Ecosystem of Care: Providing Behavioral Health Services to Pregnant Women

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: working together at every level to ensure women get the behavioral health assistance they need to have successful pregnancies, deliveries, and postnatal experiences.

BRIE REIMANN:
We talk about things like the social determinants of health and a broader ecosystem of health. Public health is that, in my mind, in my perspective, that overarching umbrella of the healthcare system. It's how systems interact and collaborate together to ensure that there are these seamless systems. It's how we look at all the things that are impacting a person's health and we make sure that there's this ecosystem of care that is wrapping around a mother and a family and making sure that they have all the resources that they need to live healthy lives.

JOHNSON:
Women need to know that they're not alone and every woman should be celebrated when she has a child. We should have a big party, a baby shower, for everyone, and sometimes that doesn't happen.

AMY ZAPATA:
I would love for Louisiana to be a state where all prenatal and pediatric clinical providers in the state will have the support that they need to screen and respond to parents' mental health concerns, such as maternal depression, which is a key risk factor affecting maternal health, child-infant mortality, and really the developmental health of children.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, we examine the challenges of motherhood and the work to develop behavioral health systems and approaches that can help women through every stage: from pregnancy, to delivery, to time at home with children.

The maternal child health population is known to be at higher risk for a range of behavioral health issues, including substance misuse and mental health disorders. Our guests know the topic well.

Dr. Rebekah Gee is secretary of the Louisiana Department of Health where, for nearly four years, she's led reform efforts aimed at improving the health of all Louisiana residents.

Amy Zapata also works in the Louisiana Department of Health—she's the state's director of the Bureau of Family Health. She and Secretary Gee will be along shortly to discuss this topic.

But first, we hear from Brie Reimann, the assistant vice president of integrated health solutions for the National Council for Behavioral Health in Washington, D.C.

REIMANN:
Maternal and child health really refers to the health of mothers, infants, and children, and families. It's important to address the health of mothers and families specifically for maternal and child health from across the spectrum: in terms of prevention, treatment, recovery; making sure that families can live their best lives; in terms of having access to the comprehensive care that they need; as well as thinking through the other support systems that they might need and making sure that families have access to things like transportation and good primary and behavioral healthcare.

JOHNSON:
How are we doing on that front these days in the United States?

REIMANN:
We do have a lot of support in place through national organizations, such as HRSA—or the Health Resources and Services Administration—that has the Maternal and Child Health Bureau that provides a lot of support for providers in improving maternal and child health.

We also have other national or federal organizations like the Substance Abuse and Mental Health Services Administration, and the Centers for Disease Control and Prevention. So, we have these systems that support programming around improving maternal and child health nationally.

Of course, with healthcare, we always have room for improvement in terms of enhancing access to quality behavioral healthcare and primary healthcare, as well as enhancing the quality of care.

So, making sure that health practitioners and health providers across the country have the right tools to implement evidence-based practices as well as the right connections to address what we call the social determinants of health so that people receive good quality care within, let's say, a primary care provider setting.

But even when leaving the building, they have access to the support that they need through, as I mentioned, food, education, transportation, things like that, that all help us live our best lives.

JOHNSON:
When you consider the work you're doing and the people you're helping, are there any areas where you feel we could do better?

REIMANN:
One area where we always are trying to address is just access issues—ensuring that mothers and families, in this case, have access to quality healthcare. And when thinking about areas of our country, rural and frontier communities, where there may be limited provider organizations, how are we ensuring that these folks have access to care in these areas?

Another area where we really need to make sure that folks have the resources to seek good quality healthcare—insurance coverage, for example, in making sure that there is no gap in insurance coverage for mothers and families; making sure that, again, I can't stress the transportation issue enough, especially in rural and frontier communities, that are making sure that there are those resources available to support families in seeking care. And so, I think that focusing on rural and frontier communities, but also the issues of access to good quality healthcare.

Making sure we're measuring the impact of the healthcare that we deliver; so, making sure that we're also implementing the best quality of care that we can so that we're getting good results, and that we're tracking that in a meaningful way so that we can provide good information back to mothers and families, but also to our provider systems so that we can make improvements where needed.

JOHNSON:
Mothers face so many challenges today.

Are you surprised that we still have these needs in 2019?

REIMANN:
This term, the social determinants of health, is such a widely used term now, but when I started working in this field 15 years ago, we didn't talk about the social determinants of health.

