Association between potentially traumatic birthing experience and worsening postpartum depression or anxiety trajectories among participants in perinatal collaborative care model.

BACKGROUND: Having a potentially traumatic birth experience (PTBE) is a known risk factor for postpartum depression (PPD) and postpartum anxiety (PPA). PTBE-related PPA or PPD can peak long after six weeks postpartum, when typical screening for PPD and PPA typically occurs, leaving many of these individuals disconnected from care. Collaborative care models (CCMs) have been shown to reduce PPD and PPA via collaboration between care managers, obstetric clinicians, and mental health professionals. Whether participating in a CCM mitigates the risk of worsening PPD or PPA after PTBE is unknown. OBJECTIVE: To examine trajectories of PPD and PPA among those who experienced a PTBE and participated in a CCM. STUDY DESIGN: This secondary analysis of a prospective cohort study included people enrolled in COMPASS, a CCM program embedded within all Northwestern Medicine prenatal clinics. All pregnant or postpartum people with a history of a mental health conditions or current mental health symptoms during pregnancy or within a year postpartum are eligible for COMPASS referral. Those who enroll in COMPASS are screened every two to four weeks for depression and anxiety symptoms using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), respectively. For this secondary analysis, COMPASS participants were stratified into two groups based on whether they had a PTBE, defined as postpartum hemorrhage, maternal intensive care unit (ICU) admission, or preterm birth <35 weeks (the gestational age cut-off for required Neonatal Intensive Care Unit (NICU) admission at this medical center). PTBE was evaluated as a composite and as its individual subcomponents. The primary outcomes were worsening trajectories for PPD or PPA, defined by a score increase of ≥1 standard deviation on the PHQ-9 or GAD-7, respectively, on at least two assessments for up to one year postpartum. A propensity score was used in multivariable models to control for covariates that significantly differed in bivariable analysis. RESULTS: Among 2,312 COMPASS participants, 413 (17.9%) had PTBE. Compared to those without a PTBE, those with PTBE were more likely to have a pregnancy conceived via IVF, public insurance, or be diagnosed with preexisting diabetes, preexisting hypertension, or obesity. Among 736 and 282 participants with at least two PPD and PPA assessments, 65 (2.8%) and 27 (1.2%) had worsening PPD or PPA trajectories, respectively. After using propensity scores to control for differences identified between groups, PTBE was not associated with worsening trajectories for PPD [aOR 0.92 (95% CI 0.36, 2.38)] or PPA [(aOR 0.64 (95% CI 0.12, 3.26)]. There was no association between individual conditions within the PTBE composite and worsening PPD or PPA trajectories. CONCLUSIONS: Among those enrolled in COMPASS, worsening PPD or PPA trajectories were uncommon, and PTBE were not associated with worsening trajectories. Given the abundance of literature suggesting that PTBE are associated with worse PPD and PPA symptoms, these findings suggest that enrollment in a CCM may be associated with mitigation of the negative impact of PTBE.

Prescribing Patterns for Postpartum Contraception Among Breastfeeding Patients Insured Under Medicaid in Rhode Island: A PRAMS Analysis.

INTRODUCTION: Disparities in contraceptive counseling are well documented in the United States. People of color, those of lower socio-economic status, and Medicaid insurance are more likely to receive contraception/sterilization counseling than White patients. Postpartum contraceptive choice is an important aspect for pregnant people, especially for those who plan to breastfeed. This study assessed postpartum contraception/sterilization prescription among breastfeeding people in Rhode Island insured under Medicaid compared to other insurance carriers. METHODS: Secondary analysis of data from the Rhode Island Pregnancy Risk Assessment Monitoring System (PRAMS) from 2016-2019. Participants who answered yes to 'having ever breastfed' were included and dichotomized based on insurance into 'Medicaid' or 'other insurance'. Primary outcome was postpartum contraception/sterilization prescription. Stata software version 15 was used to perform multivariable logistic regression accounting for complex survey design and weighting. RESULTS: Of 3686 participants, 868 (24.4%) were insured under Medicaid. Medicaid participants were younger, had higher BMIs and were more likely to identify as Black or mixed race or Hispanic ethnicity than those with other insurers. Those insured under Medicaid were 1.5 times more likely to be prescribed postpartum contraception than those with other insurers (95% CI 1.26,1.78). After adjusting for race/ethnicity, education level, marital status and preterm delivery, those with Medicaid were 1.28 times more likely to be prescribed contraception (95% CI 1.05,1.57). CONCLUSION: In this study, breastfeeding participants with Medicaid were more likely to be prescribed postpartum contraception than those with other insurances. Future research should be focused on assessing provider bias, contraception coercion, and initiatives to provide equitable and patient-centered counseling in this population.

