Maternal Mental Health Disorders (MMHDs) are the most common complications of pregnancy and impact, on average, up to one in five expecting and postpartum mothers in the US. 1,2

Though postpartum depression is the most commonly known MMHD, there are a range of disorders, including anxiety, OCD, and psychosis.1 The onset of these disorders can occur before pregnancy, during pregnancy, and in the postpartum period. These disorders disproportionately affect mothers of color. For example, Black women are at a greater risk of experiencing postpartum depression and are less likely to receive care compared to white women.3 Black women also experience greater barriers to accessing mental health care due to social inequality and structural racism.3 Because of the high prevalence of MMHDs and their life-long impact on women, children, families, and society, it is vital to understand contributing factors to reduce the incidence effectively. This includes the role of family planning and related health care.1

According to the World Health Organization (WHO), reproductive health is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.”4 WHO expands this definition by stating that reproductive health requires the capability to reproduce and the freedom to decide whether to reproduce, when to, and how often.4 

This brief outlines the available research regarding the relationships between the ability to decide when and how often to have children and maternal mental health. Key definitions, the latest research, emerging reproductive health measures, and policy considerations surrounding family planning, family planning counseling, birth control, and abortion are presented. 

Family planning is defined by the WHO as the ability of an individual to attain their desired number of children and to plan the spacing of their births accordingly.5 Family planning aims to:

  • Support people in assessing their readiness for children: Families can assess whether they have the resources they determine are needed to have a child, such as finances, education, and social support.5
  • Help women understand the optimal age to become a mother: There are a wide range of long-term social, economic, and physical considerations of when a person has a child:
    • Becoming pregnant under the age of 20 increases the risk for mortality, bleeding during pregnancy, toxemia, hemorrhage, prolonged labor, anemia, and disabilities. Teenage birth is also associated with low birth weight infants, birth injuries, childhood illness, and mental and physical disabilities.6  
    • Research shows teen mothers also have more limited educational and career opportunities than non-teen mothers.6
    • There are risks associated with being pregnant over the age of 35, including a higher risk of premature birth, birth defects, low birth weight, gestational diabetes, high blood pressure, and miscarriage.7
  • Address spacing between births: Research shows that the amount of time from one child’s birth until the next pregnancy, known as the interpregnancy interval (IPI), impacts the health of the mother and baby.8 
    • Pregnancies that begin within six months after birth are associated with an increased risk of delayed prenatal care, preterm birth, placental abruption, neonatal morbidity, low birth weight, maternal anemia, and schizophrenia. Pregnancies that are close together may not provide enough time for the mother to recover. Further, breastfeeding during pregnancy can lower nutrient values in mothers, requiring time to recover before the next birth.9
    • On the flip side, research suggests that a long IPI may increase health risks for mothers, such as preeclampsia.9

Adverse outcomes associated with the mother’s age, sub-optimal interpregnancy intervals, and having a child when a person did not want to can place a physical, mental, and financial burden on women and the whole family.5

Family planning counseling is defined by the National Institute of Health (NIH) as “an interactive process between the skilled attendant/health worker and a woman and her family during which information is exchanged, and support is provided so that the woman and her family can make decisions, design a plan, and take action to improve their health.” 10

Counseling can help women and families proactively think through when and if they want to have children and put steps in place to activate their plan, including preventing unplanned or unintended pregnancies. 10

An unplanned or unintended pregnancy is defined by the Centers for Disease Control and Prevention as  a pregnancy that is either unwanted, such as the pregnancy occurred when no children or no more children were desired, or the pregnancy is mistimed, such as the pregnancy occurred earlier than desired.”11

Research suggests that unplanned/unintended pregnancies may create a mental and physical burden which can lead to poor health outcomes for the mother and baby.12 Individuals need to make the often difficult decision to carry the pregnancy to term, undergo abortion, choose to raise the child, or consider adoption.12 These decisions often involve medical, ethical, social, legal, and financial complications, perpetuating added stress which can lead to anxiety and depression.12 Additionally, unintended pregnancies have been associated with postpartum depression.13

Unintended pregnancy has been the conventional population health measure to determine if women are achieving their desired reproductive outcomes. There is a growing number of researchers who have pointed to the flaws of this measure and its inability to depict the complexities and nuances of pregnancy and childbearing.14 According to the Society of Family Planning, identifying unintended pregnancy as a problem stigmatizes fertility and equates unintended births and abortions as equivalent adverse outcomes.14 Because individuals can have different levels of pregnancy acceptability during an unintended pregnancy, it is problematic to automatically equate unintended pregnancy with negative health outcomes.14 Additionally, the measure of unintended pregnancy does not differentiate between unwanted and mistimed pregnancy and assumes access to and acceptability of specific contraception types, placing the blame for the unintended pregnancy on the individual.14

