A systematic review of postpartum psychosis resulting in infanticide: missed opportunities in screening, diagnosis, and treatment.

PURPOSE: Impacting 1 in 1000 women, untreated postpartum psychosis is associated with a 4% infanticide rate. This systematic review aims to identify factors that are associated with infanticide resulting from psychosis in the puerperal period and pinpoint areas of missed opportunity for intervention. METHODS: A systematic literature review was conducted in accordance with PRISMA guidelines to identify and synthesize cases of maternal infanticide among perinatal females with evidence of postpartum psychosis. Four independent reviewers screened 231 articles identified in searches of three databases (PsycInfo, PubMed, and Web of Science) for studies conducted from 2013 to 2023. RESULTS: Twelve studies were included in the final review. Findings indicate that those experiencing puerperal psychosis have increased incidence of infanticide suggesting missed opportunities for intervention and treatment. Common factors in mothers who committed infanticide as a result of delusions and/or hallucinations associated with PMADs were identified, including lack of standardized screening tools, preference for traditional and/or cultural healing practices, and access to care. CONCLUSION: The current body of evidence supports developing and evaluating clinical interventions aimed at improving maternal mental health outcomes and infant outcomes in perinatal women experiencing puerperal psychosis.

Models of care: Opportunities and challenges.

Perinatal mental health models can broadly be described by scope and structure. Within these two broad domains lies an array of diverse methodologies that have attempted to increase access and coordination of care. These efforts have uncovered many opportunities that, if addressed, may improve our current parent and infant outcomes within our healthcare system and community. Furthermore, there are several opportunities that, if addressed, will result in more equitable, inclusive care. These include being attentive to the unique needs of vulnerable populations, emphasizing community efforts, and closing the current gaps in legislation.

A critical need for the concept of matrescence in perinatal psychiatry.

The concept of matrescence, akin to adolescence but for mothers, has gained increasing attention in perinatal psychiatry, marking a paradigm shift towards understanding the holistic development of mothers. Matrescence encompasses the myriad psychological, social, cultural, and existential changes which occur as women transition into motherhood. Despite advances in maternal mental health, a bias towards pathologizing maternal experiences persists in research and practice. This commentary advocates for the integration of matrescence into perinatal psychiatry, drawing from the work of Dana Raphael and contemporary scholarship. Matrescence offers a strengths-based framework that acknowledges both the challenges and opportunities of motherhood, emphasizing the normative aspects of a mother's self-development. By adopting matrescence terminology and nosology, clinicians and researchers can enhance traditional psychiatric classifications. Additionally, matrescence underscores the importance of considering ecological systems and historical factors in maternal well-being, highlighting the need for comprehensive and compassionate healthcare services. Embracing matrescence as a fundamental concept in perinatal psychiatry holds promise for improving maternal mental health outcomes and promoting the flourishing of mothers worldwide.

Disparities in spatiotemporal clustering of maternal mental health conditions before and during the COVID-19 pandemic.

Mounting evidence indicates the worsening of maternal mental health conditions during the COVID-19 pandemic. Mental health conditions are the leading cause of preventable death during the perinatal and postpartum periods. Our study sought to detect space-time patterns in the distribution of maternal mental health conditions in pregnant women before (2016-2019) and during (2020-2021) the COVID-19 pandemic in North Carolina, USA. Using the space-time Poisson model in SaTScan, we performed univariate and multivariate cluster analysis of emergency department (ED) visits for perinatal mood and anxiety disorders (PMAD), severe mental illness (SMI), maternal mental disorders of pregnancy (MDP), suicidal thoughts, and suicide attempts during the pre-pandemic and pandemic periods. Clusters were adjusted for age, race, and insurance type. Significant multivariate and univariate PMAD, SMI, and MDP clustering persisted across both periods in North Carolina, while univariate clustering for both suicide outcomes decreased during the pandemic. Local relative risk (RR) for all conditions increased drastically in select locations. The number of zip code tabulation areas (ZCTAs) included in clusters decreased, while the proportion of urban locations included in clusters increased for non-suicide outcomes. Average yearly case counts for all maternal mental health outcomes increased during the pandemic. Results provide contextual and spatial information concerning at-risk maternal populations with a high burden of perinatal mental health disorders before and during the pandemic and emphasize the necessity of urgent and targeted expansion of mental health resources in select communities.

