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Zivin K, Courant A. Disparities in Utilization and Delivery Outcomes for Women with Perinatal Mood and Anxiety Disorders. JOURNAL OF PSYCHIATRY AND BRAIN SCIENCE 2024; 9:e240003. [PMID: 38817312 PMCID: PMC11138136 DOI: 10.20900/jpbs.20240003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Perinatal mood and anxiety disorders (PMAD), which include depression and/or anxiety in the year before and/or after delivery, are common complications of pregnancy, affecting up to one in four perinatal individuals, with costs of over $15 billion per year in the US. In this paper, we provide an overview of the disparities in utilization and delivery outcomes for individuals with perinatal mood and anxiety disorders in the US. In addition, we discuss the current US screening and treatment guidelines as well as the high societal costs of illness of PMAD for both perinatal individuals and children. Finally, we outline opportunities for quality improvement of PMAD care in the US, including leveraging increased engagement with healthcare system during prenatal care, working toward a more cohesive national strategy to address PMAD, leaning into evidence-based policymaking through collaboration with a panel of experts, and generating state-level profiles focused on PMAD.
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Affiliation(s)
- Kara Zivin
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Program on Women’s Healthcare Effectiveness Research, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI 48109, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor MI 48109, USA
- VA Ann Arbor Healthcare System, Ann Arbor MI 48105, USA
| | - Anna Courant
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI 48109, USA
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Schaefer AJ, Mackie T, Veerakumar ES, Sheldrick RC, Moore Simas TA, Valentine J, Cowley D, Bhat A, Davis W, Byatt N. Increasing Access To Perinatal Mental Health Care: The Perinatal Psychiatry Access Program Model. Health Aff (Millwood) 2024; 43:557-566. [PMID: 38560809 DOI: 10.1377/hlthaff.2023.01439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Perinatal psychiatry access programs offer a scalable approach to building the capacity of perinatal professionals to identify, assess, and treat mental health conditions. Little is known about access programs' implementation and the relative merits of differing approaches. We conducted surveys and semistructured interviews with access program staff and reviewed policy and procedure documents from the fifteen access programs that had been implemented in the United States as of March 2021, when the study was conducted. Since then, the number of access programs has grown to thirty state, regional, or national programs. Access programs implemented up to five program components, including telephone consultation with a perinatal psychiatry expert, one-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, trainings for perinatal professionals, and practice-level technical assistance. Characterizing population-based intervention models, such as perinatal psychiatry access programs, that address perinatal mental health conditions is a needed step toward evaluating and improving programs' implementation, reach, and effectiveness.
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Affiliation(s)
- Ana J Schaefer
- Ana J. Schaefer , Downstate Health Sciences University, Brooklyn, New York
| | | | | | | | | | | | - Deborah Cowley
- Deborah Cowley, University of Washington, Seattle, Washington
| | | | - Wendy Davis
- Wendy Davis, Postpartum Support International, Portland, Oregon
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Zivin K, Pangori A, Zhang X, Tilea A, Hall SV, Vance A, Dalton VK, Schroeder A, Courant A, Tabb KM. Perinatal Mood And Anxiety Disorders Rose Among Privately Insured People, 2008-20. Health Aff (Millwood) 2024; 43:496-503. [PMID: 38507649 DOI: 10.1377/hlthaff.2023.01437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Nationwide, perinatal mood and anxiety disorder (PMAD) diagnoses among privately insured people increased by 93.3 percent from 2008 to 2020, growing faster in 2015-20 than in 2008-14. Most states and demographic subgroups experienced increases, suggesting worsening morbidity in maternal mental health nationwide. PMAD-associated suicidality and psychotherapy rates also increased nationwide from 2008 to 2020. Relative to 2008-14, psychotherapy rates continued to rise in 2015-20, whereas suicidality rates declined.
