Integrating routine psychological health screening and treatment during and after pregnancy may reduce the risk of adverse pregnancy outcomes and improve maternal cardiovascular health, according to a new scientific statement published today in a Go Red for Women^® spotlight issue of the Journal of the American Heart Association, an open access, peer-reviewed journal of the American Heart Association. This spotlight issue focuses on research about sex differences in cardiovascular disease and their implications for care.

The new scientific statement, “Optimizing Psychological Health Across the Perinatal Period: An Update on Maternal Cardiovascular Health,” highlights the need to support maternal cardiovascular health by including comprehensive screening of psychological health during the perinatal period (pregnancy through one year postpartum). Cardiovascular issues are the No. 1 cause of maternal death. The new statement summarizes the evidence associating psychological health concerns and adverse cardiovascular outcomes; highlights effective management strategies and integrated care delivery models; and identifies current challenges and future directions for improving maternal health outcomes.

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. We also recognize the importance of providing 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.”

Garima Sharma, M.D., FAHA, writing group Chair, director of preventive cardiology and women’s cardiovascular health at Inova Schar Heart and Vascular in Fairfax, Virginia

Maternal psychological and cardiovascular health linked

The maternal mortality rate in the United States is two to three times higher than estimates from other high-income countries and has worsened since the COVID-19 pandemic, with significant disparities among people in underrepresented races and ethnicities. The mortality rate for non-Hispanic Black birthing women is 2.6 times higher than for non-Hispanic white women.

Perinatal psychological health conditions such as depression and anxiety are among the leading causes of maternal mortality in the U.S. and are associated with adverse pregnancy outcomes and long-term cardiovascular outcomes. Psychological health, often used interchangeably with mental health, encompasses emotional, social and functional well-being and is affected by factors such as living conditions, traumatic events and daily stressors.

An estimated 52% of women of reproductive age report having a history of a psychological health condition, and 40% of those from underrepresented races and ethnicities experience anxiety or depression in the perinatal period.

People with suboptimal mental health may engage in negative health behaviors (such as poor diet, irregular sleep, low physical activity, tobacco, alcohol and/or illicit substance use and/or difficulty adhering to medical recommendations), which can negatively affect their cardiovascular health. Maternal psychological health can also affect the child’s neurodevelopment and well-being.

Screening for risk factors for psychological health

“Pregnancy is an important time of life from a health perspective. 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,” said Sharma.

Risk factors for psychological concerns include domestic violence, sleep disorders, personal or family history of psychological conditions, incarceration, active-duty military service, Veteran status, lack of partner support, unemployment, and racism and discrimination. Adverse outcomes in prior pregnancies, including miscarriage, ectopic pregnancy and high blood pressure during pregnancy, are also risk factors for perinatal anxiety and depression.

Incorporating regular psychological health screening into perinatal care involves training health care professionals to use screening tools effectively and establishing protocols for follow-up care, including comprehensive assessment and appropriate interventions. For example, the Patient Health Questionnaire (PHQ-9) can be used by health care professionals to screen for symptoms of depression and anxiety. This universal screening tool has been effective at increasing awareness of and decreasing stigma associated with psychological health challenges.

Initial prenatal mental health screening should take place as early as practical in pregnancy and should be repeated at least once. During the initial obstetric visit, it is essential to review the patient’s psychological history and use of psychopharmacotherapies or other treatments to identify risk factors for mental health conditions.

“During pregnancy and postpartum, identifying and intervening on modifiable risk factors that increase the risk of depression, such as social isolation, no or inadequate partner support, depression before pregnancy and poor sleep quality, may improve maternal psychological health as well as future cardiovascular health,” Sharma said.

Since psychological symptoms may fluctuate over time, inquiring about emotional well-being (and the well-being of their partner, if appropriate) should ideally be part of every prenatal or postpartum visit.

Considerations for managing maternal psychological health

Whatever the setting and circumstances, perinatal psychological care should be culturally responsive, language-appropriate and family-centered. It should involve shared decision-making with the patient (and their significant other(s), if the patient agrees), including a full discussion of the potential risks and benefits of any treatments offered to the mother and the fetus or newborn.

When considering pharmacologic treatment for depression or anxiety, the choice of medication should be based on efficacy in pregnancy, safety in pregnancy, safety during breastfeeding (if applicable) and consideration of interactions with other medications.

As medications carry potential side effects to both mother and child, there is significant interest in non-pharmacological strategies to both prevent and treat depression and anxiety symptoms during and after pregnancy. Counseling, cognitive behavioral therapies, exercise, stress management strategies and other treatment methods may be preferred.

Health professionals providing care, such as psychologists, clinical social workers, psychiatrists, general internal medicine specialists and obstetricians, should work as a team and have appropriate training and skills and work collaboratively to provide continuity of care for patients and their families during pregnancy and postpartum.

Opportunities for improvement and future research needs

Barriers to integrating perinatal psychological health care into cardiovascular health care exist at individual, health system, community level and government and policy levels along the perinatal care continuum. Known barriers to addressing perinatal mental health concerns include stigma, fears of Child Protective Services removing the child, clinician time constraints, clinician inexperience, workforce issues and reimbursement related concerns.

There is a need to create health care delivery models to incentivize health systems and clinicians to adopt evidence-based, accessible models of care focused on awareness, screening and optimization of psychological health with partnerships with community-based organizations. Initiatives that could potentially improve outcomes and reduce racial and socioeconomically-mediated inequities include expanding reimbursement for doulas, midwives and community health workers.

Additionally, there is a critical need for long-term research on perinatal psychological health because it influences cardiovascular health and other chronic disease outcomes across the individual’s lifespan. Considering the known disparities in maternal health based on race, ethnicity and social drivers of health, more people of underrepresented races and ethnicities need to be included in studies on maternal psychological and cardiovascular health. Increased research is also needed related to other psychological factors besides depression, such as anxiety, adverse childhood experiences, post-traumatic stress disorder and psychosocial stressors that disproportionately or differentially affect women.

This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association’s Cardiovascular Disease & Stroke in Women and Underrepresented Populations Committee of the Council on Clinical Cardiology; the Council on Cardiovascular and Stroke Nursing; the Council on Cardiovascular Radiology and Intervention; the Council on Cardiovascular Surgery and Anesthesia; the Council on Lifelong Congenital Heart

Disease and Heart Health in the Young; the Council on Lifestyle and Cardiometabolic Health; the Council on Quality of Care and Outcomes Research; and the Stroke Council.

American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association’s official clinical practice recommendations.