For many women, an OB-GYN clinician is the physician they see most often. Women often visit their OB-GYN during vulnerable periods of life, including adolescence, pregnancy, postpartum and the menopausal transition, which can trigger bouts of depression or anxiety.
The integration of behavioral health and women’s health care has become more common as OB-GYNs encounter mental health issues that fall outside their specialty. Still, a lot of training is needed before behavioral health can be fully integrated into women’s health, industry insiders told Behavioral Health Business.
The consequences of lack of treatment for interrelated behavioral health and women’s health issues can be severe. The CDC found that mental health conditions, including substance use disorders (SUDs), account for 23% of deaths during pregnancy or in the year following.
Multiple issues contribute to the high percentage of behavioral health-related deaths, according to Nancy Byatt, a perinatal psychiatrist and tenured professor at UMass Chan Medical School.
The stigma surrounding behavioral health issues may cause patients to be hesitant about discussing their concerns with their clinicians. Additionally, a shortage of providers, including psychiatrists, can prevent patients from accessing needed care and inadequate training can make it challenging for clinicians to address problems outside their area of expertise.
“The obstetrician isn’t necessarily an expert in mental health,” Byatt told BHB. “General psychiatric providers may not have the self-efficacy, knowledge or skills to manage pregnant or postpartum individuals that need medication treatment.”
Problems are even worse for marginalized populations, who have higher rates of maternity-related deaths, may struggle to get specialized care and experience racism and oppression.
Many providers see patients presenting conditions they are not confident in caring for, Byatt said.
“Perinatal individuals are left to try to navigate this when the availability of providers to see them can be quite limited sometimes,” Byatt said.
These problems are being met with rising national interest to increasingly integrate women’s health and behavioral health, according to Elise Valdes, research director at Relias.
Cary, North Carolina-based Relias provides workforce education and enablement technology solutions to more than 11,000 health care and human services organizations.
“We now know that maternal death rates and morbidity not only have clinical components but also social and mental health determinants,” Valdes told BHB. “When we look at birthing people, there is a movement nationally to look more holistically; just working on the clinical side at the time of delivery is not enough to improve outcomes.”
Action needs to be taken on all ends of the health care industry to improve outcomes for women, sources told BHB.
“Tools should be developed and communities should be assessed to see where they lack resources to support families,” Valdes said. “Hospitals and health systems should demonstrate an increased sense of urgency here, as should payers.”
More training is needed
Insufficient training is not due to lack of provider interest.
A study published in the Journal of Maternal-Fetal and Neonatal Medicine surveyed 794 health care team members in the acute care and behavioral health fields who come into contact with pregnant or recently pregnant women. While almost all respondents said they had a protocol for screening for peripartum depression (PPD), 96.5% also reported that they would benefit from additional training on PPD.
“Clinicians are so busy and face so many demands that it can feel burdensome to add tasks like training to their to-do lists,” Valdes, one of the study’s researchers, said. “That the overwhelming majority feels more training is needed highlights the importance of this topic and clearly demonstrates that those in behavioral health and acute care recognize this.”
The study’s authors said they recognized a discrepancy between their study and existing research.
“Other research indicates that high rates of screening may not lead to improved outcomes, and there are still high rates of maternal suicide and suicidal ideation in the US,” the researchers wrote. “It is possible that high self-reported screening rates may indicate a false sense of security such that care team members feel the issue is addressed while problems remain. Alternatively, many respondents felt their organizations would benefit from further training, perhaps indicating an awareness of this gap.”
While many said they had screening protocols in place, 25% said that they have no process for following up on referrals from screenings and 8% did not report that they followed up with a social worker.
“Together, this implies that significant numbers of women with PPD are falling through the cracks and not receiving a diagnosis and/or treatment, which needs to be addressed,” Valdes said.
Efforts to improve training and integration
While training in women’s health, specifically during and after pregnancy, is not currently required for psychiatrists, efforts to better train behavioral health physicians are gaining momentum.
Not only are efforts focused on increased screenings for OB-GYNs, but also improved follow-ups, treatment plans and monitoring.
Treatment plans also need to include referrals to the right providers, plenty of follow-ups to ensure the patient gets treatment and be affordable for the patient, Valdes said.
Working with the American College of OB-GYN, Byatt’s team helped develop a suite of resources to help OB-GYNs integrate anxiety-related care into their workflow.
‘It’s parallel to diabetes,” Byatt said. “People are screened for diabetes and if that screen is positive, they are followed up with. They are started on medication and it’s followed up until the blood sugar is under control. So what we’ve done is develop resources that really help OBs to implement mood anxiety care in the same way. It’s detected, assessed and followed up until treatment remission.”
Other solutions include a peer support model created by CU Boulder as well as efforts to train doulas to provide ongoing, trauma-informed care, Byatt said.
Some providers are offering integration interventions to improve current conditions.
Iron Health, launched in 2023, partners with OB-GYN clinicians to provide a virtual care team of multidisciplinary providers, including primary care, behavioral health, chronic disease management and nutrition.
The digital platform significantly eases burdens for clinicians, Stephanie Winans co-founder and CEO of Iron Health, told BHB.
“With mental health, it takes some trial and error to get patients exactly where they need to be,” Winans said. “Medication is important, but so is cognitive behavioral therapy and a broader model around behavioral health. That’s not something that the OB-GYN is positioned to provide.”
The B2B company allows OB-GYNs to refer patients who screen positive for behavioral health conditions to its virtual care platform. Iron Health delivers collaborative care services through its patient app and then collates patient data back into the OB-GYN’s electronic medical record (EMR).
“Once we deliver care, we are dropping that [data] back into the OB-GYN’s electronic medical record [EMR] to really help them become kind of the primary medical home for women,” Winans said. “It’s important for our patients to understand that we do have a relationship with your OB-GYN and we are creating more continuous care for you as a result.”
Another program, launched in early 2023, leverages peer specialists to support women with substance use disorders who may become pregnant.
Elevance Health’s (NYSE: ELV) Empower program was designed to integrate behavioral health, physical health and social health for women.
“Unless you’re addressing all of it, you’re not addressing it,” Tiffany Inglis, national medical director for women and children’s health at Carelon, told BHB. “If you ignored behavioral health when re-envisioning [the impact on] people who are pregnant, early families and people considering pregnancy, you’d be missing a huge component.”
Carelon is Elevance’s health care services arm.
While existing efforts aim to enhance coordination, significant gaps in care for women persist, underscoring the need for additional work to integrate services and optimize outcomes.
“I don’t think enough is being done in women’s health in any corner so I wouldn’t say that behavioral health particularly disappoints me,” Winans said.
Some current policies drive negative health outcomes for women, Byatt said, including reimbursement policies, lack of mental health parity and access to reproductive planning. These policies force providers to react rather than work toward prevention.
“One of the challenges when we think about the gaps is the policies that drive these negative outcomes, ” Byatt said. “We need to be focusing on prevention so that we can prevent the illness before they start. We also need to be focusing on having policies that actually promote health, women’s health and family health.”