This study directly responds to Notice of Special Interest (NOSI): Administrative supplements for NIH grants to add or expand research focused on maternal mortality (NOT-OD-20-104). The United States fares worst among developed nations in preventing pregnancy-related deaths; over the past two decades, mortality rates doubled in the US while decreasing elsewhere. For every maternal death, >100 women experience severe maternal morbidity, a life-threatening diagnosis, or undergo a life-saving procedure during delivery hospitalization. Striking disparities in severe maternal morbidity and mortality (SMMM) persist even though two-thirds of SMMM cases may be preventable. Non-Hispanic Black and low-income women have significantly higher rates of SMMM compared to their counterparts. Behavioral Health (BH) conditions such as suicide, drug overdose, homicide, and unintentional injury are among leading contributors to SMMM, yet these deaths are excluded from population-based pregnancy-related death statistics, likely leading to underestimates of SMMM. In addition to BH causes of SMMM, BH conditions may exacerbate SMMM from other causes. The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), and subsequent federal legislation affecting mental health and substance use disorder benefits, provided one of the largest expansions of behavioral health (BH) coverage in a generation by increasing coverage and extending federal parity protections to over 60 million Americans. Most health plans, including commercial, employer-based plans must cover BH care and cannot provide less generous BH coverage relative to medical/surgical care. Over half of pregnant women are privately insured, and improved coverage due to BH policy changes could affect their BH service receipt. The proposed study capitalizes on R01MH120124, which examines how federal BH policy changes affect outcomes for perinatal mood and anxiety disorders (PMAD). This study will examine SMMM overall and among high-risk populations. It will use a large, economically, racially diverse national sample of enrollees in employer- based insurance, Optum, from 2005-2018. This proposed one-year study will use patient- and plan-level analyses of delivering women to examine associations of mandated federal BH policy changes with: 1) changes in SMMM in the perinatal period (e.g., 21 severe maternal morbidity indicators, overdose, suicidality, and death from any cause during pregnancy, delivery hospitalization, and up to one year postpartum; 2) changes in SMMM within high-risk subgroups. For each Aim 1 outcome, we will examine how changes vary: 1) for those with and without co-occurring PMAD and substance use disorders; 2) by race/ethnicity, 3) by income, 4) in states with strong vs. weak pre-existing parity laws, and 5) in plans subject to new parity laws vs. those not subject to the laws. Despite growing awareness of lethal consequences delivering women face, we know little about BH contributors to these outcomes. For NIH to effectively Implement a Maternal health and PRegnancy Outcomes Vision for Everyone (IMPROVE), we must not ignore the impact of BH conditions, treatments, and coverage policies.
The United States fares worst among developed nations in preventing pregnancy-related deaths and more than 100 women experience a life-threatening severe maternal morbidity for every maternal death. Disparities in severe maternal morbidity and mortality (SMMM) persist by race/ethnicity and the presence of behavioral health conditions. Characterizing the impact of federal health insurance coverage changes and expansions of behavioral health coverage since 2008 on SMMM overall and among high risk subgroups will inform potentially lifesaving future policy and targeted interventions to address unmet needs and systemic disparities.
