New Hampshire’s pregnancy-associated deaths are relatively low, yet a majority of these cases are linked to substance abuse, with mental health conditions often being the underlying cause.

In 2022, state data revealed that out of eight pregnancy-related deaths, five resulted from substance use overdoses.

Patricia Tilley, the associate commissioner of the state Department of Health and Human Services, acknowledged that while New Hampshire fares better compared to other states, the number of pregnant and postpartum women dying is still too high.

“One death is too many,” she said. “If anyone is dying from something preventable, that’s too many.”

In New Hampshire, mental health conditions are the leading cause of maternal deaths, exacerbated by limited resources for mental health referrals.

Despite increased screening efforts, the lack of perinatal care navigation presents a significant challenge.

Alison Palmer, an OBGYN and psychiatric mental health nurse practitioner, pointed out that depressed mothers with newborns and potentially other children, burdened with returning to work and finding affordable childcare, often neglect their mental health.

“By the time a mom calls and then she’s struggling, she’s probably waited too long to pick up the phone and that has negative outcomes for her children and her babies,” said Palmer.

Palmer added that screening alone is insufficient. Follow-up and access to behavioral health services are crucial and also needed.

Barriers to maternal mental healthcare

Most often, the waitlist for mothers seeking mental health professionals is long, sometimes even up to eight weeks mirroring the experience of all New Hampshire residents.

However, it is even more challenging because mothers usually prefer perinatal mental health-trained professionals who can address the psychological and emotional challenges during this period, such as perinatal depression, anxiety, and psychosis. These professionals understand the interplay between physical and mental health during the perinatal period and provide targeted interventions and support.

Unfortunately, New Hampshire has a shortage of such specialized professionals.

Palmer said 10 providers in the state currently hold the necessary certification to see patients.

According to Postpartum Support International, New Hampshire needs at least 42 additional certified prenatal mental health providers to meet the recommended minimum.

Heather Martin, a maternal mental health coordinator at Dartmouth Health Pediatrics, explained that the lack of access to mental health providers often drives mothers to self-medicate. These substances could range from alcohol and marijuana to opiates.

“There’s easier access to substances than there is to get an actual appointment with a provider to get, say, an SSRI (Selective serotonin reuptake inhibitors) or some other medication to help them with their mood disorder,” Martin said.

The fear of losing custody of their baby can also deter mothers from seeking help for substance abuse or mental health issues.

But a report to state Child Protection Services doesn’t always automatically result in removal. Babies are typically removed only if there is a risk of neglect or harm.

Mothers who engage in treatment programs, work on recovery and have a sober caregiver available, reduce their chances of losing custody.

During pregnancy, drug use increases the risk of growth restriction in babies. These infants may be born smaller than average or preterm, and they might spend time in the NICU to be monitored for withdrawal symptoms.

Challenges ahead

To improve maternal mental health, New Hampshire’s 2024-2025 roadmap includes several initiatives to support mothers and babies.

One key effort is introducing mental health screenings at Women, Infants & Children (WIC) Nutrition Program facilities. This new screening program will be piloted this fall and winter at the Greater Seacoast WIC agency in Stratford and Rockingham counties.

Advocates argue that funding is needed to address maternal mental health with the same urgency as substance abuse.

“I think the money is invested in substance abuse because we can measure that better,” said Martin. “But I think we need to look at the overall picture of maternal mental health and not just substance abuse because they are related, but at the same time, moms don’t necessarily have to have a substance use disorder to get help.”

Insurance issues also complicate mental health care during pregnancy.

Prenatal care often falls under a global payment package, meaning providers receive a fixed amount for all care related to pregnancy and delivery, regardless of the number of visits or complications.

While providers can bill for depression and anxiety, there’s minimal reimbursement for mental health screening.

“The insurers are not paying for OB providers to spend that extra time to be navigating resources,” explained Palmer. “I think the majority of OB providers don’t have a significant comfort level with screening and treating and knowing what the resources are.”

To tackle this issue, the state has set a goal in its roadmap to significantly boost the number of perinatal health practitioners trained to screen, treat and refer patients to perinatal mental health specialists by March.

From childcare access and affordability to mental health care and substance abuse recovery programs for mothers during and after pregnancy, as well as training medical professionals in mental health and encouraging mothers to seek treatment, Martin highlighted that ensuring women and their families the right to abortion is also crucial for maternal mental health.

At this year’s legislative session, House Bill 1248 proposed replacing the 24-week abortion limit with a 15-day ban, but the bill was defeated in the House.

Martin pointed out that while many focus solely on the physical aspects of abortion bans, it’s crucial to also consider their impact on mental health.

“If a woman that has a mental health condition and gets pregnant and is forced to have a pregnancy it can exacerbate their mental health condition,” Martin said. “You’re taking that option away from them as well.”

Although New Hampshire is a supportive state for moms and babies, Tilley acknowledged that more work is needed.

The state is using collected data to develop solutions to improve the situation, whether by addressing behavioral health challenges, improving access to prenatal care in rural areas, or supporting other underserved groups.

“There are so many pockets where we could do better,” said Tilley. “We want to use our data to make sure that we’re providing opportunities that are easy to access for all women.”

If you need help

National Maternal Mental Health Hotline: Call or text 833-943-5746 for confidential support before, during, and after pregnancy. It is a free 24-hour helpline with counselors who speak English and Spanish.

Veterans: To connect with a Veterans Crisis Line responder anytime day or night, dial 988 then Press 1

National Suicide Prevention Lifeline: Call or text 988 or chat at 988lifeline.org

National Alliance for Eating Disorders: Call the helpline at +1 (866) 662-1235

The Trevor Project: A national 24-hour, toll-free confidential suicide hotline for LGBTQ youth. If you are a young person in crisis, feeling suicidal or in need of a safe and judgment-free place to talk, call 1-866-488-7386.

Veterans: To connect with a Veterans Crisis Line responder anytime day or night, dial 988 then press 1.

Sruthi Gopalakrishnan can be reached at sgopalakrishnan@cmonitor.com.