Bonus Episode! Perinatal Mental Health and Tailored Prenatal Care

In our first ever bonus episode, we have a discussion with Dr. Alex Peahl, Assistant Profession of University of Michigan Health and a primary author of the new Tailored Prenatal Care guidance published by ACOG in May of 2025. We learn how the guidance kept maternal mental health top of mind during the development, and tailored care meets the individual needs of all pregnant patients, especially those with mental health conditions. 

This podcast is sponsored by Sage Biogen. 

Transcript

00:00:00 Speaker: Hi, my name is Lisa Satterfield and I'm on Acog's Health and Payment Policy team. We have a special edition podcast series for you. This month is on perinatal mental health, and our first conversation is with Alex Peel out of the University of Michigan and one of the primary authors of Tailored prenatal care. So we'll be talking to her about how the tailored prenatal care guidance that was released by Acog this spring relates to mental health care for our pregnant people. In addition, we will also be having a couple of presentations on the web to support these podcasts on how to bill for all of these services. So we're really excited to do this and I hope you enjoy the Our presentations.

00:00:57 Speaker: Hello and welcome to our podcast series on maternal mental health. I'm excited today to have Alex Peel with us from the University of Michigan. Hi, Alex. Hi. It's great to be with you today. It's great to see you and to be with you. So, introduce yourself and tell us all about you and and some kind of fun fact about you that our listeners can enjoy. So my name is Alex Peel. I'm a practicing OBGYN and a health services researcher at the University of Michigan. I've been in practice. It's a generalist for seven years. I do full spectrum obstetric practice, um, including providing tailored prenatal care. I'm also the co-director of the partnering for the Future Clinic, which is a clinic that specializes in comprehensive care for birthing people with opioid and other substance use disorders, as well as chronic pain. And in that clinic, I'm co-located with a psychiatrist in a behavioral health consultant to really get to provide those wraparound services with Acog. I have been the chair of the Acog Redesigning Prenatal Care Initiative, which helped to support the new Acog clinical consensus on tailored prenatal care. And I'm a member of the clinical consensus OB committee. And a fun fact about me is, in the time that I was creating or helping to support the new prenatal care guidelines, I actually got to go through prenatal care twice myself. So I have a four month old and a four year old at home right now. Amazing. That's how long we've been working on this, right? Not that I did a lot of work on prenatal care, but I remember first meeting you, Alex, when you were working on the Mypath. The to the the precursor to the guidance document. And we started talking at the coding committee about how this, um, guidance will change the way OB needs to be coded and billed for, which is very timely. So it was a very fun project to work kind of parallel while you guys were working on the guidance document and while we were working on the coding. So, um, very excited that we're here talking about the guidance, and we will be talking about the coding in the next year or two. So excited about that. Um, can you briefly describe the process you took from my path to tailored prenatal care? And then we'll dive into the tailored prenatal care itself? Absolutely. I'll start with a little bit of my personal journey to this topic. So I became interested in prenatal care redesign during my training. I really saw there how that one size fits all model of care just wasn't working for my patients. Like many clinicians we've heard from around the country, I watched how for some people, especially those who are taking multiple buses or juggling children in work, this 12 to 14 in-person visit schedule was just too much. It was really burdensome. And for other patients, it wasn't enough. Those patients needed additional support or reassurance between visits. And across both of these groups, prenatal care was being delivered in these short, ten minute, medically focused visits that just weren't fulfilling for patients or providers. So I really started to wonder if we could do better. And part of coming to Michigan for me was actually to get training in health and health policy, to learn exactly how to enact that change. I had started talking with Acog leadership about the need to rethink prenatal care when the Covid 19 pandemic hit, and that really catalyzed many of the elements of tailored care that have become part of our new guidelines at U of M and many places across the country. During the pandemic, we started to use telemedicine, targeted visit schedules, home monitoring to reduce viral exposure and maintain our resources. These laid the foundation for many of the options that are now part of tailored prenatal care. So with that background, in December of 2020, we brought together this national panel of experts to take the best available evidence. We had clinical judgment where we needed it and develop a new plan for appropriate, tailored healthcare and pregnancy. Our path and the path panelists and developing that plan really highlighted the importance of continuing to bring in more data and also public opinion to support those future recommendations. So after 2020, we spent five years doing just that, getting as much data as we could. We worked with Ahrq to complete systematic reviews of the evidence for key parts of tailored prenatal care. And we also completed a national listening tour with over 100 participants across 25 organizations with patients, advocates, clinicians, researchers and policymakers even payers at the table. And all of that information has come together through Acog's rigorous clinical consensus process to create the new tailored prenatal care guideline. That's amazing, and I did. I was honored to be part of some of those conversations with the payers when we were working on this early on. Um, because one of the issues that we've had with the OB global, as you are well aware, is that because only one code is being billed for the entire episode