CHAMPAIGN, IL — A team of researchers is calling for sweeping changes in U.S. health and social policies to improve the diagnosis and treatment of perinatal mental illness and mitigate the dramatic disparities that put women of color at significantly higher risk of morbidity and mortality than with with white women.
In a commentary published in the journal Health Affairs, the researchers suggest seven sweeping health care and economic policy changes to mitigate the burden of undiagnosed and untreated perinatal mental health problems, which are greatest among racial minority populations.
Dr. Emily S. Dossett, professor of psychiatry and obstetrics at the Keck School of Medicine at the University of Southern California, was the first author of the group’s report, and she was among the scientists who discussed their findings during Health Affairs’ virtual briefing on perinatal health.
Photo courtesy of Keck Medicine of USC
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The researchers’ recommendations include a national training and certification program for health care providers; payment models that allow women to receive services through community providers; paid family leave; expanded funding for perinatal psychiatry access programs; and access to safe, legal abortion and contraception. They also proposed strategies to alleviate poverty, such as restoring 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 a safe, healthy environment.
During the April 3 Health Affairs virtual briefing, University of Illinois at Urbana-Champaign social work professor Karen M. Tabb Dina, senior and corresponding author of the commentary, spoke about the urgent need for a comprehensive strategy to improve maternal health outcomes and promoting equity.
“The challenges of perinatal mental health are a microcosm of the US health care system, bringing into focus gaps in equity, access, research data, and social determinants of health,” said Tab Dina, who is co-principal investigator of a grant-funded project that examines the impact of racial bias and discrimination on women’s health care interactions during the perinatal period, defined as the time before and after birth.
While the team acknowledged that the proposed reforms were significant, they said none of them were unachievable – “the challenges lie in who we value and how we choose to demonstrate that”.
“Expanding our understanding of what constitutes perinatal mental illness and well-being and building on our understanding of reproductive justice would lead to policies that close some of these gaps,” said first author Emily S. Dossett, Ph.D., professor of psychiatry and in Behavioral Sciences and in Obstetrics at the University of Southern California Keck School of Medicine. Dossett is also the medical director of CHAMP for Moms – Child Access to Mental Health and Psychiatry, a consultation and education service for pediatric primary care providers based at the University of Mississippi Medical Center.
Their co-authors are Dr. Alison M. Stuebe, 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, executive director of HealthConnect One, a Chicago-based nonprofit focused on community-based birthing education and research.
A 2022 report from the U.S. Centers for Disease Control and Prevention found that mental health conditions — including suicide and substance use overdose — 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 focuses primarily on postpartum depression, should be expanded to include other mental health conditions that may precede conception and continue after labor and delivery or miscarriage, the team suggested. Likewise, research samples should include greater diversity in terms of race and ethnicity, gender and sexual orientation, and non-English speakers.
Women’s health care needs are often not prioritized as highly as those of their babies and children by very well-funded maternal health programs such as home visiting and family managers who tend to view “the baby as candy and the mother like a wrapper,” Steube said.
However, community-based and patient-centered care, such as doulas and birthing centers, have shown promise for improving maternal health outcomes. To begin scaling these services, HealthConnect One and several other doula programs have partnered in the Doula Data + Reimbursement Consortium, a group organization specifically designed to collect 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 affordable for women in need, the researchers suggested. Additionally, research shows that community birth centers protect women of color from the discriminatory treatment and trauma they often experience in traditional clinical settings, the team said.
In addition, they called for greater funding for perinatal psychiatry access programs that would allow lay providers to consult by telephone with behavioral health clinicians for assistance in diagnosing, treating, and managing the mental health care of pregnant women and women after childbirth. The Health Resources and Services Administration currently funds these programs in more than 20 states, and they consistently demonstrate more equitable access to care and cost savings, the team wrote.
Accordingly, the team called for the restoration of the federal child tax credit starting in 2021, which had devastating effects on the mental health of recipients, especially black and Hispanic families. Almost 50% of the reduction in depression symptoms and about 70% of the reduction in anxiety symptoms were related to recipients’ improved ability to afford food and housing.
Similarly, the team proposed the implementation and evaluation of a universal basic income program for perinatal families, as the research found that these programs significantly improved the mental health of recipients. Cash-based, unconditional universal basic income programs that decouple childbearing from benefit receipt also support the reproductive rights of recipients to decide whether or not to have children, and the rights of parents to raise their families in a safe, healthy environment , the researchers said.
Finally, the team advocated for workplace policies that support families—particularly paid parental leave and high-quality child care. Four states currently offer paid family leave policies that allow parents up to 12 weeks off in the first year after a birth or adoption. Preliminary data suggest that these policies are associated with improvements in maternal mental health, while problems accessing affordable childcare negatively impact parents’ mental and physical well-being, the team said.