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Affiliation(s)
- Kara Zivin
- Kara Zivin , University of Michigan, Veterans Affairs Ann Arbor Healthcare System, and Mathematica, Ann Arbor, Michigan
| | | | | | | | | | - Ashlee Vance
- Ashlee Vance, Henry Ford Health System, Detroit, Michigan
| | | | | | | | - Karen M Tabb
- Karen M. Tabb, University of Illinois at Urbana-Champaign, Champaign, Illinois
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Maharjan S, Goswami S, Rong Y, Kirby T, Smith D, Brett CX, Pittman EL, Bhattacharya K. Risk Factors for Severe Maternal Morbidity Among Women Enrolled in Mississippi Medicaid. JAMA Netw Open 2024; 7:e2350750. [PMID: 38190184 PMCID: PMC10774990 DOI: 10.1001/jamanetworkopen.2023.50750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Importance Mississippi has one of the highest rates of severe maternal morbidity (SMM) in the US, and SMMs have been reported to be more frequent among Medicaid-insured women. A substantial proportion of pregnant women in Mississippi are covered by Medicaid; hence, there is a need to identify potential risk factors for SMM in this population. Objective To examine the associations of health care access and clinical and sociodemographic characteristics with SMM events among Mississippi Medicaid-enrolled women who had a live birth. Design, Setting, and Participants A nested case-control study was conducted using 2018 to 2021 Mississippi Medicaid administrative claims database. The study included Medicaid beneficiaries aged 12 to 55 years who had a live birth and were continuously enrolled throughout their pregnancy period and 12 months after delivery. Individuals in the case group had SMM events and were matched to controls on their delivery date using incidence density sampling. Data analysis was performed from June to September 2022. Exposure Risk factors examined in the study included sociodemographic factors (age and race), health care access (distance from delivery center, social vulnerability index, and level of maternity care), and clinical factors (maternal comorbidity index, first-trimester pregnancy-related visits, and postpartum care). Main Outcomes and Measures The main outcome of the study was an SMM event. Adjusted odds ratio (aORs) and 95% CIs were calculated using conditional logistic regression. Results Among 13 485 Mississippi Medicaid-enrolled women (mean [SD] age, 25.0 [5.6] years; 8601 [63.8%] Black; 4419 [32.8%] White; 465 [3.4%] other race [American Indian, Asian, Hispanic, multiracial, and unknown]) who had a live birth, 410 (3.0%) were in the case group (mean [SD] age, 26.8 [6.4] years; 289 [70.5%] Black; 112 [27.3%] White; 9 [2.2%] other race) and 820 were in the matched control group (mean [SD] age, 24.9 [5.7] years; 518 [63.2%] Black; 282 [34.4%] White; 20 [2.4%] other race). Black individuals (aOR, 1.44; 95% CI, 1.08-1.93) and those with higher maternal comorbidity index (aOR, 1.27; 95% CI, 1.16-1.40) had higher odds of experiencing SMM compared with White individuals and those with lower maternal comorbidity index, respectively. Likewise, an increase of 100 miles (160 km) in distance between beneficiaries' residence to the delivery center was associated with higher odds of experiencing SMM (aOR, 1.14; 95% CI, 1.07-1.20). Conclusions and Relevance The study findings hold substantial implications for identifying high-risk individuals within Medicaid programs and call for the development of targeted multicomponent, multilevel interventions for improving maternal health outcomes in this highly vulnerable population.
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Affiliation(s)
- Shishir Maharjan
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University
- Center for Pharmaceutical Marketing and Management, University of Mississippi School of Pharmacy, University
| | - Swarnali Goswami
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University
- Center for Pharmaceutical Marketing and Management, University of Mississippi School of Pharmacy, University
- Now with Complete Health Economics and Outcomes Solutions, LLC, Chalfont, Pennsylvania
| | - Yiran Rong
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University
- Center for Pharmaceutical Marketing and Management, University of Mississippi School of Pharmacy, University
- Now with MedTech Epidemiology and Real-World Data Sciences, Johnson and Johnson, New Brunswick, New Jersey
| | | | | | | | - Eric L. Pittman
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University
- Center for Pharmaceutical Marketing and Management, University of Mississippi School of Pharmacy, University
| | - Kaustuv Bhattacharya
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, University
- Center for Pharmaceutical Marketing and Management, University of Mississippi School of Pharmacy, University
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Attanasio L, Jeung C, Geissler KH. Association of Postpartum Mental Illness Diagnoses with Severe Maternal Morbidity. J Womens Health (Larchmt) 2023. [PMID: 38153367 DOI: 10.1089/jwh.2023.0244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Background: This study aimed to determine whether birthing people who experience severe maternal morbidity (SMM) are more likely to be diagnosed with a postpartum mental illness. Materials and Methods: Using the Massachusetts All Payer Claims Database, this study used modified Poisson regression analysis to assess the association of SMM with mental illness diagnosis during the postpartum year, accounting for prenatal mental illness diagnoses and other patient characteristics. Results: There were 128,161 deliveries identified, with 55.0% covered by Medicaid. Of these, 3.1% experienced SMM during pregnancy and/or delivery hospitalization, and 20.1% had a mental illness diagnosis within 1 year postpartum. In adjusted regression analyses, individuals with SMM had a 10.6% increased risk of having any mental illness diagnosis compared to individuals without SMM, primarily due to an increased risk of a depression or post-traumatic stress disorder diagnosis among people with SMM than those without SMM. Conclusions: Individuals who experienced SMM had a higher risk of a mental illness diagnosis in the postpartum year. Given increases in SMM in the United States in recent decades, policies to mitigate mental health sequelae of SMM are urgently needed.