of care, we don't really have easy data to show how many visits are really resulting in the best outcomes. Right. So I'm very excited to start working on getting that part of it all changed as well. Um, so describe for me the principles of tailored prenatal care. Now we know how you got here. Now what? How would you summarize the principles of the guidance? So the goal of this new guidance is to really promote equitable care by focusing on the upstream drivers that contribute to maternal morbidity and mortality, and in particular, the disproportionate maternal morbidity and mortality seen among marginalized populations. The plan has three key steps one. Screening for medical and social drivers of health, two asking patients their preferences for care delivery to inform shared decision making, and then three developing that tailored plan. And that plan is tailored in three key areas the frequency of visits, the modality through which those visits are delivered, and then how we address social and structural drivers of health. This allows for flexible care plans that are tailored to each patient's needs and their preferences. So really stepping away from that one size fits all model and it differs from that traditional approach to care, where every patient gets 12 to 14 visits regardless of their risk factors. It really allows us to deliver care in the context of patients lives. A few other things that I just want to highlight. Tailored care is comprehensive. It asks maternity care professionals to be at the center of all services, not necessarily delivering everything, but coordinating and serving as that care quarterback. Tailored care is not less care. And in fact, in many ways it's more, um, doing one size fits all is really a little bit easier for health systems, right? You just have your template. Every patient gets the same thing. Tailoring requires time. It requires thought. It requires conversation and flexibility. Um, and sometimes, for example, when using the streamline visit schedule, this can be more effective with longer visit times. So patients who move from a traditional to targeted visit schedule but with extended visits have more time with their provider, but less time spent traveling between visits. That makes so much sense. Um, I, you know, I'm older and my kids are in their 20s and 30s now, but back in the day, having four kids, I remember that fourth one. I'd already done it four times. Why did I have to do all 13 visits? You know, nothing was complicated about it, the idea of being tailored to not only the medical needs of the patient, but the social needs and the family needs as well, what an exciting turn this is in the delivery of prenatal care for patients. So, building on that screening and the care plan piece of that, how do you consider, um, how maternal mental health fits into the tailored prenatal care plan model? Mental health was really top of mind in thinking about the need for prenatal care tailoring, and it's listed as one of the key medical conditions to be screened for and addressed throughout the routine prenatal care experience. Just as some patients may need additional services for chronic hypertension or diabetes, so too may additional follow up be needed for depression, anxiety, other mental health conditions. I think the beauty of tailored care is that it encourages clinicians to think critically about what services are needed for that condition, how they can best be delivered, and by whom. So, for example, a patient requiring medication titration for anxiety and pregnancy may require frequent visits, but those can be done virtually if other in-person services are not needed at that time. Similarly, if a clinician is co-managing with psychiatry or behavioral health consultants, more frequent prenatal visits with the OB-GYN or other maternity care professional may not be helpful. And in fact, they may add an additional burden to already stressed patients who may be facing unmet social needs. And so this kind of individualization is really important for helping us find the right service, for the right patient, in the right place and time. And these principles can be applied to patients with chronic conditions or pregnancy complications, like a patient with chronic hypertension or gestational hypertension who's coming in for weekly monitoring. Instead of asking that patient to come in for multiple prenatal visits, perhaps some of the services we need to be delivered can be streamlined through that testing. That makes so much sense. Now, in all of this, I would imagine there are still like the standards, right? That there's it's tailored. But there are still the certain things that every patient is going to receive. And I'm assuming that a comprehensive assessment that is usually around ten weeks, if I'm correct, feel free to correct me. Um, you've got it. It includes a mental health assessment, for every patient You got it. Yeah. So ideally that assessment is happening before ten weeks. But if a patient is not able to be seen before that time as soon after as possible. And I want to highlight that visit does not have to be in person. That can be completed virtually. Um, and can be done by any trained member of the care team. It doesn't necessarily have to start with the maternity care professional. That assessment should be comprehensive, and that means medical and social drivers, including mental health concerns. Um, again, mental health was really considered an integral part of those medical factors. The clinical consensus does not specify which screening tool should be used. Clinicians can refer to Acog, CPG five, the treatment and management of mental health conditions during pregnancy and postpartum for recommendations on the specific tools for screening, but the process and the timing with which that can be done is shared in that tailored document. Great. And then assuming two things change during pregnancy, including mental health conditions. Right. So, it'd be appropriate to reassess at certain periods. Is there a reassessment schedule or is it again tailored to the the needs of the patient? 