Matched cohort study of healthcare resource utilization and costs in young children of mothers with postpartum depression in the United States

Identification and transfer to stepped care of depressed and psychosocially stressed parents during peri- and postpartum-UPlusE: study protocol for cluster randomized trial of a screening intervention

BACKGROUND

Perinatal depression affects 10-15% of mothers and approximately 5% of fathers. However, only a small number of affected individuals seek treatment. If left unrecognized and untreated, it can have negative long-term consequences for the family's health, leading to subsequent high costs. Early treatment is crucial, yet there is a notable underdiagnosis and undertreatment. Affected individuals are often seen during this time, e.g. in paediatric practices, but not by specialists in mental health. Consequently, this study aims to increase detection and treatment rates of affected individuals by implementing a screening for depression and psychosocial stress in perinatal and postpartum parents within routine obstetric and paediatric care with subsequent advice and-if necessary-further referral to a mental health specialist.

METHODS

UPlusE is a prospective, cluster-randomized controlled trial conducted in an outpatient setting. Obstetric and paediatric practices will be randomized into an intervention and control group (1:1 ratio). Practices and enrolling patients will be required to use specific smartphone apps (practice apps) for interaction. The screening will occur with the apps at each paediatric checkup up to the child's age of 12 months, using the Edinburgh Postnatal Depression Scale (EPDS), KID-PROTEKT questionnaire, and the scale 1 (impaired bonding) of the Postpartum Bonding Questionnaire (PBQ-1). The goal is to screen 10,000 patients across Germany. Gynaecologists and paediatricians will receive certified training on peripartum depression. Participants in the intervention group with scores above cut-offs (EPDS ≥ 10, KID-PROTEKT ≥ 1, PBQ-1 ≥ 12) will receive counselling through their treating gynaecologists/paediatricians and will be provided with regional addresses for psychiatrists, psychotherapists, and "Frühe Hilfen" (early prevention) as well as family counselling centres, depending on symptom severity. At each screening, participants will be asked whether they sought support, where, and with whom (utilization). Utilization is the primary outcome.

DISCUSSION

The screening is designed to reduce underdiagnosis to enable suitable support at an early stage (especially for those often overlooked, such as individuals with "high-functioning depression") and hence to avoid manifestation of mental health problems in the whole family, especially infants who are exceptionally dependent on their parents and their well-being will benefit from this program.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00033385. Registered on 15 January 2024.

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.

The impact of maternal health on child's health outcomes during the first five years of child's life in countries with health systems similar to Australia: A systematic review

INTRODUCTION

The first five years of life is an important developmental period that establishes the foundation for future health and well-being. Mothers play a primary role in providing emotional and physical nourishment during early childhood. This systematic review aims to explore the association between maternal health and child health in the first five years of the child's life.

MATERIALS AND METHODS

As primary aims, we systematically synthesised published evidence relating to the first five years of life for associations between maternal health exposures (mental, physical and Health-Related Quality of Life (HRQoL) and child health outcomes (physical health, mental health, HRQoL and Health Service Use (HSU) /cost). As a secondary aim, we explored how the above associations vary between disadvantaged and non-disadvantaged populations. The search was limited to studies that published and collected data from 2010 to 2022. The systematic review was specific to countries with similar health systems to Australia. The search was conducted in MEDLINE, CINAHL, APA PsycINFO, GLOBAL HEALTH, and EMBASE databases. The quality of the included studies was assessed by The Effective Public Health Practice Project (EPHPP) tool.

RESULTS

Thirteen articles were included in the final synthesis from the identified 9439 articles in the primary search. Six (46%) explored the association between maternal mental health and child's physical health, two (15%) explored maternal and child's physical health, one (8%) explored maternal and child's mental health, one (8%) explored maternal physical health and child's HRQoL, and three (23%) explored maternal mental health and child's HSU. We found an association between maternal health and child health (physical and mental) and HSU outcomes but no association between maternal health and child's overall HRQoL. The results for disadvantaged communities did not show any difference from the general population.

DISCUSSION AND CONCLUSION

Our review findings show that maternal health influences the child's health in the first five years. However, the current evidence is limited, and the findings were primarily related to a specific maternal or child's health condition. There was no evidence of associations of child health outcomes in healthy mothers. There is an extensive research gap investigating maternal health exposures and child outcomes in quality of life and overall health.

