When Julie Bjorklund was pregnant with twins in 2023, doctors discovered one of her babies had a heart defect and the other was struggling to grow.
Bjorklund had a C-section at 27 weeks to deliver the twins after one of them, Elin, died in utero three days prior. The other twin, Hayley, weighed 1.5 pounds.
During her month-long stay in October of that year at the Colorado Fetal Care Center at Children’s Hospital Colorado in Aurora, Bjorklund saw psychiatrist Dr. Heather Buxton to cope with her difficult pregnancy.
“Nothing prepares you for motherhood in general but definitely not for a complicated pregnancy, so getting the support you need from the beginning and before you need it is important,” Bjorklund, 41, who lives in Castle Rock, said.
One in five new parents deal with mood or anxiety issues during pregnancy or postpartum, according to national data. In Colorado, 1 in 11 women experience postpartum mood and anxiety disorders.
That a psychiatrist was embedded in Bjorklund’s health care team and could provide both medication and psychotherapy for pregnant patients is unique, Buxton noted.
Bjorklund’s care was part of a new program in Colorado, launched in September 2023, that utilizes psychiatrists to provide better care and improve health outcomes for pregnant patients and new mothers, who have experienced higher rates of postpartum depression over the past decade.
Another new program, established in August of last year, is a free telephone hotline where health care providers can talk to psychiatrists about their pregnant and postpartum patients with anxiety, depression and addiction. The program started in Massachusetts two decades ago, and Colorado and 12 other states received funding in 2023 to launch a similar initiative.
Nick Bjorklund waters the sapling where his late child Elin’s ashes are spread on Saturday, Feb. 8, 2025, at the Bjorklunds’ home in Castle Rock, Colo. When his wife Julie Bjorklund was 27 weeks pregnant, she had a C-section to deliver her twins. Elin had died in utero, and Hayley was 1.5 pounds. Photo by Eli Imadali / Special to The Colorado Trust
Medical experts in both programs hope their efforts can reduce the risk of death for Colorado patients during pregnancy and the first year of motherhood. Unintentional overdose and suicide are the two leading killers of new mothers in Colorado.
From 2017 to 2021, there were 188 pregnancy and postpartum deaths in Colorado. Almost all were preventable with appropriate screening and treatment, according to the Colorado Maternal Mortality Review Committee, said Maria C. Livingston, a Colorado Department of Public Health and Environment spokesperson.
“Maternal mental health conditions are the most common complication during pregnancy and the postpartum period,” Livingston said, who noted that Colorado and the U.S. overall had increased maternal mortality from 2017 to 2021 compared to 2016 to 2020. One contributing factor is unintentional drug overdose deaths, including the increased presence of fentanyl in Colorado.
People of color—particularly those who are Black or Native, people living in poverty and people living in remote and sparsely populated rural areas—are among those who face disproportionately higher rates of maternal mortality, according to a CDPHE report. The report was published in 2023 and analyzed maternal mortality rates between 2016 and 2020. Native women were three times as likely and Black women were twice as likely to die during pregnancy or within their first postpartum year than the overall population in Colorado, the report stated.
A 2024 Colorado law aims to reduce maternal mortality by increasing access to midwives and studying the impact of maternity facility closures on Black, Native and Hispanic people. As part of the law, CDPHE will deliver best practices and recommendations to the Colorado House of Representatives Health and Human Services Committee by July 2026.
Hotline for rural clinicians and those serving women of color
In the summer of 2024, the University of Colorado launched the PROSPER website and hotline with a 5-year, $3.75 million federal grant award. PROSPER stands for Perinatal Resource Supporting Obstetric Screening Psychiatric Education and Referral.
The university oversees the program, which is free to obstetrician-gynecologists, midwives, pediatricians and any other Colorado health care provider to call with questions about patients. Someone from a team of 12 maternal health specialists calls the provider back within 24 hours.
PROSPER is a statewide program that tries to reach clinicians caring for pregnant or postpartum people of color and those in rural areas. The risk of pregnant people dying is more than three times higher in more rural counties (referred to as frontier counties in the study) compared to urban counties, according to the CDPHE maternal mortality report.
“We really want to reach out to rural areas and hopefully be a phone call away,” said Dr. Celeste St. John-Larkin, the program’s lead psychiatrist and project director and an associate professor at the University of Colorado School of Medicine.
Dr. Jenni Adams, a family medicine and obstetrics physician at Heart of the Rockies Regional Medical Center in Salida, first called the PROSPER hotline in the fall of 2024 to get advice on managing medications for a pregnant patient with depression.
Heart of the Rockies serves the roughly 20,000 residents of Chaffee County and the nearby counties of Custer, Fremont, Park and Saguache. Some patients drive over an hour one way for care. Anxiety disorder and depression are the most common mental health conditions in Adams’ pregnant patients. They also experience post-traumatic stress disorder, bipolar disorder and substance use disorders involving alcohol and opioids.
