Improve Postpartum Care for Low-Income Women

TMA Testimony by Lisa Hollier, MD

House Public Health Committee
House Bill 3115

Tuesday, April 7, 2015

Good morning/afternoon Chairwoman Crownover and committee members. Thank you for the opportunity to testify on House Bill 3115. I am Lisa Hollier, MD, a practicing maternal-fetal medicine specialist in Houston testifying today on behalf of the Texas Medical Association, Texas Pediatric Society, Texas Academy of Family Physicians, Texas Association of Obstetricians and Gynecologists, American Congress of Obstetricians and Gynecologists-Texas Chapter, Federation of Texas Psychiatry, March of Dimes and Texans Care for Children. Our organizations strongly support this legislation, which if enacted will vastly improve postpartum screening and treatment for low-income women. We are grateful to Governor Abbott and Representative Coleman for championing this issue.  

Postpartum depression (PPD) is not just the “baby blues,” which affects as many as 85 percent of new mothers. Crying, mood swings, irritability, and mild anxiety are normal reactions to the physical and mental changes after childbirth. Baby blues fade quickly, lasting generally no more than a few weeks, and will pass without medical treatment.

Postpartum depression is much more serious — and potentially fatal when left untreated. PPD is a persistent and debilitating form of depression that occurs soon after delivery to as much as a year afterwards. PPD is more likely to occur in young mothers, women with a previous history of depression, and low-income women. A study conducted in 2014 by Northwestern University Feinberg School of Medicine found one in seven new mothers — 14 percent — experienced PPD, though the Centers for Disease Control and Prevention (CDC) estimates the rate could be as high as 20 percent. Using these prevalence rates, roughly 29,000 to 42,000 postpartum women with prior pregnancy-related Medicaid coverage could suffer from PPD each year. Women losing CHIP Perinatal coverage would add another 4,700 to 6,800 women suffering the illness. 

PPD has serious implications for the health and well-being of both women and their babies. Untreated, mothers with PPD report a sense of hopelessness, lack of energy, and change in appetite and sleep, all of which interfere with their ability to nurture their child. In more extreme cases, women may have thoughts of harming themselves or their baby. PPD-associated suicide is one of the leading causes of postpartum death.

Further, according to CDC, among U.S. women with major depression, “most (89%) have one or more chronic physical conditions or risk factors, such as diabetes, smoking, binge or heavy drinking, obesity, and physical inactivity.” Depressed mothers also may have difficulty bonding with their babies, which can impair not only their child’s emotional development but also the child’s cognitive and motor functioning. In more severe cases, PPD may result in child abuse or neglect. The impact of PPD may extend well beyond a child’s first year of life into early childhood and beyond. What makes PPD so insidious is it harms two people, potentially for a lifetime. 

Yet, PPD is treatable. There are many types of therapies, such as counseling, psychotherapy, antidepressants, and outpatient mental health treatment. For the most severe cases, women may require inpatient hospitalization. It is important that physicians have a battery of options to choose from so they can tailor treatment to each patient’s particular needs.

Unfortunately, many low-income women with PPD struggle to obtain treatment. Stigma is certainly one factor, as is failure to recognize PPD symptoms. But so is the lack of health insurance. Pregnancy-related Medicaid ends 60 days postpartum; the CHIP Perinatal program covers only two postpartum visits. Without access to coverage, low-income mothers not only miss opportunities to be screened but also may ignore symptoms, hoping they will go away, or forego care because they cannot afford it. Many women turn to the emergency department, but EDs provide acute care. They are not equipped to provide ongoing interventions, such as therapy.

By providing screening and treatment for PPD, HB 3115 will provide a vital lifeline for thousands of Texas women who otherwise may go untreated. Screening will be a critical component of the new program, and our organizations support allowing such services to be done in a range of practice settings. Women often do not recognize symptoms of postpartum depression; thus they may seek care for what they believe is a physical illness from their primary care physician, urgent care clinic, or even the emergency department. Screening should be available by all these providers. Pediatric practices are another ideal place for screening. During the first year of life, pediatricians provide six to eight well-baby exams, at which time pediatricians interact with mothers regarding a variety of topics, including parent-child well being. The relationship between the pediatrician and mother provides a critical opportunity to intervene in the early stages of postpartum depression. 

Our organizations do have questions about the mechanics of the new program, including the eligibility determination process. For instance, will the state provide presumptive eligibility to postpartum women who screen positive for PPD so they will gain immediate coverage? Will retroactive Medicaid reimbursement be allowed for providers who diagnose PPD for a woman who obtained services prior to enrollment in the new program? Will services be provided via Medicaid fee-for-service or Medicaid HMOs? We look forward to working with Chairman Coleman and the Texas Health and Human Services Commission on the program’s design.

I would be remiss if I did not point out that women’s mental health is fundamentally intertwined with their physical health. Physicians cannot treat one without addressing the other. As noted above, the vast majority of women with depression also suffer from one or more chronic illness. Physicians must be able to care for the entire woman, not just her brain. 

Postpartum depression impairs a mother’s ability to care for her newborn. But so do chronic illnesses. In the year following birth, heart disease, diabetes, and obesity are risk factors for maternal illness and death. Alarmingly, Texas’ maternal morbidity and mortality rate is increasing. Further, if unmanaged, illnesses such as hypertension and diabetes put future pregnancies at risk by increasing the likelihood for a preterm or low birth-weight baby. Prematurity not only poses short and long-term risks to the baby, but also contributes to higher Medicaid costs. 

HB 3115 is an excellent start to caring for Texas’ postpartum women. As you consider this important legislation, we urge you also to consider a more comprehensive strategy to improve the lives of mothers and babies. Thank you for your consideration.

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June 17, 2016

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