WOMENS HEALTH

Extending Medicaid coverage after birth may increase postpartum treatment for depression, anxiety

A new study found that extending Medicaid eligibility for birthing people increase treatment for perinatal mood and anxiety disorder by more than 20 percentage points, compared to birthing people with commercial insurance

Peer-Reviewed Publication

BOSTON UNIVERSITY SCHOOL OF PUBLIC HEALTH

Extending postpartum Medicaid eligibility extensions may increase treatment for perinatal mood and anxiety disorders (PMADs), a leading cause of perinatal illness and mortality, according to a new study led by Boston University School of Public Health (BUSPH) and Brown University researchers.

Published in the journal Health Affairs, the study found that retaining Medicaid coverage after birth increased outpatient mental health and medication treatment for PMADs by 20.5 percentage points, compared to birthing people who received commercial coverage. Retaining postpartum Medicaid also appeared to significantly lower patients’ out-of-pocket spending for mental healthcare.

The majority of US states have now extended postpartum Medicaid coverage to 12 months through the American Rescue Plan Act, but the new findings provide critical data and insight into the role of Medicaid coverage on perinatal mental health, and why Medicaid extensions are so important for the health of low-income birthing people postpartum. Without this coverage, many people would otherwise become uninsured or struggle to pay for high-cost commercial insurance and medical care. Untreated PMADs can increase birthing people’s risk of substance use, depression, anxiety, and suicide, as well as developmental delays among their newborns. Estimates show that one in three pregnancy-related deaths occur between six weeks and one year after childbirth.

“We know that maternal mental health conditions are a leading cause of maternal morbidity and mortality, and postpartum mood and anxiety disorders are the most commonly occurring maternal mental health condition,” says study lead and corresponding author Dr. Sarah Gordon, assistant professor of health law, policy & management at BUSPH, and who served as a senior advisor on health policy for the US Department of Health and Human Services from 2021-2024. “Evidence-based treatments are available and effective, but underutilized. Insufficient health insurance coverage is one reason for low treatment rates among the postpartum population that extending postpartum Medicaid coverage can address.”

For the study, Dr. Gordon and colleagues utilized data on insurance claims and income, as well as birth records in Colorado between 2014-2019, before Colorado extended Medicaid eligibility. The researchers compared postpartum PMAD treatment among patients with incomes at or below 138 percent of the federal poverty level (FPL) and who were eligible to remain in Medicaid after 60 days postpartum, to patients with incomes above 138 percent of the FPL, who were ineligible to receive Medicaid beyond 60 days postpartum and enrolled in commercial insurance.

Compared to birthing people with commercial health insurance, remaining on Medicaid for 12 months postpartum was also linked to a 16 percentage point increase in patients filling a prescription medication for depression or anxiety, and a 7.3 percentage point increase in patients receiving at least one outpatient mental health visit. Retaining Medicaid beyond 60 days postpartum was associated with almost a 20 percentage point increase in “continuous” postpartum treatment, which is considered three or more outpatient mental health visits or prescription refills.

This extended Medicaid coverage also alleviated healthcare costs for birthing people, lowering out-of-pocket costs by $40.84 for outpatient mental health visits, and by $3.24 for each prescription refill, compared to costs for commercially insured birthing people.

Medicaid-insured birthing people may have higher PMAD treatment rates because of more affordable care, and fewer gaps in coverage that likely occur among birthing people who became ineligible for Medicaid. The researchers say these findings underscore the fact that commercial insurance is not an equal alternative for low-income postpartum people, and losing Medicaid eligibility can be detrimental to both health and finances.

“Our findings suggest that postpartum Medicaid extensions are likely an important policy lever to promote postpartum maternal mental health by lowering barriers to accessing treatment,” Dr. Gordon says. “However, mental health screening and referrals, availability of providers, and quality of mental healthcare are also critical to supporting the mental health of postpartum people.”

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About Boston University School of Public Health

Founded in 1976, Boston University School of Public Health is one of the top ten ranked schools of public health in the world. It offers master's- and doctoral-level education in public health. The faculty in six departments conduct policy-changing public health research around the world, with the mission of improving the health of populations—especially the disadvantaged, underserved, and vulnerable—locally and globally.

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JOURNAL

Health Affairs

DOI

10.1377/hlthaff.2023.01441 

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Extended Postpartum Medicaid In Colorado Associated With Increased Treatment For Perinatal Mood And Anxiety Disorders

ARTICLE PUBLICATION DATE

1-Apr-2024

COI STATEMENT

Dr. Gordon was a senior adviser on health policy in the Office of the Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services from 2021-2024.

Women with serious mental illness want pregnancy information, resources from mental health providers

UNIVERSITY OF CALIFORNIA - LOS ANGELES HEALTH SCIENCES

Women with serious mental illness (SMI) who are pregnant or planning a pregnancy face gaps in information, support and resources in mental health services, new research suggests.