Examining the Relationship Between Screening for Postpartum Depression and Associated Child Health Service Utilization and Costs: A Study Using the All Our Families Cohort and Administrative Data

INTRODUCTION

Despite a recognized association between maternal postpartum depression (PPD) and adverse child health outcomes, evidence examining the relationship between PPD symptoms and associated child health service utilization and costs remains unclear. In addition, there is a paucity of evidence describing the relationship between early identification of maternal PPD and associated health service utilization and costs for children. This study aims to address this gap by describing the secondary associations of screening for maternal PPD and annual health service utilization and costs for children over their first five years of life.

METHODS

Mothers and children enrolled in the prospective All Our Families cohort were linked to provincial administrative data in Alberta, Canada. Multivariable generalized linear models were used to estimate the average annual inpatient, outpatient, physician, and total health service utilization and costs from a public health system perspective for children of mothers screened high risk for PPD, low/moderate risk for PPD, or unscreened.

RESULTS

Total mean costs were greatest for children during their first year of life than other years. Those whose mothers were not screened had significantly lower costs compared to those whose mothers were screened low/moderate risk, despite equivalent health service utilization.

DISCUSSION

Findings from this study describe the secondary associations of screening for maternal PPD using a public health system perspective. More research is required to fully understand variations in health costs for children across maternal PPD screening categories.

Health economic evaluations of preventative care for perinatal anxiety and associated disorders: a rapid review

OBJECTIVES

Perinatal mental health problems affect one in five women and cost the UK £8.1 billion for every year of births, with 72% of this cost due to the long-term impact on the child. We conducted a rapid review of health economic evaluations of preventative care for perinatal anxiety and associated disorders.

DESIGN

This study adopted a rapid review approach, using principles of the standard systematic review process to generate quality evidence. This methodology features a systematic database search, Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram, screening of evidence, data extraction, critical appraisal and narrative synthesis.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Applied Social Sciences Index and Abstracts, PsycINFO and MEDLINE.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies that evaluated the costs and cost-effectiveness of preventative care for perinatal anxiety and associated disorders carried out within the National Health Service and similar healthcare systems.

DATA EXTRACTION AND SYNTHESIS

A minimum of two independent reviewers used standardised methods to search, screen, critically appraise and synthesise included studies.

RESULTS

The results indicate a lack of economic evaluation specifically for perinatal anxiety, with most studies focusing on postnatal depression (PND). Interventions to prevent postnatal mental health problems are cost-effective. Modelling studies have also been conducted, which suggest that treating PND with counselling would be cost-effective.

CONCLUSION

The costs of not intervening in maternal mental health outweigh the costs of preventative interventions. Preventative measures such as screening and counselling for maternal mental health are shown to be cost-effective interventions to improve outcomes for women and children.

PROSPERO REGISTRATION NUMBER

CRD42022347859.

Characterizing Fit-for-Purpose Real-World Data: An Assessment of a Mother-Infant Linkage in the Japan Medical Data Center Claims Database

Purpose

Observational postapproval safety studies are needed to inform medication safety during pregnancy. Real-world databases can be valuable for supporting such research, but fitness for regulatory purpose must first be vetted. Here, we demonstrate a fit-for-purpose assessment of the Japan Medical Data Center (JMDC) claims database for pregnancy safety regulatory decision-making.

Patients and Methods

The Duke-Margolis framework considers a database's fitness for regulatory purpose based on relevancy (capacity to answer the research question based on variable availability and a sufficiently sized, representative population) and quality (ability to validly answer the research question based on data completeness and accuracy). To assess these considerations, we examined descriptive characteristics of infants and pregnancies among females ages 12-55 years in the JMDC between January 2005 and March 2022.

Results

For relevancy, we determined that critical data fields (maternal medications, infant major congenital malformations, covariates) are available. Family identification codes permitted linkage of 385,295 total mother-infant pairs, 57% of which were continuously enrolled during pregnancy. The prevalence of specific congenital malformation subcategories and maternal medical conditions were representative of the general population, but preterm births were below expectations (3.6% versus 5.6%) in this population. For quality, our methods are expected to accurately identify the complete set of mothers and infants with a shared health insurance plan. However, validity of gestational age information was limited given the high proportion (60%) of missing live birth delivery codes coupled with suppression of infant birth dates and inaccessibility of disease codes with gestational week information.

Conclusion

The JMDC may be well suited for descriptive studies of pregnant people in Japan (eg, comorbidities, medication usage). More work is needed to identify a method to assign pregnancy onset and delivery dates so that in utero medication exposure windows can be defined more precisely as needed for many regulatory postapproval pregnancy safety studies.

