The murder trial of Lindsay Clancy in the January 2023 killing of her three young children ended in a mistrial in Massachusetts on Friday when one of 12 jurors refused to join the others in finding her not guilty by reason of insanity.
What happens next in Clancy’s case is yet to be determined, but the trial has sparked a conversation on perinatal mental health and women’s access to care across the United States — including in Arkansas, which ranks near the bottom among states for maternal and infant mortality. Risk factors such as delayed or nonexistent prenatal care, teenage pregnancy and preterm birth occur in the state at rates significantly higher than the national average.
Mental health issues such as depression are the leading cause of maternal mortality nationwide, accounting for 28% of deaths in 2022, the last year of data to be analyzed by the U.S. Centers for Disease Control and Prevention and an increase of 5% from 2021. In Arkansas, up to 16% of maternal deaths are caused by mental health conditions, according to Arkansas’s Maternal Health Scorecard — the fifth-most frequent cause of pregnancy-related maternal deaths in the state, after infections, cardiomyopathy, cardiovascular conditions and hypertensive disorders.
Arkansas women report suffering from depressive symptoms before, during and after pregnancy at significantly higher rates on average than they do nationally.
One in four women in Arkansas report depression during pregnancy, while 1 in 5 report postpartum depression — rates seven to eight percentage points higher than the national average. The disparity is largest during the three months leading up to pregnancy, when over 25% of women in Arkansas experience depression, compared to 17% nationally.
“Unfortunately, postpartum depression is common; murdering your three children is not,” Arkansas Gov. Sarah Huckabee Sanders said in a statement emailed to the Arkansas Democrat-Gazette. The state “offers resources for women suffering from pregnancy challenges like depression, but that is in no way a justification for Ms. Clancy’s horrible actions.”
While the killing of three young children seems impossible to justify, can it perhaps be explained? And could such an explanation, if based on solid science, help prevent similar tragedies?
According to a 2024 article published in a journal of the American Psychiatric Association, 1 to 2 in 1,000 women experience postpartum psychosis after giving birth, the condition on which Clancy’s defense attorneys based their argument for her lack of criminal liability, as defined under Massachusetts law, for the horrific act she admits she committed.
There are about 3.6 million births annually in the U.S., meaning about 3,600 women suffer from the condition each year — conservatively. Postpartum psychosis can occur when a pregnancy-related mood or anxiety disorder is not effectively diagnosed or treated, and often when it’s exacerbated by poor sleep or other stressors.
Although often described as “rare,” maternal mental health advocates point out that postpartum psychosis occurs at least as often as many other conditions diagnosed during the perinatal stage, such as sudden unexpected infant death or Down syndrome, which are much better understood. The difference, they say, lies in who suffers from them: the baby, not the mother.
The Women’s Mental Health Program at the University of Arkansas for Medical Sciences in Little Rock treats two cases of postpartum psychosis per year on average. This number skyrocketed to nine cases over a 12-month period at the beginning of the COVID-19 pandemic starting in March 2020, however, which UAMS providers attributed to increased stress and social isolation at a time when moms already tend to be stressed and isolated.
A staggering 63% of maternal deaths nationwide occur in the postpartum period, or within one year after delivery. In Arkansas, this rate is even higher, with 71% of maternal deaths classified as postpartum, and half of these occurring late in the postpartum year between 43 and 365 days after delivery.
Women need more “touch points” during the postpartum stage where they interact with the healthcare system and have access to other support resources, said Jennifer Callaghan-Koru, professor of public health at UAMS and executive director of the Arkansas Perinatal Quality Collaborative.
“There’s a lot that we can do to better support moms” during the postpartum period, Callaghan-Koru said. “They typically stop care with their obstetricians within a couple of months after pregnancy, but they’re still going through so many changes that whole year postpartum,” she said, with hormonal shifts, loss of sleep and adjusting to what is perhaps the biggest life transition a human being will ever experience.
For a normal, low-risk pregnancy, women typically are seen for routine visits with an obstetric provider 12 to 14 times over the course of nine months, but this standard of frequent monitoring all but disappears after delivery — for the mom, at least.