Though it is desirable to help women and families plan their pregnancies, when surveyed, 42% of women who did not currently desire a pregnancy indicated that a current pregnancy would be acceptable due to feeling prepared for children, having relational stability, having knowledge of parenting, or having a “whatever happens” perspective.15

Although unintended pregnancy has been the predominant measure, other measures are developing to broaden our understanding of people’s reproductive needs and experiences. New potential measures are exploring the unmet need for contraception, sexual and reproductive well-being, pregnancy acceptability, and patient-reported experiences with contraceptive counseling.14

Another measure that has been developed to understand reproductive healthcare better and improve health outcomes is the PCCC Measure. The PCCC Measure was created by the University of California San Francisco (UCSF) Person-Centered Reproductive Health Program to measure patient-centeredness and contraceptive care quality in any healthcare setting that provides contraceptive counseling.16 The PCCC scale measures three domains of person-centered contraceptive counseling:16

  1. Interpersonal connection, 
  2. Adequate information, and
  3. Decision support

The responses are aggregated and reported to the provider and facility to outline areas of success and need for improvement.16 In November 2020, this measure was endorsed by the National Quality Forum, and UCSF received a grant to disseminate and socialize the measure.16

Contraception, also known as birth control, is generally used to prevent pregnancy.17 The Centers for Disease Control and Prevention (CDC) recognized the invention of contraception as one of the ten great public health achievements of the 20th century.12 This is because it has reduced maternal mortality, improved maternal and child health through pregnancy spacing, and increased economic opportunities and self-sufficiency of mothers.12 Contraception options include:

  • Permanent methods such as vasectomies and tubal ligations, which are performed by medical doctors.
  • Long Acting Reversible Contraceptives (LARCS) such as progestin arm implants and intrauterine devices (IUDs), which are prescribed and administered by women’s healthcare providers.
  • Short-acting hormonal methods include oral contraception pills (OCPs), vaginal rings, skin patches, and contraceptive injections, which are prescribed and/or administered by women’s healthcare providers. These methods are used on a daily to monthly basis.
  • Barrier methods include male and female condoms, the diaphragm, the cervical cap, and the contraceptive sponge. These methods are typically not covered by insurance plans because most of these are available without a prescription. 
  • Emergency contraception (EC), also known as the “morning-after pill,” is a contraceptive method that prevents pregnancy when taken immediately after intercourse.17 This is predominately accessed over the counter, but there is one brand that is only available by prescription.17

When easily accessible and affordable, these diverse types of birth control allow women to choose the option that is the most appropriate for their situation, reproductive health, mental health, and well-being. 

It’s important to note that in addition to preventing pregnancy, the use of contraception may impact mental health in various ways, including:

  1. Hormonal Birth Control May Impact Mental Health 

Hormonal changes from birth control can be a risk factor for depression. 

Although the body of research is limited, some studies point to higher rates of depression and anxiety among users of hormonal birth control compared to non-users.19 Further, many women report hormonal contraceptives negatively influencing their mood.20 Two interesting studies which show this correlation include: 

  • In a study of more than 1 million women in Denmark, researchers found an increased risk for the first use of an antidepressant and the first diagnosis of depression among those who used different types of hormonal contraception and disproportionately affecting adolescents.21 
  • Research also shows that oral contraceptive pills that used higher doses of hormones in the 1960s and 1970s were associated with increased depressive symptoms, compared to the current hormonal contraceptives that use lower doses and have not been shown to be associated with depressive symptoms.13

Although further research is needed on the relationship between hormonal birth control and rates of mental health disorders, it is vital to recognize hormonal changes can be a potential risk factor for depression. 

  1. Hormonal Birth Control Used to Reduce Menstrual Pain

Birth control is often utilized to minimize adverse side effects associated with menstrual cycles. 

It’s common for menstruating people to face uncomfortable to severe physical symptoms, including bleeding for more than 20 days, intermenstrual bleeding, missed periods, cramping, mastalgia, bloating, and acne.22 Additionally, research shows that hormonal changes during the menstrual cycle can lead to psychological distress and irritability, including decreased self-esteem, nervousness, depressive symptoms, mood swings, and loss of energy.22 The severity of these physical and mental symptoms can limit daily activity and can lead to a wide range of mental health concerns.22 

In a study on the relationship between women using oral contraceptive pills (OCPs) and the prevalence of symptoms, researchers found that those using OCPs reported less mastalgia, cramping, hair loss, acne, nervousness, and mood swings relative to those not using hormonal contraception.23 Research shows that hormonal IUDs can reduce the loss of blood and related problems at a higher rate than OCPs.24 

By controlling pain, decreasing bleeding, and addressing nervousness and mood swings, birth control can be used to increase comfort during a menstruation cycle.

