Maternal mental health disorders pose a significant public health challenge. By definition, maternal mental health disorders are a range of mental health disorders that arise during the perinatal period. Although postpartum depression and anxiety are the most common, maternal mental health disorders can also include postpartum obsessive-compulsive disorder, postpartum posttraumatic stress disorder, bipolar disorder in the postpartum period, and in rare instances, postpartum psychosis (World Health Organization [WHO], 2008a). Up to 20% of mothers experience maternal mental health disorders during the perinatal period (WHO, 2008a; Wisner et al., 2013). Women with postpartum depression frequently experience suicidal thoughts, and suicide is the leading cause of mortality in postpartum women (Sit et al., 2015). Depression causes unrest and impairment that affect not only the health of the mother but also the health and development of the child (WHO, 2008b).
Mothering is a primary occupation that entails caring for and nurturing people and relationships (Arrendel, 2000). However, maternal mental health disorders impair a mother's ability to manage the occupations and activities necessary to nurture a child. For example, a study found that depressed mothers are less likely to follow safety precautions such as placing the child in a safe sleep position, using a car seat, or having a working smoke alarm (Balbierz, Bodnar-Deren, Wang, & Howell, 2015). They are also more likely to have difficulty maintaining a stable home and accessing nutritious foods (Corman, Curtis, Noonan, & Reichman, 2016), are less likely to engage children through practices such as child development enrichment activities (Zajicek-Farber, 2010), and may have trouble with communication, attunement, and responding to their children (Field, 2010; Letourneau et al., 2012). In addition, mothers with postpartum anxiety disorders are less likely to bond with their children (Tietz, Zietlow, & Reck, 2014). Moreover, maternal obsessive and intrusive thoughts are associated with lower breastfeeding rates and less sensitive parenting styles (Challacombe et al., 2016). When neglected, maternal mental health disorders can result in long-term effects on both child development and the entire family unit (Agnafors, Sydsjö, Dekeyser, & Svedin, 2013; Challacombe et al., 2016; LA Best Babies Network, 2009).
Maternal Mental Health: A Recognized Public Health Challenge
A series of recent public health and policy initiatives showed an increasing awareness of maternal mental health disorders and the need to address this critical issue. For example, the U.S. Preventive Services Task Force has recommended screening mothers during the perinatal period (Sui & U.S. Preventive Services Task Force, 2016). Similarly, the Council on Patient Safety in Women's Health Care offers a safety bundle that stresses the importance of screening, detection, and response to maternal mental health disorders (Council on Patient Safety in Women's Health Care, 2016). Likewise, the American Congress of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the Center for Medicaid and Medicare Services call for screening new mothers for maternal mental health disorders (Centers for Medicare & Medicaid Services, 2016; Committee on Obstetric Practice, 2015; Olson, Dietrich, Prazar, & Hurley, 2006).
In the United States, federal and state legislative policies to address maternal mental health disorders are emerging. For example, the 21st Century Cures Act (2016) includes screening and treatment for maternal depression. In California, the Maternal Mental Health Bill (2018) mandates that obstetric and primary care providers screen women for maternal mental health disorders and that private and public health plans and insurers create maternal mental health programs. The Maternal Mental Health Conditions Bill (2018) requires hospitals to provide maternal mental health training to clinical staff who work with pregnant and postpartum women. It also requires hospital staff to teach families about the signs and symptoms of maternal mental health disorders and to provide information on local treatment options. In Florida, the Florida Families First Act (2018) obligates the Florida Department of Health to provide information about perinatal mental health resources, including screening for postpartum depression.
Recognition of the importance of maternal mental health disorders extends beyond the United States. In 2016, the United Kingdom launched the Five Year Forward View for Mental Health to tackle mental health concerns, including perinatal mental health, by investing in maternal mental health awareness, workforce development, and the advancement of evidence-based treatment pathways (NHS England, 2017). In Australia, from 2007 to 2013, the government allocated funds to the National Perinatal Depression Initiative (Department of Health, 2013) for programs including perinatal mental health screening, support, and treatment as well as health care provider training, development, and research.
