Timing of Perinatal Mental Health Needs: Data to Inform Policy.

Abstract Background Policies pertaining to perinatal health care should be informed by medical needs. The windows of standard obstetric care and mandated Medicaid coverage eligibility typically end around 8 weeks postpartum even though women may have perinatal health concerns, including suicidal ideation, that are identified beyond this time period. Objective To evaluate the timing of mental health needs across the perinatal period with a focus on how frequently the initial referral and suicidal ideation occur outside of standard obstetric care windows. Study Design This retrospective cohort study included all women during pregnancy or up to one year postpartum referred to a perinatal mental health collaborative care program (COMPASS) between September 2017 and September 2019. The timing of initial referral to COMPASS was identified, with women referred postpartum categorized by whether the referral was made after 8 weeks postpartum. Characteristics of women were compared according to the timing of the initial mental health referral, with receiver operating characteristic curves to identify whether patient characteristics could accurately classify women whose initial mental health needs were not recognized until after 8 weeks postpartum. Similarly, the assessment of suicidal ideation, either at or after referral, was ascertained, with evaluation of the timing at which suicidal ideation was first expressed. Results Of 1421 women referred for mental health care during the study period, 774 (54%) were initially referred antenatally and 647 (46%) were initially referred postpartum. Women referred antenatally exhibited no clustering in the timing of referral. Of women referred postpartum, 203 (31%) were referred after 8 weeks postpartum. Sociodemographic and medical characteristics were unable to accurately classify which women were referred for mental health care after 8 weeks postpartum (AUC=0.64, 95% CI = 0.58-0.68). A total of 215 (16%) women reported suicidal ideation at or after the time of initial referral: 129 (17%) antenatally and 86 (14%) postpartum. The incidence of suicidal ideation was not significantly different before versus after 8 weeks postpartum. Conclusion Perinatal mental health needs, including suicidal ideation, are often first recognized beyond 8 weeks postpartum. These data should be taken into consideration in policymaking discussions pertaining to the approach to medical care continuity and health care coverage postpartum.