Q&A: Maternal mental health findings shed light on health equity in the U.S.

Mental health and behavioral health have become increasingly vital indicators of the state of overall health in the U.S. Mental healthcare has now become one of the most rapidly-growing sub-specialties of care, with 25% of the U.S. population predicted to utilize behavioral health services by 2027.¹

However, access to mental health and behavioral health services is still a challenge. Mothers, in particular, are a large demographic that often suffers from mental health conditions, and maternal mental health can be especially difficult to identify and treat. While approximately 1 in 7 mothers experience perinatal depression within their first year of childbirth², many of these cases go undiagnosed and untreated—about 50% of those diagnosed do not receive treatment.³ Despite regular screenings being a known and effective method for identifying perinatal depression, one study found that as few as 9% of commercially insured women were screened in a postnatal visit.

With this in mind, Allison Roberts, Quantitative Research Manager at athenahealth, endeavored to conduct research that would help shed light on the state of maternal mental health, as well as health equity, in the U.S. today. She used the expansive athenahealth network to help identify a sample of data from roughly 730 freestanding women’s health clinics between 2020-2023.

We sat down with Allison to learn more about the results of her maternal mental health research, and its role in helping drive actionable change to expand maternal healthcare and health equity in the U.S.

athenahealth: Why don't we start by talking through some of the background for this research? What inspired it?

Allison: So, this research was on maternal mental health, and I think it's been a big point of interest for our team. Specifically, we happen to be all women and have been all women for as long as I have been in athenahealth, which makes it near and dear to our hearts.

But we were really inspired when athenahealth started rolling out support for specific healthcare specialties. And we thought it would be really interesting to echo that a bit in our own research and pick a specialty area to really deep dive into. So, we picked maternal health both because it is one of the specialties being focused on and because we had a lot of interest in it.

We zeroed in on this question around mental health and health equity because we have a strong passion to better understand health equity issues in particular. We knew that this was a really big issue that's being talked about a lot in the larger research community right now.

athenahealth: Yes, absolutely. I know that in the background of your findings you also talk about the larger landscape for maternal mental health, and you've included a stat that about 15% of new mothers have perinatal or postpartum depression⁴, but a lot of them don't get the care that they need for those diagnoses or it's hard for them to access that care. So, I think that’s a really good way to frame these findings and why they’re so critical.

Allison: Absolutely, and I think one interesting point about that too is those numbers that you quoted, and many like them, are from pretty small or non-representative studies.

One of the other reasons that we thought this was important is the data that’s currently out there isn’t great, so athenahealth's pretty unique in the sheer size of the data that we have, especially around maternal health offerings in freestanding clinics. A lot of the data out there is for single health systems or large hospitals, whereas we have a fairly nationally represented sample of clinics which has enabled us to actually make better estimates around how many women really are getting these screenings that need them.

athenahealth: So, with that in mind, I would love to dive into a few questions I have for you about your experience getting this data and interpreting it. My first question for you is similar to what we talked about in our introductions. Given the reasons why we chose to pursue this research, what did we hope to learn from this data?

Allison: We hoped to learn a few things. At a really basic level, we hoped to learn what the screening rates look like within our network. Because as I mentioned broad, nationally representative data on this subject is hard to find. So, we wanted to contribute to that conversation and see what it looks like for women in our network.

We also really wanted to do a deeper dive into the health equity aspect of that. There's a huge body of literature on inequality within maternal healthcare, generally everything from maternal mortality rates to infant mortality rates to access to mental healthcare. There's a big conversation out there around whether or not we’re adequately providing care for women of all backgrounds. So, we wanted to use this research as way to see whether different racial groups were experiencing different levels of screening because that’s something that's modifiable by physicians and has really important outcomes.

athenahealth: Absolutely. I think we've already touched on why these learnings are so critical, but just to quickly recap, it sounds like you know this is a group that there have previously only been smaller studies done on. It's not one that gets a lot of attention it seems, and there's a lot to still be learned. Is there anything else that would tell someone who's learning about this research why it's so important?

Allison: I think you touched on a lot of it. I do want to say that it's not so much that people don't care about this, it's just that the data itself is hard to come by because often looking at screening isn't something that's easy to ascertain from claims data, which is what most people have available. So, I think it's critical that athenahealth takes the opportunity to help contribute to the conversation and research. Because as I mentioned, this is something that's modifiable. There's a lot that providers can do. There are even potentially things that we as a company could consider doing to try to help boost these rates. Doing this research and identifying that the problem is out there is a critical first step to enacting change.

athenahealth: Definitely. My next question is, is this research the first of its kind at athenahealth? Or if not, do we have a point of comparison from previous years?

Allison: I would say yes and no. The concept of doing health equity research is very much not new here. It's a lens that we apply to all of the work that we do. That said, we have not done maternal mental health research at all as far as I'm aware. We've never really done anything around maternal health. So, this is our first venture into research for that specialty.

athenahealth: Interesting. So, following up on that, let's get into the details of the results. What did you learn? And what are the top three major takeaways that you got from diving into this data?

Allison:

1) I would say the first is a pretty basic one, but we found that screening rates are low. For context, here we focused on specifically the Edinburgh Post Natal Depression Scale, or EPDS, which is a clinically verified way to screen for specifically perinatal depression in women either during pregnancy or postpartum. Traditionally, this is given at their first like 3-month checkup. Postpartum is the most ideal time to do the screening test. There are other screenings that exist, but we excluded them from this study. These are also only with OB Gyns.

