Mental health issues were the second leading cause of death among pregnant people in Texas in 2019, according to a report by the Texas Maternal Mortality and Morbidity Review Committee. Stress, anxiety and depression can worsen health outcomes for parents and babies, even a year after giving birth. Maternal health advocates are on a mission to change that, through support programs and better access to care.
A note: This story discusses mental health and data related to suicide. For resources and support, call 988 to reach the Suicide and Crisis Lifeline, text HOME to 741741 to connect to the Crisis Text Line, or call 1-833-943-5746 for the National Maternal Mental Health Hotline.
A little before 6 p.m. on a Tuesday in April, people start to cycle into a small brick house off the University of North Texas Health Science Center’s campus in Fort Worth. Tacos for the guests warm in pans, and the smell of rice floats through the air as the doors open and close.
A lively set of health students from the university cut out square pieces of paper at a long table, with affirmations saying, “I am worthy of loving myself deeply,” and “I am doing my best and that is always enough.” Misty Wilder, the director of Healthy Start at UNT Health Science Center, finishes last-minute logistics.
Anxiety, depression and stress are common mental health concerns that come up for pregnant people. Left untreated, these issues can lead to long-term effects on maternal and infant health, like pre-term birth, low birthweight and maternal and neo-natal death.
Black women experience this “at higher rates than any other racial group, even when matched with women of the same socioeconomic status,” according to a 2022 study in the Maternal and Child Health Journal.
While therapy and psychiatric medication might not be the best option for everyone, there’s a greater need for mental health support for new parents in Texas. That’s where Wilder’s new program fits in.
The program – called the Circle, a play on the daytime talk show The View – is a space for people to connect over food and shared activities.
Wilder’s organization is one of five federally funded Healthy Start programs in Texas, with 101 across the country. They’re part of the federal Maternal and Child Health Bureau, to help improve health outcomes for pregnant people and babies through home visits, case management, health education and reproductive planning.
“Our whole goal is that we move our families from surviving to thriving, and ultimately, that our pregnant, birthing individuals will have a successful birth outcome,” Wilder said. “[We] work with them during the postpartum period, and then until the child is at least 18 months.”
Lack of support leads to worse mental health outcomes for new parents
Studies show that a lack of social support for pregnant people leads to worse mental health outcomes, like increased depression and anxiety. In the United States, about 20% of maternal deaths are due to suicide.
Black women are also three times more likely to die from pregnancy-related causes than their white counterparts. According to a 2021 article in the journal of Infant Mental Health, Black pregnant people with young children have mental health “symptoms that are more serious, chronic, and debilitating” than their white peers, and often don’t access formal mental health services due to experiences with systemic racism and discrimination.
Wilder said looking at all these statistics can overwhelm her.
“As a Black woman in maternal health, looking at data all the time, seeing yourself in the data, you just sometimes are weighed down,” she said. “And so when we come into this space, once a week, we're able to forget about those things.”
The activity she prepared that day is all about affirmations: she opens boxes with pink, blue and white mirrors, laying out markers on the table. The idea is to write positive affirmations on the mirrors, and then use the mirrors, along with affirmation cards, throughout the week.
A small but mighty group of about five clients have been attending regularly. Healthy Start serves about 500 clients a year. One client, Destani Hoskins, said she appreciates the space because she’s able to be herself. She’s 22, and her daughter Octavia is seven months old.
“It’s really good, like, peaceful,” she said. “I can come here from having a stressful day, and then as soon as I get here, the atmosphere is super-different. They’re all positive, always smiling. They’re always here, and they’re listening.”
She said being a new mom and co-parenting can be hard. She’s still trying to find balance in her life.
“I definitely learned a lot about self-care,” Hoskins said about the program. “That's always been something I've been terrible at. I feel like when you become a mom, especially for the first time, self-care is a rare thing. But they taught me how to make time, like, you don’t always have to be so busy.”
Maternal mental health in Texas
Maternal mental health is often overlooked as a health concern during pregnancy, despite 1 in 8 women experiencing symptoms of postpartum depression, according to data from the U.S. Centers for Disease Control and Prevention.
Bonnie Cook, the executive director of Mental Health America of Greater Dallas, thinks it’s because pregnant people are experiencing “a stigma on top of a stigma.”
“We’re supposed to be thrilled, we’re supposed to be happy,” Cook said. “A new life in our family — everything’s wonderful, peachy-keen. And then we’re made to feel guilty if it’s not the joy of our lives. I still think we’re talking about [mental health] in hushed tones.”
