, organizational, community, and policy levels (Fig 2).16,17 The individual level of the social ecological model in this case was the clinician or practitioner, the interpersonal level represented the relationship between the staff from different hospital divisions, the organizational level represented institutional changes that promoted a supportive climate for screening, the community level was the external community with which the Task Force members collaborated, and, finally, the policy level represented the advocacy opportunities that were sought to sustain these initiatives not only for our hospital but also for hospitals nationwide.
Outcomes
The Social Ecological Model Outcomes
Individual: Increasing Individual Practitioner Knowledge, Skills, and Behavior
PMAD training was provided to members of the Task Force focusing on divisions currently screening (primary care, ED, and NICU) and those interested (cardiac ICU and the Prenatal Pediatric Institute). Feeling comfortable and competent to address the mental health concerns identified through screening was frequently noted to be a persistent barrier to providers being open to and prepared for screening, so trainings were intended to alleviate these concerns. Three Task Force members completed a regional perinatal mental health “train-the-trainer” teaching certificate program and were integral in disseminating knowledge and best practices across hospital divisions. The Task Force created standardized protocols to define both what constituted a positive screen result and how to respond to positive screen results and suicidal thoughts.22–24 Additionally, HealthySteps psychologists with expertise in postpartum mental health were embedded into 2 primary care clinics helping to support the early identification and treatment of PMADs.24,25 These embedded psychologists were also able to offer additional training to their local clinic staff. In November 2019, a hospital-wide grand rounds presentation was given; ∼75 people attended, and the recording has been viewed >500 times since its posting.
Interpersonal: Relationship Building and Resource Sharing
The Task Force created a forum for providers from different hospital divisions to share best practices and knowledge, which was integral to creating an environment where providers felt that they had the information and confidence to identify and manage PMADs. In year 1 of the Task Force (September 2017 to August 2018), the group convened 9 times and included 43 members from 11 divisions. As of June 2020, this group has further expanded to include 56 members from 15 hospital divisions (Table 1). Meeting topics included resources to support families and providers, staff trainings, addressing adult mental health emergencies, data sharing, mental health stigma, billing and coding, and referrals. These meetings were centered on learning from members’ experiences, providing suggestions to current barriers, and discussing lessons learned. Protocols were created to address situations in which a caregiver expressed positive suicidal or homicidal ideations. The interdisciplinary relationships created through the Task Force were critical in developing best practices and led to a peer network with amplified PMAD advocacy.
Divisions Involved in the Task Force
| Divisions |
|---|
| 1. Primary care |
| 2. Emergency medicine |
| 3. NICU |
| 4. Prenatal Pediatric Institute |
| 5. Cardiac ICU |
| 6. Developing Brain Institute |
| 7. Gastroenterology |
| 8. Department of nursing |
| 9. Parent navigators |
| 10. Child and Adolescent Protection Center |
| 11. Hospital medicine |
| 12. Psychiatry |
| 13. Psychology |
| 14. Developmental psychology |
| 15. Infectious diseases |
| Divisions |
|---|
| 1. Primary care |
| 2. Emergency medicine |
| 3. NICU |
| 4. Prenatal Pediatric Institute |
| 5. Cardiac ICU |
| 6. Developing Brain Institute |
| 7. Gastroenterology |
| 8. Department of nursing |
| 9. Parent navigators |
| 10. Child and Adolescent Protection Center |
| 11. Hospital medicine |
| 12. Psychiatry |
| 13. Psychology |
| 14. Developmental psychology |
| 15. Infectious diseases |
For example, the ED and NICU fostered a significant collaborative relationship through the Task Force. Pilot data in the ED and NICU highlighted the high rates of mental health symptoms in parents and the need for collaboration between divisions.20,21 ED and NICU leaders recognized that many parents were being missed, despite professional health organizations’ recommendations to screen for postpartum depression in outpatient visits, because the ED and NICU serve a population of caregivers who may fall outside the screening safety net in pediatricians’ or obstetricians’ offices.20,21 As a result, they worked together to determine how shared resources could be used to implement universal screening. This partnership allowed both divisions to approach administrators in a collaborative fashion to advocate for additional support, including dedicated personnel. Working together, a proof-of-concept grant (2018–2020) was secured. As a result, 710 caregivers were screened in the ED and 670 were screened in the NICU over the span of 2 years, with real-time linkage to resources and referrals (Table 2). In addition, the clinical cultures within the ED and NICU have shifted such that staff prioritize both an infant’s physical health and the caregivers’ mental health. Subsequently, additional philanthropic funding was secured, providing additional personnel, increasing screening rates, formalizing linkages to community-based care, and creating constructs for sustainability.
