Improving maternal mental health is key to addressing U.S. maternal mortality


Many people know that the United States has the worst maternal mortality rate among high income countries. What they might not know is that the leading cause of these deaths is attributed to mental health. 

Mental health conditions, including deaths to suicide and overdose/poisoning related to substance use disorder, account for 23% of pregnancy-related deaths, according to the Centers for Disease Control and Prevention.  

Preventing these deaths is an important area of research and practice for public health professionals. Students at the University of Washington School of Public Health have been partnering with organizations to understand how everything from appointment scheduling to state insurance policies can be improved to better support the mental health of pregnant people.  

As part of their practicum experience, Masters of Public Health (MPH) Epidemiology students Hiwot Weldemariam and Sandra McAteer worked with the UW Perinatal Mental Health and Substance Use Education, Research & Clinical Consultation Center (PERC) to support them in improving equitable access to mental health care for perinatal populations (the period of time when someone becomes pregnant and up to a year after giving birth). The UW PERC Center works across mental health and substance use delivery systems through clinical consultation, education and health services research. 

“If we can say that the leading cause of maternal mortality is this mental health challenge, then most maternal deaths, including those caused by mental health, are largely preventable,” McAteer said. “It’s a public health responsibility to share this, advocate for solutions, and address what is causing this problem.” 

Improving access to mental health appointments

Weldemariam, who is pursuing a MPH degree, became interested in perinatal health after experiencing the challenges of mental health and pregnancy. Weldemariam moved to the United States 12 years ago from Ethiopia with her husband for work, and had a child soon afterwards. In addition to losing her social connections after the move, Weldemariam experienced postpartum depression, and saw the inequitable impact of health care systems on specific populations, such as immigrant communities. 

“Going through that struggle opened my eyes to see the surrounding community members,” said Weldemariam. “I see east African immigrant communities going through mental health challenges, especially the moms, postpartum depression, anxiety and even children going through challenges like substance use and gun violence. I saw a calling for me there.” 

For her practicum experience, Weldemariam worked with the PERC Center’s virtual perinatal psychiatry clinic that provides one-on-one virtual mental health consultation for perinatal people across Washington state with mental health disorders. These virtual mental health services are helpful for people who live in rural areas, who are working, or can’t find child care to come for in-person visits.  

Part of the mission of the PERC Center is to make perinatal mental health care more accessible to populations that experience greater health disparities, which is why the clinic serves patients with Medicaid insurance (a proxy for low-income individuals) and those living in rural areas, said Amritha Bhat, MD, MPH, director of the PERC Center and Weldemariam’s site supervisor. 

“We aim to improve access to equitable care through all of our programs,” Bhat said. “We had mechanisms in place to make sure that the patients who needed our care the most were reached, so we wanted to do an evaluation to assess whether we were meeting our goals of reaching as many people as we would like to.” 

The clinic was experiencing high no-show rates, so the team implemented a bidirectional text messaging intervention to help remind patients of appointments, cancel appointments and reschedule them. Weldemariam was part of a team that studied whether this intervention was having an impact.  

Through their data analysis, they found that the text messaging service successfully reduced the no-show rate. Leaders at the clinic are hoping to use a similar texting service for making appointments, as opposed to relying on phone-call scheduling.  

Some of the reasons it can be difficult to reach patients for these virtual maternal mental health consultations can be due to patients having limited access to the internet, an inability to log on to online video chats, or an inability to take time off work, Weldemariam said. Cultural stigmas can also cause patients to feel reluctant about seeking out mental health services. For immigrant communities, not being able to find a provider from one’s own cultural or linguistic backgrounds is also a deterrent. 

“There needs to be more study in this area to figure out what are these challenges that patients are facing,” Weldemariam said. “Equal access doesn't mean equity. Do patients know they have access to insurance? Do they have the same resources, knowledge and education? That’s what equity is: providing that system that supports their access to care.” 

Health insurance coverage and its impacts on mental health care  

Perinatal mental health and substance use disorders are common, and seen in 10 to 40% of perinatal individuals, with a disproportionate impact on Black, Latinx and Indigenous communities and people with low income. When untreated, they can have negative impacts on the parent, such as risk of suicide, as well as on the child, such as preterm birth, low birth weight, emotional and behavioral problems. 

One of the PERC Center’s projects focused on understanding how states’ Medicaid policies impacted access to mental health care for perinatal populations. This would help the team establish best practices for screening, referral, follow-up, symptom tracking and clinical care for all perinatal individuals insured by Medicaid. MPH student Sandra McAteer supported the team in this work for her practicum. 

Medicaid coverage supports low-income pregnant people, children and families, and finances almost half of all births in the U.S., according to KFF. Additionally, 61% of the 73 million beneficiaries of Medicaid are Black, Hispanic, Asian American, or another non-white race or ethnicity. States operate their own Medicaid programs within the federal guidelines, which means Medicaid coverage varies widely from state to state, from the type of services paid for to the income requirements. This impacts the services that perinatal patients using Medicaid receive. 

To understand the variances in mental health coverage across states, the team studied report cards published in 2023 by The Policy Center for Maternal Mental Health that ranked how well each state supported maternal mental health. To narrow their focus, the team analyzed only the best performing states to learn more about what they were doing right. 

The states that scored highest in maternal mental health supports offered case management services to a wide range of patients, so not just those with high-risk mental health concerns or histories, but others who were also seeking care. (Case management services include connection to care or consultations with social workers, nurses, or other intake professionals.) The ones that performed well also allowed patients to seek services for longer periods of time amidst the pregnancy and postpartum continuum.  

One of the most surprising findings, however, was just how much variance existed between the top 14-performing states, McAteer said. The highest ranked state scored a B- on its report card, demonstrating just how far the U.S. has to go in supporting maternal mental health. Even within these top-performing states, there was still a wide range in which organizations would accept Medicaid for mental health services, and the programs and duration Medicaid was allowed to be used for. These types of discrepancies are challenging for patients to parse through. 

“For pregnant people, if you're trying to look at mental health or substance use resources or other related services that are so highly stigmatized, especially in that phase of life, it can be really disheartening and frustrating,” McAteer said. “It’s confusing to understand who qualifies, and if you do qualify, there may be wait lists. It’s not as easy as ‘I’m interested in services, here’s the insurance plan I have, so here are my options.’” 

McAteer said that the team looked at policy changes that could expand access to maternal mental health services, including increasing Medicaid reimbursement rates. Not only can this kind of research and quality improvement support the PERC Center’s efforts, but it can be part of the collective effort to understanding maternal mental health and addressing the mortality crisis in the U.S.  

“Our work together with Sandra will hopefully improve the care pathway for pregnant or postpartum individuals to ensure that they receive the appropriate mental health care and support that they need,” said PERC Program Coordinator Alicia Kerlee. 

Other PERC Center team members who were involved in the projects include Jamie Adachi,  Alicia Kerlee, Deborah Cowley, Nadejda Bespalova, Mollie Forester, Jennifer Magnani, Perla Raga, Lauren Oickle, Suwilanji Chisebuka, and Kellsie Pence (virtual perinatal psychiatry clinic).