The cost-effectiveness of zuranolone versus selective serotonin reuptake inhibitors for the treatment of postpartum depression in the United States

AIMS

The objective of this research is to evaluate the cost-effectiveness of zuranolone, the first oral treatment indicated for postpartum depression (PPD) in adults approved by the United States Food and Drug Administration.

METHODS

Zuranolone and selective serotonin reuptake inhibitor (SSRI) trial-based efficacy was derived from an indirect treatment comparison. Long-term efficacy outcomes were based on a large longitudinal cohort study. Maternal health utility values were derived from trial-based, short-form 6-D responses. Other inputs were derived from literature and economic data from the US Bureau of Labor Statistics. We estimated costs (2023 US dollars) and quality-adjusted life-years (QALYs) for patients with PPD treated with zuranolone (14-day dosing) or SSRIs (chronic dosing). The indirect costs and QALYs of the children and partners were also estimated.

RESULTS

The incremental cost-effectiveness ratio for zuranolone versus SSRIs was $94,741 per QALY gained over an 11-year time horizon. Maternal total direct medical costs averaged $84,318 in the zuranolone arm, compared to $86,365 in the SSRI arm. Zuranolone-treated adults averaged 6.178 QALYs compared to 6.116 QALYs for the SSRI arm. Costs and utilities for the child and partner were also included in the base case. Drug and administration costs for zuranolone averaged $15,902, compared to $30 for SSRIs over the studied time horizon. Results were sensitive to the model time horizon.

LIMITATIONS

As head-to-head trials were not available to permit direct comparison, efficacy inputs were derived from an indirect treatment comparison which can be confounded by cross-trial differences. The data used are reflective of a general PPD population rather than marginalized individuals who may be at a greater risk for adverse PPD outcomes. The model likely excludes unmeasured effects for patient, child, and partner.

CONCLUSIONS

This economic model's results suggest that zuranolone is a more cost-effective therapy compared to SSRIs for treating adults with PPD.

Impact of visiting restrictions on Edinburgh postnatal depression scale screening scores at one month postpartum during the spread of COVID-19: a single-center case-control study in Japan

BACKGROUND

This study aimed to evaluate whether "visiting restrictions" implemented due to the coronavirus disease 2019 (COVID-19) pandemic are a risk factor for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS).

METHODS

This case-control study participants who gave birth during the spread of COVID-19 (COVID-19 study group) and before the spread of COVID-19 (control group). Participants completed the EPDS at 2 weeks and 1 month after childbirth.

RESULTS

A total of 400 cases (200 in each group) were included in this study. The EPDS positivity rate was significantly lower with visiting restrictions than without (8.5% vs.18.5%, p = 0.002). Multivariate analysis of positive EPDS screening at the 1st month checkup as the objective variable revealed that visiting restrictions (odds ratio (OR): 0.35, 95% confidence interval (CI): 0.18-0.68), neonatal hospitalization (OR: 2.17, 95% CI: 1.08-4.35), and prolonged delivery (OR: 2.87, 95% CI: 1.20-6.85) were factors associated with an increased risk of positive EPDS screening.

CONCLUSION

Visiting restrictions on family during the hospitalization period for delivery during the spread of COVID-19 pandemic did not worsen EPDS screening scores 1 month postpartum, but stabilized the mental state of some mothers.

Allopregnanolone Concentrations in Breast Milk and Plasma from Healthy Volunteers Receiving Brexanolone Injection, With Population Pharmacokinetic Modeling of Potential Relative Infant Dose

Background and Objective

Women with postpartum depression (PPD) may expose their infants to antidepressants via breast milk. Brexanolone is the only FDA-approved antidepressant specifically indicated for the treatment of PPD. This open-label, phase Ib study of healthy lactating volunteers assessed pharmacokinetic (PK) properties of brexanolone and a population PK (PopPK) model determined the relative infant dose (RID) in breastfeeding mothers.

Methods

Twelve participants received a 60-h infusion of brexanolone (titration up to 90 µg/kg/h). Allopregnanolone concentration was measured in breast milk and plasma. The RID was computed using a nonlinear mixed-effects PopPK model of patients with PPD and healthy women (N = 156). Model results were extended across an integrated dataset of participants through day 7.