The findings, published April 1 in the peer-reviewed journal Health Affairs, highlight the need to integrate pregnancy and parenting interventions, education, and other resources for women with SMI into mental health services.

Policies that increase mental health provider and clinic capacity to address pregnancy and parenting can dramatically improve care for women living with mental illness, which would ultimately advance maternal and child outcomes, said Dr. Nichole Goodsmith, psychiatrist and health services researcher at Veterans Affairs Greater Los Angeles Healthcare System, and assistant clinical professor of psychiatry at the David Geffen School of Medicine at UCLA.

“Our study suggests that the topic of pregnancy may be under-discussed in mental health care, leading to a missed opportunity to understand patients’ pregnancy goals and desires and offer appropriate support and services,” said Goodsmith, the study’s senior author who conducted the research while in the National Clinician Scholars Program at UCLA. “The women we spoke to wanted more information on the potential impact of their psychiatric medications on fertility, pregnancy, fetal development, and breastfeeding. The mothers we interviewed expressed needing more parenting support and resources—things like parenting classes, on-site childcare during mental health visits, and referrals for resources like baby supplies.”

The researchers conducted telephone interviews with 22 reproductive-age women being served at four Los Angeles County Department of Mental Health outpatient clinics in 2020 and 2021. Most participants were Black or Latina and had children.

Among the findings, few women recalled discussions of pregnancy with their mental health providers, and those who did described them as “quick conversations.” In addition, many were dissatisfied with the information they received about potential safety concerns of taking their psychiatric medications in pregnancy.

As for parenting, most described their mental health providers as helpful and supportive, though some were concerned that even talking about their mental health symptoms could lead to losing custody of their children.

The study has some limitations, the researchers write. It was conducted in a large, urban safety-net mental health system, so the findings may not apply to other locations or populations, it surveyed only English-speaking women did not include other languages or gender identities.

But the findings shed light on the need to build mental health providers’ capacity to discuss and address their patients’ pregnancy- and parenting-related needs.

“Overall, results underscore the need for greater integration of pregnancy and parenting interventions, education, support, and resources into mental health services for women living with SMI,” the researchers write. “Incorporating educational content related to pregnancy and parenting into academic, professional, and continuing education curriculums can help close this knowledge gap.”

Additional authors are Karissa Fenwick, Kristina Cordasco, and Alison Hamilton of Veterans Affairs (VA) Greater Los Angeles Healthcare System; Emily Dossett of the University of Southern California, and Rebecca Gitlin of the Los Angeles County Department of Mental Health.

The project was funded by the National Clinician Scholars Program at UCLA, the Veterans Affairs (VA) Office of Academic Affiliations through the Health Services Research Fellowship Program (TPH 65-000-15), the VA Research Career Scientist (VA Health Services Research and Development Grant No. RCS 21-135), the VA Office of Academic Affiliations, and a K12 (K12HS26407) career development award from the Agency for Healthcare Research and Quality and the Patient-Centered Outcomes Research Institute.

 

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JOURNAL

Health Affairs

DOI

10.1377/hlthaff.2023.01450 

METHOD OF RESEARCH

Survey

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Addressing Pregnancy And Parenting In Mental Health Care: Perspectives Of Women With Serious Mental Illness

ARTICLE PUBLICATION DATE

1-Apr-2024

 

First time moms with breech pregnancies experience reduced risk of complications if they plan caesarean rather than vaginal delivery - but have increased risk of uterus rupture in subsequent pregnancies

PLOS

 

IMAGE: 

MATERNAL OUTCOMES OF PLANNED MODE OF DELIVERY FOR TERM BREECH.

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CREDIT: JOSEPHINE NOLTE, CC-BY 4.0 (HTTPS://CREATIVECOMMONS.ORG/LICENSES/BY/4.0/)

First time moms with breech pregnancies experience reduced risk of complications if they plan cesarean rather than vaginal delivery - but have increased risk of uterus rupture in subsequent pregnancies

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Article URL:  https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0297971

Article Title: Maternal outcomes of planned mode of delivery for term breech in nulliparous women

Author Countries: Denmark

Funding: This study was supported by grants from the Health Research Foundation of Region Zealand and Carsten Lenstrup’s research foundation for Danish obstetrics. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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JOURNAL

PLoS ONE

DOI

10.1371/journal.pone.0297971 

ARTICLE TITLE

Maternal outcomes of planned mode of delivery for term breech in nulliparous women

ARTICLE PUBLICATION DATE

3-Apr-2024

Paper: Policy reforms urgently needed to mitigate racial disparities in perinatal mental health conditions

UNIVERSITY OF ILLINOIS AT URBANA-CHAMPAIGN, NEWS BUREAU

 

IMAGE: 

SIGNIFICANT REFORMS IN U.S. HEALTH CARE AND ECONOMIC POLICIES ARE NEEDED TO MITIGATE THE DISPARITIES IN PERINATAL MENTAL HEALTH DIAGNOSES AND TREATMENT THAT PLACE WOMEN OF COLOR AT GREATER RISK OF MORTALITY AND MORBIDITY, ACCORDING TO SOCIAL WORK PROFESSOR KAREN M. TABB, THE SENIOR AUTHOR OF A PAPER PUBLISHED IN HEALTH AFFAIRS.

