Health Affairs Explores Mental Health Link to Birth Outcomes

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Illustration of pregnant people and parents with children walking
Illustration: Sandra Dionisi

Improving maternal mental health has far-reaching benefits for mothers and birthing people, babies, and society at large. All mothers and birthing people* deserve to have a healthy birth, to have their mental health care needs met, and to have providers who recognize and respect their cultural and racial differences.

Essential CoverageThere are effective interventions to manage perinatal mental health conditions, which include the most common complications from pregnancy and childbirth up to one year postpartum. But too few mothers and birthing people are screened and treated for these conditions, and as the October issue of the journal Health Affairs shows, birthing people with poor mental health are more likely to have poor health outcomes.

The experience of birth differs across groups. The researchers wrote in the journal that Black mothers and birthing people come to the birth experience psychologically burdened by the trauma of living in a racist society. White mothers and birthing people with mental health conditions are most likely to die from complications stemming from those conditions in the perinatal and postnatal periods. And birthing people with low incomes and no health insurance have difficulty accessing needed mental health care before they become pregnant.

Poor mental health among these populations is connected to racial and gender microaggressions and the impacts of social determinants of health. It is fueled by factors such as housing instability, food insecurity, and intimate partner violence. Untreated perinatal anxiety in the last trimester increases the likelihood of conditions such as preeclampsia and cesarean birth, for instance, and it makes it more probable that newborns will require hospital intensive care. Poor mental health among mothers and birthing people may also harm the parent-child bond and the child’s long-term physical, emotional, and developmental health.

With effective interventions, however, perinatal mental health can be dramatically improved. The research presented in Health Affairs, published with support from CHCF, Perigee Fund, and Zoma Foundation, suggests that steps like expanding health insurance for all adults and fostering a system that normalizes culturally competent care will create better health outcomes for parents.

Racism and Maternal Mental Health Must Be Addressed

Black women experience maternal mental health conditions, particularly postpartum depression and anxiety, at rates higher than the overall US population, according to the authors of the Health Affairs article “Pathways to Equitable and Antiracist Maternal Mental Health Care: Insights from Black Women Stakeholders.”

Data from California indicate similarly high rates in the state. During pregnancy, 30% of Black women reported symptoms of anxiety, and 20% reported signs of depression, according to CHCF’s 2018 Listening to Mothers in California survey.

The Health Affairs article featured analysis of interviews with Black women who work in the maternal health field and summarized their suggestions for improving the experiences of Black mothers and birthing people.

“More Black women report higher symptoms of mental health problems but have the lowest diagnoses,” one respondent explained. “So we need to understand more of what’s behind that.”

The birth process can trigger this trauma, another participant said. “Like a lot of things with trauma it’s kind of unsaid. It’s silent. So, a lot of times it’s a provider just simply not asking for consent to touch you when you’re birthing your child, or simply acting as if you’re not in the room, or you having a birth trauma that someone doesn’t recognize.”

The study participants suggested that the health care system educate and train practitioners in culturally competent care, invest in a mental health workforce of Black women, help Black women–led community-based organizations, and promote integrated care and shared decisionmaking.

Taken together, these interventions could create care that addresses the needs of Black mothers and birthing people. “Without a cohesive model of care,” the authors wrote, “Black birthing people, along with other marginalized populations, will continue to fall through the fractures of the system.”

Support from Black women–led organizations is available in California. The California Black Women’s Health Project offers mental health support through a program called “Are You Ok, Sis?” and resources are also available through the organization Maternal Mental Health Now.

Since 2020, California has required hospitals that provide perinatal care, alternative birthing centers, and certain primary care clinics to implement an implicit bias training program for all providers involved in the perinatal care of patients within those facilities. The Dignity in Pregnancy and Childbirth course, developed by Diversity Science and funded by CHCF, allows providers to complete their required training online.

Preventable Deaths

A significant proportion of pregnancy-related deaths are related to poor maternal mental health, and are largely preventable, according to the authors of “Preventing Pregnancy-Related Mental Health Deaths: Insights from 14 US Maternal Mortality Review Committees, 2008–17.”