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Affiliation(s)
- Laura Attanasio
- Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health and Health Sciences, Amherst, Massachusetts, USA
| | - Chanup Jeung
- Department of Health Policy, Management and Behavior, School of Public Health, State University of New York-University at Albany School of Public Health, Albany, New York, USA
| | - Kimberley H Geissler
- Department of Healthcare Delivery and Population Sciences, UMass Chan Medical School-Baystate, Springfield, Massachusetts, USA
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Du R, Ali MM, Sung YS, Pandit AA, Payakachat N, Ounpraseuth ST, Magann EF, Eswaran H. Maternal comorbidity index and severe maternal morbidity among medicaid covered pregnant women in a US Southern rural state. J Matern Fetal Neonatal Med 2023; 36:2167073. [PMID: 36683016 DOI: 10.1080/14767058.2023.2167073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The rates of SMM have been steadily increasing in Arkansas, a southern rural state, which has the 5th highest maternal death rate among the US states. The aims of the study were to test the functionality of the Bateman index in association to SMM, in clustering the risks of pregnancies to SMM, and to study the predictability of SMM using the Bateman index. STUDY DESIGN From the ANGELS database, 72,183 pregnancies covered by Medicaid in Arkansas between 2013 and 2016 were included in this study. The expanded CDC ICD-9/ICD-10 criteria were used to identify SMM. The Bateman comorbidity index was applied in quantifying the comorbidity burden for a pregnancy. Multivariable logistic regressions, KMeans method, and five widely used predictive models were applied respectively for each of the study aims. RESULTS SMM prevalence remained persistently high among Arkansas women covered by Medicaid (195 per 10,000 deliveries) during the study period. Using the Bateman comorbidity index score, the study population was divided into four groups, with a monotonically increasing odds of SMM from a lower score group to a higher score group. The association between the index score and the occurrence of SMM is confirmed with statistical significance: relative to Bateman score falling in 0-1, adjusted Odds Ratios and 95% CIs are: 2.1 (1.78, 2.46) for score in 2-5; 5.08 (3.81, 6.79) for score in 6-9; and 8.53 (4.57, 15.92) for score ≥10. Noticeably, more than one-third of SMM cases were detected from the studied pregnancies that did not have any of the comorbid conditions identified. In the prediction analyses, we observed minimal predictability of SMM using the comorbidity index: the calculated c-statistics ranged between 62% and 67%; the Precision-Recall AUC values are <7% for internal validation and <9% for external validation procedures. CONCLUSIONS The comorbidity index can be used in quantifying the risk of SMM and can help cluster the study population into risk tiers of SMM, especially in rural states where there are disproportionately higher rates of SMM; however, the predictive value of the comorbidity index for SMM is inappreciable.
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Affiliation(s)
- Ruofei Du
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mir M Ali
- Institute for Digital Health & Innovation, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Yi-Shan Sung
- Institute for Digital Health & Innovation, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ambrish A Pandit
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nalin Payakachat
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Songthip T Ounpraseuth
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Everett F Magann
- Department of Obstetrics & Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Hari Eswaran
- Institute for Digital Health & Innovation, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Martin CE, Britton E, Shadowen H, Johnson J, Sabo R, Cunningham P. Postpartum medication for opioid use disorder outcomes associated with prenatal treatment and neighborhood-level social determinants. Am J Obstet Gynecol MFM 2023; 5:101173. [PMID: 37783277 PMCID: PMC10727449 DOI: 10.1016/j.ajogmf.2023.101173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/07/2023] [Accepted: 09/24/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Opioid use disorder is a leading cause of death through the year postpartum. OBJECTIVE This study aimed to identify the association of neighborhood-level social determinants of health and prenatal opioid use disorder treatment receipt with the outcomes of medication treatment for opioid use disorder through the year postpartum among a cohort of birthing people. STUDY DESIGN This was a population-based retrospective cohort study that used state Medicaid claims and enrollment data for the 1690 individuals who delivered a live infant between July 1, 2016 and December 31, 2020 and received medication for opioid use disorder at delivery. The primary exposure was the state Health Opportunity Index, a composite measure of social determinants of health linked at the census-tract level. Secondary exposures included comprehensiveness of opioid use disorder treatment and duration of medication treatment for opioid use disorder received prenatally. Outcomes included the duration and continuity of postpartum medication treatment for opioid use disorder, operationalized as the time from delivery to the discontinuation of medication treatment for opioid use disorder, and percentage of days covered by medication treatment for opioid use disorder within the 12 months after delivery, respectively. RESULTS Within the study sample, 711 deliveries were to birthing people in the lowest state Health Opportunity Index tercile (indicating high burden of negative social determinants of health), 647 in the middle state Health Opportunity Index tercile, and 332 in the highest state Health Opportunity Index tercile. Using stepwise multivariable regression (Cox proportional hazards and negative binomial models) guided by a socioecological framework, prenatal receipt of more comprehensive opioid use disorder treatment and/or longer duration of prenatal medication treatment for opioid use disorder was associated with improved 1-year postpartum opioid use disorder treatment outcomes (duration and continuity of medication treatment for opioid use disorder). When the state Health Opportunity Index was added to the models, these significant associations remained stable, with the state Health Opportunity Index not demonstrating an association with the outcomes (duration hazard ratio, 1.39; 95% confidence interval, 0.551-3.512; continuity relative risk, 1.024; 95% confidence interval, 0.323-3.247). CONCLUSION Targeted efforts at expanding access to and quality of evidence-based opioid use disorder treatments for reproductive-age people across the life course should be prioritized within the spectrum of work aimed at eradicating disparities in pregnancy-related mortality.
