An initiative launched this week by the Perinatal-Neonatal Quality Improvement Network of Massachusetts (PNQIN) offers new tools to address the devastating effect mental health conditions can have on pregnant people, their babies and their families. 

PNQIN’s mental health initiative:

• provides information and support in the form of a bundle of best practices designed to address perinatal mental health conditions;
• involves outreach to obstetric and pediatric practices that work with pregnant and postpartum individuals;
• offers monthly informational webinars and opportunities to share lessons learned with others implementing the bundle; 
• collects structure, process and outcome measures that will be de-identified and shared.

The initiative will last for at least one year. Participating organizations are asked to develop a plan for sustaining the work beyond the bundle’s implementation phase. 

The bundle is one in a series developed by the Alliance for Innovation on Maternal Health (AIM), a quality improvement effort sponsored by the Health Resources and Services Administration and American College of Obstetricians and Gynecologists (ACOG). Since 2019, PNQIN has implemented three of AIM’s patient safety bundles and most recently developed its own bundle to address perinatal health equity, systemic racism and implicit bias.

Tiffany Moore Simas, M.D., Chair of the Department of Obstetrics & Gynecology at UMass Chan Medical School/UMass Memorial Health in Worcester, explains, “The goal of PNQIN’s initiative is to increase the capacity of frontline individuals to address mental health in the obstetric care environment.” Dr. Moore Simas helped develop AIM’s Perinatal Mental Health Bundle and serves as the lead for PNQIN’s initiative. 

Dr. Moore Simas is also a founder and Obstetric Director of Lifeline for Moms and the Obstetric Engagement Liaison for the Massachusetts Child Psychiatry Access Program for Moms. “The goal is to build on those experiences and help PNQIN help hospitals and practices across Massachusetts do this work,” she says.

Mental health conditions are a leading cause of pregnancy-related death

Mental health conditions are the most common complication of pregnancy and the underlying cause of most pregnancy-related deaths. A study of data from Maternal Mortality Review Committees in 14 states shows that among pregnancy-related mental health deaths, 100% were deemed to be preventable. The study also reveals differences in outcomes according to demographics such as race, economic status and education level. 

Obstetric providers are best positioned to identify pregnant people in need of mental health care and begin treatment but may lack appropriate training and experience. New clinical practice guidelines focused on the screening, assessment and treatment of perinatal mental health conditions, published last year by ACOG, state that addressing mental health is within the scope of practice of obstetricians/gynecologists.

“This is the first time ACOG has stated that addressing perinatal mental health is within the scope of an obstetrician/gynecologist," Dr. Moore Simas notes, "and thus by proxy really does need to be part of ob-gyn training.” 

That does not mean that obstetric providers need to be equipped to address all mental health needs alone, she adds. “We partner with psychiatrists, psychologists and other mental health specialists as individuals and through access programs and other resources.” 

Collaboration across settings is key

Addressing the mental health of obstetric patients requires collaboration among medical specialties. National data show that from 2008 through 2017, 63% of pregnancy-related deaths occurred between 43 and 365 days following delivery, a period during which most people have completed postpartum care and are focused on pediatric care for their newborns. 

Organizations that join PNQIN’s initiative begin by identifying a team roster that includes obstetric, nursing and ambulatory champions; completing a pre-implementation assessment; and signing a memorandum of understanding for confidential data sharing with the Betsy Lehman Center. Nineteen organizations have enrolled so far, and PNQIN encourages others to join at any time, as their capacity allows.

Kali Vitek, M.P.H., Program Manager for Obstetric Initiatives at PNQIN, says, “The perinatal mental health bundle is the first time we’ll be engaging ambulatory members of a pregnant person’s clinical team in AIM bundle implementation.” 

Five MA hospitals pilot-tested the mental health bundle

Five hospitals participated in a mini collaborative through the summer to pilot-test the bundle. Dr. Moore Simas estimates that one-third of the groups concentrated their early work within obstetric practices rather than inpatient hospital units. 

Lowell General Hospital was one participant. Laura Federico, M.S.N., R.N., Director of Women and Children's Service Line and the Obstetrical Emergency Department offers an example of the need for collaboration across settings. When new parents bring babies to pediatric offices for care, the adults are screened for depression. It is not clear, however, how best to follow up with those who screen positive. Pediatricians may not know where to document those screening results; the parent is not the patient. The hospital is working on how to retain and flag results from the depression screening in the electronic health record. 

“We have a lot on our plate, but I couldn't imagine saying no to perinatal mental health. With this project, we never hesitated to say yes,” Federico says.

Mount Auburn Hospital in Cambridge already had a perinatal mental health working group in place when Julie Mann, C.N.M., M.P.H., Director of Obstetrics, learned about the PNQIN initiative. The group began its work on the bundle by examining mental health screening in Mount Auburn’s ambulatory practices. 

“We found that each office was doing it differently,” says Mann. “We want to create a system that works for everyone. We found some holes in our screening processes, went back to PNQIN and reevaluated. We tried screening a different way, which worked better, and then we found other gaps.” Mount Auburn has completed three Plan-Do-Study-Act cycles and looks forward to rolling out the new screening process in seven obstetrical practices.

Mount Auburn adds the PNQIN initiative to other actions it takes to improve mental health care for obstetric patients and new parents. For example, the hospital is working to destigmatize the choice patients make to stay on antidepressant medications during pregnancy. Mann says providers talk with patients “to let them know we support their wonderful decision to take care of themselves, which will in turn take care of their baby.”  Because antidepressants can cause babies to need extra, temporary support immediately after birth, neonatologists may be involved in those discussions. “We have worked hard with them to develop supportive messaging around caring for our patients and their newborns,” Mann says. “Those have been rich discussions.”

PNQIN also focuses on helping sustain gains

Organizations that join the PNQIN initiative will participate in monthly informational webinars and have opportunities to share lessons learned with others implementing the bundle. 

Hospitals are asked to submit data on structure, process and outcome measures for at least six-out-of-12 months between October 2024 and September 2025. Surveys are submitted confidentially to the Betsy Lehman Center and shared as de-identified data with AIM. Participating hospitals will not be able to view each other's results.

In addition, PNQIN wants to help organizations continue their improvement efforts beyond the official endpoint of this and other initiatives. Vitek says Malavika Prabhu, M.D., a maternal-fetal medicine specialist at Massachusetts General Hospital, has joined the PNQIN team part-time and will help sustain work on AIM bundles by, for example, sharing information on emerging technologies and helping hospital teams set benchmarks or milestones for sustainment data collection.

PNQIN will ask organizations participating in the mental health bundle to submit a sustainability plan toward the end of the first year. “When you start a quality improvement project, you should already be thinking about sustainability,” says Vitek. “When active implementation ends, how will you sustain the gains met during implementation?” 

Federico of Lowell General agrees that the work needs to be sustained to have an impact. “With some of the catastrophes that have happened with Massachusetts families, we know how important this is,” she says. “We aim to provide everything we can for our mothers. Are we perfect? Absolutely not. But we strive to improve; that is our goal.”