Most states received a D or F grade on maternal mental health. It could get worse.

By Carlotta Dotto and Alex Leeds Matthews, CNN

Nearly every state in the United States is neglecting access to maternal mental health care, according to a recent report, and experts fear the situation could get worse as more states severely restrict or ban abortion.

All but 10 US states received either a D or F grade on a number of key measures of maternal mental health risk policies and access to care — including access to therapists, psychiatrists or mental health treatment programs, according to a May report released by the nonprofit Policy Center for Maternal Mental Health, in partnership with researchers from George Washington University. This is the group’s first report grading states on maternal mental health resources and policies.

Forty states and the District of Columbia received grades of a D or F, while just one state – California – earned a grade higher than a C. No state where abortion was banned or severely restricted received a grade higher than a D+.

More than a dozen states have banned abortion access in the year since the Supreme Court’s landmark decision overturning Roe v. Wade, which has had severe consequences for maternal mental health, some providers told CNN. Other states continue to restrict abortion – most recently, Iowa legislators passed a six-week ban that has since been temporarily blocked by the courts. A 12-week ban went into effect in North Carolina on July 1.

“The truth is that access to mental care in this country – specifically in states where abortion has been restricted – has been abysmal for a very long time,” said Dr. Colleen McNicholas, the chief medical officer at Planned Parenthood of the St. Louis Region and Southwest Missouri.

The Policy Center report found that most states lack specialized care for pregnant and postpartum women. For instance, only five states — California, Illinois, Louisiana, New Jersey and Oklahoma — require ob/gyns to conduct maternal mental health screening during prenatal and postpartum visits, Caitlin Murphy, research scientist at the George Washington University’s Milken Institute School of Public Health, told CNN.

Alabama and Mississippi – two states that banned abortion almost immediately after the Supreme Court reversed Roe vs. Wade – already had among the lowest numbers of certified perinatal mental health providers relative to the expected number of births, according to data from the report. Both states received an F on the report cards.

About 4 million babies are born every year in the country, and roughly 600,000 (20%) of US mothers may experience challenges with their mental well-being every year, according to the Policy Center. Black women are twice as likely as White women to experience maternal mental health conditions but half as likely to receive treatment, according to the Maternal Mental Health Leadership Alliance.

“What we see is that the areas where there is the most need are actually the areas with the fewest resources and providers available,” Murphy said.

Texas is among the 15 states that received an F. Before the Dobbs decision, it banned abortions after six weeks of gestational age – before many people realize they are pregnant.

Elaine Cavazos, the chief clinical officer at a reproductive mental health care clinic in Austin, said that abortion bans have worsened an already-poor state of access to reproductive and mental health care in the state. She told CNN fears over prosecution for aiding and abetting an abortion have created a barrier between patients and providers to speak openly about their reproductive experiences, from pregnancy termination in another state to pregnancy loss.

“Mental health is already tricky as it is, but when you add in a layer of ‘We can’t even talk about these things openly for fear that some negative repercussion could happen to our client,’ it just adds a layer of oppression,” Cavazos said.

Researchers at the University of California, San Francisco found in an ongoing study that when people are denied abortion and are forced to carry an unwanted pregnancy, their mental health suffers, increasing the risk of perinatal mental health conditions such as depression and anxiety.

The UCSF researchers found that people who were denied an abortion experienced more symptoms of anxiety and low self-esteem than people who received one, according to their Turnaway Study.

For people who are able to obtain an abortion out of state, bans have introduced major practical and financial barriers, McNicholas said.

“Seeking an abortion in this country at this time – particularly if you live in the Midwest and the South, and most certainly if you live in a ban state – is a moment of incredible anxiety,” she said. “Not necessarily because you need an abortion but because it is so difficult to do so.”

McNicholas said she has often encountered people seeking abortions due to pre-existing mental health conditions that could be exacerbated by a pregnancy. This includes people in recovery from addiction or who already experienced a case of postpartum depression from a previous pregnancy.

“Abortion has been a really critical tool for them to continue to manage mental health crises in their lives and to keep them healthy and safe,” McNicholas said.

Maternal health professionals are also moving away from abortion-restricted states which experts said may result in even less capacity to screen for and detect maternal mental health conditions.

Most states have low access to maternal mental health care professionals already. The report cards allocated points for any state that had at least 5 certified perinatal mental health providers per 1,000 annual births. Just two states – Vermont and Montana – met that threshold. Those two states had fewer than 20,000 births combined in 2022, according to provisional CDC data

Residency applications decreased slightly last year nationally, but those decreases were larger in states with total abortion bans, particularly for ob/gyns, according to research from the Association of American Medical Colleges.

Although there is no systemic process to measure how many women receive maternal mental health screening and diagnosis in the United States, the CDC estimates that more than half of pregnant women suffering from depression don’t receive treatment.

“Providers are already leaving the states with abortion restrictions because they feel like they really can’t do their job properly,” Murphy said. “They feel they can’t provide high-quality care to patients, whether that’s through counseling or to ensure that a birthing person who needs to terminate their pregnancy for health reasons can do it.”

More providers fear also being held responsible for facilitating an abortion if their patient miscarries, which is especially common early in pregnancy, Murphy told CNN.

“This is a big risk for the mother and the baby, both in terms of mental health and general health,” Murphy said.

While experts told CNN they are most concerned about states where abortion bans were enacted — and where bans may still be introduced —  the state of maternal mental health is poor nationally, and bans stand to affect patients beyond a state’s boundaries.

Providers in states with access to abortions are seeing an increase in patient loads, as well as misinformation and mistrust – all of which create barriers to care, said Anna King, a perinatal counselor and training director of the LA-based non-profit Maternal Mental Health NOW.

“Providers and communities across the board are feeling really impacted in terms of their ability to proceed in the way that they were,” King said.

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