More pregnant and postpartum women in Colorado die from suicide or drug overdoses than any other causes, and those deaths represent only a small percentage of moms who need help, advocates say.

Nonprofits, state agencies and health care providers are trying to not only encourage new parents to seek out help if they need it, but also to ease the process of actually getting that support. Mental health and addiction care can be difficult to find under any circumstances, and perhaps even more so when mothers are juggling child care and may fear losing custody of their children if they admit they’re struggling.

In Colorado, 174 people died during pregnancy or within a year of giving birth between 2016 and 2020. Of those, 34 died by suicide and 33 died of accidental overdoses, according to the state’s 2023 maternal mortality report. The state doesn’t publish annual data, because of the relatively small number of deaths.

The problem extends beyond Colorado. Nationwide, the Centers for Disease Control and Prevention estimated mental health conditions contributed to about 28% of maternal deaths and substance use contributed to about 25%. In some cases, both may have contributed.

While dying in pregnancy or the year after is rare, experiencing mental health trouble during that time isn’t: About 20% of women in the perinatal period have either an anxiety disorder or a mood disorder, such as depression, according to the nonprofit Patient-Centered Outcomes Research Institute.

For a long time, stigma and practical concerns like transportation and child care have prevented mothers from getting the care they need, said Christen Lara, interim deputy commissioner at the Colorado Behavioral Health Administration.

Nationwide, about half of women who have postpartum depression receive a diagnosis, and only 20% get appropriate care.

“If you’re a mom who’s experiencing some sort of substance use disorder problems, there are a lot of barriers,” Lara said.

Something to offer

About 30% of Colorado women who died during pregnancy or the postpartum period took their lives, which was twice the percentage of suicides among non-pregnant women in the same age group who died during the same period. (While some people who can give birth don’t identify as women, the state doesn’t have data on whether any of those who died were transgender or nonbinary.)

The majority of those suicide deaths happened at least six weeks after the pregnancy ended.

Women who died made up only a small fraction of those who reported mental health struggles, though. About 12% of moms who gave birth in 2020 reported postpartum depression symptoms, and 32% reported anxiety in the first year after their child’s birth, according to a survey conducted by the Colorado Department of Public Health and Environment. Data from more recent years isn’t yet available, but the 2020 numbers weren’t significantly different from pre-pandemic years.

With more than 60,000 people giving birth in Colorado in a typical year, that’s potentially thousands of new mothers in need of medical care, or at least support, to manage their mental health.

In June, the American College of Obstetricians and Gynecologists recommended screening for depression at least twice during pregnancy, and at a postpartum visit. About 90% of women who took the health department’s survey said that someone had asked them about their mental health at a postpartum health-care visit, but the survey didn’t answer how many of those who reported concerns received appropriate treatment.

Until about 2018, maternal mental health screening at Intermountain Health’s Front Range hospitals was somewhat more haphazard, because providers weren’t confident they had anything to offer patients who might be struggling, said Heather Hagenson, director of operations and development for women’s outpatient health programs.

Now, they screen at least four times: when the patient first comes in for prenatal care; in the second trimester; before leaving the hospital after the delivery; and during the first postpartum visit, she said.

“If you don’t have the right resources, it’s hard to open up the conversation,” Hagenson said.

Not everyone who screens positive needs mental health care — some might be dealing with a temporary stressor, such as a death in the family, said Dr. Kathleen Rustici, medical director of women’s health for Intermountain’s Front Range hospitals.

When a patient does need care, though, Intermountain can offer what’s known as the Bloom program, in which the obstetricians and mental health providers partner to coordinate care, she said. For now, grants cover participants’ mental health care, though that could change in the future.

“Before the Bloom program, what we had was a stack of business cards” and patients had to call to find out where they might be able to get care in the community, Rustici said.

Madalaine Heiser, of Aurora, said her midwife referred her to the program after she burst out crying during an appointment.

She’d had anxiety for years, but coping became harder as she felt beset by worries about her baby’s health, how the birth would go and the seemingly impossible expectations that mothers get everything right, from deciding whether to have an epidural to choosing the best solid foods to introduce and getting their pre-pregnancy shapes back.

Hauser said she participated in therapy for more than a year after her son Brecken, now 17 months old, was born. She still uses some of the breathing and visualization techniques she learned and said she’ll look into the program again if she and her husband have a second child.

“It has made me such a better mom and such a better woman,” she said.

Care beyond the clinic

Not everyone is comfortable talking about their mental health in a clinical setting, though, said Sona Dimidjian, director of the Renee Crown Wellness Institute at the University of Colorado Boulder. The institute is studying a program called Alma, which pairs mothers experiencing depression during pregnancy or the postpartum period with trained mentors who have been through something similar.