So, really understanding how systems work together, implementing multifaceted approaches to improving maternal and child health and the integration of primary and behavioral health care and public health to really improve care and to address things like maternal mortality. We know that maternal mortality in the United States has more than doubled since the 1980s, which I think is something that we absolutely have to address.

But we are starting to see more of, I guess, a common language around the importance of implementing evidence-based screening tools for depression, things like evidence-based screening for alcohol use.

We're also seeing a rise in women in binge drinking and things like routine alcohol use, which is something that we have to address—and early on that continuum, you know, making sure that primary care providers are routinely talking about depression and the health impact of drinking more than, for example, seven drinks in a week, how that impacts long-term health. So, having these regular conversations in a primary care setting.

You know, we have some more work to do in this area, but since I have been in the field, we have come a long way also in just making sure that we're addressing mental health and substance use just as we do any other health concerns, that it just becomes a routine part of healthcare.

JOHNSON:
Give us a little more detail about the tools you just mentioned—some people might not know about those.

REIMANN:
Routinely screening for depression—and perinatal and postpartum depression for mothers—is a pretty streamlined process as long as the healthcare providers understand that it's important to implement evidence-based screening tools. So, things like the patient health questionnaire, which is a depression screener that is evidence-based and really guides the provider in asking questions of the mother, but also providing follow up resources and support to make sure if the woman is engaged in care, to lead with that.

And then for substance abuse, implementing routine screening, such as—there's a screener for alcohol use called the AUDIT, or the Alcohol Use Disorder Identification Test, which is a simple screener that every primary care provider can integrate that screens for risky alcohol use or what we call unhealthy alcohol use. And many people don't know that there are standard guidelines or recommended guidelines that women—and, there are for men as well—should not exceed so that they can prevent long-term health consequences and for a woman, for example, that really no more than seven standard drinks in a week.

And the research says any more than that can lead to health consequences, things like, we know, the elevated risk of breast cancer and heart disease, and really specific impacts for women that are not the case for men. So, helping women to understand that there's actually an elevated risk for alcohol use and that they need to be thinking about that.

And then, the common misperception that there may be a safe level of alcohol use during pregnancy—that is absolutely not the case. So, making sure that women know that there is no safe amount of alcohol use during pregnancy.

And so, training providers to have these conversations with patients in a way that maybe has not always been the case. For a long time, we've really separated out substance use and mental health from the routine healthcare environment; and we want to see that it's all addressed in a single setting so that mothers and families, in this case, have access to the services and the care that they need.

JOHNSON:
These tools you talk about—the screenings—they seem simple enough to implement.

What is standing in the way?

When we talk about trying to reach as many women as possible, what keeps us from doing that?

REIMANN:
I have been working in the screening field for quite a while now and in promoting what we call universal screening for substance use and depression, especially in the case of maternal and child health. However, everybody can benefit from a routine conversation about their mental health and substance use.

Some of the common barriers are still stigma: "Why should I talk to my primary care provider about my alcohol use? I came for something completely unrelated." So, really breaking down that barrier of stigma.

Also, reimbursement. Only recently did we have reimbursement for routine alcohol screening in primary care settings. Primary care providers, they have a lot of areas to address in the case of providing healthcare; so, making sure that they're to be compensated or reimbursed for the additional conversation around substance use.

And then also just things like workforce or capacity in terms of—I mentioned there's so many things that primary care and behavioral health providers are doing within the context of a pretty short visit. How do you streamline and make sure that those processes are the most efficient so that they can provide this comprehensive approach to care?

And that's some of what we do in terms of helping to streamline workflow efficiencies and incorporate screening into routine practice and training providers how to do this. Because, again, this hasn't always been the case. And even so, a lot of primary care providers, for example, weren't always trained in medical or nursing school to routinely address depression and substance use.

So, I think that that's something earlier on that we have to address in terms of these are standard parts of their curriculum. They are not elective courses that you can select if you're interested in. This is just seeing these issues, behavioral health concerns, as healthcare concerns, just with any other healthcare concerns.

JOHNSON:
How do you go about getting the word out to the professionals on the front lines?

REIMANN:
So, well at the National Council, we have a pretty captive audience in terms of our members. And so, we are continuously putting out newsletters and webinars and resources in that way.

We also have a pretty large presence on the Hill. So, we're constantly advocating for the improvements in policy to support access and improvement enhancement in behavioral health services.