A lack of therapists and psychiatrists in this part of Colorado cannot meet the demands of pregnant people with these issues. Adams noted that wait times, cost and transportation challenges are all barriers to caring for her rural patients.
PROSPER has been a lifeline for Adams, who says her patients with mental health disorders deserve good care. It’s helpful to get a specialist to advise about complicated scenarios in pregnancy, like multiple medications or side effects, she said.
“There is no easy way to refer them to a perinatal psychiatrist,” Adams said. “They’d have to drive to Anschutz [medical campus in Aurora], and that’s impossible for many people, especially if you have severe mental illness.”
Roughly 40% of counties in Colorado are designated maternity care deserts without birthing hospitals or obstetrics care, and these often overlap with a lack of mental health or substance use services. Only one mental health provider exists for every 1,282 rural Coloradans, according to the nonprofit Colorado Rural Health Center.
Telehealth could help those in rural areas who don’t have access to mental health providers. In the fall, PROSPER will begin referring providers and their patients to a new peer-to-peer support hub online called Alma. Launched at the University of Colorado in 2018, the six- to eight-session program pairs trained mentors who have experienced depression during motherhood with pregnant or postpartum women dealing with the issue.
PROSPER also refers patients and providers to telehealth services across the state.
Overcoming fear and stigma about medication
Psychiatrists at both PROSPER and Children’s Hospital Colorado want to reduce the stigma about using medications to treat mental health and substance use during pregnancy.
The notion of avoiding psychiatric medications during pregnancy “has been a narrative for a long time that is honestly incorrect,” Buxton of Children’s Hospital Colorado said. “We have safe and effective medications we can offer.”
Sixty percent of Buxton’s patients take medications for mental health or substance use, while the other 40%, including Bjorklund, do not and respond well to psychotherapy or other social-emotional support.
Providers may also not know about newer drugs like Suboxone (buprenorphine and naloxone) that can be used to treat opioid use disorder, which quadrupled in the U.S. from 1999 to 2014 in pregnant people, and mirrors a rising prevalence of opioid use disorder in the general population. Suboxone is considered safe for pregnant people and infants. Unlike methadone—which must be administered at specialty clinics that are sparse outside the Front Range—suboxone can be taken at home.
All drugs have risks, including those to treat substance use or mood disorders, but untreated mental health and substance use disorders also pose challenges and are associated with preterm birth, low birth weight, impaired bonding and increased mental health concerns for children in the long term.
An embedded psychiatrist to help at-risk moms
With Buxton, Bjorklund participated in cognitive behavioral therapy, a type of talk therapy that identifies and changes negative thoughts into positive behaviors. Bjorklund said it felt like a conversation about her difficult pregnancy and helped her navigate the unknowns.
Julie Bjorklund feeds Hayley a bottle of thickened formula before bed on Saturday, Feb. 8, 2025, at their home in Castle Rock, Colo. Photo by Eli Imadali / Special to The Colorado Trust
Bjorklund continued seeing Buxton while baby Hayley lived at the neonatal intensive care unit (NICU) at Children’s Hospital Colorado for five months, undergoing several surgeries and sometimes being placed on acute life support. This is a critical time, said Buxton, when the focus can quickly shift to the baby rather than the mental health of new parents.
The NICU can be one of the most stressful experiences for new parents, and prolonged stays like Hayley’s can make the experience seem endless. Nearly half of mothers with babies in the NICU meet the criteria for acute stress disorder.
Buxton knows this stress on a personal level.
She experienced her own difficult pregnancy when her water broke at 27 weeks in September of 2022, and then her newborn was in the NICU. She realized how much support parents need during high-risk pregnancies and births. Before Bjorklund’s delivery, Buxton explained how the NICU could be mentally and emotionally draining and told Bjorklund and her husband about the unfamiliar sights and sounds they might encounter, like their baby being on an oscillator, the highest form of life support.
Bjorklund waited eight days after delivery to hold Hayley in the NICU. Two days later, Hayley underwent surgery that she initially wasn’t expected to survive. Bjorklund and her husband Nick waited another week to hold Hayley as she recovered.
“Most people just get to see and hold their baby, but I had to look at her like she’s in an aquarium,” Bjorklund said. “That was probably the hardest part, adjusting and knowing that it wouldn’t always be like that and that once we got out of the critical phase, it would feel more like a normal experience.”
Hayley shouts and plays as she eats dinner while her parents Julie and Nick Bjorklund watch on Saturday, Feb. 8, 2025, at their home in Castle Rock, Colo. Photo by Eli Imadali / Special to The Colorado Trust
For Bjorklund, Buxton and social worker Katie Arora-Frank went above and beyond from the first week Hayley and her mother arrived at Children’s Hospital Colorado. This team approach is ideal, Buxton said. She points out that psychiatrists are not substitutes for social workers, some of the hospital’s hardest-working and most important people.