Caregivers Screened for PMADs: 2018–2020
| Division (Metrics) | 2018 | 2019 | 2020a | 2021 (January to June) |
|---|---|---|---|---|
| Emergency medicine | ||||
| Proportion screened, % | 3 | 4 | 11 | 45 |
| No. screens completed/infants eligible for screenb | 124/4912 | 180/5082 | 406/3544 | 679/1518 |
| NICU | ||||
| No. screens completedc | 111 | 203 | 356 | 312 |
| Primary care | ||||
| Proportion screened, % | 81 | 79 | 77 | 76 |
| No. screens completed/No. well-child visits eligible for screend | 1602/1984 | 1519/1934 | 1273/1651 | 635/841 |
| Division (Metrics) | 2018 | 2019 | 2020a | 2021 (January to June) |
|---|---|---|---|---|
| Emergency medicine | ||||
| Proportion screened, % | 3 | 4 | 11 | 45 |
| No. screens completed/infants eligible for screenb | 124/4912 | 180/5082 | 406/3544 | 679/1518 |
| NICU | ||||
| No. screens completedc | 111 | 203 | 356 | 312 |
| Primary care | ||||
| Proportion screened, % | 81 | 79 | 77 | 76 |
| No. screens completed/No. well-child visits eligible for screend | 1602/1984 | 1519/1934 | 1273/1651 | 635/841 |
2020 PMAD screening numbers were affected by the coronavirus disease 2019 pandemic. Pediatric visits to our institution decreased during this time, and screening in the ED and NICU was paused for 2 mo because of staffing limitations.
Caregivers presenting to the ED with infants 6 mo or younger are eligible for a PMAD screen.
The NICU performs screening after 2 wk of age and monthly thereafter. Because of repeated screening, it was difficult to assign a denominator, and only counts were measured.
Screening is conducted at the 1-, 2-, 4-, and 6-mo well-child visits in each primary care clinic. The screens represented in this table include the 2-mo visit (the corporate goal). The total number of screens completed at all well-child checks is much higher.
Organizational: Institutional Engagement and Spread
Through our collective training efforts and the interpersonal relationships built through the Task Force, routine screening was expanded to several other clinical areas, including the cardiac ICU and developmental psychology clinic. Task Force members served as consultants for other divisions looking to implement screening. An intranet Web page was created to host resources as well as promote trainings and presentations. The link was shared via all-staff e-mails and newsletters, and from May 2018 to May 2020, the Web site received 821 views from 213 unique viewers.
An additional success point was the support garnered from our institution, which reaffirmed the hospital’s commitment to improving caregiver mental health. Senior hospital leadership identified screening as a component of the institutional corporate goals for fiscal year 2018, with a specific goal of increasing screening rates in primary care by 15%. Universal PMAD screening has been maintained as standard of care at all CNH primary care clinics. Within the NICU, a peer-to-peer supporter was permanently hired by the institution to periodically check in with parents after discharge to ensure that emotional and social needs were being addressed. Institutional support from our highest levels of leadership was also critical for obtaining additional philanthropic funding for screening initiatives. The NICU and ED ultimately received philanthropic funds to support expansion of personnel to include a full-time family services associate, dedicated mental health clinicians, and a care coordinator to screen for and address PMADs. This increased the screening capacity and improved the quality of care provided.
In addition, this early postnatal mental health work, in combination with other prenatal CNH initiatives, led hospital and external stakeholders to invest in perinatal mental health, resulting in large-scale philanthropic investments for the hospital. Multiple leadership levels needed to be engaged in the work to obtain this type of funding, including midlevel managers and senior administrators. Engagement of our public relations and marketing team helped highlight parent stories and narrate our journey. We used opportunities such as national presentations, mention in a newspaper article, and citywide policy changes to convey our successes to leadership. Senior hospital leadership continues to track our efforts, particularly as it relates to patient satisfaction initiatives and formally operationalizing screening across hospital divisions.
These organizational changes, coupled with ongoing individual-level trainings and collaborative relationships fostered through the Task Force, enabled us to significantly expand our screening efforts (Table 2). After standardization of workflow, scoring, and use of electronic SmartForms, the EPDS was administered with relative ease and little additional burden on providers and staff. Providers were trained to provide referrals to an internal behavioral health specialist or external community resources with expertise in PMADs, as appropriate.
Community: External Partnerships
Systemic changes and successes were facilitated by external partnerships. CNH leads the District of Columbia Collaborative for Mental Health in Pediatric Primary Care (hereinafter “the Collaborative”), a consortium of private and public organizations working to improve the integration of mental health into primary care. Task Force leaders and the Collaborative assisted in developing the Perinatal Mental Health Screening Tool Kit and currently works with the Task Force to make annual updates. The tool kit introduces providers to the EPDS, defines a positive screen result score cutoff, provides examples of language to use with families when discussing screening results, details a sample plan for crisis management and responding to suicidality, and includes a local resource navigation guide for community-based referrals. The tool kit has been shared with pediatric providers (2266 Web page views cumulatively), and it is being adapted for providers in the obstetric setting. Supplemental tools have been developed by the Task Force and the Collaborative, including the Path to Wellness and Well-being Plan, which is available online in English and Spanish.26 This work paved the way for providers across the city to implement screening and link families to care.