100% pregnancy risk evolves over time. Medical needs can change, including the development of pregnancy complications. Social risk factors can change, and with both of those, mental health can also evolve. The guidance does recommend reconsidering patients risks and preferences as pregnancy continues. There is not specific guidance set for this cadence, however, I will share in my own practice at the University of Michigan, we screen patients at least three times in pregnancy for mental health conditions, once at the initial prenatal visit, again at 28 weeks, and again postpartum. And those are formal screenings using validated measures for patients with additional risk factors. For mental health conditions like a history of anxiety or postpartum depression. We will often schedule a virtual mood check at 1 to 3 weeks postpartum to reassess how the patient's coping and connect them to resources if needed. There's also some interesting work being done by my colleague, Doctor Carey Bell. She's designed an SMS based program that Pregnancy to Parent Wellness program, and this program proactively sends text messages asking patients about a variety of needs, including postpartum mental health, and provides an easy referral back to services. So I think, in short, this really should be tailored in that frequency of assessment, and follow up should be based on the patient's needs and preferences. But it may be helpful to have some formalized time points put in to make sure that no one falls through the cracks. I think that makes absolute sense. One of the things I'm thinking about as you talk is, you mentioned earlier that because the visits might be more comprehensive and longer, hopefully there's a closer building of trust between the patient and the OB so that there are opportunities for the patient to feel like this is a safe space to talk about my mental health issues. 100%, that relationship based component can be really critical for creating a safe space. talk to me about the plan of care. the plan of care for tailored prenatal care, um, is is very unique to this, model of care. How does it work with external providers? You said that you have in your clinic a psychiatrist and a Paterson and behavioral health expert. do their plans of care, when appropriate, become a part of the tailored prenatal plan of care. Tailored prenatal care asks clinicians and patients to partner to develop a care plan based on needed services, not an arbitrary visit schedule. And this includes services like mental health, including those with mental health professionals. In practice, this may mean that a patient with mental health concerns has a targeted visit schedule with the maternity care professional to meet their prenatal care needs, but this can be interspersed with appointments with mental health care professionals for their mental health needs. So really matching that service to the right provider and context. Historically, we have not done this. A really clever study by Doctor Elizabeth Kranz in 2014 showed that maternity care professionals, including obese and family medicine physicians and midwives, were more likely to add prenatal visits for psychosocial risk factors, including mental health concerns. The only tool you have is a hammer. Everything's a nail. And as obese and other professionals, our only real tool for addressing concerns was with prenatal visits. So tailored care really reframes the question as what services are needed and how can these play out over the course of pregnancy and the postpartum period? That's excellent. And I would imagine that it can be applied differently in different types of settings too. So you're at the University of Michigan setting, which is a pretty large, medical facility. But, tailored prenatal care is not limited to that. it could be used in rural health as well. And even with the telehealth component, Right? Yeah. Telehealth is really an integral part of the options available through tailored prenatal care. So every patient's. Journey in tailored care is a little bit different, but it builds on that same foundation with a positive pregnancy test. There's a comprehensive needs assessment, and that can be done virtually to minimize the burden and help to improve access to that service. Support early optimization of health and well-being. The first prenatal visit often needs to be done in person to complete those in-person services. Laboratory testing the viability ultrasound if needed. But after that, the services can really be thought about in the context that they need to be delivered. Often, patients will prefer in-person care until they can perceive fetal movement. That allows patients to have that check in point to hear the fetal heartbeat. But after around 20 weeks at appointments where those in-person services aren't needed, virtual care may be an option, and certain patients may be more likely to select that than others. For example, a first time mom living away from friends and family without good social support who has high pregnancy related anxiety may not desire telemedicine. And that's okay. But a working mom who lives 90 minutes from clinic and really has significant barriers to making those appointments, may feel a lot of relief in not having to travel. So the goal is to really, again, match the services to what's needed and help patients to access care in a way that best supports them. With telemedicine, I think it's also important to think about home monitoring. This can really be used to improve the monitoring of routine pregnancy parameters. Blood pressure is the key area that we think about this to date. Monitoring blood pressure is important for timely detection of complications and management of chronic hypertension or pregnancy related hypertension as well. Um, this can also be important in just routine care. Patients who are receiving telemedicine need to have some way of measuring their blood pressure. And certainly the most straightforward way is for them to have a blood pressure monitor at home. Our survey work from U of M has shown that in patients who have Medicaid insurance, access to that blood pressure monitor is one of the biggest barriers to virtual care. I think there's a lot of advocacy work to be done there, but it's an easy win. It gives patients access to an important piece of equipment that they can use not only throughout their pregnancy and postpartum, but also for lifelong health. Exactly. I'm going to