Data from California show that more than half of pregnancy-related suicides had a good to strong chance of preventability and that there were missed opportunities to intervene, according to a 2019 report from the California Department of Public Health.

During pregnancy, White birthing people are most likely to die for reasons related to mental health, the data from the Health Affairs study suggested. This finding is consistent with previous research that indicates White women are more likely to die from suicide and overdoses than those of other races and ethnicities.

Reviewing data from Maternal Mortality Review Committees (MMRCs) in 14 states, the authors found that 11% of pregnancy-related deaths between 2008 and 2017 were caused by poor mental health.

Among all deaths reviewed by the 14 state MMRCs from 2008 to 2017, 421 pregnancy-related deaths were identified as having an underlying cause-of-death determination. Of those, 46, or 11%, were due to mental health conditions. One hundred percent of the 46 deaths were preventable and might have been averted by timely interventions, they found.

“The finding that most people with a pregnancy-related mental health death had a history of depression highlights the potential need for ongoing prevention and treatment,” the authors wrote.

Expanding Insurance Coverage

Insurance and easier access to care would help people get the treatment they need before and after pregnancy and birth, researchers suggested. Between 13% and 25% of people who recently gave birth reported poor mental health, suggesting that a significant portion of expectant mothers and birthing people grappled with psychological distress while they were pregnant, said the authors of the Health Affairs article “Medicaid Expansion Associated with Some Improvements in Perinatal Mental Health.”

Birthing people with low incomes are less likely to have health insurance before they become pregnant than those with higher incomes. They are also more likely to have poor mental health.

When Medicaid expanded enrollment eligibility in 32 states and DC as part of the Affordable Care Act, insured people with low incomes overall reported less psychological distress.

The authors analyzed survey data from people with low incomes giving birth between 2012 and 2018 and found a 22% increase in prenatal Medicaid coverage and a 16% decrease in prepregnancy depression. These results suggest that people with low incomes who gained health insurance through Medicaid used more preventive health care before their pregnancy.

The authors of “Policy Opportunities to Improve Prevention, Diagnosis, and Treatment of Perinatal Mental Health Conditions” also see insurance as crucial to improving maternal mental health. Birthing people with low incomes and no insurance are eligible for Medicaid during pregnancy, but in states that chose not to expand Medicaid eligibility, that coverage typically ends 60 days after birth.

The swift termination of coverage leaves parents to self-manage conditions such as postpartum depression, which conflicts with “evidence-based recommendations from maternal health experts to replace the single six-week postpartum visit with ongoing support tailored to individual needs,” the authors note. They recommend that states extend Medicaid eligibility to 12 months after birth.

California expanded its postpartum coverage for Medi-Cal enrollees to 12 months in this year’s state budget, with the expanded coverage period beginning on April 1, 2022.

Other Policy Solutions

Easing access to care by offering it in one facility would also improve mental health for mothers and birthing people, suggested the authors of the same article. They recommend “co-locating care to support same-day, same-location appointments for the postpartum person and infant.”

The COVID-19 pandemic fostered innovations like Curbside Care for Moms and Babies at Boston Medical Center, which created a mobile health van that brought care to the community. Other models of community-based care and telehealth appointments could also break down barriers to needed mental health treatment for pregnant and birthing people.

“The scale of human suffering and economic cost associated with perinatal mental health conditions cries out for a response,” the authors wrote. “Fortunately, policy options are available to address various barriers that still stand in the way of the identification and treatment of these conditions and the achievement of high-quality outcomes.”

These potential solutions would provide all mothers and birthing people with the means to have a healthy birth and have their mental health care needs met within a system that respects them.

* CHCF uses the term “birthing people” to recognize that not all people who become pregnant and give birth identify as a woman or a mother.

Sandra Dionisi

Sandra Dionisi’s work has been commissioned by a wide range of publications in the US, Canada, and Europe. She has provided images for commissions by magazines, graphic design firms, book publishing, and corporate communications. Sandra lives and works in Toronto, Ontario, Canada.

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