Results

Allopregnanolone concentration–time profiles were similar between breast milk and plasma (partition coefficient for concentration gradient [milk : plasma] 1.36). Mean (95% CI) C_max was 89.7 ng/mL (74.19–108.39), and median (95% CI) t_max was 47.8 h (47.8–55.8) in plasma. The overall PK profile was best described by a two-compartment model with linear elimination and distribution. Body weight was the only significant covariate identified. There were no apparent differences in PopPK AUC and C_max between participants with or without concomitant antidepressant treatment. Maximum RID was 1.3%.

Conclusion

The PopPK model successfully described the variability and concentration–time profiles of allopregnanolone in breast milk and plasma in healthy participants and in the plasma of brexanolone-treated patients with PPD. The rapid elimination of allopregnanolone from plasma and breast milk, and low RID, suggests the appropriateness of brexanolone weight-based dosing and supports other PK-related labeling recommendations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40262-022-01155-w.

Maternal perinatal depression and health services utilisation in the first 2 years of life: a cohort study

OBJECTIVES

Maternal perinatal depression is a common phenomenon, influencing infants' development. Studies have shown an inconsistent association between perinatal depression and healthcare resource utilisation. This study aimed to assess whether perinatal depression in mothers is associated with their infants' healthcare utilisation, during the first 2 years of life.

DESIGN

A cohort study based on computerised medical records.

SETTING

Nationwide primary care clinics in the second largest health maintenance organisation in Israel.

PARTICIPANTS

593 children of women with depression (the exposed group) and 2310 children of women without depression.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome variables included general practitioner/paediatrician (GP/Paed) visits (regular and telehealth), emergency room (ER) visits, hospital admission rates and child-development clinic visits. Secondary outcomes included antibiotic use and anaemia status. The exposure variable, perinatal depression, was based on Edinburgh Postnatal Depression Scale. A score of ≥10 was classified as depression.

RESULTS

Multivariable analysis of the number of regular visits and telehealth to the GP/Paed showed an adjusted incidence rate ratio (aIRR) of 1.08, 95% CI 1.03 to 1.13 and aIRR 0.95, 95% CI 0.82 to 1.10, respectively. Children of mothers with perinatal depression had more hospital admissions (aIRR 1.21, 95% CI 1.01 to 1.46) and more visits to child development clinics (aIRR 1.33, 95% CI 1.04 to 1.70). There was a non-significant increase in ER visits (IRR 1.26, 95% CI 0.66 to 2.42), and non-significant decrease in antibiotics prescriptions (IRR 0.95, 95% CI 0.86 to 1.05) and anaemia status (IRR 0.93, 95% CI 0.72 to 1.20).

CONCLUSION

This study shows higher health services utilisation among children of mothers with perinatal depression, including regular GP/Paed visits, hospital admission rates, and child-development clinics.

Identifying urban built environment factors in pregnancy care and maternal mental health outcomes

Backgrounds

Risk factors related to the built environment have been associated with women’s mental health and preventive care. This study sought to identify built environment factors that are associated with variations in prenatal care and subsequent pregnancy-related outcomes in an urban setting.

Methods

In a retrospective observational study, we characterized the types and frequency of prenatal care events that are associated with the various built environment factors of the patients’ residing neighborhoods. In comparison to women living in higher-quality built environments, we hypothesize that women who reside in lower-quality built environments experience different patterns of clinical events that may increase the risk for adverse outcomes. Using machine learning, we performed pattern detection to characterize the variability in prenatal care concerning encounter types, clinical problems, and medication prescriptions. Structural equation modeling was used to test the associations among built environment, prenatal care variation, and pregnancy outcome. The main outcome is postpartum depression (PPD) diagnosis within 1 year following childbirth. The exposures were the quality of the built environment in the patients’ residing neighborhoods. Electronic health records (EHR) data of pregnant women (n = 8,949) who had live delivery at an urban academic medical center from 2015 to 2017 were included in the study.

Results

We discovered prenatal care patterns that were summarized into three common types. Women who experienced the prenatal care pattern with the highest rates of PPD were more likely to reside in neighborhoods with homogeneous land use, lower walkability, lower air pollutant concentration, and lower retail floor ratios after adjusting for age, neighborhood average education level, marital status, and income inequality.

Conclusions

In an urban setting, multi-purpose and walkable communities were found to be associated with a lower risk of PPD. Findings may inform urban design policies and provide awareness for care providers on the association of patients’ residing neighborhoods and healthy pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04056-1.

