In the shadow of America’s maternal health crisis, Medicaid mothers are fighting an uphill battle against systemic neglect. Many of these mothers are facing a cruel reality: the more they need help, the harder it is to get.
It is far from uncommon for new mothers in the United States to find themselves thrust into the throes of postpartum depression after welcoming a new life. Most of them, about three-quarters, will never receive treatment for their perinatal mental health conditions. And while the postpartum journey can be difficult for many, the path to recovery for Medicaid mothers is fragmented beyond navigability.
Recent years have seen a heightened focus on the maternal health crisis that has gripped the United States for decades, capturing the attention of policymakers, health care institutions, and innovators. This crisis reflects deep-rooted issues in how our health care system supports mothers through and after pregnancy. Researchers and regulators are attempting to address the long-lasting implications of postpartum depression on the health and well-being of mothers and their children.
The U.S. Surgeon General’s recent advisory on the mental health and well-being of parents, for example, shines a light on the widespread effects of postpartum depression in America, and prescribes a series of steps federal and state governments can take to improve mental health outcomes for American families.
While this, and other national initiatives, strive to improve outcomes for mothers, the fact remains that Medicaid moms – a population that accounts for 41% of all births in the United States – are often left behind.
Medicaid mothers with perinatal mental health conditions are likely to be experiencing a host of comorbid behavioral, social, and clinical needs that have a caustic impact on their health and the health of their children. I’ve treated countless women who are struggling with postpartum depression in addition to the fallout of systemic societal problems like lack of childcare. These are poor mothers with small children who have lost their jobs and are struggling to pay their rent. The role of the psychiatrist in these cases becomes more about triaging resources than treating depression.
Our system is telling low-income mothers to seek mental help without addressing the root causes of their agony. Their experiences reveal a broader chasm in our country’s movement to improve maternal health.
Maternal mental health is getting attention, but vast gaps persist.
On the surface, the maternal mental health crisis may seem anchored to the problem of access to diagnostics and preventive care. Notable efforts have been made to improve maternal mental health, including state-level initiatives to mandate screenings and the creation of a federal task force charged with developing a strategy to expand access to diagnostic testing.
But progress has not been uniform, and little has been done to bridge the rift that still remains between screenings and access to care. The shortage of mental health professionals – let alone those who accept Medicaid – has exacerbated this problem, leaving many mothers to navigate their mental health care on their own, with limited support.
More daunting is the gap that exists between the current state of prevention and the availability of specialized care.
When I was in training, there was little to no emphasis on specialized mental health care for women, let alone for women experiencing one or more of the extremely complex, interconnected conditions common among the Medicaid population. While this field has made leaps and bounds since then, unfortunately, many health care providers lack the training to offer appropriate treatment for pregnant and postpartum women yet today.
Prescribing practices, for example, are just one of many components of care that have been affected by a general lack of specialized knowledge. Confronted with uncertainty, many providers fall back on the practice of deprescribing. While well-intentioned, deprescribing can ramp up to disastrous outcomes; postpartum depression, when untreated, can very quickly morph into chronic depression and anxiety.
The lack of personalized care required to keep this population healthy is compounded by the financial barriers many mothers on Medicaid face. Right now, specialized treatments are rarely covered by state Medicaid plans, forcing mothers to make difficult choices between life-saving care and life-sustaining necessities for their families. Even if they decide to opt in, these out-of-pocket costs can be difficult to sustain for most Medicaid families, contributing to higher no-show rates and engagement challenges.
And yet, as intractable as this burgeoning crisis may seem, it is fixable.
Equitable maternal mental health care is attainable with better program design.
To truly meet the needs of Medicaid mothers, states must work to ensure the availability and accessibility of high-quality, specialized mental health care. This requires developing programs designed to work closely with case managers and other supplemental support services to offer comprehensive care.
An effective approach must include an omnichannel engagement strategy that enables mothers to access the support they need when they need it. This is a population with highly specific needs. A high-touch model of care –whether it be in-person visits, phone consultations, or virtual care – is not a luxury but a necessity. In fact, a pilot study published in 2021 found virtual psychiatric care not only increased care accessibility for mothers with perinatal depression, but reduced depressive symptoms on a scale comparative to in-person consultations.
Our movement to improve maternal health will fail if it cannot meet the needs of our most vulnerable mothers. It is time to ensure that all mothers, regardless of their background, receive the care necessary to keep them – and their children – healthy.
Shama Rathi is a psychiatrist and physician executive.