Cardiovascular and obstetrical outcomes among delivering patients with Marfan or Loeys-Dietz syndrome: a retrospective analysis by hospital delivery setting.

BACKGROUND: Pregnancy is a high-risk time for patients with Marfan syndrome or Loeys-Dietz syndrome because of the risk for cardiovascular complications, including the risk for aortic dissection. Little is known about the differences in obstetrical and cardiac outcomes based on delivery hospital setting (academic or academic-affiliated vs community medical centers). OBJECTIVE: This study aimed to evaluate the obstetrical and cardiac outcomes of patients with Marfan syndrome or Loeys-Dietz syndrome based on delivery hospital setting. STUDY DESIGN: This was a secondary analysis of a retrospective, observational cohort study of singleton pregnancies among patients with a diagnosis of Marfan syndrome or Loeys-Dietz syndrome from 1990 to 2016. Patients were identified through the Marfan Foundation, the Loeys-Dietz Syndrome Foundation, or the Cardiovascular Connective Tissue Clinic at Johns Hopkins Hospital. Data were obtained via self-reported obstetrical history and verified by review of medical records. Nonparametric analyses were performed using Fisher's exact tests and Wilcoxon rank-sum tests. RESULTS: A total of 273 deliveries among patients with Marfan syndrome or Loeys-Dietz syndrome were included in this analysis (Table 1). More patients who had a known diagnosis before delivery of either Marfan syndrome or Loeys-Dietz syndrome delivered at an academic hospital as opposed to a community hospital (78.6% vs 59.9%; P=.001). Patients with Marfan syndrome or Loeys-Dietz syndrome who delivered at academic centers were more likely to have an operative vaginal delivery than those who delivered at community centers (23.7% vs 8.6%; P=.002). When the indications for cesarean delivery were assessed, connective tissue disease was the primary indication for the mode of delivery at community centers when compared with academic centers (55.6% vs 43.5%; P=.02). There were higher rates of cesarean delivery for arrest of labor and/or malpresentation at community hospitals than at academic centers (23.6% vs 5.3%; P=.01). There were no differences between groups in terms of the method of anesthesia used for delivery. Among those with a known diagnosis of Marfan syndrome or Loeys-Dietz syndrome before delivery, there were increased operative vaginal delivery rates at academic hospitals than at community hospitals (27.2% vs 15.1%; P=.03) (Table 2). More patients with an aortic root measuring ≥4 cm before or after pregnancy delivered at academic centers as opposed to community centers (33.0% vs 10.2%; P=.01), but there were no significant differences in the median size of the aortic root during pregnancy or during the postpartum assessment between delivery locations. Cardiovascular complications were rare; 8 patients who delivered at academic centers and 7 patients who delivered at community centers had an aortic dissection either in pregnancy or the postpartum period (P=.79). CONCLUSION: Patients with Marfan syndrome or Loeys-Dietz syndrome and more severe aortic phenotypes were more likely to deliver at academic hospitals. Those who delivered at academic hospitals had higher rates of operative vaginal delivery. Despite lower frequencies of aortic root diameter >4.0 cm, those who delivered at community hospitals had higher rates of cesarean delivery for the indication of Marfan syndrome or Loeys-Dietz syndrome. Optimal delivery management of these patients requires further prospective research.

Neonatal Outcomes Are Similar between Patients with Resolved and Those with Persistent Oligohydramnios.

