This survey of OBGYN and Family Medicine trainees found that the majority of respondents felt well equipped to screen patients for perinatal mental health and substance use disorders. Participants also felt moderately comfortable with the initial treatment of depression and anxiety and when to refer for substance use disorder treatment. Almost all respondents felt they could benefit from further training in terms of treatment for mental health and substance use disorders.
Mental health and substance use disorders are among the most common complications of pregnancy and the postpartum period and contribute significantly to maternal morbidity and mortality as the leading overall and preventable causes.1, 3 Obstetric physicians are in a unique position to diagnose and treat these disorders given the frequency of prenatal care visits1, 30. Prior studies have examined the practices, confidence, and self-efficacy of practicing Ob/Gyns around perinatal mental health issues, but none have studied current residency or fellowship program curricula and training modalities.17, 31, 32 In a 2003 survey, less than one half of recent Ob/Gyn graduates felt that treating depression was their responsibility.17 Between 2003 and the present, a major paradigm shift has occurred, with significant national attention from professional societies being brought to the role of obstetric care clinicians in, and the importance of, recognizing and treating perinatal mental health disorders. As of 2020, both the Council on Resident Education in Obstetrics and Gynecology (CREOG) and the American Academy of Family Physicians (AAFP) national curricula include learning objectives that trainees should be able to diagnose and treat perinatal mental health and substance use disorders.24, 25, 33 Consistent with these recommendations, the majority of respondents in our study reported at least some formal didactics about addressing perinatal mental health, though the amount and type of training varied widely.
The perinatal mental health care pathway is composed of (1) screening, (2) assessment, (3) triage and referral, (4) treatment access, (5) treatment initiation, (6) symptom monitoring, and (7) adaptation of treatment based on measurement until symptoms remit28. While most respondents reported confidence with steps 1–3, they also indicated the need for significant changes in current training to address steps 4–7. Consultation from providers with experience in treatment of perinatal mental health disorders is critical in comprehensive training of obstetric care clinicians, and could be used to address the gaps in trainee knowledge and confidence in the latter steps of the perinatal mental healthcare pathway.34 In fact, two-third of participants in this study felt that mentoring/consultation from experienced mental health providers would be, or has been, useful in learning to address perinatal mood and anxiety disorders. Unfortunately, only 9% of respondents had access to such mentorship experiences.
One way to increase access to education/consultation from experienced perinatal mental health professionals to obstetrics trainees is through the use of perinatal psychiatry access programs. Perinatal psychiatry access programs aim to build providers' capacity to address perinatal mental health and substance use disorder through (1) trainings and toolkits on depression screening, assessment and treatment; (2) telephonic access to perinatal psychiatric consultation for providers serving pregnant and postpartum women; (3) One-time patient facing consultation with perinatal psychiatry expert (4) care coordination to link women with individual psychotherapy and support groups; and (5) technical assistance.4, 35 A major tenet of these psychiatry access programs is education and sustainability; they are driven to interact and engage with obstetric training programs. Furthermore, the data support that perinatal psychiatry access programs are highly utilized. One study of the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms – the first such access program – showed that 77% of obstetric programs in the state were trained and enrolled. A recent study of the effectiveness of MCPAP for Moms demonstrated a significant sustained improvement in depression symptoms from enrollment through 13 months postpartum.36 While initially most clinician consultations were focused on treating unipolar depression, over time those utilizing the access program became more comfortable providing direct mental healthcare to patients for more complex perinatal mental health disorders including bipolar disorder.34
Since this survey, additional resources have been developed to assist in integrating sustainable mental health care into obstetric practices. The ACOG Clinical Practice Guidelines Committee – Obstetrics expanded the scope of perinatal mental health screening and treatment, and in 2023, published two new clinical practice guidelines (CPGs).1, 30 These guidelines specifically note that addressing perinatal mental health is within the scope of practice of obstetric care clinicians and detail clear recommendations and clear practice points regarding the screening, diagnosis and treatment of perinatal mental health conditions. Additionally, in 2023, the Alliance for Innovation on Maternal Health (AIM) published its revised and updated perinatal mental health conditions patient safety bundle, making it one of its core bundles.37 This bundle focuses on the 5Rs: readiness, recognition and prevention, response, reporting and systems learning and respectful, equitable and supportive care for patients with perinatal mental health disorders.37 The bundle is accompanied by a change package led by the Institute of Health Care Improvement (IHI) to promote complete bundle implementation.37 ACOG along with AIM and the Lifeline for Moms Program at UMass Chan Medical School worked together to create an E-module called “Addressing Perinatal Mental Health Conditions in Obstetric Settings”.38 This is a self-paced course that focuses on detection, assessment, treatment and follow-up of patients with different perinatal mental health conditions.38 Access to such resources as the E-module, CPGs and AIM Patient Safety Bundle provide critical information and training for perinatal providers in an effort to increase provider comfort with caring for perinatal mental health conditions.
This study surveyed trainees from a broad range of program sizes and geographic locations and included both family medicine and OBGYN trainees which increases the generalizability of the results. This study’s findings were limited by a low response rate to the survey. The results may reflect a selection bias towards those trainees who are more interested in perinatal mental health and therefore more likely to complete the survey. Similarly, more than half of the respondents were located in the North East, which may be particularly relevant as perinatal psychiatry access programs originated in the North East and thus have the greatest longstanding history. This may further highlight that an even smaller portion of all obstetric trainees across diverse geographies may feel confident in treating perinatal mental health and substance use disorders in general. Furthermore, the survey invitation was sent to program directors or coordinators to forward to their trainees. Given the anonymity of the survey, we cannot determine whether the survey invitation was actually forwarded to trainees and if so, whether some programs are over-represented in the responses.
Despite these limitations, this study helps to inform contemporary trends in obstetric care clinician training for perinatal mental health and substance use disorders. Didactics alone are not sufficient to prepare trainees. Ultimately, it is likely than an intentional and purposeful combination of the several available training modalities need to be used to educate trainees how to master the several steps along the comprehensive perinatal mental health care pathway, along with continued support through resources like Access Programs. Increasing education on screening for these disorders in the perinatal period must be seen as a vital first step along the mental health pathway but cannot be the endpoint. Training the obstetric workforce to initially manage these conditions is paramount to ensuring sustainable improvements in perinatal outcomes.