With that being said, we found that while the rates of screening have increased from 2020 to 2023, they're still quite low. In 2020, we saw that about 18% of women were receiving a screening at some point during her post-pregnancy. By 2023, that had increased, but only to about 26%. That still means that over 70% of women are not receiving the recommended screenings.

2) The second finding that we had was beyond that, screening rates are even worse for certain racial groups. We found that Black and African American women specifically had the lowest percentage of pregnancies receiving a screening. Whereas White and Asian women had higher rates, and Hispanic women actually had the highest rates of screening overall.

3) Finally, the very last thing that we looked at was if digital tools like telehealth might be impacting these rates and improving outcomes for women. We looked for if a woman used telehealth any point during her pregnancy. So, we're not asking “did she use it specifically to get this screening?” We're just checking whether or not she used telehealth at all to help meet with her provider more regularly.

And we found that when she uses telehealth, it really does improve the likelihood of getting a screening. Additional access and touch points do seem to be making a positive difference. However, we found that the impact is really modified by whatever race the woman identifies as. So again, for Black women, even if they had access to telehealth and were using it, it had a much lower impact on receiving screenings. It only increased their likelihood by about 5%, whereas for White women, for example, it increased it by about 20%, even after we controlled for what type of insurance (if any) that each woman had during their pregnancy. So, there's clearly more to the story.

athenahealth: Yes, that provides a lot of helpful texture and detail when we're looking at the bigger picture, especially with health equity in mind. So, how did these results compare with what we thought we would find? Were there any results that were really surprising to you or really stood out?

Allison: I think overall they broadly supported our hypothesis. This really aligned with what we've seen in the literature. What those smaller studies that we’ve seen, we weren't expecting the screening rates to be amazing. They were fairly in line with what the research has found. I think the part that was surprising for me was the differential impact of telehealth. Often when we talk about whether or not telehealth will improve someone's outcomes, we talk about whether they can use the tool at all.

Because when we’re discussing any digital tool, it requires the patient to have a reliable internet connection, or to have a smartphone or laptop that's capable of supporting it. And having the literacy to know how to set up that connection. So, often we talk about telehealth as a potential increase of inequality because not everyone can use it.

However, in this case, we observed the difference among women who all had access to telehealth. So that wasn't the issue. The technology was there, but it still didn't improve outcomes for everyone equally. And so, I think it has implications for how we talk about telehealth and policies there. Often, the policies right now are focused around getting people access to it and getting it covered by insurance, not necessarily talking about what differential use of it might look like.

athenahealth: Right. That's really interesting. And my follow-up to that is to ask how these results tie into some of the larger trends that are happening within the Women's Health and within the Behavioral Health specialties, because this is kind of the perfect crossover between the two.

Allison: Yes, absolutely. I think on the maternal health side, as we've been talking about throughout this discussion, it really ties into larger findings around health and equity. We found so much great research out there, qualitative and quantitative, looking at why Black women in particular have lower care outcomes. In maternal health, but also in behavioral health. There are existing biases among physicians, there's a lack of trust among patients. Both can lead to lower screening rates, as Black women may have less confidence that their physician will listen to them, and some providers may be less likely to provide them screenings. What we're seeing here is that it can lead to other poor health outcomes, so we're really tying into that larger trend.

Then I think the other thing that we're really speaking about is that use of technology in medicine and what that means. I think behavioral health has really been on the forefront there in terms of using telehealth and other technologies to enable better access to providers from patients. And younger patients are increasingly reliant on telehealth for access to mental health care.

athenahealth: Right. So, you touched on this a little bit earlier in our conversation, but we know that these findings are actionable. They're able to lead to change. How can we translate these findings on the state of maternal mental health into actionable changes and goals that we can use to improve healthcare for mothers across the U.S.?

Allison: I think there's so much that we can do. Whether you're a physician or a patient or someone who's working in the EMR software space.

For example, our team is actually meeting with a group of physicians at the annual Thrive conference where we're going to be presenting this research to them and really asking them for their thoughts. Why do they think these screening rates are so low? What are the issues that they're running into? And also hoping to identify actions physicians can take to make sure that patients who need these screens are getting them, but also actions EMR software companies like us can take. For example, are we adding a friction point? Is there one too many clicks to get to the right screening page to give these women their screenings?

And if you're a patient, just be aware that these services are available to you and that you also have the ability to advocate.

athenahealth: Right. That's such a key takeaway from this. So, with these critical findings in mind, do we have any next steps planned? What are some potentially unanswered questions that we'd still like to pursue and identify in the future?

Allison: Oh, absolutely. I think one classic trend of research, no matter what you're studying, is that it ends up raising more questions, especially when you’re doing quantitative work like this. Often when we go out to solve a problem, we just have one hundred more and so I think for our team, we're really interested in doing more research on screenings that happen in other contexts. I mentioned pediatric visits are another place where women often get an opportunity to be screened.

We weren't able to do it for the initial study, but something I would love to follow up on is to see if we find similar trends or if they're radically different in that pediatric setting. I’d also love to see if other screening tools, like the Patient Health Questionnaire, have similar trends. We also have an awesome qualitative arm, so I'd love to reach out to physicians and even patients to get their opinions on this so we can have a little bit more context and voices around this topic.

athenahealth: That's really amazing. This is super critical research that you guys are doing. I'm really excited to be able to explore this more and I want to thank you for sitting down with me today and talking through this. I'm really excited for all the great things you have planned for your team through the end of this year and also next year as well.

Thank you very much for having this conversation with me, I appreciate it.