Studies show that screening for maternal mental health disorders is effective when incorporated into existing child developmental screening programs (Vasta et al., 2018). Consequently, public policy efforts have examined the integration of maternal mental health screening and support into early intervention programs (Robert Wood Johnson Foundation, 2014). Despite increasing policy efforts to address maternal mental health disorders, the processes necessary to screen, refer, and treat mothers for maternal mental health disorders in community settings are insufficient (Boyd, Mogul, Newman, & Coyne, 2011; Lind, Richter, Craft, & Shapiro, 2017). Policy solutions that focus on integrating maternal mental health into early intervention can address this public health challenge.
Gaps in Maternal Mental Health Care
In the United States, the focus on physical health and the lack of efficient collaboration and referral pathways between adult and pediatric care and mental health systems are large-scale barriers to maternal mental health care (California Task Force, 2017; Reynolds, Sontag-Padilla, Schake, Hawk, & Schultz, 2012). The stark separation between adult-focused behavioral health systems and child-centered, early intervention, and pediatric systems makes it particularly difficult for mothers to address and manage their own depression while ensuring that their children's developmental needs are met (Schultz et al., 2013). For this reason, innovative changes to care delivery systems that incorporate prevention and the integration of physical and mental health services are necessary to remove barriers to care (California Task Force, 2017). Specifically, the following two changes can improve service delivery and mitigate the barriers to maternal mental health care: (a) collaboration between programs that screen, identify, and treat maternal mental health disorders and programs that address developmental delays and (b) integration of maternal mental health support into pediatric occupational therapy practice and early intervention programs (Schultz et al., 2012). Through these approaches, the needs of both mothers with maternal mental health disorders and children with developmental delays can be addressed.
Integrating Maternal Mental Health into Pediatric Occupational Therapy Practice
Occupational therapy aims to enhance individuals' participation in activities and co-occupations (American Occupational Therapy Association, 2014). Although pediatric occupational therapy focuses on child development, a growing number of pediatric occupational therapists (OTs) have found that the mothers of children with developmental delays have maternal mental health disorders (Sepulveda, 2018). Because the health and well-being of a mother and her child are interconnected, OTs need to acquire knowledge about maternal mental health disorders, address this immediate health challenge, and work to strengthen the mother-child bonds that are crucial to human development.
Studies have shown that parents of children with developmental delays are at higher risk for depression (Boyd et al., 2011) and that a child's developmental delays can contribute to parental stress and depression (Alvarez, Meltzer-Brody, Mandel, & Beeber, 2015). Also, children with developmental delays need more attention and care, but depression often impedes a parent's ability to provide the necessary support (Reynolds et al., 2012). Although these two conditions are frequently concurrent, health care systems identify and treat them separately and do not communicate across networks (Reynolds et al., 2012).
Traditional early intervention in occupational therapy focuses on children's specific developmental delays. Attachment theory suggests that the foundation of development is an infant's emotional bond with caregivers (Ainsworth, 1989; Bowlby, 1982; Malekpour, 2007). The relationship-based approach of early intervention addresses the parent-child relationship and functions and is based on the premise that healthy child development depends on a child's primary attachment to the parents, physical and emotional safety, and predictable routines (Mahoney & Perales, 2005; Stoffel & Schleis, 2014). Therefore, OTs use interventions to promote engagement in occupations such as feeding, sleeping, resting, playing, socializing, education, and communication to foster physical, social, and emotional development (Clark & Kingsley, 2013). Thus far, the primary aim of these approaches has been to address child development and not maternal mental health needs.