Abortion is defined as a procedure to end a pregnancy through medication or surgery.25 Medication abortion, also known as the abortion pill, can be taken up to 11 weeks after the last day of the individual’s last period.26 It is important to note that medication abortion is different from emergency contraception because emergency contraception prevents pregnancy when taken immediately after intercourse.17 After 11 weeks, abortion happens surgically. Surgical abortions include vacuum aspiration, which is typically used until 14-16 weeks after the individual’s last period, and dilation and evacuation (D&E), which can be used if it has been 16 weeks or longer after the individual’s last period.27

Fast Facts 

  • In the United States in 2020, one in five pregnancies ended in abortion.28 
  • 95% of abortions in the U.S. occur due to unintended pregnancies.13 
  • 60% of people seeking abortions in the U.S. are already mothers.29

In November 2017, the American College of Obstetricians and Gynecologists (ACOG) issued a Statement of Policy listing abortion as a vital service that makes up gynecologic care, highlighting the wide range of factors that may contribute to a woman’s decision to have an abortion.30  These factors include but are not limited to lack of access to contraception, contraceptive failure, rape, incest, placing a woman in greater danger of intimate partner violence, illness, and pregnancy complications that can endanger the mother and the fetus.30 

Because abortion is a controversial topic, there are different interpretations and frameworks that researchers use to look at mental health and abortion. In a comprehensive review conducted by the American Psychological Association, researchers found that the most methodologically sound research shows that among individuals who have a first-trimester, legal abortion of an unplanned pregnancy, the associated mental health risks are not greater than those who deliver an unplanned pregnancy.31 There are numerous studies that conclude an abortion does not increase the risk of subsequent mental health problems.32 Additionally, this report outlined the methodological limitations and failings of research on abortion and mental health.31 These limitations in empirical research present challenges in understanding the impact of abortion on mental health and policy implications.31

The Turnaway Study is a landmark analysis of the mental health implications associated with abortion and was conducted by researchers from Advancing New Standards in Reproductive Health (ANSIRH) at the University of California, San Francisco. This prospective longitudinal study examined the mental health, physical health, and socioeconomic outcomes of receiving an abortion compared to carrying an unwanted pregnancy to term. This study was conducted from 2008 to 2010 and followed 1,000 women seeking abortions from 30 abortion facilities across the country. Researchers conducted interviews for five years with women who received abortions and were denied abortions to understand their physical and mental health, employment status, educational attainment, relationship status, and emotions about pregnancy and abortion. 

This study found that overall, receiving an abortion does not have negative effects on the health and well-being of women but that being denied an abortion leads to negative financial and health outcomes. This study found that: 

  • 95% of those who had an abortion reported that it was the right decision for them over five years after the procedure
  • Those who were denied an abortion and were forced to carry a pregnancy to term have four times greater odds of being below the Federal Poverty Level
  • Those who were denied abortion were more likely to have pregnancy complications, stay with abusive partners, suffer from anxiety, and experience poor physical health 

Although the Turnaway Study is a commonly cited study, there are some limitations. First, ANSIRH has openly stated its mission is to debunk common justifications for new abortion restrictions, which has led some to question their ability to remain unbiased during research.34 Second, there is unclear information on the number of clinics recruited and retained for all years of the study.34 Some have also raised concerns that this study grouped together abortions at all gestational stages and reasons why individuals were denied an abortion. More research may be needed to understand the mental health implications of abortion and access to abortion.34

There are also several studies highlighting the harm that abortion can have on one’s mental health. In a systematic review of the relationship between abortion and mental health, studies found that abortion is a risk factor for subsequent mental illness when compared to childbirth and that the risk for subsequent mental illness is similar when compared to miscarriage or the birth of an unplanned baby.35 Although there is contradicting research on the relationship between mental health and abortion, there is common ground that mental health services should be provided for those considering an abortion or choosing an abortion to support the psychological needs of individuals.35

Research shows those who are pregnant and not ready to have a baby and  don’t have an abortion are more likely to have a child in an unhealthy and unstable environment or have an unsafe/or self-inflicted abortion.29 Around 21 million women worldwide receive unsafe, illegal abortions every year, leading to 50,000 deaths a year.29 Further, the American Psychological Association reports people who are denied abortions are at greater risk of high levels of anxiety, lower life satisfaction, and lower-self esteem in comparison with those who have access to legal abortions.32 This research controls for prior mental health complications, current adverse experiences, and sociodemographic factors show no association between abortion and subsequent mental health problems.32