Are virtual services equivalent for mood, anxiety, and bonding? examining a perinatal intensive outpatient program.

PURPOSE: Perinatal Intensive Outpatient Programs (IOPs) address severe perinatal mood and anxiety disorders (PMADs) and mother-infant relationship concerns. Given the impact of PMADs on mothers and infants, rapid transitions to virtual services (telehealth) amid COVID-19, and service expansions to populations in need, it is critical to evaluate how effectively virtual and in-person perinatal IOP services treat PMADs and mother-infant bonding. METHODS: This quality-improvement record review examined patient records (n = 361) for a perinatal IOP from May 2016 to July 2023, amid multiple transitions between in-person and virtual services related to COVID-19, influenza, and respiratory syncytial virus. Patients in the completed measures sample (n = 115) completed depression (EPDS), anxiety (GAD-7, PASS), and mother-infant bonding (PBQ) measures over the first 3 weeks of treatment. Patients also anonymously provided program satisfaction ratings and qualitative feedback. RESULTS: While anxiety and depression symptoms improved similarly across service settings, mother-baby bonding only significantly improved with in-person treatment. Patient symptom outcomes also differed by public/private insurance, race, and number of children. Patients reported high service ratings and overall satisfaction, and available feedback indicates some preference for in-person services. CONCLUSION: As perinatal mental health services and IOPs continue to expand, virtual services can similarly address anxiety and depression symptoms and help to reach in-need populations. However, for perinatal IOPs, the core treatment target of mother-infant bonding may be uniquely addressed via in-person services.

Differences between rural and urban residence in the detection and treatment of perinatal mood and anxiety disorders.

BACKGROUND: Perinatal mood and anxiety disorders are common, serious complications of pregnancy. Disparities exist by race and income in the prevalence and treatment of these conditions, and overall treatment rates remain low. Outside of pregnancy, a small body of literature suggests that rural residency may contribute to higher rates of depression for those who identify as women. However, among more diverse populations, evidence suggests urban residency may be associated with higher rates of depression among women of color. It is not known whether these trends hold for mood and anxiety disorders during pregnancy and postpartum. OBJECTIVE: We examined differences in the detection and treatment of perinatal mood and anxiety disorders by rural and urban residents and assessed if the observed differences varied by maternal race or ethnicity. STUDY DESIGN: We conducted a cross-sectional study using linked Medicaid claims and birth certificate records from Oregon and South Carolina from 2016 to 2020. We identified perinatal mood and anxiety disorder diagnoses during the perinatal period (pregnancy and within 60 days postpartum) using International Classification of Disease 10th edition codes and enumerated receipt of pharmacotherapy and psychotherapy treatment using Medicaid claims. We used logistic regression models controlling for relevant clinical and sociodemographic characteristics to estimate associations between rural residence and mood disorder detection and treatment. RESULTS: Among the 185,809 births in our sample, 27% of births (n=50,820) were to people who lived in rural areas and 73% (n=134,989) to those in urban areas. The prevalence of any perinatal mood and anxiety disorders diagnosis was higher for urban residents (19.5%) than for rural residents (18.0%; P<.001). Overall treatment rates were low among people with a perinatal mood and anxiety disorder (42% [n=14,789]). In our adjusted models, those living in urban areas had higher odds of a perinatal mood and anxiety disorder diagnosis (adjusted odds ratio, 1.059 [95% confidence interval, 1.059-1.059], P<.001). We found a significant interaction between maternal race and rurality (P<.001). When we stratified by race, we found that among those who identified as Black, the odds of a perinatal mood and anxiety disorder diagnosis were increased for urban residents (odds ratio, 1.188 [95% confidence interval, 1.188-1.188]), whereas among those who identified as White, there were no such increased odds (odds ratio, 1.027 [95% confidence interval, 0.843-1.252]). CONCLUSION: We saw small but meaningful differences between rural and urban residents in perinatal mood and anxiety disorder diagnosis rates. We detected an interaction between race and rural vs urban maternal residence that impacted the observed differences. By elucidating the intersection between race and other sociodemographic factors, we hope more targeted and meaningful investments can be made in the communities most in need.

Review of the Assessment and Management of Perinatal Mood and Anxiety Disorders.