OBJECTIVE: Oligohydramnios (defined as amniotic fluid volume < 5 cm or deepest vertical pocket < 2 cm) is regarded as an ominous finding on prenatal ultrasound. Amniotic fluid, however, is not static, and to date, there have been no studies comparing perinatal outcomes in patients who are diagnosed with oligohydramnios that resolves and those who have persistent oligohydramnios. STUDY DESIGN: This is a secondary analysis of a National Institutes of Health-funded retrospective cohort study of singleton gestations delivered at a tertiary care hospital between 2002 and 2013 with mild hypertensive disorders and/or fetal growth restriction (FGR). Maternal characteristics, delivery, and neonatal information were abstracted by trained research nurses. Patients with a diagnosis of oligohydramnios were identified, and those with resolved versus persistent oligohydramnios at the time of delivery were compared. The primary outcome was a composite of neonatal resuscitation at delivery: administration of oxygen, bag-mask ventilation, continuous positive airway pressure, intubation, chest compression, or cardiac medication administration. Secondary outcomes included FGR, timing, and mode of delivery. RESULTS: Of 527 women meeting study criteria, 42 had oligohydramnios that resolved prior to delivery, whereas 485 had persistent oligohydramnios. There were no significant differences in patient demographics between groups. The gestational age at diagnosis was significantly lower for patients with resolved versus persistent oligohydramnios (median: 33.0 [interquartile range, IQR: 29.1-35.9] vs. 38.0 [IQR: 36.4-39.3], p < 0.001). There was not a substantial difference in rate of neonatal resuscitation (41 vs. 32%, p = 0.31). Patients with resolved oligohydramnios were more likely to have developed FGR than those with persistent oligohydramnios (55 vs. 36%, p < 0.02). There were no significant differences for gestational age at delivery, birth weight, or neonatal intensive care unit admission. CONCLUSION: Patients whose oligohydramnios resolved were diagnosed earlier yet had similar rates of neonatal resuscitation but higher rates of FGR than those who had persistent oligohydramnios. KEY POINTS: · When diagnosed earlier in pregnancy, oligohydramnios was more likely to resolve prenatally.. · Patients who were diagnosed with oligohydramnios earlier in pregnancy had higher rates of FGR.. · There were no differences in the rates of the composite outcome of need for neonatal resuscitation when comparing those with resolved versus those with persistent oligohydramnios. No differences in composite neonatal morbidity were noted between those with resolved versus persistent oligohydramnios..

The effect of digital health interventions on postpartum depression or anxiety: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This study aimed to examine the effect of digital health interventions compared with treatment as usual on preventing and treating postpartum depression and postpartum anxiety. DATA SOURCES: Searches were conducted in Ovid MEDLINE, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. STUDY ELIGIBILITY REQUIREMENTS: The systematic review included full-text randomized controlled trials comparing digital health interventions with treatment as usual for preventing or treating postpartum depression and postpartum anxiety. STUDY APPRAISAL AND SYNTHESIS METHODS: Two authors independently screened all abstracts for eligibility and independently reviewed all potentially eligible full-text articles for inclusion. A third author screened abstracts and full-text articles as needed to determine eligibility in cases of discrepancy. The primary outcome was the score on the first ascertainment of postpartum depression or postpartum anxiety symptoms after the intervention. Secondary outcomes included screening positive for postpartum depression or postpartum anxiety --as defined in the primary study --and loss to follow-up, defined as the proportion of participants who completed the final study assessment compared with the number of initially randomized participants. For continuous outcomes, the Hedges method was used to obtain standardized mean differences when the studies used different psychometric scales, and weighted mean differences were calculated when studies used the same psychometric scales. For categorical outcomes, pooled relative risks were estimated. RESULTS: Of 921 studies originally identified, 31 randomized controlled trials-corresponding to 5532 participants randomized to digital health intervention and 5492 participants randomized to treatment as usual-were included. Compared with treatment as usual, digital health interventions significantly reduced mean scores ascertaining postpartum depression symptoms (29 studies: standardized mean difference, -0.64 [95% confidence interval, -0.88 to -0.40]; I2=94.4%) and postpartum anxiety symptoms (17 studies: standardized mean difference, -0.49 [95% confidence interval, -0.72 to -0.25]; I2=84.6%). In the few studies that assessed screen-positive rates for postpartum depression (n=4) or postpartum anxiety (n=1), there were no significant differences between those randomized to digital health intervention and treatment as usual. Overall, those randomized to digital health intervention had 38% increased risk of not completing the final study assessment compared with those randomized to treatment as usual (pooled relative risk, 1.38 [95% confidence interval, 1.18-1.62]), but those randomized to app-based digital health intervention had similar loss-to-follow-up rates as those randomized to treatment as usual (relative risk, 1.04 [95% confidence interval, 0.91-1.19]). CONCLUSION: Digital health interventions modestly, but significantly, reduced scores assessing postpartum depression and postpartum anxiety symptoms. More research is needed to identify digital health interventions that effectively prevent or treat postpartum depression and postpartum anxiety but encourage ongoing engagement throughout the study period.