In 1973, the Supreme Court Case Roe v. Wade guaranteed a constitutional right to abortion by deciding that the right to privacy in the 14th Amendment protected abortion rights.36 At this time, state governments were able to regulate and restrict abortion access depending on the stage of pregnancy, as long as they were not in violation of the constitutional right guaranteed in Roe v. Wade.36 On June 24th, 2022, the Supreme Court overturned Roe v. Wade in Dobbs v. Jackson, declaring that abortion is not a constitutional right.36 This decision leaves all law-making authority regarding abortion to the states. As of July 2023, 26 states have laws that restrict the right to abortion, and 16 states and Washington, D.C., have laws to protect the right to abortion.37 

Research shows that underserved communities, people of color, sexual and gender identity minorities, and those living in rural areas often have limited access to healthcare, including family planning counseling and contraception, and often experience bias from providers.38 Limiting access to abortion exacerbates these already existing health disparities.38

It’s important to note that healthcare coverage is foundational in family planning and related health services. Coverage is provided in a variety of manners in the U.S., including through employers, the health benefit exchange, and public programs like Medicaid. As of June 2022, Medicaid provided health coverage to 82.3 million people, including low-income adults, children, pregnant women, elderly adults, and people with disabilities.39 Medicaid is funded by states and the federal government but is administered by the states following federal requirements.39 The Affordable Care Act (ACA) gave  states the option to expand Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level.40 As of July 2023, 41 states (including DC) have adopted the Medicaid expansion, and 10 states have not adopted the expansion.40 Expanding access to Medicaid is vital to support access to family planning services for people in these states.  

Additionally, through the American Rescue Plan Act of 2021, states can extend Medicaid postpartum coverage to 12 months instead of limiting coverage to the federally mandated minimum of 60 days postpartum.40 Because the Medicaid program covers 40% of births in the U.S., extending this coverage is critical to improve maternal health outcomes and address racial disparities with maternal mortality and morbidity.40 States can apply for this extension through a state plan amendment (SPA) or a Medicaid 1115 waiver. As of June 2023, 35 states and DC have extended Medicaid coverage to 12 months postpartum from the original 60 days postpartum.41

A study was conducted in Texas on the health service utilization by postpartum people before and after the implementation of the Families First Coronavirus Response Act (FFCRA) that extended expanded Medicaid coverage from 60 days to 12 months postpartum during COVID-19.42 After implementing FFCRA: 

  • 10 times as many contraceptive services were used, 
  • There were 37% fewer services utilized for subsequent pregnancies within the first year postpartum.
  • Mental health (MH) and substance use disorder (SUD) services were utilized three times more than before FFCRA.42 

This case study shows that increased access to contraception after postpartum may decrease the prevalence of short-interval pregnancies, which is associated with poor maternal and child health outcomes. The study further demonstrated the high need for MH/SUD services past 60 days postpartum.

In order to expand access to reproductive healthcare, increase reproductive autonomy, and reduce MMHDs, the Policy Center for Maternal Mental Health  is calling the following parties to take action.

  1. Remaining States Should Expand Medicaid Under the ACA

The ACA gives states the option to expand Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level.40 Because access to contraception is mandated under the ACA, it is vital for all states to expand Medicaid access.43 As of March 2023, 9  states have not expanded Medicaid under the ACA, limiting access to reproductive healthcare and mental health services.40  

  1. Remaining States Should Extend Medicaid Coverage to 12 Months Postpartum

As of June 2023, 35 states and DC  have expanded Medicaid coverage to 12 months postpartum from the original 60 days postpartum via State Plan Amendments.41 Because Medicaid covers access to family planning services, this increases access to contraception and decreases the likelihood of postpartum people losing access to coverage. 

  1. Should Apply for Family Planning Benefit Waivers

States can utilize family planning benefit waivers to provide coverage of some family planning services to people who do not qualify for full Medicaid.43 States can create these programs through federal Section 1115 research and demonstration waivers or State Plan Amendments (SPA) approved by the Centers for Medicare and Medicaid Services (CMS).43 Each state can decide which family planning services are covered under its waiver. Although coverage under these waivers is not a substitute for full healthcare coverage, they allow people to access contraception if they lose Medicaid coverage.43

