Maternal Mental Health as a Contributor to Adverse Perinatal Outcomes: Observations from Prior Literature

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The Contribution of Maternal Mental Health to the
 Long-Term Non-Medical Costs of Adverse Maternal Outcomes

Posted: November 2025. (Original Project Report Date: December 2023)

Introduction
Our Safe Babies Safe Moms (SBSM) Health Economics Team conducted a set of targeted literature reviews on topics or questions pertinent to our evaluation of SBSM and the economics of high-risk pregnancies, perinatal outcomes, and perinatal medical care.  These reviews inform the design and interpretation of our program evaluation of SBSM and suggest opportunities to contribute to a broader understanding of the economics of high-risk pregnancies. Previous SBSM literature reviews documented the economic impacts associated with delivery complications, hospital stays in neonatal intensive care units, the challenges of preterm and low birth weight infants, state-led alternate Medicaid financing models, as well as the economic burdens resulting from severe maternal morbidity (SMM) and adverse infant outcomes.

In our previous review of SMM, it was observed that it was necessary to include maternal mental health conditions (MMHC) as a leading contributor to the long term and non-medical costs of maternal morbidity due to the prevalence and persistence of MMHCs, and exacerbating effects on the health and productivity, and social needs of all members of the birthing person’s family.  Numerous studies, including one that used data from the Pregnancy Risk Assessment Monitoring System, a surveillance project of the Centers for Disease Control and Prevention, reported recent prevalence estimates ranging from 7% to 25% of mothers experiencing MMHCs (Luca et al. 2020). Preliminary findings from the SBSM population between 2020 and 2022 are within range of that estimate.  We observed that over 20% of prenatal patients who delivered at MedStar Washington Hospital Center had screening results or diagnoses consistent with a variety of mental health or behavioral conditions during their perinatal care at MedStar.  

While a majority of SMM conditions are life-threatening with immediate cost implications, MMHCs often represent more insidious, long-term multi-faceted effects. Mental health issues are often interlinked with other adverse outcomes, exacerbating the chronic health and economic impacts of morbidity on affected pregnant or post-partum persons, their children, families, and society. While applying findings from our prior literature reviews, it became apparent that the aggregate burden of MMHCs likely exceeds that of many SMM conditions. Accordingly, we devote this seventh report to understanding the societal costs of MMHCs at the individual patient level, as a contributor to our broader estimate of the long-term and non-medical costs of maternal morbidity.

Methods         

Intent to utilize insights and findings from this review to refine our estimates and model the cost of adverse perinatal outcomes, we approached the review process with heightened scrutiny. Studies we selected were relevant, specific, and methodologically transparent enough to inform our subsequent analyses at the per-patient level. Several studies limited their assessment to effects within the first year postpartum,  but we did find a few that empirically measured the potential for significant societal impacts of morbidity, extending beyond the perinatal episode.

Studies in this review used cross-sectional and longitudinal empirical data, as well as modeling analysis to estimate the economic burden of MMHCs, drawing upon a diverse array of data sources. We prioritized US-focused studies for the quantitative estimates, but did find relevant evidence on the nature of the economic burden of MMHC from selected international studies (Dukhovny 2013, Bauer et al. 2015 and 2016, Kolu 2016). Comparative studies involving MMHC treatment interventions were included only if they explicitly presented some incremental societal impact attributable to a morbidity condition or demonstrated how appropriate preventative measures could significantly reduce societal costs. Studies that primarily accounted for direct medical costs, such as hospitalization or pharmaceutical expenses, were included if they also accounted for wider societal impacts attributable to maternal morbidity. These impacts include factors such as the mother’s productivity loss, increases in welfare utilization, and adverse child outcomes in addition to others.

Results

A total of 110 studies were initially identified in our initial search. After a preliminary screening for scope, approach, and relevance to our SBSM analysis, fewer than 20 studies were deemed pertinent and ultimately included in our report (Table 1).  A recurring theme across the studies is the significant economic burden posed by MMHCs, extending to a wide array of stakeholders beyond the affected person and their new baby. This includes other members of the birthing person’s immediate family, such as partners, other dependents in the household, employers, public welfare programs, and society at large. A total of 9 studies reported on the indirect costs associated with postpartum depression. One study (Luca et al. 2020) provided particular insights into the costs related to Perinatal Mood and Anxiety Disorders (PMADs), and three studies offered insights into the mechanisms through which MMHCs escalate societal costs. The accrual period for costs also ranges widely, from the immediate postpartum period up to 16 years after birth, underscoring the long-term nature of these costs.

A substantial body of research indicates that a mother’s mental health significantly shapes her child’s development, both through biological and social pathways. (Crenna-Jennings 2019). Studies support the presence of a significant genetic factor in the development of mental illness. However, MMHC is also associated with less engaged parenting, poor emotional attachment, and suboptimal early childhood development. In the immediate postpartum period, birthing persons’ behavioral health complicates their effectiveness in managing child nutrition or use of food security resources, and distorts utilization of routine well-child care and emergency room services. (Engle and Lhotska 1999). Over time, these factors have an integral impact on an infant’s lifelong outcomes, including educational attainment, employment opportunities, and overall adult health and well-being.  For instance, the study by Nguyen et al. (2013) revealed a significant association between MMHCs and child undernutrition conditions, specifically stunting and underweight status, in children aged 0–5 years. Such adverse spillover effects on infants are often a direct ramification of MMHCs and thus, instrumental to their heightened effect on long-term non-medical costs of morbidity. Thus, at the household level, indirect societal costs accumulate when a mother’s impaired mental health impacts her capacity to engage in essential maternal behaviors and practices.