Obstetric considerations for aortopathy in pregnancy.

Aortic dissection (AD) associated with pregnancy can have catastrophic consequences for the mother and/or fetus. AD occurs in 4-5 per 1,000,000 pregnancies and, despite its rarity, is the third most frequent maternal cardiovascular cause of death. AD associated with pregnancy is most likely to occur in the third trimester or postpartum period. In individuals with genetic aortopathy, pregnancy is considered a high-risk time for AD. There are management strategies in the preconception, antepartum, delivery and postpartum periods to optimize patient care. A multi-disciplinary team that includes capability to perform cardiovascular surgery is critical. Imaging modalities including maternal echocardiogram and magnetic resonance imaging can be safely performed in pregnancy for surveillance of the aortic size. Computed tomography (CT) scan is reserved for scenarios where there is a high index of suspicion for AD in a pregnant person to limit fetal exposure to radiation. After counseling about the potential risks of a pregnancy, the decision to pursue pregnancy is ultimately at the discretion of the individual. The duty of the cardio-obstetric team is to ensure that the patient and their family understand the risks of a pregnancy and the plan of care.

Postpartum Depression-New Screening Recommendations and Treatments.

This Insights in the Women's Health series describes perinatal depression (occurring prepregnancy through postpartum periods) and new recommendations and treatment guidelines for this condition.

The relationship between body mass index and perceived control over labor.

BACKGROUND: Individuals with an increased body mass index (BMI) (≥ 30 kg/m2) experience higher rates of perinatal mental health disorders than individuals with BMI < 30. Personal experience of decreased control over labor has been associated with the development postpartum mood and anxiety disorders. However, no studies have investigated the association between BMI and experience of control over labor. This study aimed to assess perceived control over labor and compare patients with BMI ≥ 30 to those with BMI < 30. METHODS: We performed a secondary analysis of a cross-sectional study of postpartum patients who delivered at term (37-41 weeks gestation). Postpartum, participants completed the Labour Agentry Scale (LAS), a validated tool to assess perceived control over labor/birth. Demographic, maternal health history and obstetric/neonatal outcomes were abstracted from the patient chart. Bivariate analyses were performed between those with BMI < 30 and those with BMI ≥ 30 using Fisher's exact test. Continuous LAS scores were compared between patients with BMI < 30 and BMI ≥ 30 using Wilcoxon rank-sum tests. Higher LAS scores indicate higher perceived control over labor. Multivariable linear regression was then performed to account for confounding factors identified a priori. RESULTS: There was no difference in LAS between those with BMI ≥ 30 and BMI < 30. When stratified by World Health Organization (WHO) class of BMI, those with BMI ≥ 40 had a significantly lower LAS scores than those with BMI < 30 (147 vs. 163, p = 0.02), however, this finding was no longer significant after controlling for length of labor and cesarean birth. CONCLUSION: Only participants with the highest BMI experienced decreased control over labor, and this finding was no longer significant after controlling for mode of delivery and length of labor. Further research into the experience of birthing people with BMI ≥ 30 is critical to understand the increased risk of perinatal mood disorders among this population.

Body Mass Index and Perceived Labor Control: Could weight stigma explain differences in birth experience?

Background: Individuals with a body mass index (BMI) of ≥ 30 kg/m2 experience weight stigma when interacting with the healthcare system. There is limited data on how weight stigma impacts patient's experience of obstetric care. This study aims to assess perceived control over the birth process and compare patients with BMI ≥ 30 to those with BMI < 30. Methods: We performed a secondary analysis of a cross-sectional study of term patients. Postpartum, participants completed the Labour Agentry Scale (LAS), a validated tool to assess perceived control over labor/birth. Continuous LAS scores were compared between patients with BMI < 30 and BMI ≥ 30. Results: There was no difference in LAS between those with BMI ≥ 30 and BMI < 30. When stratified by World Health Organization (WHO) class of BMI, those with BMI ≥ 40 had a significantly lower LAS scores than those with BMI < 30 (147 vs. 163, p = 0.02), however, this finding was no longer significant after controlling for length of labor and cesarean birth. Conclusion: Only participants with the highest BMI experienced decreased control over labor, and this finding was no longer significant after controlling for mode of delivery and length of labor. Further research is necessary into how weight stigma influences birthing people's experience.