“I just think there’s a little room for psychiatry if we want to be able to do medical management for all birthing parents in the NICU,” Buxton said.
Challenges ahead
Colorado’s new PROSPER hotline is based on a 2004 Massachusetts program that was so successful that it has become a model for others across the U.S. The Massachusetts iteration now has multiple state and private funding streams.
That type of money for maternal mental health is hard to come by in Colorado.
“Colorado is in a different place with mental and behavioral health funding,” said Alexandra Andrews, PROSPER’s program manager, adding that the state is likely decreasing funding for several initiatives in the coming years that the university oversees, including substance use disorders in the workplace and support for educator mental health.
For the next four years, PROSPER will continue seeking a renewal of funding from the federal government for its five-year award, but it currently only has funding secured through September, St. John-Larkin said.
Buxton, like Andrews, sees funding as a challenge. Many rural hospitals have already cut back on basic obstetric and gynecologic care for pregnant people; psychiatric care is even harder to come by in many such locales. There are more pregnant people in need than appointment slots to see Buxton.
Buxton said offering psychiatry for parents who are in the NICU with their babies is a challenge. Babies—not their parents—are technically patients at Children’s Hospital Colorado, so billing for psychiatric services is tricky. For example, Buxton only treats parents in the NICU who have come over from the hospital’s Colorado Fetal Care Center. Still, she would like to treat the other 70% of parents who have come to the NICU after delivering in other Colorado hospitals.
“We are still missing people and need more funding for our integrated program to meet this need. I emphasize ‘integrated’ because we need to meet these birthing parents where they are, physically and emotionally,” Buxton said.
Julie and Nick Bjorklund give Hayley a steroid through an inhaler for her lungs on Saturday, Feb. 8, 2025, at their home in Castle Rock, Colo. Photo by Eli Imadali / Special to The Colorado Trust
St. John-Larkin agrees that reimbursement is a challenge in providing mental health care during pregnancy. Insurance coverage often bundles payment as a lump sum for prenatal care and delivery, so providers may not be able to bill for extra visits for mental health. She said there is no financial incentive to integrate behavioral health into care.
Lack of awareness or screening for mood disorders means many go undetected, despite new recommendations during pregnancy and postpartum and pediatric visits. But many pediatricians may not be aware there is a way to bill Medicaid for these screenings, said Laurel Hicks, a research scientist at University of Colorado Boulder’s Renée Crown Wellness Institute and a licensed clinical social worker who helps oversee PROSPER.
“No formula” for a typical pregnancy
Bjorklund’s ongoing relationship with Buxton has helped her cope with joy and heartbreak since first becoming pregnant two years ago.
When Bjorklund and her husband finally came home with Hayley in April, six months after giving birth, Bjorklund continued talking to Buxton over the phone and via Zoom to manage the “shock and overwhelming emotions” that suddenly hit her. Hayley’s lungs were so tiny that she could only survive without her oxygen machine for five minutes at a time, and someone had to stay awake with her 24 hours a day.
“It took its toll on our family, but we made it through that,” Bjorklund said.
Today, Hayley is 15 months old and weighs 20 pounds. She’s still on an oxygen machine, but her providers are happy with her progress. She loves her physical therapist and nanny, who Bjorklund said is Hayley’s favorite caregiver other than her aunt. Hayley has started babbling and sprouted a few teeth. She adores baths so much that she giggles when she hears the water running.
Hayley, 15 months, plays in the bathtub while her dad watches her on Saturday, Feb. 8, 2025, in their home in Castle Rock, Colo. Photo by Eli Imadali / Special to The Colorado Trust
Bjorklund was pregnant a second time this past fall when she found out her new baby also had a heart defect at 20 weeks—a shock since Bjorklund and her husband had undergone genetic screening to rule out this possibility. Buxton was the first person to call to check in on Bjorklund after the news.
She continued to check in with Bjorklund until an appointment at 30 weeks in December showed that Bjorklund needed an emergency C-section. Buxton was with Bjorklund, offering comfort and steadiness until her husband arrived at Children’s Hospital Colorado.
Her baby boy Anders died shortly after delivery. Despite how heartbroken she is, Bjorklund said she was grateful to her physician for helping her meet her son alive. She was grateful for Buxton’s support that day.
As part of her medical team, Buxton knew things about Bjorklund beyond what was in her chart. Bjorklund said that having that relationship beforehand is so important, especially during a crisis. “This holistic approach helped me process and make decisions when everything seemed to be closing in,” Bjorklund said.
“There’s no formula for what pregnancy is going to look like, so the more support you can have in place, the better,” Bjorklund added. “Integrated care teams are essential to moms and families thriving.”