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Affiliation(s)
- Caitlin E Martin
- Department of Obstetrics and Gynecology, School of Medicine, Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA (Dr Martin).
| | - Erin Britton
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA (Dr Britton, Ms Shadowen, and Dr Cunningham)
| | - Hannah Shadowen
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA (Dr Britton, Ms Shadowen, and Dr Cunningham)
| | - Jasmine Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN (Dr Johnson)
| | - Roy Sabo
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA (Dr Sabo)
| | - Peter Cunningham
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA (Dr Britton, Ms Shadowen, and Dr Cunningham)
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Hawkins SS, Harper S, Baum CF, Kaufman JS. Associations Between State-Level Changes in Reproductive Health Services and Indicators of Severe Maternal Morbidity. JAMA Pediatr 2023; 177:93-95. [PMID: 36374506 PMCID: PMC9664365 DOI: 10.1001/jamapediatrics.2022.4136] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022]
Abstract
This cross-sectional study examines the legislative, state, economic, and racial factors in increased severe maternal morbidity risk in pregnant individuals.
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Affiliation(s)
| | - Sam Harper
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
| | | | - Jay S. Kaufman
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada
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Carmichael SL, Girsen AI, Ma C, Main EK, Gibbs RS. Using Longitudinally Linked Data to Measure Severe Maternal Morbidity Beyond the Birth Hospitalization in California. Obstet Gynecol 2022; 140:450-452. [PMID: 35926198 PMCID: PMC9669097 DOI: 10.1097/aog.0000000000004902] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/17/2022] [Indexed: 01/05/2023]
Abstract
Most studies of severe maternal morbidity (SMM) include only cases that occur during birth hospitalizations. We examined the increase in cases when including SMM during antenatal and postpartum (within 42 days of discharge) hospitalizations, using longitudinally linked data from 1,010,250 births in California from September 1, 2016, to December 31, 2018. For total SMM, expanding the definition resulted in 22.8% more cases; for nontransfusion SMM, 45.1% more cases were added. Sepsis accounted for 55.5% of the additional cases. The increase varied for specific indicators, for example, less than 2% for amniotic fluid embolism, 7.0% for transfusion, 112.9% for sepsis, and 155.6% for acute myocardial infarction. These findings reiterate the importance of considering SMM beyond just the birth hospitalization and facilitating access to longitudinally linked data to facilitate a more complete understanding of SMM.
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Affiliation(s)
- Suzan L Carmichael
- Division of Neonatology and Developmental Medicine, Department of Pediatrics, and the Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics & Gynecology, Stanford University School of Medicine, Palo Alto, California
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Abstract
PURPOSE OF REVIEW Health equity is an important priority for obstetric anesthesia, but describing disparities in perinatal care process and health outcome is insufficient to achieve this goal. Conceptualizing and framing disparity is a prerequisite to pose meaningful research questions. We emphasize the need to hypothesize and test which mechanisms and drivers are instrumental for disparities in perinatal processes and outcomes, in order to target, test and refine effective countermeasures. RECENT FINDINGS With an emphasis on methodology and measurement, we sketch how health systems and disparity research may advance maternal health equity by narrating, conceptualizing, and investigating social determinants of health as key drivers of perinatal disparity, by identifying the granular mechanism of this disparity, by making the economic case to address them, and by testing specific interventions to advance obstetric health equity. SUMMARY Measuring social determinants of health and meaningful perinatal processes and outcomes precisely and accurately at the individual, family, community/neighborhood level is a prerequisite for healthcare disparity research. A focus on elucidating the precise mechanism driving disparity in processes of obstetric care would inform a more rational effort to promote health equity. Implementation scientists should rigorously investigate in prospective trials, which countermeasures are most efficient and effective in mitigating perinatal outcome disparities.
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