Testimony by Laura Gephart, MD
Senate Health and Human Services
Senate Bill 1929
April 12, 2017
Submitted on behalf of:
- Texas Medical Association
- American Congress of Obstetricians and Gynecologists-District XI (Texas Chapter)
- Texas Association of Obstetricians and Gynecologists
- Texas Academy of Family Physicians
- Texas Pediatric Society
- March of Dimes
Chairman Schwertner and members of the committee, my name is Dr. Laura Gephart, and I am an obstetrics-gynecology resident practicing in Temple. On behalf of the Texas Medical Association, American Congress of Obstetricians and Gynecologists-District XI (Texas Chapter), Texas Association of Obstetricians and Gynecologists, March of Dimes, and the other specialty societies listed on my written testimony, thank you for the opportunity to comment on Senate Bill 1929.
We applaud Senator Kolkhorst’s commitment to improving birth outcomes, which she championed as a state representative by establishing the Perinatal Advisory Council, among other initiatives. SB 1929 directs the Texas Health and Human Service Commission (HHSC) to evaluate options for reducing maternal deaths by focusing on their causes as outlined by the Maternal Mortality and Morbidity Task Force. (My colleague, Dr. Lisa Hollier, will discuss this in detail.) As you are aware, the task force’s report proposed multiple recommendations to help reduce the incidence of pregnancy-related deaths and severe maternal morbidity (illness). Today, I want to focus on one specific area of the report’s findings: access to behavioral health services for new and expectant mothers.
A 2016 report by HHSC and the Texas Department of State Health Services found maternal depression also is largely underreported among the Texas Medicaid population. Yet, as the task force reported, mental health and substance use disorders play a significant role in maternal death.
Perinatal depression (commonly known as postpartum depression) — a range of mood and anxiety disorders and depressive conditions that may occur during pregnancy and up to a year after childbirth — is one of the most common complications of pregnancy, affecting as many as one in six Texas mothers. Prenatal care and postpartum visits are critical opportunities to identify and treat perinatal depression symptoms early. If untreated, perinatal depression can have devastating effects on women’s health as well as their children’s safety and development. Research shows that women with maternal depression incur 90 percent higher health care costs and are four times more likely to have emergency department visits compared with their counterparts. Moreover, untreated perinatal depression can harm a child’s language and brain development and disrupt a child’s stress response system, leading to higher chance of later behavioral problems, social disorders, and learning disabilities. It also can increase the risk of child abuse or neglect, and parents may be less likely to use injury prevention measures, such as putting their baby on her back to sleep.
Tragically, suicide is one of the top causes of maternal deaths in Texas, underscoring the need for prenatal and postpartum care to ensure women are screened and referred to mental health services before symptoms get worse.
Substance abuse is another significant contributor to maternal mortality, with the nationwide opioid epidemic fueling the crisis. Opioid use among U.S. pregnant women increased fivefold between 2000 and 2009. Opioids are a drug class that includes prescription pain relievers such as oxycodone, hydrocodone, and morphine, and illicit substances such as heroin. As opioid use has increased, we have seen a parallel increase in the incidence of neonatal abstinence syndrome (NAS) among newborns — a neonatal drug-withdrawal condition primarily caused by the mother using opioids. NAS has become a public health concern in Texas: between 2010 and 2014, rates of NAS in Texas increased by 51.3 percent.
Opioid use harms a woman’s health and increases the risk of pregnancy complications and poor infant outcomes, including babies born addicted to these same drugs. Opioid misuse during pregnancy is associated with increased risk of placental abruption, preterm labor, pregnancy complications, and fetal death. Opioid misuse can disrupt fetal development at any stage during a pregnancy — even before a woman knows she is pregnant. In fact, the first months of pregnancy are a time of greater risk of congenital heart defects and other negative neonatal and maternal outcomes. Opioid-affected newborns are more likely to be born premature, have low birth weight, have breathing complications, and be at increased risk of neural tube and congenital heart defects.
Over the past few years, Texas has taken positive steps to address perinatal depression and opioid addiction. Last year, the Healthy Texas Women (HTW) program began covering counseling and antidepressant prescription medications in a primary care setting, allowing women to be treated by their primary care physician. For women addicted to opioids, Texas funds a neonatal abstinence syndrome program, providing women addicted to these drugs medication-assisted treatment to safely manage their addiction while pregnant, along with services to safely withdraw them from opioids following delivery. The Population Health and Management Journal (2015) studied infants from a large Medicaid plan born with NAS, and found most stayed an average of 21 days in the hospital. They estimate hospital stays half as long would save $396 million annually. By investing in these support services, we can reduce incidence or severity of NAS, in turn costing the state less in Medicaid funds, and resulting in shorter hospital stays for mom and baby. Keeping children and families close to their support networks only enhances their rates of success in recovery. Most importantly, the NAS program recognizes opioid addiction among pregnant women as what it is — a disease — and helps to keep mothers and babies together.
But challenges remain. When postpartum women are diagnosed with moderate to severe perinatal depression, if they are past the Medicaid 60-day postpartum period, treatment is difficult to obtain. HTW allows treatment of perinatal depression only in the primary care setting. Specialty care, including psychiatric, psychological, and counseling services, are not a benefit. Women can be referred to their local mental health authorities, but these providers must manage other priority mental health disorders, making it difficult for women to obtain timely services. We recommend increasing funding to HTW specifically allocated for specialty psychiatric and psychological services to treat women with perinatal depression who cannot be managed safely by a primary care physician or provider.
We also strongly support expanding availability of NAS treatment to additional locations across Texas to ensure women and their babies can obtain it in their own community, which is important to long-lasting recovery.
Our organizations appreciate your significant investment and dedication to improving the health of mothers and babies. Thank you for your time and consideration.
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