Linking cardiovascular and mental health to childbirth, the American Heart Association is recommending that doctors include psychological screening for new and expectant mothers to help reduce the nation’s disturbingly high maternal mortality rate.
The guidelines, which the AHA issued Tuesday, also call for adding a behavioral health specialist to a patient’s overall maternal care team. Paying attention to a patient’s mental health, they say, can help with everything from preeclampsia — a common, potentially deadly childbirth complication — to postpartum depression.
While maternal, cardiovascular and psychological health don’t seem to align, the AHA believes the connection is the key to lowering the risk of adverse pregnancy outcomes, including miscarriage or death. Data shows Black women are far more likely to die during childbirth as white women.
Guidance for Clinicians
“It’s critical that we redefine maternal cardiovascular health to include psychological health because there is robust evidence on the association of psychological health with cardiovascular outcomes,” said Dr. Garima Sharma, director of preventive cardiology and women’s cardiovascular health at Inova Schar Heart and Vascular in Fairfax, Virginia. Sharma chaired the AHA writing group that produced the statement, which appears in a Go Red for Women® spotlight issue of the Journal of the American Heart Association.
Along with the recommendation, he says, it’s important to provide “guidance to clinicians on how to integrate psychological health screening into the perinatal period and focus on providing a holistic approach with the mind and heart interconnection.”
As with the overall U.S. population, cardiovascular issues, like heart disease, stroke, and high blood pressure, are the leading cause of maternal deaths. The maternal mortality rate in the United States is two to three times higher than estimates from other high-income countries, and has increased since the COVID-19 pandemic.
The rate for Black women is even worse, at 2.6 times higher than white women.
There is robust evidence on the association of psychological health with cardiovascular outcomes.
Dr. Garima Sharma, Cardiologist
Just over half of all women of childbearing age report having a history of mental health issues. Roughly 4 in 10 women in marginalized groups experience anxiety or depression during and after pregnancy.
Research shows that depression and anxiety are among the leading causes of maternal mortality in the U.S., associated with pregnancy complications and poor, long-term cardiovascular health.
Cognitive behavioral therapy and interventions, such as antidepressants and other medications, can be used to improve long-term maternal health outcomes.
“Pregnancy is an important time of life from a health perspective,” says Sharma. “However, it is not known how many health care professionals understand the connection between the mind and heart and routinely screen and optimize psychological health during the perinatal period.”
“Screening for psychological health before, during, and after pregnancy should be used alongside screening for high blood pressure, Type 2 diabetes, and other modifiable risk factors for cardiovascular disease,” he says.
Racism and Other Stressors
Social factors such as a person’s living conditions, traumatic events, and combating daily stress affect mental health, which may show up as negative health behaviors, ranging from having a poor diet or not sleeping or exercising regularly to smoking tobacco and drinking alcohol or using prescription or illegal drugs.
Additional stressors such as experiencing racism and discrimination, living with domestic violence, having high blood pressure during pregnancy, dealing with incarceration or active-duty military service for pregnant women or a loved one increases the risk of anxiety and depression.
But there are also barriers to addressing and treating maternal mental health. These include stigma, fears of Child Protective Services removing the infant or other children from the home, limited time and attention from healthcare providers, and concerns that health insurance won’t cover mental health treatment.
Patients can talk with their healthcare providers if they need help accessing state and nationwide programs designed to help pregnant women who are in crisis.
Other suggestions for reducing racial and socioeconomic inequities include expanding reimbursement for the cost of using doulas, midwives, and community health workers for maternal care.
Identifying and intervening on modifiable risk factors that increase the risk of depression, Sharma says — including social isolation, no or inadequate partner support, depression before pregnancy, and poor sleep quality — could improve maternal psychological health as well as future cardiovascular health.
Maternal Mental Health Resources
- Postpartum Support International
- Policy Center for Maternal Mental Health
- Maternal Mental Health NOW
- National Maternal Mental Health Hotline: They help patients and clinicians identify specialists with competencies in caring for patients with suboptimal psychological health. 1-833-TLC-MAMA is the hotline, which is 24/7, free, and available and includes counselors, local support groups, and organizations. This is operated by the Human Resources and Services Administration.
- Perinatal Psychiatric Consult Line: The PSI perinatal psychiatric consultation program is a service provided at no cost.
- Lifeline for Moms
- Veterans Affairs Reproductive Mental Health Consultation Program
If you are thinking about suicide, worried about someone else, or need emotional support, call or text the Suicide & Crisis Lifeline at 988. Help is available 24/7. TTY users can dial 711 then 988 to get help.