And we also partner pretty closely with our other associations so that we can get the word out to their members as well—so, the American Hospital Association, for example, or the Primary Care Associations that exist across the country. So, making sure that we're working together to sort of universally promote our collaborative efforts to enhance and improve health care.

JOHNSON:
Dr. Rebekah Gee is an OB/GYN who was appointed to head Louisiana's Department of Health in January 2016. She's had a full agenda since those very first days in office with a priority to help women in the state get healthy.

GEE:
No, I mean, certainly as an practicing obstetrician, and policymaker, and secretary of the largest department in our state covering over 60% of our births, you know, I'm right on the front line.

Then, the main issue we are addressing right now is the issue of maternal mortality. It's simply unacceptable that women are dying in childbirth in our country and further that they are more likely to die because of the color of their skin.

And so, we're addressing issues of health equity, and making sure that hospitals are measuring blood loss, doing the things that they should do and ought to do to ensure that no woman dies giving life.

But certainly on the mental health front, we also run the office of behavioral health, and so I have a lot of levers that we pull on that area as well, in addition to Medicaid.

JOHNSON:
What are some of the biggest issues or challenges you deal with when trying to tackle the behavioral challenges that women face?

GEE:
Well, and I don't like the word behavior—people have bad eating behaviors, they have bad behaviors like smoking—and so I don't like the term behavioral health. I use the term mental health.

I think the brain is an organ and the brain gets disease just like any other organ in the body, and mental health affects women, just like it does men. And certainly, when women are pregnant, there are hormonal vacillations that exacerbate sometimes underlying mental illness, things like postpartum depression and psychosis are good examples of that.

And so, you know, we have tremendous challenges because I think—one thing that's unfortunate is I do think that if men got pregnant, we'd know a lot more about pregnancy. I think historically we have not done the research we need to do. Even in the eighties, you know, we were using male lab rats at the NIH because of the complexity of hormone on the research. So, you know, drug companies and researchers are often wary of doing studies in pregnant women. And we don't understand as we should, I think, the impacts of different hormone replacement products and hormonal changes in the body on mental health and wellness, and more research is needed.

At the NIH, for example, we spend way more money looking at the National Institute of Child Health and Development—of course it's called that, but it's supposed to also cover pregnancy in the peripartum period—so much more research is done on children that are on pregnant women. And that's a problem because those two things are linked and we need to understand and do the research on why women have mental health issues and what we can do to address them.

JOHNSON:
From your experience, do you feel these mental health issues are becoming more common, or are we getting a handle on some of them, if not all of them?

GEE:
I don't know if they are more common, but we certainly are getting better at measuring them. That means that we have better data that shows the conditions that people do have.

And right now, you know, I just finished coming from a summit—we had 500 people meeting—and one of the topics of today is substance abuse in pregnancy. And, you know, we are in the midst of an opioid epidemic and women are using, at unprecedented levels, opioids in pregnancy, and it's resulting infants born addicted. It's certainly an important issue to solve and one that we're addressing.

Another problem is, as marijuana becomes more available throughout the country, more marijuana use in pregnancy. And that's certainly concerning as it impacts a developing fetus in ways that we don't fully understand but should have concerns about and be looking at. So, you know, drug abuse and use in pregnancy are major concerns.

And of course, depression is the most common mental health disorder experienced during pregnancy with estimates that up to quarter of women experience perinatal depression, and only about 40% of them seek treatment.

So, it's something that we need to do a better job of. As doctors, we often ask people about bleeding and other symptoms that they might be having; but we don't do a good enough job asking women if they feel depressed, what can we do to support them.

And just finally, you know, we are so focused on illness. We are not as focused on wellness and how we can support families, how can we support readiness for parenting, how can we support women—whether it's maternity leave or equal pay, all those policies that allow women to have functional stable environments while they're trying to raise their little babies that have just been born.

And we certainly don't do enough in this country to support them. It's no wonder women are more stressed. We often don't have the types of supports and services that are necessary to ensure that women and their families get a good and optimal start.

JOHNSON:
So, what's happening in Louisiana to address these concerns?

GEE:
Well, first and foremost, Governor John Bel Edwards' Medicaid expansion. On his first full day in office, he expanded healthcare for our people, resulting in nearly half a million people gaining coverage. Most of them are women, most of them are women of reproductive age. It’s had a phenomenal impact.