The only routine postpartum visit following an uncomplicated delivery has historically taken place around six weeks. Then the woman is typically discharged from care.
In 2018, the American College of Obstetricians and Gynecologists updated its guidelines for postpartum care to include contact with a maternal care provider within three weeks of birth, to assess physical recovery and mental health. The final postnatal visit should occur no later than 12 weeks, the group says, at which point the provider should ensure the patient has or will soon establish care with a primary care provider for ongoing needs.
A patient’s insurance status often dictates whether this actually happens. Arkansas is the only state in the U.S. that has elected not to extend mandatory postpartum Medicaid coverage from 60 days to a full year.
Callaghan-Koru pointed to UAMS’ Proactive Postpartum Call Center, which contacts women who have given birth at 20 of the state’s 32 birthing hospitals about a week post-delivery to check in. Nurses assess how they are doing and connect them to needed care and resources. The program has helped to identify mental health concerns experienced by new moms as well as serious medical problems warranting emergency care.
Callaghan-Koru co-leads a randomized controlled trial that is testing the effectiveness of such early postpartum contact combined with the usual six-week visit, versus the six-week visit alone.
But the American College of Obstetricians and Gynecologists’ recommendation for early postpartum contact has not been widely implemented in Arkansas, Callaghan-Koru said. Clinics often cite insufficient staffing or space. At a policy level, she said, requiring insurers to reimburse these check-ins would help ensure they actually happen, she said, and also make the data easier to track.
The same is true for depression screening during pregnancy and at the postpartum stage. The OB-GYN group recommends depression and anxiety screening at the initial prenatal visit, again later in pregnancy, and at the final postpartum visit. Women with a history of mental health concerns or who develop symptoms in the perinatal period should be monitored more frequently.
WARNING SIGNS
According to the 2024 American Psychiatric Association article, about 4% of women with postpartum psychosis may commit filicide — that is, intentionally kill their own children. Five percent commit suicide, which Clancy attempted immediately after the killings, leaving her partially paralyzed.
Clancy’s defense team and some of the providers who evaluated her following the event state that she reported hearing “command voices” — specifically, a male voice ordering her to kill herself and her children, to keep them safe.
Auditory hallucinations in the form of command voices are a common feature of psychosis. Though sometimes benign, they can also be malevolent and dangerous, and they’re strongly linked to self-harm or harm to others. The person hearing the voices often perceives them as all-knowing and all-powerful, two factors which, studies show, increase the likelihood they will comply with the voices’ orders.
Symptoms of psychosis can vary and are more likely to be identified by people close to the person experiencing them than by the person themselves, as psychosis by definition means loss of contact with reality and an inability to conceptualize what’s happening. Hallmark symptoms are delusions, hallucinations and disorganized thinking, often foreshadowed during the postpartum period by mood or behavior changes such as confusion, agitation, social withdrawal, mania, paranoia or catatonia.
Severe and persistent sleep deprivation, such as what Clancy experienced in the months leading up to the killings, greatly increases the risk of psychosis. That, coupled with marked changes in mood or strange, out-of-character behavior, are signs that people close to a new mom can watch for.
Although postpartum psychosis can be dangerous, it’s also highly treatable when recognized and managed appropriately. The best form of treatment is prevention, which means risk factors such as bipolar disorder and poor sleep must be identified and mitigated, patient care must be closely coordinated between all providers involved, and support must be made available for moms to address difficulties with mother-infant bonding, another risk factor for postpartum psychosis.
In Arkansas, workforce issues often prevent women from getting the care they need, especially for mental health, said Callaghan-Koru. No amount of screening to identify issues is going to help, she said, “if you don’t have enough mental health providers to provide the support and care that those women need.”
According to data from the U.S. Health Resources and Services Administration, over one-third of Arkansans live in a Mental Health Care Professional Shortage Area, a federal designation used to identify areas and groups in the U.S. where there are not enough primary care, dental care or mental health providers to meet existing needs.
