Western medicine gets fair criticism for how it can “miss the forest for the trees” and this is found throughout our healthcare system. We have stomach doctors, liver doctors, pancreas doctors, psychologists, therapists, and more, yet all of it is connected via a large dynamic, and complicated system with multi-directional feedback loops, our body. And if health plans and providers do not look at the bigger picture to find the inter-related effects with other areas of healthcare, we risk inhibiting our progress and innovation.
The most recent edition of Health Affairs looked at one example of inter-related issues in healthcare, perinatal mental health with maternal and infant outcomes.
What’s the Deal with Perinatal Mental Health?
We’ve devoted substantial time on this blog to mental health topics, such as:
- Mental Health Awareness for Employers
- Workplace Mental Health
- How Behavioral Health Spending Correlates to Overall Health Plan Spending
Mental health disorders and symptoms exacerbate nearly every medical issue, with research finding a connection between mental illnesses and diabetes, cancer, multiple sclerosis, and hypertension, to name just a few.
Mental health conditions are diagnosed in one in five pregnant or postpartum people. And when our infant mortality rate is one of the highest among developed nations, we need to understand why. In 2018 alone, over 21,000 infants died.
Infant mortality and morbidity are caused by preterm birth, low birth weight, and growth restrictions on the infant while in the uterus.
Unfortunately, the health disparities we’ve touched on before are correlated to mental health, as we find that the mortality rate of Black infants was almost twice that of White infants in 2018.
The research in this month’s issue of Health Affairs looked at this issue and connection from a number of different angles.
Simonovich et. al “Meta-Analysis of Antenatal Depression and Adverse Birth Outcomes in US Populations 2010-20”
These researchers did a systematic review of a number of papers, finding that pregnant people with depression gave birth preterm at a rate 46 percent greater than pregnant people without depression, and delivered a low birth weight baby 90 percent more often.
The researchers recommend universal screening for depression during pregnancy, which is in fact a recommendation from the American College for Obstetricians and Gynecologists. Additionally, they suggest that states employee policy mandate strategies and payers provide adequate reimbursement.
As the study indicated that depression during pregnancy is tied to a greater risk for low birth weight and preterm birth for African Americans, the authors suggest that universal depression screening would ensure that every pregnant person received early assessments, referrals, and treatment options at similar rates. When inequities exist in healthcare, policy changes should address the risks and target specific strategies to create a more equitable healthcare system.
Clare Brown et. al Find Mental Health Conditions Increase Maternal Morbidity and Cost the US $102 Million per Year
Researchers started with the understanding that mental health during pregnancy is understood as a contributor to adverse maternal outcomes and estimate specific costs and statistics associated with perinatal mental health disorders, by both payer and mental health condition.
They found that a pregnant person with a mental health condition had $458 higher delivery costs and a 50% greater rate of severe maternal morbidity. They then extrapolated these costs across projected annual births and estimate an extra $102 million in delivery costs for people with a perinatal mental health condition.
Severe Maternal Morbidity: “Unexpected outcomes of labor and delivery that result in significant short- or long-term consequences to a woman’s health”
The researchers noted a lower diagnosed rate of mental health disorders among non-White populations, which shows the need for greater assessment and screening for mental health conditions among these groups.
These estimated cost estimates are even worse for people with trauma or stress-related mental health disorders. The estimated additional costs in delivery nearly doubled to $825 and had 87 percent higher rates of severe maternal morbidity. This leads the researchers to suggest a policy update beyond the recommended screenings by the American College for Obstetricians and Gynecologists and the American College of Nurse-Midwives to also include screening for trauma- or stress-related disorders. And as previous research found higher rates of these type disorders among Black populations, people with low incomes, and those unhoused or formerly incarcerated, this screening may reduce both overall adverse maternal outcomes and also address disparities in outcomes among different populations.
The researchers also suggest that payers increase coverage for innovative prenatal and perinatal care such as midwifery, group prenatal care, and doulas. These models of care can enhance social support, connection, and help people navigate their pregnancy. Additionally, only some states have updated death certificates to include a checkbox for whether a person was pregnant within the last 12 months.
Zochowski on Trends in C-Section Rates and Connection to Perinatal Mental Health
Researchers started with one of the objectives within Healthy People 2030 to reduce the rate of C-sections among women with low-risk pregnancies. They analyzed commercially insured women to better understand the relationship between perinatal mental health and first-time C-section deliveries.
Their data covered 2008 to 2017 and included 360,225 deliveries, 24 percent of which resulted in a C-section and 3 percent of which had a diagnosis of depression or anxiety.
Through their analysis, they estimated a predicted probability of C-section delivery among women with such a diagnosis that was 3.5 percent higher than those without or about 20 percent greater on a relative basis.
These findings indicate that perinatal mood and anxiety disorders increase the risk for C-section deliveries in otherwise healthy women. Future research can seek to better understand the underlying mechanisms, which may be caused by elevated stress hormones or different provider decisions when caring for a woman with distress.
Employers Can Build On These Findings for Better Maternal Health
Employer’s insure nearly 140 million Americans and thus share some responsibility for how employees and their family members engage with the healthcare system. With our concerning birthrate trends and concerns women express about the healthcare system and how it relates to their pregnancies, employers and health plans can lead change through payer recommendations above and a focus on health equity and mental health.