Rollins Ask an Expert: Mental Health, Pregnancy, and the Postpartum Experience with Sarah Blake

May 24, 2023
Ask An Expert Sarah Blake

Rollins Ask an Expert is an ongoing series from the Rollins School of Public Health that aligns research experts with pressing public health topics.

By Karina Antenucci

Sarah Blake, PhD, MA, associate professor of health policy and management, believes we have a maternal mental health crisis on our hands nationally, and especially in Georgia. Much of Blake’s current research examines women’s overall health during and after pregnancy.

“We must address mental health in pregnant and postpartum women at the individual, community, and policy level,” says Blake. “We must help women take care of themselves to take care of their families. In order to do this, we have to acknowledge the challenges they face in accessing health care in their communities.”

In this Q&A, she discusses the state of mental health care for pregnant and postpartum women in Georgia and some of the work being done to improve it. 

Why is mental health care access so important for pregnant and postpartum women?

In general, we know that pregnant and postpartum women experience a great deal of stress and anxiety, particularly those who are new mothers or who have pre-existing mental health conditions. For women with limited access to health care, where the continuity of care drops after the postpartum period, their health care needs are often not met, and in particular their mental health needs. We know it can be a stressful time having a newborn. For women who are low-resourced—based on their insurance, income, maybe where they live—it’s really difficult for them to find support.

What work is currently underway to improve it?

Until recently, women who were covered under Medicaid during pregnancy would be disenrolled 60 days postpartum. This left women without any assurance of health care access in the postpartum period, including any assistance to take care of their mental health and primary care needs. This created health disparities among low-resourced women, and most importantly, gaps in their ability to take care of their mental health. It was tragic and didn’t make sense.

This has fortunately changed due to a law that passed during COVID that allows states to expand Medicaid in the postpartum period for up to 12 months. In states where the Medicaid postpartum extension was implemented, women will be continuously enrolled after the delivery of their child. Georgia is one of 33 states, plus Washington D.C., that has implemented this new Medicaid policy for mothers.  

This new policy initiative in Georgia is a positive change. We are looking forward to seeing if that makes a difference in mental health, physical health, and whether it enables women to take care of other health care needs, such as managing chronic conditions or taking care of any that developed during or after pregnancy, such as gestational diabetes or certain conditions, such as cardiomyopathy or hypertension. All of these are really big risk factors for maternal health and morbidity.

What else needs to be done to improve mental health for pregnant or postpartum women?

We still face the problem of having an insufficient mental health care provider network, especially for pregnant and postpartum women. We need more investment in telehealth, psychiatry, and mental health support because it is important for access. For instance, if a woman in rural Georgia is without access to a car or transportation to get to a doctor, telehealth may be the only option if they have access to a phone and the internet.

Telehealth was especially helpful during COVID when women couldn’t get to their doctors. I did a study called the COVID Perinatal Experience (COPE) Study, that was funded by Rollins to examine what was happening to women and their psycho-social barriers to pregnancy and postpartum care during COVID. One of the things women talked about positively was that they could still connect to their providers to talk about any concerns they had. There were some COVID-specific downsides as well, like not being able to get an ultrasound with a partner. But, the telehealth option became very important both during and after pregnancy so we continue to think about telehealth options for ways women might be able to address their mental health care needs. I hope to do a follow-up study to examine the long-term effects of the COVID pandemic on maternal health outcomes, including mental health. 

Are you doing additional research looking at mental health in the context of COVID?

We have just completed a study for the Georgia Department of Public Health that analyzed preventable mental-health-related, pregnancy-associated deaths in Georgia. Our maternal health research team will embark on a new study this fall to examine the influence of the COVID pandemic on pregnancy-related deaths in Georgia. We expect to see mental health as a major contributing factor to these maternal deaths, given the challenges that many mother faced during the early phase of the pandemic. 

Is there anything else you’d like to see improved for pregnant or postpartum women right now?

Healthy Mothers, Healthy Babies Coalition of Georgia has recently completed a doula Medicaid reimbursement pilot project to enhance perinatal services for low-income women in Georgia. This work will provide important evidence to Georgia to consider reimbursing doulas as health care providers in the Medicaid program, an initiative that many other states have implemented as a way to improve maternal health outcomes.

There is some preliminary work we are doing at Emory to expand the Medicaid doula pilot project to incorporate doulas who are trained in perinatal mental health support. Expanding the perinatal mental health provider network in Georgia is essential, and training doulas to assist in this work is a critical next step to addressing our mental health crisis in the state.

How does Georgia compare to other states related to mental health issues surrounding pregnancy?

I think we’re doing terrible. I serve as an appointed member on the Maternal Mortality Review Committee for Georgia, so I review maternal mortality cases for the committee and serve as the Medicaid policy expert. The Georgia Department of Public Health released the most recent maternal mortality data, and for the very first time, mental health conditions was the second cause of pregnancy-related deaths in the state. I don’t know any other state where mental health is a leading cause of death for pregnant and postpartum women. Women in our state are suffering and need greater support during and after pregnancy.

Medicaid is a great expansion of access, but we have to not only look at it through the lens of “let’s expand health insurance,” we also have to build the perinatal health workforce. We have to make sure women know that they can access these services and that they’re not just tailored to women who have a mental health diagnosis. These are resources that should be available to them during and after pregnancy for anything that is causing them stress or anxiety. If we can’t keep mothers healthy, we won’t have healthy babies. We have to have a multi-factored approach to addressing mental health for pregnant and postpartum women.

Sarah Blake, PhD, is an associate professor and Director of the MPH and MSPH programs in the Department of Health Policy & Management at the Emory University Rollins School of Public Health. As a health services researcher with particular expertise and training in maternal health care and program evaluation, Blake’s research aims to build evidence-based interventions and policies that reflect communities’ perspectives and needs.