Why mental health should be front and center in prenatal and postpartum care delivery

Nobody needs to tell you that pregnancy, childbirth, and parenthood are experiences that come with massive changes. Your body goes through this incredible transformation — but so do your identity, your relationships, and even how you think about and relate to the world. These can be really exciting times! But all of these changes are also ripe opportunities for uncertainty and anxiety.

As many as 10-15% of pregnant and postpartum people experience significant anxiety or depression — and 5% may continue experiencing depression a full three years after giving birth. And, according to a 2018 report from the CDC, perinatal depression is more commonly reported by Black and Indigenous birthing people when compared to white and Latine people. Mental health conditions during pregnancy, in general, are shown to increase the risk of complications like preeclampsia — and they’re one of the leading underlying causes of maternal mortality. They can even impact a child’s development through adolescence.

All of this to say that mental health during and after pregnancy is extremely important — especially now, given COVID’s dramatic effect on the rates of perinatal depression and anxiety. The problem, however, is that the standard delivery of maternity care in the U.S. doesn’t reflect that importance — or the full spectrum of our needs and experiences as birthing people.

The Millie founding team has seen this firsthand, both as moms and as care providers, and we’ve heard it from countless others who have given birth or cared for people who have. Below is why we believe these issues exist, and what Millie does differently.

The state of perinatal mental healthcare in the U.S.

1. Standard 15-minute appointments and quick questionnaires are not enough to address needs for mental health support.

Clinical guidelines recommend that healthcare providers screen all birthing people at least one time throughout pregnancy and postpartum for symptoms of anxiety and depression. One time. But the reality is that the way providers commonly screen for these symptoms leaves a lot to be desired. The standard screening tools are limited in what they cover, and have to be squeezed into the typical 15-minute visit, which doesn’t create much space for real conversations.

While we also, as of 2019, have a recommendation from the U.S. Preventive Services Task Force to refer birthing people “at risk” of perinatal mood and anxiety disorders — those with a history of depression or current depression and those who have lower incomes or are single or young parents — to clinical treatment for mental health. But given just how many people actually  experience anxiety and depression in the perinatal period, many end up being left out. These recommendations may also overlook other related conditions, like generalized anxiety disorder, disordered eating, or history of sexual trauma. It’s just not enough.

It also overlooks the real fears and anxieties many people giving birth feel around the childbirth process itself. Some people have the ability to pay for classes and doulas for childbirth that can help build their confidence. But that isn’t always an option or the right answer for many.

2. Pregnant and postpartum people don’t all have the same access to mental healthcare.

42% of births in the U.S. happen in low-income families relying on public health insurance. In California, half of births are covered by Medi-Cal. But as anyone who’s searched for a therapist can tell you, finding someone you like and who actually takes your insurance is incredibly difficult. While those with private insurance may have a longer list of providers to choose from, many providers don’t even take insurance.

The people who often have the most emotional support through pregnancy and postpartum tend to be those who have private insurance or can afford to pay for it out of pocket. Since birthing people of color enroll in public health insurance at higher rates, this creates a divide in how birthing people access mental healthcare. We see this reflected in the data: One 2011 study found that when compared to white birthing people, Black birthing people who experience postpartum depression have lower rates of initiating and following up on treatment, as well as filling antidepressant prescriptions.

3. Pregnant and postpartum people don’t always know what’s just “baby blues” and what’s something to be concerned about.

It’s incredibly common to experience some depression and anxiety in the days after birth. These feelings are often called “baby blues” and may go away within a few weeks. But when you’re dealing with the many stressors of new parenthood, or even pregnancy, it’s hard to know when what you’re feeling is considered “normal” — or when those depressive or anxious thoughts “count” as something more significant. And if you don’t have a close friend or loved one who’s pregnant, postpartum, or who’s recently gone through these experiences, you may have to make sense of what you’re feeling with minimal guidance.

In a care model where mental health is managed through a narrow, limited screening tool in the course of a few minutes, how are you supposed to know when to ask for help? Or when you need more than just time to feel better? One of our founders didn’t even realize just how extreme their anxiety was in the postpartum period until they had reflected on the experience a year later. Expecting pregnant and postpartum people to have the headspace to identify when they’re struggling is too much to ask.

Why is perinatal mental healthcare so often overlooked?

Many of the limitations in perinatal mental healthcare stem from the same problems with postpartum care in the U.S.:

• Our healthcare system is too focused on the clinical and the physical. Even though perinatal mood and anxiety disorders are the most common pregnancy complications, there’s too much separation of the mental from the physical. Mental health conditions deserve just as much care as physical conditions do, yet they continue to be deprioritized.
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• Our healthcare system is too reactive. It’s oriented around diagnosing and treating conditions rather than proactively supporting birthing people with education and skill building — and integrating mental healthcare into prenatal and postpartum care delivery.

The U.S. care model pushes birthing people to our breaking points before we can get help. But we deserve space to reflect on what we’re dealing with. We deserve proactive information that better prepares us. And we deserve a community of people who get what we’re experiencing.

Mental health is never an afterthought at Millie

With Millie, you don’t have to know when to ask for help or pay extra for the support you and your mental health need. Our approach considers the whole you, and all of what you may experience:

• Proactive education and planning: We know firsthand how preparation can support emotional well-being. The Millie app delivers weekly clinical information and creates space to help you plan and feel prepared for your birth and postpartum experiences.
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• One-on-one sessions with a practicing doula: You’ll be partnered with a Millie doula for trimesterly sessions on key topics, in-depth birth and postpartum planning, and messaging whenever you have questions or need support.
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• Lessons from midwives-turned-therapists: We’ve also integrated Millie-exclusive tools to manage anxiety and depression into the app — crafted for you by clinicians with deep expertise in the relationship between maternity and mental health.
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• Access to mental health experts when you need them: Your mental health will be a focus of Millie care from day one. If individual sessions with a therapist is what you need, we’ll have a network of vetted providers you can work with.
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• A community of peers who get it: Sometimes you need to talk to people dealing with the same things you are. Share your experience, ask questions, and get advice from peers who are right there with you in the Millie app and at community events.

At Millie, we know what it feels like to have your mental health pushed to the side by one-dimensional clinical experiences. We don’t separate emotional well-being from clinical excellence because we know they’re both important.

We see the whole you — who you are, where you’re coming from, and, importantly, how you’re feeling every step of the way.

When we’re fully prepared — physically, mentally, and emotionally — we have what we need to give ourselves as parents, as well as our families, the strongest starts.

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