The mentors and their clients meet about eight to 10 times, in person, online or over the phone, Dimidjian said. They try to match mentors who come from the same community or have similar experiences, to make the clients more comfortable, she said.

“The peers learn to use these skills in their own life, and it’s from that experience that they share them,” she said.

Pia Long, a Denver-area doula and peer mentor, said the first step is to help the client talk through any mental health history or traumas that may be contributing to their struggles, and then go through what activities they’ve been doing recently and how those influence their feelings. People with depression often stop doing things they enjoyed and withdraw from people who could support them, which only makes them feel worse in the long run, she said.

After identifying people and actions that could help, the mentors then encourage the clients to take small steps toward re-engaging.

“The goal is to help break the downward spiral,” she said.

Long said a similar program would have helped her when she was a young mother. She experienced anxiety after giving birth to her first child, who is now 26, and depression after her second, now 24. Her family members were emotionally supportive, but they didn’t have training on specific skills to help her work through those difficult periods, she said.

“If I had something like this, what would life have been like?” she said. “It would be amazing if practitioners could refer someone to a peer mentor.”

Other groups have built on the Alma peer mentor model to address their own communities’ needs. Paulina Erices, project director at Lifespan Local in southwest Denver, said they expanded the peer mentoring to include fathers, grandparents and other caregivers of children up to 3 years old in their targeted neighborhoods.. They also offer a play group, a social group for mothers and access to items families need, such as donated clothing.

A mental health professional is available to talk with families who need that kind of care, but tangible supports like donated items and the community found in groups are just as important, she said.

“Sometimes we think mental health is something that only happens in clinical spaces,” she said. “Mental health is something that we do together.”

Creating safe spaces

While suicide risk is higher during pregnancy and weeks afterward, overdoses were about equally common in Colorado women who were pregnant or new mothers and in women in the same age group who weren’t. Evidence on how often women use drugs during pregnancy is sparse, but whether drug use is going up or not, the drug supply is more dangerous than it was a decade ago because of the proliferation of fentanyl.

New mothers do face some increased risks compared to other women, though. People who receive an opioid prescription for the first time after delivery could overdose if they take too many pills or mix substances, and those who previously used drugs but stopped during pregnancy will have a lower tolerance if they start using again.

That means health care providers need to distribute naloxone, a drug that can reverse overdoses, to as many at-risk families as possible, said Rachael Duncan, a pharmacist and treasurer of the Colorado Naloxone Project.

All but five of the Colorado hospitals that deliver babies have agreed to talk to their labor and delivery patients about naloxone and to offer free doses that the project donated, Duncan said. In the past, they generally recommended giving naloxone to take home if the mother had been prescribed opioids or said she or another family member used drugs like heroin or fentanyl. Now, they suggest offering it to anyone who uses illicit drugs or lives with someone who does, because cocaine or methamphetamine may have fentanyl mixed in, she said.

“It has really changed the way that we’ve had to approach this,” Duncan said.

Sixteen hospitals also have agreed to work with the Colorado Naloxone Project on the Maternal Overdose Matters Plus program to start treatment with buprenorphine or methadone for mothers who use opioids while they are in the hospital recovering from the birth, Duncan said. They then refer the women who started treatment to community providers who can keep dispensing medications to curb their drug cravings after they leave the hospital, she said.

Of course, not everyone who uses drugs during pregnancy will admit that, particularly if they fear being referred to child protective services. States where women can be charged for prenatal drug use actually have higher rates of harm from drinking during pregnancy and maternal opioid use, possibly because mothers aren’t willing to risk seeking help.

The Behavioral Health Administration has been trying to change attitudes toward mothers who use substances with its Tough as a Mother campaign that emphasizes addiction is a treatable disease, Lara said. The agency also is working with the addiction nonprofit HardBeauty to run support groups for mothers struggling with substance use disorder.

HardBeauty founder Raquel Garcia said the group meets online, which is easier for mothers who can’t get away from their home responsibilities, even to take care of their own health. The only requirement is the ability to use Zoom, she said.

“Women are usually only allowed education or healing in the cracks of the people around them,” trying to meet their needs when their children are asleep and all the chores are done, she said.

The group’s peer mentors also are available to meet with mothers struggling with substance use when they or their children are in the hospital. That helps individual mothers navigate the system, but the culture needs to shift away from faulting mothers who use drugs or need to leave their kids for a time to seek treatment, Garcia said.

The knowledge they could be blamed is particularly scary for mothers who are in custody disputes, because they have no legal guarantee they won’t lose their children if they admit needing help, she said.

“Until substance use disorder treatment is seen as a positive rather than a demerit, we’re not making any progress,” she said.

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