Podcast: Pathways to equitable and antiracist maternal mental health
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The Latest Research, Commentary, And News From Health Affairs

Tuesday, October 19, 2021

Dear John,

Today, we are turning over the newsletter to Jennifer Moore, theme
adviser for and one of the authors in the perinatal mental health paper
cluster

in the October issue

of Health Affairs.

Navigating Mental Health Services While Pregnant

Mood and anxiety disorders, including depression, are shockingly common
among pregnant individuals, with prevalence estimated at one in five.
Yet only half of these people receive treatment, leading to negative
consequences for the parent, child, and society as a whole.

I was thrilled to serve as adviser for the October issue of Health
Affairs

focusing on perinatal mental health. I loved reading the scientific and
policy pieces that advance our understanding of this critical issue.

With Medicaid covering half of all births in the United States, I wanted
to go behind the numbers for this newsletter.

I interviewed Gabrielle, a Medicaid enrollee in Washington, D.C., who
gave personal insights regarding what it means to grapple with mental
health challenges during pregnancy. I also spoke with Ebony Marcelle, a
certified nurse midwife at Community of Hope
, a federally qualified health
center (FQHC) in D.C., who shared the perspective of a provider.

Gabrielle, Medicaid enrollee

Jennifer:  Gabrielle, I am grateful and honored that you trust me to
share your personal story. Tell me about your pregnancy experience as it
relates to your mental health.

Gabrielle:  My first pregnancy ended in miscarriage, and I was nervous
during subsequent pregnancies that I would miscarry.

I had a panic attack when I thought I was going to lose my baby. I had a
lot of work stress. It was hard to get approval to get time off to go to
my doctor's appointments. I was high-risk for premature birth.

It created stress and impacted my mental health. I needed and wanted to
work full-time, but I also needed to go to my appointments. I was
[later] fired.

Jennifer: Share with me the types of services you received while
enrolled in Medicaid that helped with meeting your mental health needs
while pregnant.

Gabrielle: The Special Supplemental Nutrition Program for Women,
Infants, and Children (WIC) was helpful for food. They helped me
identify the right types of foods to eat and made sure that I had them
at home.  

Also, the program through [AmeriHealth Caritas DC, a Medicaid managed
care organization] called Bright Horizons assigned a caseworker for me.
She would help me to get to my doctor's appointments, get
transportation, [and] a breast pump.

The program gives you so much access and connections. It helped my
mental health and to reduce stress.

Jennifer: There is a misperception that mental health only refers to the
conditions that you can be diagnosed for, such as depression and
anxiety. However, mental health is also about achieving optimal health
and wellness. Tell me about the services you received that supported
your overall mental health and wellness and what that meant to you.

Gabrielle: After I was fired for being pregnant, I wasn't depressed
but I was "down." There was a therapy program to let me know that it is
OK to feel "down" and that it doesn't necessarily mean that I was
depressed.

The AmeriHealth case worker helped to link me with a therapist. She
helped me to take care of myself, like yoga, taking walks, meditation,
and connecting me to group therapy for pregnant individuals. [They] gave
steps and tools to make you feel better.

Ebony Marcelle, certified nurse midwife

Jennifer: Tell me about your experience as it relates to your role as a
midwife at an FQHC, specific to Medicaid enrollees who are pregnant and
have mental health needs.

Ebony: There are a lot of people who are undiagnosed. Oftentimes, I see
the same diagnosis repeatedly, and I think it is because of the
[assessment] tools. The tools are not culturally congruent. Bias exists
in the tools. I see a lot of people who are not properly diagnosed.

Jennifer: Tell me more about what you have seen work for those enrolled
in Medicaid.

Ebony: Integrated care is really the key with mental health during
pregnancy. It works best if during the prenatal care appointment, a need
is identified, and then they are connected to a behavioral health
specialist that day, onsite.

This is key for the Medicaid population.

People who do not have integrated behavioral and medical care experience
more challenges accessing care. You can ask the questions and identify
what they need, but if the services aren't available onsite, that day,
they won't get the care. They won't follow through with a referral
or appointment.