Pediatric OTs are encountering more mothers who struggle with maternal mental health disorders (Sepulveda, 2018). The interplay among individuals, their environment, and the occupations in which they engage shapes their experience (Law et al., 1996). The Person-Environment-Occupation (PEO) framework considers a mother's mental, physical, spiritual, and cultural influences as she navigates her environment with her baby. This framework is well suited to understanding and addressing the needs of postpartum mothers. Optimal occupational performance can be achieved when the interaction between the mother-baby dyad, the environment (domestic, societal, cultural, institutional), and the meaningful activities in which the mother and baby must engage are harmonious. Application of the PEO framework in parenting of babies in the neonatal intensive care unit highlights how the occupational performance of parents and babies can be improved (Gibbs, Boshoff, & Lane, 2010). Specifically, in the Project Bien Estar, which is a project on mothering children with disabilities, the interaction of the person (mother's own identity), environment (her support system), and occupation (learning new skills to care for a child with disabilities) has provided a framework for understanding the mother's experience (McGuire, Crowe, Law, & VanLeit, 2004). The environment influences the mother's health and well-being. Consequently, promoting supportive environments through occupation-based programs can enhance a mother's well-being by reducing the occurrence of postpartum depression (Dennis & Dowswell, 2013).
The Helping Families Raise Healthy Children initiative created a sustainable network among behavioral health, early intervention, and maternal and child health care systems to address and meet the needs of caregivers experiencing depression and their children at risk for developmental delays (Schultz et al., 2013). In this program, early intervention practitioners (including OTs) are trained in relationship-based approaches to engage parents and children. The outcomes of the initiative include better identification of parents with depression, greater engagement in early intervention services, and decreased levels of depression and parental stress (Robert Wood Johnson Foundation, 2014).
As stated earlier, public policies for maternal mental health are being established and confirm that OTs need to be ready and equipped to serve mothers with maternal mental health disorders. Although public and professional interest in maternal health is resulting in more publications on maternal health in occupational therapy (Fernandes, 2018; Slootjes, McKinstry, & Kenny, 2016), literature on the practice of maternal mental health care in occupational therapy is limited, and few established frameworks and guidelines are available for OTs who are interested in maternal mental health. As the profession's capacity to respond to the challenges of maternal mental health disorders increases, so too will evidence-based literature on the efficacy of occupational therapy interventions in maternal mental health.
In addition to OTs, many providers, including licensed clinical social workers, counselors, psychologists, psychiatrists, and marriage and family therapists, have insufficient training and education in maternal mental health. For this reason, the university curriculum should provide instruction in basic maternal mental health (Macmillan, n.d.). Currently, OTs can attain core competencies in maternal mental health through certificate courses (Postpartum Support International, n.d.; 2020 Mom, n.d.) to be prepared to practice in maternal mental health. More specifically, pediatric occupational therapy practice should do the following to enable competency in maternal mental health: (a) incorporate maternal mental health screening into pediatric occupational therapy assessment; (b) recognize the complexity of maternal mental health disorders and the associated risk factors; (c) emphasize relationship-based approaches to help strengthen the mother-child relationship and alleviate the effects of maternal mental health disorders on children; and (d) incorporate occupational therapy approaches that support mothers in their roles and routines. The development of evidence-based occupational therapy treatments and interventions will reinforce the contribution of the occupational therapy profession to this area and advance reimbursement models, which will alleviate one of the most pressing barriers to this emerging field of practice. Interprofessional education leads to collaborative practice and integration and can help to break silos in health systems.
Recent public policy legislation has demonstrated the urgent need to respond to the challenge of maternal mental health disorders. From an occupational therapy perspective, maternal mental health disorders negatively affect both parent-child relationships and child development outcomes because of their devastating effect on a mother's ability to perform basic occupations. Because OTs in pediatric practice already work with mothers, they can play a critical role in addressing this challenge by screening mothers for maternal mental health disorders, providing them with support and care, and collaborating with resources within the community. These efforts place OTs at the forefront of addressing this public health challenge.
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