A pilot randomized control trial of topical capsaicin as adjunctive therapy for nausea and vomiting of pregnancy.

BACKGROUND: Nausea and vomiting is one of the most common complications of pregnancy, affecting 50% to 80% of pregnant persons. Moreover, despite its prevalence, it remains a challenging condition to treat. Treatment often involves oral and intravenous medications with potential side effects, particularly when taken in combination. Capsaicin cream is proven to decrease nausea and vomiting in cyclic vomiting syndrome; however, its use has not been well studied among pregnant patients. OBJECTIVE: This study aimed to test the feasibility of the off-label use of capsaicin for the treatment of nausea and vomiting in pregnancy. STUDY DESIGN: This was a double-blinded randomized controlled trial of pregnant individuals in their first trimester of pregnancy seeking care at a tertiary care hospital for nausea and vomiting. Consenting participants were randomized to abdominal application of topical capsaicin vs placebo. All participants received intravenous hydration and metoclopramide. The primary outcome, total treatment time, was recorded for all participants. In addition, symptom severity was assessed every 30 minutes using a visual analog scale. Data were analyzed using the Wilcoxon rank-sum test for continuous variables and the Fisher exact test for binary variables. RESULTS: Of the 38 eligible individuals approached, 30 were randomized. There was a trend toward decreased mean treatment time in the capsaicin group compared with the placebo group (79.9 vs 97.3 minutes; P=.1). There was no significant difference in visual analog scale scores at any time point between groups. Furthermore, capsaicin was well tolerated, with only 1 individual requesting the medication be removed. CONCLUSION: This study demonstrated that capsaicin is an acceptable treatment of nausea and vomiting in pregnancy and additional explorations of its use as treatment are feasible. A larger randomized controlled trial is needed to determine the efficacy of capsaicin in this population.

The Impact of Maternal Obesity on Neonatal Outcomes of Pregnancies Complicated by Fetal Growth Restriction.

OBJECTIVE: This study aimed to characterize the relationship between maternal obesity, fetal abdominal size, and neonatal morbidity in pregnancies complicated by fetal growth restriction (FGR). STUDY DESIGN: Pregnancies complicated by FGR, which resulted in delivery of a live, singleton, nonanomalous infant at a single center between 2002 and 2013 were identified in a large, National Institutes of Health-funded database of detailed pregnancy and delivery information extracted by trained research nurses. Pregnancies complicated by diabetes were excluded. Fetal biometry measurements from third trimester ultrasounds performed at the same institution were extracted from another institutional database. Pregnancies were divided into cohorts based on fetal abdominal circumference (AC) gestational age percentile (<10th centile, 10-29th centile, 30-49th centile, and ≥50th centile) at the ultrasound closes to the date of delivery. Obesity was defined by prepregnancy body mass index >30 kg/m2. The primary outcome was a composite of neonatal morbidity (CM) including 5-minute Apgar < 7, arterial cord pH <7.0, sepsis, respiratory support, chest compressions, phototherapy, exchange transfusion, hypoglycemia requiring treatment, or neonatal death. Outcomes were compared between women with versus without prepregnancy obesity overall and then stratified by AC cohort. RESULTS: A total of 379 pregnancies met criteria; CM occurred in 136 (36%). Overall, there was no difference in CM between infants born to women with versus without obesity (risk ratio (RR): 1.11, 95% confidence interval: 0.79-1.56). When stratified according to AC at ultrasound closest to delivery, there was higher prevalence of CM occurring among women with prepregnancy obesity than those without prepregnancy obesity when the fetal AC was >50th or 30 to 49th centile However, these differences did not reach statistical significance. CONCLUSION: Our study identified no significant difference in risk of CM among growth-restricted infants of obese versus nonobese mothers, including among infants with very small AC. More research is needed to further examine the potential relationships postulated here. KEY POINTS: · No significant differences in neonatal outcomes of FGR pregnancies in obese versus nonobese patients.. · No significant differences in AC percentile distribution in FGR pregnancies in obese versus nonobese.. · Pregnancies complicated by obesity had a higher need for cardiac support but not chest compressions..

Occurrence of emerging contaminants in biosolids in northern Queensland, Australia.