Ammerman et al. (2016), and Moore et al. (2019) estimated the impact of MMHCs on out-of-pocket expenses, indirect labor costs, and increased expenditures for insurers. For spillover impacts on partners and children, Eldar-Lissai et al. (2020) and Epperson et al. (2020) highlighted the costs incurred by the families of mothers with Postpartum Depression (PPD) under treatment.

Productivity loss, as a direct consequence of chronic MMHCs, was identified as the most financially burdensome of indirect expenses. The magnitude reported exceeded related maternal medical costs or productivity costs from other morbidity conditions (i.e., hypertension, preeclampsia, gestational diabetes; O’Neil et al. 2022; Luca et al. 2020). Second to productivity loss, a considerable portion of the total societal costs arising from MMHCs is accounted for by adverse infant outcomes, such as preterm birth and developmental disabilities: 74% of total costs in O’Neil et al. (2022), 35% in Luca et al. (2020), and 45% in Caroline et al. (2021).

Lastly, though not as substantial as productivity loss or the increased risk of adverse infant outcomes, a spillover effect on societal costs includes a heightened reliance on social welfare programs by households. Caroline et al. (2021) estimated the societal costs associated with MMHCs in Texas to exceed $2.2 billion, primarily due to mothers’ productivity losses and increased reliance on state public assistance programs.

Overall, Luca et al. (2020) assessment of untreated PMADs revealed an estimate of around  $14 billion in a six-year peripartum period, inclusive of  $11 billion from the societal costs of mothers’ absenteeism, presenteeism, and unemployment.  Of all the studies in our review,  the observations and methodology in Luca and O’Neil (which drew heavily from Luca) were especially informative for our work going forward. 

Limitations

Several limitations must be acknowledged for a complete understanding of our findings. Firstly, there is a fundamental challenge in precisely quantifying the costs associated with MMHCs, especially when accounting for indirect societal impacts. These factors, including the mother’s productivity loss, emotional distress, and family dynamics, including the impact on infants and the partners of affected mothers, are often subjective and vary greatly from case to case. Fully capturing these costs in empirical terms presents a significant obstacle in our analysis as they are also susceptible to a range of confounders, including such as socioeconomic status, physical health issues, and a lack of familial or state support systems, making it extremely challenging to derive precise and reliable figures as acknowledged by many of the studies.

The existing literature also does not clearly distinguish between the economic implications of treated and untreated MMHCs. This ambiguity arises partly because it’s unclear whether patients are actually using and/or benefiting from treatments, potentially skewing the results. For instance, Eldar-Lissai et al. (2020) and Dukhovny (2013) were able to identify a sample of mothers with MMHCs using methods like the Edinburgh Postnatal Depression Scale (EPDS) or SSRI prescriptions. However, they acknowledged that their cost estimates are significantly underestimated due to a lack of detailed information on treatment utilization, the extent of treatment received, and the appropriateness of such treatments for the mothers in question, all of which are critical yet often overlooked factors. Additionally, the widespread social stigma surrounding mental health, along with a general lack of awareness about MMHCs and insufficient screening methods, especially among communities of color, where women are often deterred from seeking mental health treatment, leads to a notably high level of underreporting and a refusal of appropriate treatment for these conditions. For instance, a study by Keefe et al. (2016) estimated that a significant number of women of color, estimated at up to 60%, do not receive any services for postpartum depression. This lack of treatment is attributed to factors such as the absence of depression screening and cultural barriers. This is a significant hindrance as up to 1 in 7 women experience postpartum depression, a serious mood disorder (Wisner, et al., 2013). Untreated MMHCs, in particular, can have far-reaching implications, including worsened health, increased risk of developmental issues in children, and an even greater strain on family dynamics. The inability to account for these undiagnosed or untreated cases further impedes our ability to accurately gauge the total economic magnitude associated with MMHCs.

Furthermore, the scarcity of empirical literature on our distinct topic compelled us to rely heavily on  a few modeling studies, which introduced its own set of limitations. These studies, including those by Bauer et al. (2015, 2016), pointed out that the availability and robustness of sources for certain outcomes were not uniform, leading to varying levels of confidence in different outcome measures. This unevenness in research depth inevitably affected the comprehensiveness and balance of our review. Notably, O’Neil et al. (2022) pointed out that MMHCs are identified as the costliest morbidity condition by their study, in part, due to their prevalence among those with well-documented cost information. This suggests that the high-cost figures associated with these conditions might be reflective not only of their economic impact but also of the availability and richness of data. This lack of uniformity in data presents a significant limitation in our understanding of the full societal impact of MMHCs at large.

Collectively, these studies reveal that the costs attributable to MMHCs extend far beyond the immediate healthcare expenditures, especially impacting maternal productivity, child health and development, and societal welfare programs. The findings underscore the imperative to elevate and operationalize the measurement and management of MMHC within interventions to improve perinatal care.

Rehman Liaqat, was a Graduate Research Assistant, and the primary author of the original version of this report, developed as an internal project report by the Health Economics Research Team of Safe Babies, Safe Moms under Dr Davis’ direction (December 2023).  It has been lightly edited for this post.

References

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