And, in fact, over a hundred thousand people in the last few years have gotten access—most of them, women—to mental health and substance abuse treatment. We simply cannot talk about addressing the health impacts of depression and substance use if you don't have healthcare coverage. So, we're very proud of that.

They also have a robust nurse family partnership program—home visiting is something that we do that I would very much like to expand.

And we have had significant efforts in reducing the number of opioids in distribution. Despite covering half a million more people, we have reduced by over 25% the number of opioids in distribution in our state—something that the governor and I are very proud of.

JOHNSON:
When it comes to supporting women, what else would you like to accomplish in the months and years ahead?

GEE:
Well, maternal mortality, as I mentioned, is my top priority right now. There is no excuse in our country today for a woman to die in childbirth. And whether it's preventable violence against women, or we're talking about mental health, or it's healthcare disparities, it's unacceptable. That even if you're African American, college-educated, you're a physician, you're more likely to die—that should not happen.

So, my top priority is to implement now, today, everything that is best practice—whether it's California or another state that's done something great, we need to have it here today and to make it unacceptable for women to die in childbirth. We're creating that—we had a wonderful summit last month where we had experts from the WHO, people from all over the country came in and shared their stories and their ideas. But also, families who had lost women, several of them spoke. And we are fighting for them and making sure that we end this epidemic of maternal deaths.

But in terms of mental health, there's also a focus on mental health. Women need to know that they're not alone, and every woman should be celebrated when she has a child. We should have a big party, a baby shower, for everyone, and sometimes that doesn't happen.

So no, again, I think another priority is just making sure that we support women. Do we have the policies and priorities that—like equal pay, like maternity leave, pay for jobs that women do, like teacher pay that the governor championed last year—you know, are we doing the kinds of things that support women's mental health. Having stable financial situation and access to healthcare certainly supports mental health. We know that people who have access to healthcare have less distress and are much more likely to do the things that they need to do to stay healthy.

So, we're really excited about our future and proud of what we've achieved. But again, some sobering challenges that we are addressing and will not rest until we have eliminated those challenges.

JOHNSON:
Amy Zapata is Louisiana's director of the Bureau of Family Health. She manages a full slate of programs, each contributing to the overall goal of improving the mental and physical health of women living in the Bayou State.

ZAPATA:
I would love for Louisiana to be a state where all prenatal and pediatric clinical providers in the state will have the support that they need to screen and respond to parents' mental health concerns such as maternal depression, which is a key risk factor affecting maternal health, child mortality, and really the developmental health of children.

So, I'm hoping within a few years that we will have available, for any provider in the state, resources that are easily accessible to supporting them in identifying and managing potential behavioral health concerns that we know have a lifelong impact on health.

JOHNSON:
Tools, Zapata says, are vital if clinicians are going to be able to do their jobs.

ZAPATA:
I think if we—when we are able to provide some relief to them in being able to respond to needs, that's what makes the difference. And clinicians are working with families now: they're seeing them struggle; they are also seeing their strengths; and, in some ways, may not feel like there are resources in their communities and, in some cases, there are challenges.

But I think in having sufficient resources—and so we're working to change that as well, to have more trained clinicians who are able to respond when more intensive intervention is needed.

JOHNSON:
Zapata expressed what many public health professionals know: that working to improve maternal child health is paramount—just like doing an honest evaluation of the programs you have in place now to determine the best way to help female populations.

ZAPATA:
To not be afraid to look at what you have or what you've been doing with a critical eye and see what are the gems and treasures that you have that should be grown and scaled for them to actually have impact; a challenge that I think, especially if public health is been in somewhat in transition, you know, for a number of years—and each state is different—has been in transition from direct services to system building things, try to make practices better and more responsive. It would be to take a critical eye at what you have and can it be scaled to reach more people.

And don't be afraid to make the difficult decisions, to say, "It's doing a wonderful job reaching these few families, but for us to really reach hundreds of thousands of people, we might need to do something differently, or we might need to divest of other things and take this thing that is a nugget and to grow it and nurture it." That's really how we're going to make a difference is by growing things that are going to have impact.

JOHNSON:
Links to information about maternal child health and the programs discussed in today's podcast can be found in the show notes for this episode; in addition, a brief examining how state public health and behavioral health agencies can collaborate to address behavioral health issues at a systems level can be found there as well.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.