Perinatal mood and anxiety disorders (PMADs) are the most common complication of childbirth. When poorly controlled, they are associated with worse obstetric outcomes, such as higher rates of preterm birth and unplanned cesarean delivery. They are also associated with suicide, a leading cause of perinatal maternal death. This article provides an overview of evidence-based recommendations for screening, assessment, and management of PMADs, including suicide risk assessment and management and pharmacological and nonpharmacological treatment options compatible with pregnancy and lactation. Although specialized reproductive psychiatrists can provide expert guidance for the management of PMADs, their scarcity means that most patients will not have access to this expert care and instead will seek guidance from general psychiatrists. This article provides a clinical guide for generalists that is based on the best current evidence, including recently released treatment guidelines.

Disparities in Utilization and Delivery Outcomes for Women with Perinatal Mood and Anxiety Disorders.

Perinatal mood and anxiety disorders (PMAD), which include depression and/or anxiety in the year before and/or after delivery, are common complications of pregnancy, affecting up to one in four perinatal individuals, with costs of over $15 billion per year in the US. In this paper, we provide an overview of the disparities in utilization and delivery outcomes for individuals with perinatal mood and anxiety disorders in the US. In addition, we discuss the current US screening and treatment guidelines as well as the high societal costs of illness of PMAD for both perinatal individuals and children. Finally, we outline opportunities for quality improvement of PMAD care in the US, including leveraging increased engagement with healthcare system during prenatal care, working toward a more cohesive national strategy to address PMAD, leaning into evidence-based policymaking through collaboration with a panel of experts, and generating state-level profiles focused on PMAD.

Improving parental mental health in the perinatal period: A review and analysis of quality improvement initiatives.

Parental mental health is an essential sixth vital sign that, when taken into consideration, allows clinicians to improve clinical outcomes for both parents and infants. Although standards exist for screening, referral, and treatment for perinatal mood and anxiety disorders (PMADs), they are not reliably done in practice, and even when addressed, interventions are often minimal in scope. Quality improvement methodology can accelerate the implementation of interventions to address PMADs, but hurdles exist, and systems are not well designed, particularly in pediatric inpatient facilities. In this article, we review the effect of PMADs on parents and their infants and identify quality improvement interventions that can increase screening and referral to treatment of parents experiencing PMADs.

Neurobiological and Behavioral Underpinnings of Perinatal Mood and Anxiety Disorders (PMADs): A Selective Narrative Review.

Perinatal mood and anxiety disorders (PMADs) profoundly impact maternal and infant health, affecting women worldwide during pregnancy and postpartum. This review synthesizes current research on the neurobiological effects of PMADs, particularly their influence on brain structure, function, and corresponding cognitive, behavioral, and mental health outcomes in mothers. A literature search across PubMed, PsycINFO, and Google Scholar yielded studies utilizing neuroimaging (MRI, fMRI) and cognitive assessments to explore brain changes in PMADs. The key findings indicate significant neurobiological alterations in PMADs, such as glutamatergic dysfunction, neuronal damage, and altered neural connectivity, particularly in postpartum depression (PPD). Functional MRI studies reveal distinct patterns of brain function alteration, including amygdala non-responsivity in PPD, differing from traditional major depressive disorder (MDD). These neurobiological changes are connected with cognitive impairments and behavioral modifications, impacting maternal caregiving. Understanding these alterations is fundamental for developing effective treatments. The findings emphasize the importance of focusing on maternal mental health, advocating for early detection, and personalized treatment strategies to improve maternal and child outcomes.

Mental Health Diagnoses on the Mini International Psychiatric Interview Are Associated With Higher Scores on the Edinburgh Postnatal Depression Scale.