[Patients] also know if they have to go somewhere else that medicine is
judgmental and paternalistic. They know that there is a mentality that
poor people just need to pull themselves [up] by their bootstraps, so
they won't access the care. Black people are constantly disappointed
in the health care system. The meanness that they talk about that they
experience is oftentimes medicine asserting its power.

Jennifer: Recent attention has been given to the number of pregnant
individuals from communities of color who are not receiving care that is
respectful or responsive to their needs. What message would you send to
other clinicians on how to give better care?

Ebony:  I am challenged with the term "respectful care." It is overused
in perinatal care.

Respectful does not give us the space to talk about the role of racism,
bias, discrimination, and white supremacy. We need to understand that
our older efforts are not working.

We need to take a cultural perspective; Black women are the nucleus to
the family. They need to take care of family first, oftentimes
neglecting themselves. That impacts how we give care.

We need to look at how we are offering care; referrals to follow-up for
themselves do not work. You have to offer repetitive attempts to
directly connect them.

It is important to meet people where they are at and take the time to
find out more about a person and their needs and then take the time to
directly connect them.

I also look like the population that I serve, and this alleviates their
stress. There need to be clinicians who look like the population.

Jennifer: What are the critical barriers that you experience with
ensuring that Medicaid enrollees have access to mental health services?

Ebony: We are still reliant on grants to cover most of the behavioral
health services. Medicaid doesn't pay for everything right now. Much
more is needed for Black women, such as doulas, access to midwives,
Centering Pregnancy [group prenatal care], out-of-hospital births, and
behavioral health specialists who look like the community.

Right now, there is only one Black clinician in D.C. who specializes in
perinatal mood and anxiety disorders. One. If Medicaid won't pay for
these services and supports now, they will end up paying more in the
long run. Social determinants of health and [diversity, equity, and
inclusion] are hot topics right now, so why isn't everyone
prioritizing this community?

Jennifer: If you could convey a message to policy makers who want to be
responsive to pregnant individuals enrolled in Medicaid who need mental
health services and support, what would be the top things that they
could do to help?

Ebony: Medicaid should pay for perinatal mental health. They need to
support integrated behavioral and medical care models. It is important
to provide coverage for a full year postpartum.

There needs to be investment in the development of culturally congruent
tools. And they need to support the investment in behavioral health
specialists representing communities of color.

The salient issues that both Gabrielle and Ebony raised during these
interviews including the lack of behavioral and physical health
integration, lack of access to culturally congruent behavioral health
services, and workforce shortages and inadequate competency are
highlighted throughout the October theme issue by leading scholars
through quantitative and qualitative data.  

Today on Health Affairs Blog, Meghan Peterson and Lauren
Brinkley-Rubinstein explain how incarceration is a structural
determinant

of individual health that also worsens population health.

Donna Cryer kicks off the Health Affairs Blog short series, "Value
Assessment: Where Do We Go Post-COVID?
"
The series explores what we have learned about value assessment and
related issues during the COVID-19 pandemic.

Advertise with Health Affairs this month to take advantage of our
October promotion. Spend $10K on advertising and get one week of
homepage ads free! Learn more about advertising opportunities
.

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Your Daily Digest

Policy Opportunities To Improve Prevention, Diagnosis, And Treatment Of
Perinatal Mental Health Conditions

Jennifer E. Moore et al.

Incarceration Is A Health Threat. Why Isn't It Monitored Like One?

Meghan Peterson and Lauren Brinkley-Rubinstein

The Future Of Value Assessment In A Post-Pandemic United States

Donna Cryer

Podcast: Pathways To Equitable And Antiracist Maternal Mental Health
Care

Alan Weil and Isabel Morgan

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Pathways to Equitable and Antiracist Maternal Mental Health Care

Health Affairs Editor-in-Chief Alan Weil interviews Isabel Morgan,
director of the Birth Equity Research Scholars Program at the National
Birth Equity Collaborative, on the effects of structural racism on Black
birthing people's mental health and how we can do better.

Listen Here

 

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