What States Can Do to Improve Black Maternal Mental Health

Looking back at the events and coverage of Black Maternal Mental Health Week (July 19–25), it is clear that the nation’s policymakers need to do more to ensure that Black mothers have the care they need to survive and thrive during the COVID-19 pandemic and beyond.

Being a mother during the pandemic extracts a heavy mental health toll, particularly for Black mothers. Even before the pandemic, according to the Centers for Disease Control and Prevention (CDC), one in eight women experienced postpartum depression, and nearly 50 percent of pregnant women with depression went without treatment. Black women in particular often experienced varying forms of depression, anxiety, and mood disorders during pregnancy and after birth. And during the pandemic response Black mothers who were pregnant or gave birth likely experienced increased mental stresses with isolating medical facility policies, exposure to racial violence and protests, and quarantine from support systems.

To address the maternal mental health crisis among Black mothers, policymakers must permanently extend postpartum Medicaid coverage—including mental health coverage—in all states for the full year of the postpartum period. Access to quality health care through Medicaid must include the full benefits of prenatal and postnatal visits with consistent and multiple mental health screenings before and during the postpartum period. As part of this initiative, community-based organizations and care providers that have supported Black women and families during their mental health journey during childbirth and beyond have an important role to play in improving outcomes.

Current State Investments in Maternal Mental Health Programs
In March of 2021, the American Rescue Plan Act provided the option for states to extend Medicaid postpartum coverage—including mental health coverage—to twelve months after birth, through a State Plan Amendment. Fully extended postpartum coverage—as called for by the U.S. surgeon general—could address the high rate of maternal mortality that occurs during the full year after birth. (It is important to note here that, while there is a push for stronger data collection on maternal deaths, self-harm deaths in the pregnancy to postpartum period are omitted from published maternal mortality data.) States currently observe different timeframes for the postpartum period, but an increasing number recognize the need for longer Medicaid coverage, with Georgia recently extending coverage from sixty days to six months, and Maine phasing up to twelve months by 2023. Access to quality maternity mental health care is critically important to improve health outcomes, as nearly 60 percent of pregnancy-related deaths during the postpartum period are preventable.

Prior to the incentives initiated by the Biden–Harris administration, states had the opportunity to extend Medicaid coverage by using the Center for Medicaid Services 1115 waiver process to pilot demonstration programs without legislative change. Furthermore, for some states that have not extended postpartum Medicaid coverage, certain other 1115 waivers provide limited coverage for postpartum mental health services. Missouri currently has an approved 1115 waiver to offer coverage for a limited population of postpartum individuals for substance use disorders and maternal mental health treatment. South Carolina offers similar coverage, with a statewide cap of only 500 postpartum participants with substance use disorders or serious mental illness. Recently approved 1115 waivers may have extended coverage for varying time frames during the postpartum period, but unfortunately they also create more restrictions for postpartum individuals. California takes a different approach with state-funded postpartum coverage for individuals diagnosed with maternal mental health conditions such as postpartum depression.
The Important Role of Community-Based Organizations and Managed Care Organizations
Extending Medicaid coverage in each state is essential but not sufficient to improve Black maternal mental health. Community-based organizations and other providers of support to birthing people have unique ways in which they can address maternal mental health needs. A local approach to maternal mental health respects relationships of community members and clients and creates an environment where hyper-localized interventions can utilize evidence-based models for specialized care. In efforts to address racial bias and inequity in health care and American society more broadly, it is vital that all community-based organizations providing maternal mental health care to women of color examine racial history in maternity care and the impacts of community health interventions on families. The history that built mistrust of government health and child welfare programs in communities of color is often rooted in parent–child separation policies through child protection services and criminal justice systems. Aggressive anti-substance use laws and surveillance created a landscape where Black, Indigenous, and People of Color (BIPOC) communities experience the highest rates of children removed from a parent’s care. When reporting a maternal mental health concern, women of color and families report feeling unheard by providers, even after many visits, leaving gaps in treatment and diagnosis.

Mental health support groups and organizations located in communities, particularly those led by Black women or people of color, often offer culturally responsive and integrated mental health services and thus garner the trust of the women they serve. Black-women-led organizations have created a nexus where reproductive justice and maternal mental health support intersect through avenues of movement building, holistic wellness services, community-based research, and advocacy. Interactive online and media platforms used by these organizations have expanded the ways in which women of color can find relatable support and resources, such as lactation support for mothers experiencing postpartum depression and community networks for discussion of shared experiences.