OBJECTIVE: To understand if Mini International Psychiatric Interview (MINI) scores in pregnancy are associated with higher scores on the Edinburgh Postnatal Depression Scale (EPDS). DESIGN: Cross-sectional pilot study of participants who completed the EPDS during pregnancy and were then invited to complete the MINI. SETTING/LOCAL PROBLEM: An urban outpatient clinic at an academic medical setting from November 2020 to June 2021. PARTICIPANTS: Convenience sample of 20 pregnant people. INTERVENTION/MEASUREMENTS: Analysis of variance was used to examine differences based on EPDS scores and MINI symptom burden. Nonparametric tests (Mann-Whitney U or Kruskal-Wallis test) were used if assumptions were violated. Descriptive statistics were used to describe sample characteristics. RESULTS: Nine participants screened 9 or higher on the EPDS and completed the MINI. There were no significant differences in demographic variables by EPDS score. There were significant differences between demographic variables, including employment status (p = .003) and type of health insurance (p = .019), between participants who met criteria for at least one diagnosis on the MINI and those who did not. Participants with public health insurance met the criteria for four more diagnoses compared to people with private insurance. Participants not employed full-time had nearly five more diagnoses compared to those employed full-time. Higher EPDS scores were correlated with all measured MINI symptoms or diagnoses. Higher EPDS scores were significantly correlated with and showed a moderate to strong positive correlation to suicidality and antisocial personality disorder. CONCLUSION: Pregnant individuals who score 9 or higher on the EPDS may also have other severe mental health diagnoses. Recognizing perinatal mood and anxiety disorders in this population can inform the development of screening protocols and interventions during pregnancy to improve maternal access to mental health treatment and symptom reduction.

Mental health impacts of climate change and extreme weather events on mothers.

Background: The perinatal period is a time of increased vulnerability for perinatal mood and anxiety disorders (PMADs). Emotional trauma is a risk factor for PMAD development and is common among survivors of extreme weather events (EWEs), which are becoming more frequent and intense as the climate crisis progresses. EWE-related stress and anxiety have not been extensively studied in the perinatal population. However, the limited available data suggest a negative impact of EWE exposure on perinatal mental health, warranting further investigation and investment.Objective: To address this knowledge gap, we interviewed new Australian mothers to understand how EWEs affect the mental health of the perinatal population.Method: Australian mothers (18 years of age or older) with a baby under 12 months of age were recruited to participate in a single virtual focus group session (seven group sessions were run in total) and complete an anonymous survey. Participants were asked questions regarding their concerns about extreme weather and its impact, as well as their general maternal functioning. Maternal functioning, depression, and climate distress were measured via the survey.Results: The study sample comprised 31 Australian mothers (Mage = 31.74, SD = 4.86), predominantly located in Queensland. Findings from the focus groups suggested six key themes; however, of focus to this study are three themes related to maternal mental health: health and well-being, helplessness and avoidant coping, and resilience and adaptation. Predominant subthemes focused on trauma resulting from EWE exposure, economic and heat concerns, social isolation, hopelessness about the future, and feelings of resilience.Conclusions: The evidence linking adverse perinatal mental health outcomes with climate change and EWEs highlights the urgent need for interventions in this context to protect perinatal mental health and well-being. By acknowledging the traumatic impact of these experiences on mothers, this study supports advocacy for policies that specifically address this issue.

The extra consideration of navigating climatic events with children represented a complicating factor in addition to the demands of motherhood.Heat presented as a serious concern for participants, often as part of maintaining the balance between protecting their children's health and well-being and preserving their own mental health.Mothers simultaneously were disengaged from climate-related discussion or action and expressed feelings of helplessness in the face of the magnitude of climate change.

Screening and Follow-Up Care for Perinatal Mood and Anxiety Disorders at a Rural Obstetric Clinic.

OBJECTIVE: To improve screening for perinatal mood and anxiety disorders (PMAD) and follow-up care while balancing team workload. DESIGN: Four rapid plan-do-study-act cycles were implemented over 8 weeks. SETTING/LOCAL PROBLEM: At baseline, only 2% of patients with PMAD were identified at a rural obstetric clinic, and none (n = 0 of 50) received screening with a validated tool. Of the 12 patients who had a current or prior history of PMAD, 92% (n = 11) were not screened for self-harm, and 67% (n = 8) received no referral. The clinic had no standardized care for PMAD. PARTICIPANTS: Patients (n = 253) screened at initial pregnancy intake, early in the third trimester, and at the 6-week postpartum visit. INTERVENTION/MEASUREMENTS: Following the screening, brief intervention, and referral to treatment model, patients were screened using the Edinburgh Postnatal Depression Scale, and brief intervention and referral to treatment were used with a point-of-care checklist. Data were collected three times weekly for run chart analysis, and team surveys measured workload. RESULTS: At the end of 8 weeks, effective screening for PMAD and follow-up care were achieved for 98% of patients and included screening, education, shared decision-making for management, referral, and clinic and phone follow-up to support mental health care uptake. CONCLUSIONS: Standardizing screening and follow-up care can increase identification of PMAD and increase uptake of mental health care. For sustainability, a decision aid can streamline patient-provider communication and reduce visit length.