Task Force members are also involved in several local and national coalitions on the topic of perinatal mental health, including the Mary’s Center Regional Perinatal Mental Health Champions program, the District of Columbia Women’s Mental Health Consortium, Zero to Three, The Center for Law and Social Policy Moving on Maternal Depression Initiative, and Mind the Gap. Task Force leadership hosted a regional perinatal mental health symposium in 2019 that has since become an annual event. Our results and lessons learned have been disseminated through national pediatric research meetings, national webinars, and various media outlets.27
Policy: Advocacy Opportunities to Support Sustainability
At the policy level, Task Force members advocated locally and nationally to support policy changes to expand access to PMAD screening. Using a strong partnership with our state Medicaid agency, the District of Columbia Medicaid Fee Schedule now has a specific caregiver mental health screening code that includes reimbursement for caregiver mental health screening in primary care. Task Force members also testified in support of a local bill to create the District of Columbia Maternal Mental Health Task Force and testified at the national level in support of the 21st Century Cures Act. Members also participated in policy roundtables, such as the Health-Economic Mobility Policy Group meeting at the Brookings Institution.
Lessons Learned
Through our collective experience implementing perinatal mental health screening across a large hospital system, we have learned many lessons. It is our hope that others wanting to replicate this work can learn from our experience and adapt their approach to meet the specific needs of their institution(s).
The Task Force provided a forum for multidisciplinary collaboration and open communication across previously siloed hospital divisions that we believe can be replicated within other institutions and communities. In pursuit of a hospital system-wide uniform approach to detection, intervention, and referrals to care, we were able to accomplish the following: improving information sharing and coalition building, providing training and education, standardizing screening and referral practices, developing a community resource list, strengthening relationships with community-based perinatal mental health providers, and advocating for reimbursement for PMAD-specific care in the pediatric setting to promote sustainability. We also benefited from and learned the importance of hospital and senior leadership placing an explicit institutional priority on mental health, which helped to advance many aspects of our work. As such, we recommend that others conducting coalition-building work within this perinatal mental health space involve community stakeholders and engage hospital leadership throughout the building, growing, and maintenance phases of the work.
The Task Force demonstrated strength in numbers to achieve large-scale change and increased impact, which we have confidence can also be accomplished within other hospital systems. A unified approach to screening was beneficial for reporting and benchmarking across hospital divisions. Listening and learning from other providers regarding topics such as how to address suicidality and possible scripted language responses to positive screen results helped to create best practices. The Task Force was able to demonstrate the importance of and enthusiasm for the treatment of PMADs within the institution and community.
We acknowledge the need to address ongoing challenges that others conducting similar work may also want to consider. It continues to be important for us to have a team leader who can manage our work plan and hold members accountable for achieving goals. Continued financial support is needed for programmatic and policy work. We have had success with philanthropic donors and with local and federal legislative change, even without a dedicated lobbyist. Although philanthropic funding is helpful, institutions need to find a stable way to financially support these programs.
Conclusions
Future directions include providing technical assistance to other hospital systems seeking to expand their screening practices, engaging technological solutions to better integrate screening into clinical workflow and electronic health record systems, ensuring equity in screening and treatment, finding sustainable payment and funding models, and advocating for policy that improves access to mental health treatment. We seek to gather feedback directly from families about their experiences with screening at our institution. It is also our hope to increase treatment options within the hospital, which can present challenges when the caregiver is not the patient. Given the prevalence and negative consequences of untreated PMADs, we continue to innovate to improve the quality care we provide for infants and their families. We hope that this case study can serve as a model for advocates looking to integrate PMAD screening within their own institutions.
Dr Jarvis conceptualized and designed the advocacy case study, reviewed and revised outcome measures, and drafted the initial manuscript; Drs Long and Beers and Ms Barclay Hoffman helped to conceptualize and design the advocacy case study, reviewed and revised outcome measures, and reviewed and revised the manuscript; Ms Theodorou helped to conceptualize and design the advocacy case study, reviewed and revised outcome measures, and critically reviewed the manuscript; Dr Soghier reviewed and revised outcome measures and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted.
FUNDING: The A. James & Alice B. Clark Foundation, the Children’s Health Board, the Health Resources and Services Administration, the Howard and Geraldine Polinger Family Foundation, the J. Willard and Alice S. Marriott Foundation, and the Patient-Centered Outcomes Research Institute were sources of funding used to support the programmatic activity of this advocacy work. Research reported in this work was funded through a Patient-Centered Outcomes Research Institute award (IHS-1403-11567). The Patient-Centered Outcomes Research Institute was not involved in design, interpretation of data, or drafting and revision of the manuscript.
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