This study aims to identify and quantify different classes of emerging contaminants (ECs), such as pharmaceutical and personal care products (PPCPs), per-and polyfluoroalkyl substances (PFAS), heavy metals (HMs), polycyclic musks (PMs) in biosolids from different sewage treatment plants (STPs) from regional councils across Northern Queensland, Australia. Biosolids samples were named BS1 to BS7 for each council. The results revealed significant variations in the concentrations of different ECs in biosolids which could be explained in some instances by the characteristics of the upstream sewage network. For instance, BS4-biosolids from a small agricultural shire (largely sugarcane) showed the highest concentration of zinc and copper, which were 2430 and 1050 mg/kg, respectively. Among PPCPs, the concentration of ciprofloxacin was found to be the highest in BS3 and BS5, two large regional council areas which are a mix of domestic and industrial (predominantly domestic) biosolids of 1010 and 1590 ng/g, respectively. In addition, the quantity of sertraline was consistently high in all biosolids except from BS7, one of the smaller regional councils, which is indicative of the domestic catchments attached. PFAS compounds were detected in all biosolids samples except in BS6, one of the small (agricultural and tourist) catchments. Two PFAS compounds emerged as the most common pollutants that were perfluorooctanoic acid (PFOA) and perfluorooctanesulfonic acid (PFOS). The largest industrial catchment biosolids, BS2 showed the highest concentration of PFOS at 253 ng/g, while the smallest regional council, BS7 showed the maximum concentration of 7.90 ng/g of PFOA. Overall, this study concludes that certain ECs such as HMs, antibiotics, PFOS and PFOA in biosolids may pose high environmental risks.

Unplanned Operative Delivery is Associated with Decreased Perception of Control over Labor.

Background: Unplanned operative delivery is associated with postpartum depression (PPD), but the mechanism is unknown. We aimed to assess the sense of control over labor for those who had unplanned delivery (unplanned cesarean or operative vaginal delivery: uCD/OVD) versus spontaneous vaginal delivery (SVD). Methods: Secondary analysis of a cross-sectional survey study of term patients admitted for delivery at a tertiary center. After delivery, patients completed the Labour Agentry Scale (LAS), a validated tool to assess perceived control over labor and birth. Demographics, obstetric and neonatal outcomes and LAS scores were compared between patients who underwent uCD/OVD versus SVD. Multivariable logistic regression to assess the relationship between uCD/OVD and LAS score controlling for confounders that differed in the bivariate analysis. Results: Of the 149 patients, 50 (33.6%) underwent uCD/OVD. There were no differences in maternal age, race/ethnicity, insurance status or education level between those who had uCD/OVD versus SVD. Patients who had uCD/OVD had higher median body mass index (BMI) than those who had SVD (33.2 vs 30.1 kg/m2, p = 0.03). There were no differences in rate of medical or psychiatric morbidity between groups. Additionally, there were no differences in reason for admission, however those who had uCD/OVD had significantly longer times to delivery than those who underwent SVD (22 vs 14 hrs, p < 0.01). Gestational age at delivery was also significantly higher for those who underwent uCD/OVD compared to SVD (40.2 vs 39.6 wks, p = 0.02). For the primary outcome, LAS scores were lower for those who underwent uCD/OVD compared to SVD (146 vs. 164, p < 0.01). This remained significant even after controlling for length of labor, BMI and gestational age at delivery (p < 0.01). Conclusions: Even after accounting for length of labor, uCD/OVD is associated with a reduction in perceived control over labor, which may mediate the known increased risk of PPD. Further qualitative research is needed to examine how to better support patients' wellbeing after uCD/OVD.

Perinatal Mental Health Disorders: A Review of Lessons Learned from Obstetric Care Settings.

Perinatal mental health has garnered significant attention within obstetrics over the last couple of decades as the long- and short-term morbidities of untreated perinatal mental health disorders on both the mother and fetus/neonate have become increasingly apparent. There have been major strides in increasing screening for perinatal mental health disorders, clinician comfort with prescribing common psychiatric medications, and integrating mental health professionals into prenatal care via health services approaches such as the collaborative care model. Despite these advances, however, gaps still remain in the tools used for screening and diagnosis, obstetric clinician training in diagnosis and management of perinatal mood and anxiety disorders, as well as patient access to mental health care during pregnancy and especially postpartum. Herein we review the state of perinatal mental health from the perspective of the obstetric provider and identify areas of ongoing innovation.