Outcomes at the Motherhood Center: A Comparison of Virtual and On-Site Versions of a Specialized Perinatal Partial Hospitalization Program.

OBJECTIVES: Remotely administered mental health care is becoming increasingly common for treatment of a range of psychiatric disorders; however, there is a dearth of literature overviewing direct comparisons between remote and in-person interventions for treatment of Perinatal Mood and Anxiety Disorders (PMADs). The sudden advent of the Covid-19 pandemic in New York City forced an abrupt conversion for an intensive day treatment program for new mothers with PMADs, from an on-site to a remote program. METHODS: The current report compares outcomes of 81 women who completed the program in-person to those of 60 women who completed the program remotely. RESULTS: Improvement in depression scores was statistically superior in the remote program, and improvement in mother-infant bonding was statistically equivalent between the on-site and remote programs. DISCUSSION: These findings indicate that specialized partial hospitalization treatment for individuals with moderate to severe psychiatric illness can be effectively provided via telehealth, thus offering improved convenience, accessibility, and safety without compromising care. We conclude that remotely administered group psychotherapy is an effective intervention for women with moderate to severe PMADs.

Feasibility and acceptability of an online mental health intervention for pregnant women and their partners: a mixed method study with a pilot randomized control trial.

BACKGROUND: Untreated perinatal mood and anxiety disorders (PMAD) have short- and long-term health and social consequences; online cognitive behavioral therapy (CBT) interventions can reduce symptoms. Despite partner support being protective online interventions rarely target couples. This study builds on research on an existing CBT-based intervention, the Mothers and Babies Online Course (eMB), by testing its feasibility with prenatal couples. METHODS: We conducted a pilot, randomized, controlled feasibility trial using a 1:1 parallel design. To be eligible, participant dyads were pregnant people (between 13-30 weeks gestation and with a score of 10 or greater on either the GAD-7 or PHQ-9 scale indicating elevated symptoms of anxiety or depression) and their cohabitating partners, living in Missouri, with access to the internet; both in the dyad consented to participate. Recruitment occurred via Facebook ads, flyers, and a snowball approach. The intervention group received eMB, and the control group received a list of community resources. We examined retention and adherence data extracted from eMB analytics and study databases. All participants were given depression and anxiety scales at baseline, 4 and 8 weeks to test preliminary efficacy; satisfaction and acceptability were measured at trial end (i.e., eight weeks) and via interview. RESULTS: There were 441 people who responded to recruitment materials, 74 pregnant people were screened; 19 partners did not complete enrolment, and 25 dyads were ineligible. There were 15 dyads per group (N = 30) who enrolled; all completed the study. The survey response rate was 90% but partners required nearly twice the number of reminders. No participant completed all lessons. Mean depression and anxiety scores dropped over time for dyads in control (M = -1.99, -1.53) and intervention (M = -4.80, -1.99). Intervention pregnant people's anxiety significantly decreased (M = -4.05; 95% CI [0.82, 7.27]) at time two compared to control. Twelve pregnant people and four partners participated in post-intervention interviews and suggested improvements for eMB. CONCLUSION: Online dyadic interventions can potentially reduce PMAD symptoms. However, to feasibly study eMB with couples, strategies to increase program adherence are necessary. Tailoring interventions to overtly include partners may be advantageous. TRIAL REGISTRATION: ClinicalTrials.gov NCT05867680, 19/05/2023.

Scoping Review of the Use of the Edinburgh Postnatal Depression Scale in the United States.

Objective: To evaluate the validity of the Edinburgh Postnatal Depression Scale (EPDS) for screening during the perinatal period in the United States and concerns regarding its acceptability and performance. Methods: We conducted a systematic search in OVID MEDLINE, EMBASE (OVID), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and PsycInfo (EBSCO) for articles published from inception of the database through February 2023. We included primary quantitative and qualitative studies on the validation of the EPDS in the United States and identified 880 articles of which 9 met criteria for inclusion. We extracted data related to aim, study population, setting, methods, outcomes, and key findings from each study into a table based on Joanna Briggs Institute (JBI) Scoping Review Guidelines. Results: We found no evidence that the original wording of the EPDS, which was developed in the United Kingdom, was adapted before validation in the United States. Conclusion: Our findings suggest that adaptation of the EPDS for use in the United States with a focus on contextual equivalence and validity could improve the performance of the tool and patients' experiences with completing the tool. Future research is warranted on optimal methods to adapt the EPDS for mental health screening in the perinatal period in the United States.