Predicting women with depressive symptoms postpartum with machine learning methods

Postpartum depression (PPD) is a detrimental health condition that affects 12% of new mothers. Despite negative effects on mothers’ and children’s health, many women do not receive adequate care. Preventive interventions are cost-efficient among high-risk women, but our ability to identify these is poor. We leveraged the power of clinical, demographic, and psychometric data to assess if machine learning methods can make accurate predictions of postpartum depression. Data were obtained from a population-based prospective cohort study in Uppsala, Sweden, collected between 2009 and 2018 (BASIC study, n = 4313). Sub-analyses among women without previous depression were performed. The extremely randomized trees method provided robust performance with highest accuracy and well-balanced sensitivity and specificity (accuracy 73%, sensitivity 72%, specificity 75%, positive predictive value 33%, negative predictive value 94%, area under the curve 81%). Among women without earlier mental health issues, the accuracy was 64%. The variables setting women at most risk for PPD were depression and anxiety during pregnancy, as well as variables related to resilience and personality. Future clinical models that could be implemented directly after delivery might consider including these variables in order to identify women at high risk for postpartum depression to facilitate individualized follow-up and cost-effectiveness.

Healthcare resource utilization and costs associated with postpartum depression among commercially insured households

OBJECTIVE

To quantify the economic burden of postpartum depression (PPD) that accrues to commercially insured households in the year following childbirth.

METHODS

Administrative claims data from OptumHealth Care Solutions (2009-2016) were used to identify households that included women identified with PPD per the algorithm and propensity score-matched comparison households of women who were not identified with PPD or a history of depression after childbirth. Study outcomes included direct total all-cause medical and pharmaceutical costs during the first year following childbirth and number of outpatient visits at the household level stratified by household member.

RESULTS

Households affected by PPD as identified by the algorithm (N = 7769) incurred 22% higher mean total all-cause medical and pharmaceutical spending than unaffected matched controls (N = 41,308) during the first year following childbirth ($36,049 versus $29,448, p < 0.01) and an average of 16 more outpatient visits than unaffected households (p < .01). Costs accrued by mothers comprised the largest share (>50%) of total all-cause spending. Mothers identified with PPD had significantly higher annual mean direct total all-cause medical and pharmaceutical spending than their matched controls without PPD ($19,611 versus $15,410, p < .01), driven primarily by an average of 11 more outpatient visits than unaffected mothers (p < .01).

CONCLUSIONS

Households affected by PPD as identified by the algorithm incurred higher mean total all-cause medical and pharmaceutical spending during the first year following childbirth than did their matched controls identified without PPD, but not all costs were attributable to maternal treatment for PPD. These findings contribute to a better understanding of the potential economic burden associated with PPD and demonstrated costs may extend beyond the mother to members of the household.

Economic burden of maternal morbidity - A systematic review of cost-of-illness studies

Aim

To estimate the economic burden of common health problems associated with pregnancy and childbirth, such as incontinence, mental health problems, or gestational diabetes, excluding acute complications of labour or birth, or severe acute adverse maternal outcomes.

Methods

Searches for relevant studies were carried out to November 2019 in Medline, Embase, CINAHL, PsycINFO and EconLit databases. After initial screening, all results were reviewed for inclusion by two authors. An adapted version of a previously developed checklist for cost-of-illness studies was used for quality appraisal. All costs were converted to 2018 Euro using national consumer price indices and purchasing power parity conversion factors.

Results

Thirty-eight relevant studies were identified, some of which reported incremental costs for more than one health problem (16 gestational diabetes, 13 overweight/obesity, 8 mental health, 4 hypertensive disorders, 2 nausea and vomiting, 2 epilepsy, 1 intimate partner violence). A high level of heterogeneity was observed in both the methods used, and the incremental cost estimates obtained for each morbidity. Average incremental costs tended to be higher in studies that modelled a hypothetical cohort of women using data from a range of sources (compared to analyses of primary data), and in studies set in the United States. No studies that examined the economic burden of some common pregnancy-related morbidities, such as incontinence, pelvic girdle pain, or sexual health problems, were identified.

Conclusion

Our findings indicate that maternal morbidity is associated with significant costs to health systems and society, but large gaps remain in the evidence base for the economic burden of some common health problems associated with pregnancy and childbirth. More research is needed to examine the economic burden of a range of common maternal health problems, and future research should adopt consistent methodological approaches to ensure comparability of results.