  1. Should Provide Medicaid Coverage of Community-Based Health Workers 

Expanding access to community providers plays a key role in linking patients to other health and social services, including mental health care and family planning counseling. Doula services have been highlighted as an effective strategy to alleviate the maternal health crisis that disproportionately affects people of color.44 Doula care has been associated with lower Medicaid costs and has been shown to improve the birthing experience and birth-related outcomes of people of color.44 As of April 2023, ten states reimburse doula services through Medicaid.45 States should apply for a State Plan Amendment (SPA) from CMS to cover doula services to improve maternal health outcomes.44

Certified peer support specialists are those with personal experiences with mental health disorders and are an important means of meeting the greater demand for mental health support. In 2007, CMS identified peer support services as an evidence-based practice for mental health care. CMS also declared that states could reimburse certified peer support specialists through Medicaid. Peer support models are vital because they decrease stigma, enhance cultural competency, increase community access, provide cost-effective services by decreasing hospitalizations, and increase provider trust in communities of color.46

  1. Group Health Plans, Insurers, and Regulators Should Ensure Compliance with the Contraceptive Provisions of the Preventive Care Benefit under the Affordable Care Act

The ACA requires access to birth control and contraceptive counseling, without cost-sharing, for those enrolled in group health plans and group and individual health insurance. Despite this, there have been reports of non-compliance.47 Group health plans, insurers, and regulators should monitor compliance with the ACA’s requirements to ensure individuals have no-cost access to contraception.

6. Should Improve Access to the Family Planning Counseling Benefit

This includes defining the role of obgyn/midwives and doulas and addressing their reimbursement streams for family planning services. Insurers should unbundle family planning counseling reimbursement from maternity global capitation and develop/implement a HEDIS measure to monitor how often family planning counseling and related services are provided.

7. Should Reduce Barriers to Long-Acting Reversible Contraceptives (LARCs)

Insurers should require Obs/Midwives to keep supplies for all FDA- approved LARCs.

8. Should Cover all FDA-approved Contraception

This includes over-the-counter birth control and male Long-Acting Reversible contraceptives (LARCs) once they are FDA approved.

9. Should Cover 12-month Supplies of Birth Control Pills

This decreases the barrier to accessing a pharmacy every 30 or 60 days. 

10. Should Cover FDA -Approved Over-the-Counter Contraception 

According to a study conducted by WHO, women who access oral contraceptives over-the-counter (OTC) without prescriptions may have higher rates of continuation than those who need a prescription to access contraception.48 Some payers require prescriptions for all products to be covered under a plan and don’t cover any OTC products, including OTC contraception. However, advocacy organizations, like Coalition to Expand Contraception Access (CECA), believe that should change, noting any FDA-approved contraceptive drug or device available OTC should be covered by Medicaid and private insurers.48

11. Congress Should Support Access to Contraception  

As of May 2022, 72% of Americans believe birth control should be made free and available for all people if abortion is not legal.49 Congress should support bills that  would provide a statutory right to access FDA- approved contraceptives and a right for health care providers to provide contraception.50

12. Congress Should Support Expanding Access to Family Planning 

Congress should support bills that expand access to birth control and family planning counseling through the Title X Family Planning Program by providing consistent funding for the program. The Title X Family Planning Program is the only federal program focused on providing comprehensive family planning services.49 In 2020, over 1.5 million patients received family planning services through Title X.49 Because this program is funded through annual appropriations, there is an unpredictable funding stream. Policy providing consistent funding and a significant increase in funding for Title X would allow more families to access family planning services.

13. Congress Should Establish Permanent, Nationwide 12-month Postpartum Medicaid Coverage in a Year-End Legislative Package

Although states can extend postpartum Medicaid coverage, establishing nationwide coverage would increase access to family planning and contraception as well as basic health coverage. 

14. Congress Should Support Families with Unplanned Pregnancies Through Social and Child Supports

Congress should support policies to improve access to affordable childcare, paid parental leave, and child tax credits. 

15. FDA Should Approve Over-the-Counter Oral Contraception

Multiple contraceptive methods are currently sold over-the-counter (OTC), without needing a prescription or a visit to a health care provider. The importance of female-administered, affordable OTC contraceptives is expected to grow substantially in the near future.51 To increase access to birth control, as of July 2022, the FDA is reviewing an application for the first over-the-counter birth control pill from the drug company HRA Pharma.51  Because nearly one-third of women who tried to get birth control reported having difficulty getting a prescription, this effort aims to diminish the barriers and increase access to contraception.51

16. The Person-Centered Contraceptive Counseling (PCCC) Measure Should be Adopted

By utilizing the PCCC Measure, payors and providers can improve the patient experience of contraceptive counseling and implement quality improvement strategies.16 This measure allows providers to better meet the needs of their patients and improve health outcomes. The PCCC Measure is appropriate to use in all healthcare settings that provide contraceptive counseling.16 

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