A Systemwide Postpartum Inpatient Maternal Mental Health Education and Screening Program.

OBJECTIVE: To expand a hospital system's maternal mental health program to standardize screening for perinatal mood and anxiety disorders. DESIGN: Quality improvement initiative using a continuous Plan-Do-Study-Act (PDSA) cycle. SETTING/LOCAL PROBLEM: In a hospital system consisting of 66 maternity care centers across the United States, there was significant variation in maternal mental health screening, referral, and education practices. The COVID-19 pandemic and increasing rates of severe maternal morbidity further elevated system-level concern about the quality of maternal mental health care being provided. PARTICIPANTS: Perinatal nurses. METHODS: An "all-or-none" bundle methodology was used to measure adherence to a system standard for maternal mental health screening, referral, and education. INTERVENTIONS: A toolkit was designed internally to support streamlined implementation and ensure standardization for screening, referral, and education. This comprehensive toolkit includes screening forms, a referral algorithm, staff education, patient education literature, and a community resource list template. Training on how to use the toolkit was provided to nurses, chaplains, and social workers. RESULTS: The initial system bundle adherence rate was 76% (2017) in the first year of the program. The following year, the bundle adherence rate increased to 97% (2018). Despite the disruption caused by the COVID-19 pandemic, this mental health initiative has maintained an overall adherence rate of 92% (2020-2022). CONCLUSION: This nurse-led quality improvement initiative has been successfully implemented across a geographically and demographically diverse hospital system. The initial and sustained high rates of adherence with the system standard for screening, referral, and education illustrate perinatal nurses' commitment to the delivery of high-quality maternal mental health care in the acute care setting.

Relationship between social support and post-discharge mental health symptoms in mothers of preterm infants.

BACKGROUND: Social support is associated with decreased symptoms of postpartum mood and anxiety disorders (PMAD) in mothers of healthy infants, but less is known about social support and PMADs in mothers with preterm infants. The purpose of this study was to examine the relationship between social support and symptoms of PMADs reported by mothers in the months following hospital discharge of their preterm infant. METHODS: Mothers of infants less than 33 weeks gestational age were enrolled from neonatal intensive care units (NICU) at 6 sites. Mothers completed PMAD measures of depression, anxiety and post-traumatic stress approximately 3 months following their infant's discharge. Multivariable regression was used to evaluate relationships between social support and PMAD measures. RESULTS: Of 129 mothers, 1 in 5 reported clinically significant PMAD symptoms of: depression (24%), anxiety (19%), and post-traumatic stress (20%). Social support was strongly inversely associated with all 3 PMADs. Social support explained between 21% and 26% of the variance in depression, anxiety and post-traumatic stress symptoms. CONCLUSION: Increased social support may buffer PMAD symptoms in mothers of preterm infants after discharge. Research is needed to determine effective screening and interventions aimed at promoting social support for all parents during and following their infant's hospitalisation.

Mapping high-risk clusters and identifying place-based risk factors of mental health burden in pregnancy.

Purpose: Despite affecting up to 20% of women and being the leading cause of preventable deaths during the perinatal and postpartum period, maternal mental health conditions are chronically understudied. This study is the first to identify spatial patterns in perinatal mental health conditions, and relate these patterns to place-based social and environmental factors that drive cluster development. Methods: We performed spatial clustering analysis of emergency department (ED) visits for perinatal mood and anxiety disorders (PMAD), severe mental illness (SMI), and maternal mental disorders of pregnancy (MDP) using the Poisson model in SatScan from 2016 to 2019 in North Carolina. Logistic regression was used to examine the association between patient and community-level factors and high-risk clusters. Results: The most significant spatial clustering for all three outcomes was concentrated in smaller urban areas in the western, central piedmont, and coastal plains regions of the state, with odds ratios greater than 3 for some cluster locations. Individual factors (e.g., age, race, ethnicity) and contextual factors (e.g., racial and socioeconomic segregation, urbanity) were associated with high risk clusters. Conclusions: Results provide important contextual and spatial information concerning at-risk populations with a high burden of maternal mental health disorders and can better inform targeted locations for the expansion of maternal mental health services.