When a doctor starts asking a new mother about feelings of depression, therapist Haley Walker said the patient may be thinking about more than her actual symptoms. 

“[It] can feel scary as a new mom,” Walker said. “You’re like, ‘Is this person going to try and take my baby if I’m honest?’” 

Walker specializes in mental health during pregnancy and postpartum at her private practice in Mexico, Missouri, about 40 miles northeast of Columbia. She said patients may not feel comfortable answering certain personal questions honestly unless providers explain why they are asking and normalize the fact that new mothers often struggle with their mental health. 

But the stakes of detecting mental health struggles in new mothers couldn’t be higher. 

In Missouri, mental health conditions are among the leading causes of death during pregnancy and in the year after giving birth. 

The state’s latest Pregnancy-Associated Mortality Review (PAMR) report found that conditions including depression, anxiety and substance use disorders contributed to nearly a quarter of pregnancy-related deaths from 2019 to 2023.

And the risk is even higher for women in rural areas, who are 21% more likely to experience perinatal depression than women in urban areas, according to a 2020 study.

Compared to how other states address mental health during and after pregnancy, Missouri falls somewhere in the middle, according to the Policy Center for Maternal Mental Health, a national think tank that doles out annual report cards for states. 

Missouri received a C in 2026, up from its D-minus in 2023. 

That’s in part because the state has tried to boost screenings for mental health conditions among pregnant and postpartum patients, creating programs to help doctors and social service providers more easily identify patients who may need help. 

But those kinds of screenings aren’t mandatory in Missouri.

And the screening, which only takes a few minutes, is just the first step to getting someone the care they need. 

Finding providers to treat patients can take weeks, could require a long drive, or could end with no appointment at all. 

Too many preventable maternal mental health deaths 

Of the 108 pregnancy-related deaths that the state of Missouri reviewed, 17 were due to mental health conditions, while another seven were due to substance use disorder.  

The numbers have stayed relatively steady, aside from an uptick during COVID-19. From 2017 to 2019, 17 women died from mental health conditions, including substance use disorder, the top cause of death during that time span. 

Overall, the pregnancy-related mortality rate was 2.9 times higher for women on Medicaid than for those on private insurance, and the rate for Black women was 2.5 times the rate for white women, the report found. 

Nearly 80% of the deaths were preventable, the review board determined, including every death related to mental health or substance use. 

Dr. Kimberly Brandt, the incoming chair of Missouri’s PAMR board, said the reviews look across a patient’s care for places providers could have intervened. 

“Can we see in their care — was there a point where somebody offered to help?” Brandt said. 

One of the biggest opportunities? Asking patients the right questions.

Missouri’s report found that in 38 of the deaths, providers failed to complete screenings for mental health conditions or other top causes of death, like cardiovascular problems. 

The findings don’t mean a questionnaire or screening alone would have prevented someone from dying. But they do show how often the healthcare system missed a chance to identify a potentially fatal condition and respond. 

Limited resources create additional barriers for women in rural Missouri. 

Northeast Missouri had the state’s highest pregnancy-related mortality rate, followed by the St. Louis region and southwest Missouri. 

Early screening

The PAMR board recommends that all providers who come into contact with new families try to complete a screening. 

A screening detects possible symptoms, and an assessment then should determine what a mental health condition may be and its severity. 

And those screenings should begin during pregnancy, said Nancy Byatt, a perinatal psychiatrist at University of Massachusetts Chan Medical School. She cited research that found among patients with postpartum depression, about two-thirds experienced the onset of depression before they gave birth. 

“If we wait to start screening until somebody’s postpartum,” Byatt said, “we’ve missed a window.” 

Parents may not recognize their own symptoms as depression or anxiety, said Alison Williams, the director of the Missouri Perinatal Quality Collaborative. 

She recalled her own experience with mental health postpartum. 

“I couldn’t have told you that I was depressed or that I had major anxiety,” Williams said. “I just knew I felt out of control.” 

“I wish we would take the term ‘baby blues’ out of our nomenclature,” Williams said, “because it’s so much more than that.”

Screenings don’t equal treatment for maternal mental health conditions

Following a screening, providers should connect patients with treatment options, including therapy, medications or social support. 

But that’s where things can get tricky.

Byatt compared mental health screenings to checking someone’s blood pressure. 

A doctor wouldn’t identify high blood pressure, tell the patient to find someone to treat it and consider the work finished, she said.

“The challenge with mental health is sometimes that’s what happens,” Byatt said. 

Williams recalled hearing about a mother who scored high on a depression screening during a pediatric visit. The mom explained her history of mental health problems and was addressing them. Their provider responded that depression was common, and moved to the next topic. 

“That’s a checkbox,” Williams said. “‘We said we were going to do a screening, and we did a screening.’” 

Michigan illustrates the gap between boosting screenings and boosting treatment. In 2018, the state began allowing pediatric providers to bill Medicaid for screening mothers during well-child visits. Screening increased but was still below 10%.

Researchers found little overall increase in treatment, although ZIP codes with the highest screening rates were associated with a 10% higher probability of getting treatment. 

Paying providers for the screening helped, but it did not guarantee people got the care they needed.

Far from care

In Mexico, Missouri, Walker’s patients are frequently frustrated by the travel required to get care.  

“The majority of the trend I notice is frustration with the fact that we don’t have anybody in Mexico that delivers babies,” Walker said. “We used to have a hospital, and now we don’t.” 

Traveling to Columbia can mean taking time away from work and finding transportation, Walker said. 

Nearly every county in the state is designated as a mental health professional shortage area, data shows. 

And the providers that Walker’s patients have easier access to aren’t always equipped to handle what’s going on, she said. Local urgent care and primary care providers often respond to immediate concerns, she said, but most don’t have the training to see how depression, anxiety or trauma appear during pregnancy and postpartum. 

“It can be very disappointing and disheartening when (patients) finally ask for help,” Walker said, “and then they go there and they’re let down or made to feel inadequate.” 

Bringing maternal mental health expertise closer

Missouri’s solution can’t be to send every patient with depression or anxiety to a psychiatrist, Byatt said. There simply aren’t enough specialists, especially in rural communities. 

“We can’t be referring everyone to a mental health specialist,” Byatt said. “It’s not realistic.” 

Byatt developed a program in Massachusetts to help fill that gap. Now, similar programs operate in 31 states. 

Missouri’s version, the Maternal Health Access Project, allows providers to consult with psychiatrists about how to respond to a positive screening and begin treatment or whether specialty care is needed. 

The goal is to bring psychiatric experts to the patient’s providers, rather than asking patients to find new providers themselves. 

Byatt acknowledged her programs aren’t a “build it and they will come” solution. Clinicians must first know the help exists, then know how to use it. 

But patients still need someone to carry out the care plan and follow their progress. 

That coordination can be difficult in rural communities when a patient’s therapist, primary care doctor and obstetrician often work in separate health systems. 

Walker said that she has sent emails and faxes to doctors without receiving a response. Meanwhile, private psychiatric care exists but is out of reach for patients who need continuing treatment. 

Clinical care is only part of what mothers need after delivery, Williams said. Family and community support matter too, and can often disappear when attention shifts to the baby. 

“Everybody comes around the mom so much until she delivers,” Williams said. “They’re there for the week afterward, then people start to scatter to the four winds. It’s like, no, no, no — that’s when she really needs you.”