Some states have implemented models of care that integrate these specific community needs, such as home visiting programs that train community care workers to reflect cultural norms and use multiple mental health screening tools during perinatal and postpartum home visits. Minnesota guidance, for example, emphasizes knowledge of local resources and developing a plan to “include a combination of resources to address depression and support wellbeing.” North Carolina offers out-patient and in-patient treatment for pregnant women and women with children who experience substance use. Managed Care Organizations (MCO) in Georgia employ Resource Mother Outreach services to help schedule appointments and apply for social services for qualifying postpartum mothers and babies. But more can be done by states —and by Congress—to integrate the lessons learned by community and managed care organizations that have been supporting Black mothers’ mental health.

What the States and Congress Should Do
Medicaid is the largest payer for mental health support in the United States. Right now, state policymakers have more opportunities than ever to address maternal mental health by taking advantage of diverse federal funding for public health care that may significantly reduce the strain on state budgets. But, despite the arrival of these federal incentives, and the coverage gaps that currently exist in states that so far have declined to expand Medicaid, some policymakers have refused to make the right choice because the issue has become highly politicized.

Put simply, policymakers should end the political jockeying over whether or not to make fundamental health care accessible and instead make a choice that enhances the quality of life so that Black communities no longer have to watch their families and mothers suffer from preventable conditions during the postpartum period. The remaining states that have not expanded Medicaid coverage perpetuate a coverage gap of uninsured or under-insured individuals that may not have access to public or private health care and are often burdened with high medical costs. While some federal policymakers are working to create alternative public health care programs similar to Medicaid in these non-expansion states for those residents, the option still remains for these states to receive funding for Medicaid expansion with a generous federal matching rate. States who have not yet expanded Medicaid should do so immediately. Furthermore, all states—whether they have expanded Medicaid yet or not, should take the federal government’s offer in the American Rescue Plan Act to pay for extending Medicaid postpartum coverage to the first twelve months after delivery.

Apart from Medicaid, the proposed federal package of bills known as the Black Maternal Health Momnibus Act of 2021 has potential to build on current legislation and programs to comprehensively address the Black Maternal Health crisis. Congress should consider all twelve bills within the Momnibus that span issues including climate change, improvements in data collection and research, diversity in the perinatal workforce, technology, and maternal mental health. The Momnibus also makes significant investments in community-based organizations that will assist in direct services to birthing people across populations including veterans, Native and Tribal communities, and incarcerated people. The Moms Matter Act within the Momnibus invests in community-based programs that provide mental and behavioral health treatments for those experiencing maternal mental health conditions or substance use disorders. The bill also includes funding to diversify the maternal mental and behavioral health care workforce and expand culturally congruent care models.

As states seek to use these new resources—from Medicaid expansion, from extension of postpartum coverage to twelve months, and potentially from parts of the Momnibus—leading state health agencies, study committees, insurance providers, and care providers should continuously, and equitably, engage with community-based organizations and allow their insights to inform policy change using a health equity lens. Maternal Mortality Review Committees (MMRCs), currently operating in most states, offer state-specific data on pregnancy-related and associated deaths. The composition of MMRCs, their practices around disaggregation of demographic data, and their frequency of reporting, however, vary from state to state. These discrepancies and the lack of standardization among MMRCs limits the opportunity to understand current maternal health information. State health agencies and MMRCs should expand data collection to community-based organizations and include metrics that reflect maternal mental health data.

State funding opportunities for public health, similar to the Maternal and Child Health Block Grant Program, should include community-based organizations and care providers as recipients, with a strong preference for entities that provide culturally congruent and holistic care that is reflective of community needs. Providers should also coordinate care with local programs exercising evidence-based care models that are culturally reflective, such as in-home visiting programs and therapy models.

Though extensive research and care models exist for perinatal and infant mental health, care providers should also prioritize maternal mental health from the perspective of birthing persons and caretakers from pregnancy through postpartum. Health care providers who treat pregnant and postpartum individuals should screen for an array of mood disorders throughout the postpartum period. Thirty-four states and the District of Columbia include postpartum mental health screening as a Medicaid benefit to identify postpartum depression. Beyond screening, state Medicaid needs to offer comprehensive, full benefits to support treatment and recovery.
As we reflect on this year’s Black Maternal Mental Health Week, the work to reach mothers and families suffering after birth continues. Family members, care workers, and nurses at postnatal visits are the first to interact with mothers who may be experiencing the “baby blues.” From a systemic view, this local interaction has rippling impacts on health care costs, public health interventions, and community-coordinated care. Community-based organizations are often on the frontlines offering direct services to address maternal mental health. States must institutionalize engagement with these groups to garner informed recommendations that reflect the needs and outcomes of each community member.