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.

About Health Affairs

Health Affairs is the leading peer-reviewed journal at the intersection of health, health care, and policy. Published monthly by Project HOPE, the journal is available in print and online. Late-breaking content is also found through healthaffairs.org, Health Affairs Today, and Health Affairs Sunday Update.

Project HOPE is a global health and humanitarian relief organization that places power in the hands of local health care workers to save lives across the globe. Project HOPE has published Health Affairs since 1981.

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