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CREDIT: PHOTO BY L. BRIAN STAUFFER

CHAMPAIGN, Ill. — 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,” said first author Dr. Emily C. Dossett, a 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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JOURNAL

Health Affairs

DOI

10.1377/hlthaff/2023.01455 

METHOD OF RESEARCH

Commentary/editorial

SUBJECT OF RESEARCH

Not applicable

ARTICLE TITLE

Perinatal mental health: The need for broader understanding and policies that meet the challenges

ARTICLE PUBLICATION DATE

3-Apr-2024

Socioecologic factors and racial differences in breast cancer prognostic scores

JAMA Network Open

JAMA NETWORK

About The Study: The findings of this study suggest that the consequences of structural racism extend beyond inequities in health care to drive disparities in breast cancer outcome. Additional research is needed with more comprehensive social and environmental measures to better understand the influence of social determinants on aggressive estrogen receptor-positive tumor biology among racial and ethnic minoritized women from disadvantaged and historically marginalized communities. 

Authors: Gregory S. Calip, Pharm.D., M.P.H., Ph.D., of the University of Southern California in Los Angeles, is the corresponding author. 

To access the embargoed study: Visit our For The Media website at this link https://media.jamanetwork.com/ 

(doi:10.1001/jamanetworkopen.2024.4862)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, conflict of interest and financial disclosures, and funding and support.

#  #  #

Embed this link to provide your readers free access to the full-text article This link will be live at the embargo time http://jamanetwork.com/journals/jamanetworkopen/fullarticle/10.1001/jamanetworkopen.2024.4862?utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_term=040324

About JAMA Network Open: JAMA Network Open is an online-only open access general medical journal from the JAMA Network. On weekdays, the journal publishes peer-reviewed clinical research and commentary in more than 40 medical and health subject areas. Every article is free online from the day of publication. 

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JOURNAL

JAMA Network Open

Depression during pregnancy is tied to increased emergency department visits for infants after birth

Rutgers Health study finds that infants whose mothers have mild and moderate to severe depressive symptoms had more emergency department visits than those who had no symptoms

Peer-Reviewed Publication

RUTGERS UNIVERSITY

Mild and moderate to severe perinatal depressive symptoms among new mothers are associated with the increased use of emergency rooms to treat their infants, according to Rutgers Health research.

 

The study, published in the April issue of  Health Affairs, examines the association between the severity of perinatal depression and the use of emergency departments in the first year of an infant’s life.

 

Perinatal mental health conditions affect up to 20 percent of pregnant or postpartum people and are associated with a wide range of adverse outcomes for the child, including increased use of a hospital’s emergency department.

 

Using the emergency department can be costly, especially for Medicaid, which is billed for disproportionately more pediatric emergency department visits compared with private insurance.

 

While perinatal people may experience a broad range of depression symptom severity, there is little research examining the relationship between symptom severity and health care use and emergency department use. To address this gap, Slawa Rokicki, an assistant professor at the Rutgers School of Public Health, reviewed data in New Jersey, a state with universal maternal depression screening.

 

Rokicki, who linked birth record data for the years 2016-2018 to hospital discharge records for infants in their first year of life, found that infants of mothers with moderate to severe depressive symptoms had 21 percent more emergency department visits than those who had no depression, while infants of mothers with mild symptoms had 10 percent more emergency department visits.

 

According to the study, for infants whose delivery was paid for by Medicaid, the total emergency department charges in the first year were 43 percent higher for infants with mothers with moderate to severe depression and 19 percent higher for mothers with mild symptoms compared to those with no symptoms.

 

“The large disparities among Medicaid beneficiaries suggests opportunities for that program to optimize screening and referrals for perinatal depression, with potential cost-saving benefits in reducing nonemergency pediatric emergency department visits,” said Rokicki.

 

The study’s findings suggest that universal screening of perinatal people at delivery may be beneficial in identifying those who may be at risk of postpartum depression before they leave the hospital. “This is critical because postpartum people often face multiple barriers to postpartum care and most people with perinatal mental health conditions are not diagnosed,” said Rokicki.

 

Additionally, routine screening in emergency departments may also help identify parental mental health conditions and connect individuals to resources.

 

“We know from prior research that postpartum depression screenings in pediatric emergency departments are feasible,” said Rokicki.

 

Rokicki said emergency department screens need to follow patient-centered, nonstigmatizing approaches as those in the emergency department who screen positive for depression are likely to be part of a socially vulnerable population.

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JOURNAL

Health Affairs

DOI

10.1377/hlthaff.2023.01443 

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Perinatal Depression Associated With Increased Pediatric Emergency Department Use And Charges In The First Year Of Life

ARTICLE PUBLICATION DATE

1-Apr-2024