A team of researchers is calling for comprehensive changes to U.S. health care and social policies to improve diagnosis and treatment of perinatal mental health conditions and mitigate the dramatic disparities that put women of color at significantly greater risks of morbidity and mortality compared with white women.
In a commentary published in the journal Health Affairs, the researchers proposed seven comprehensive changes to health care and economic policies to mitigate the burden of undiagnosed and untreated perinatal mental health challenges that are greatest among racial minority populations.
The researchers' recommendations include a national training and certification program for health care providers; payment models that enable women to obtain services through community-based providers; paid family leave; expanded funding for perinatal psychiatry access programs; and access to safe, legal abortions and contraception. They also proposed poverty-mitigation strategies such as reinstating the federal child tax credit and implementing a universal basic income program.
The team said their recommendations are a call for reproductive justice – which includes rights to bodily autonomy, decisions to have or not have children and to live in safe, healthy environments.
During Health Affairs' virtual briefing on April 3, University of Illinois Urbana-Champaign social work professor Karen M. Tabb Dina, the senior and corresponding author of the commentary, spoke about the urgent need for a comprehensive strategy to improve maternal health outcomes and promote equity.
"Perinatal mental health challenges are a microcosm for the U.S. health care system, bringing into focus gaps in equity, access, research data and social determinants of health," said Tabb Dina, who is co-principal investigator on a grant-funded project that is examining the impact of racial bias and discrimination on women's health care interactions during the perinatal period, defined as the time before and after giving birth.
While the team acknowledged that the reforms proposed are significant, they said that none of these are unattainable – "the challenges lie in who we value and how we choose to demonstrate that."
Broadening our understanding of what constitutes perinatal mental illness and wellness, and grounding our understanding in reproductive justice would lead to policies that close some of these gaps."
Dr. Emily C. Dossett, first author, professor of psychiatry and the behavioral sciences and of obstetrics in the Keck School of Medicine at the University of Southern California
Dossett is also the medical director of CHAMP for Moms – Child Access to Mental Health and Psychiatry, a consultation and educational service for pediatric primary care providers based at the University of Mississippi Medical Center.
Their co-authors were Dr. Alison M. Stuebe, a professor of maternal and child health, and of obstetrics and gynecology at the University of North Carolina-Chapel Hill School of Medicine; and Twylla Dillion, the executive director of HealthConnect One, a Chicago-based nonprofit focused on training community birth workers and research.
A 2022 report by the U.S. Centers for Disease Control and Prevention indicated that mental health conditions – including suicide and overdoses associated with substance use – are the leading cause of pregnancy-related death. However, more than 80% of these deaths are preventable, the report said.
Current policy and research, which focus primarily on postpartum depression, should be expanded to include other mental health conditions that can predate conception and continue after labor and delivery or miscarriage, the team suggested. Likewise, research samples must include greater diversity in race and ethnicity, gender and sexual orientation, and non-English speaking individuals.
Women's health care needs are often not prioritized as high as those of their infants and children by many well-funded maternal health programs such as home visits and family case managers, which tend to view the "baby as the candy and the mother as the wrapper," Stuebe has said.
However, community- and patient-centered care, such as doulas and birth centers, has shown promise at improving maternal health outcomes. To begin scaling up these services, HealthConnect One and several other doula programs have partnered on the Doula Data + Compensation Consortium, a crowdsourced organization specifically designed to gather research data on the health outcomes associated with these services.
Community-based care may be more cost-effective, and alternative payment models such as bundled payments and capitation that prioritize value-based care over fee-for-service care would make services more accessible to women in need, the researchers proposed. Moreover, research has shown that community birth centers protect women of color against the discriminatory treatment and trauma they frequently experience in traditional clinical settings, the team said.
Additionally, they called for broader funding for perinatal psychiatry access programs that would enable nonspecialty providers to consult by phone with behavioral health clinicians for help diagnosing, treating and managing pregnant and postpartum women's mental health care. The Health Resources and Services Administration is currently funding these programs in more than 20 states, and they have consistently demonstrated more equitable access to care and cost savings, the team wrote.
Accordingly, the team called for reinstatement of the 2021 federal child tax credit, which had striking effects on recipients' mental health, particularly Black and Hispanic families. Almost 50% of the reduction in depressive symptoms and about 70% of the decrease in anxiety symptoms were associated with recipients' improved capacity to afford food and housing.
Likewise, the team proposed implementing and evaluating a universal basic income program for perinatal families as research has found that these programs significantly improve recipients' mental health. Cash-based, unconditional universal basic income programs that uncouple childbearing from the receipt of benefits also support recipients' reproductive rights to decide to have or not have children, as well as parents' rights to raise their families in safe, healthy environments, the researchers said.
Finally, the team advocated workplace policies that support families – specifically, paid parental leave and high-quality child care. Currently, four states offer paid family leave policies that allow parents up to 12 weeks off during the first year after birth or adoption. Preliminary data suggest these policies are associated with improvements in maternal mental health, while struggles with access to affordable child care negatively impact parents' mental and physical well-being, the team said.
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