take us off on a little tangent here before we wrap up, but I noted that you again said you have a psychiatrist and a behavioral health, manager or expert in, in your, clinic. And I am talking to Doctor Emily Miller out of Rhode Island, who, also has a psychiatrist and behavioral health, care manager on her team, for collaborative care model. So we're going to have a discussion about that later. But do you have, any insight on how, the tailored prenatal care and the collaborative care model, if you use that, how they interact with each other? Yes. So, um, in our partnering for the future clinic, we care for a really high risk group of patients, patients with opioid and substance use disorder, as well as chronic pain. And these are patients who have many mental health and social needs. Um, about 80 to 90% of our patients have concurrent mental health concerns. And a similar proportion also have unmet material and social needs. So I feel really privileged to get to work in this clinical setting where we're able to provide that gold standard wrap around support in our clinic to support collaboration. We start with case review, where every member of the care team sits down and runs the patient list for clinic that day, but also clinics, clinic patients in our panel who aren't being seen, but we are following that allows each team member to contribute their expertise and really allows us to understand the expertise of other care members and how we can work together. We try to have our clinic coordinator in social work, social worker, present patients first to bring those perspectives to the top of mind as we consider care delivery. And we're also able to bring in learners to the environment so that they're able to see the power of this care model. We've developed resources that translate the path the plan for appropriate tailored health care into paths. The path specialized. Um, and that allows us to visually represent how the mental health, behavioral health and physical resources all work together to support patients, including education and social support. So we see tailored care as the foundation of what we do in partnering for the future, and bring in all of these additional folks to help provide the best support to our patients. That's amazing. I'm just so excited about this change in prenatal care and the, the focus it puts on the individual and the family. It's just so critical, I think, in medicine. And I know, like, the payor side of me is like, ah, but it's going to be different for, you know, for everybody. But that's, that's the beauty of it. Right. So it should be different for everybody. We're all different people. so just to wrap up here, what what advice would you give to OBS across the country when considering implementing this tailored prenatal care model and how to ensure that, persons with mental health issues are not left out of the the model itself. It is not easy to change a century old way of delivering care. And yet we have heard from patients, clinicians like you across the country that there's a global recognition of the need for change. Um, we've heard this in our listening tour of 100 people from 25 organizations. We've heard it in the talks we've given locally and on the national level at Acog. And there really is that need to improve care outcomes and experience for all patients, especially those facing the worst pregnancy outcomes and those with mental health conditions who are often marginalized by the current health care system. We are aware of the headwinds that everyone is facing. There's limited quality infrastructure in outpatient spaces, making it difficult to scale change. Clinics are already overwhelmed with rural hospital closures and limited key support. We know that there are big barriers that Lisa your team has been working so hard to overcome. So making this change when resources are limited may seem insurmountable. We get that. And for those reasons, our team has built a suite of implementation resources that will be available on the Acog website for all practices to download and use. These include patient handouts, a provider CME presentation, documentation, support, even a tool that will demonstrate the operational efficiency gained by transitioning to tailored prenatal care. We really want to make tailoring care the easy thing to do. Just as you said, every pregnant person is unique and so too should their prenatal care plan. We really believe that by better integrating medical, mental and social needs from the beginning of pregnancy, tailored care can make sure patients access the services they need with limited burden. This can support patient autonomy, help us to overcome the negative experiences. We know our patients are coming to us with and build trust. So as we're trying to overcome some of the biggest challenges in maternity care and maternal morbidity and mortality crisis, inequities and outcomes and misinformation crisis, I really believe that tailored prenatal care represents that needed paradigm shift to improve access, outcomes and experience. Oh, I completely agree. I cannot wait to create the resources that that change the coding construct for all of this. Right now we do have some coding tips. but um, we will be under the OB global till at least 2027. Hopefully there'll be changes in 27, that we are working diligently on, as you know, and I cannot wait to develop those resources that tailor the coding to the tailored prenatal care. So, thank you, Alex, for this. It's it's so important and so helpful, especially as we talk about meeting the needs of individuals with mental health issues. And I really appreciate your long time work on this important endeavor and initiative, and look forward to seeing how it rolls out here in the future. Thank you for all of your work to support the the initiative, and it's been such a pleasure getting to talk to you today.

00:25:57 Speaker: Again, I want to thank everybody for their participation in this series on perinatal mental health, for the Payment and practice podcast and videos. and a big thank you to our sponsors, Sage Biogen, for providing the resources necessary to get this evidence based, solid, advice out to OB GYNs across the country. Thank you, Sage Biogen, for your ongoing support of this program.