Depression and anxiety are two of the most common issues pregnant people face, even if they’ve never had a mental health diagnosis in the past. Postpartum depression symptoms can appear anywhere between six months to a year after giving birth, which Cook said can sometimes be confused for the general fatigue of parenting.
Postpartum depression can look like loss of energy and appetite, feelings of hopelessness, and doubts about your ability to parent.
“I don't think people know enough to look for the symptoms,” she said. “Being able to recognize those symptoms that are not just a normal part of our postnatal journey, and being able to say, OK, this might not be what I ought to be experiencing.”
She also said social support, like Healthy Start’s The Circle and her organization’s six-week Mothers and Babies course, can make a difference for new parents. Cook said clients frequently list loneliness as the top reason for poor mental health.
“We've got our brain playing tricks on us that we're not worthy of getting this help, because we should be able to do it by ourselves,” she said. “Why would we ever think that something we've never done in our lifetime, we're going to be automatically ready to cope with from day one?”
The Texas Maternal Mortality and Morbidity Review Committee’s latest report, from 2022, said improving postpartum care management for people with mental health conditions is one of their top recommendations to improve maternal health outcomes in the state.
New pilot program helps doctors treat mental health issues in pregnant patients
One way Texas is working to get more pregnant people connected to mental health resources is through a new pilot program, called the Perinatal Psychiatry Access Network (PeriPAN). It uses the same framework as the Child Psychiatry Access Network, which equipped pediatricians to diagnose and treat mental health conditions in their patients through consultation from psychologists and psychiatrists.
The program, which launched last August, serves four regions throughout North Texas. Dr. Anastasia Ruiz is the medical director for PeriPAN at Texas Tech University Health Sciences Center, which includes Lubbock, Potter and Wichita counties. She said mental health conditions during pregnancy are common, and the availability of treatments should be, too.
“We screen everyone for gestational diabetes, and we really should be doing the same for mental health conditions,” Ruiz said.
She specializes in perinatal psychiatry, and answers the phone when physicians call into PeriPAN with questions.
“Oftentimes people feel fragmented in their care,” Ruiz said. “I have to see a primary [doctor], now I have to see an OB, now I have to see a psychiatrist. But when you have the same doctor that you're seeing, you feel comfortable telling them what's going on, and you trust that doctor to start care for you.”
According to a 2022 article in the journal of General Hospital Psychiatry, programs like PeriPAN can help improve maternal health equity by lowering barriers to care, especially for BIPOC pregnant patients. Many Black patients especially “fall through the net,” according to a 2010 study in the same journal, because their doctors either can’t identify or don’t know how to treat perinatal and postpartum depression.
Ruiz said helping primary care doctors get support for their patients improves the entire family’s health outcomes.
“Being pregnant and postpartum is a golden opportunity to implement change, and to give these [parents] hope and support,” Ruiz said.
A focus on maternal health in the Texas legislature
Wilder with Healthy Start and Cook with Mental Health America of Greater Dallas are both looking at bills moving through the Texas legislature that would extend postpartum Medicaid coverage for pregnant people. Right now, pregnancy Medicaid covers people two months after giving birth, which advocates have said is not enough time to address health concerns.
“When it comes to access to care in Texas, we're last” when compared to other states, Cook said. “When it comes to insurance, getting to see a doctor, we are dead last and we are consistently dead last.”
House Bill 12, introduced by Rep. Toni Rose, D-Dallas, would extend pregnancy Medicaid coverage up to twelve months after giving birth. It was approved in the House committee that focuses on health care reform in mid-March and is headed to the full Texas House of Representatives for a vote in the coming weeks.
Rep. Dade Phelan, R-Beaumont, the speaker for the House, identified this Medicaid coverage extension as a priority for the 2023 legislative session. In 2021, Gov. Greg Abbott signed a bill into law that would extend the coverage to six months postpartum; the law is still under review by the federal government.
Wilder said finding resources for clients can be difficult when there’s a ticking clock on coverage.
“We are always hoping that one day we will see the full year [of coverage],” she said. “Not all of our clients are on Medicaid, but we do have a heavy population. We know how important it is to have insurance.”
Cook said she’s hoping the Medicaid extension becomes law and makes it easier for pregnant people to find resources.
“I would expand postnatal care for at least two years,” she said. “I would have educational programs where we talked about prevention before intervention. I would start upstream as opposed to downstream. I would start talking about our mental health. It makes sense to do this.”
Affirmations and social support for pregnant people
At Healthy Start in Fort Worth, Misty Wilder asks everyone gathered at the table to read out what they’ve written on their mirrors. Words of affirmation loop in colorful, swirling letters around the perimeter of the glass in front of each person.
Wilder goes first, sharing she wrote “You got this, sis!” Others chime in: “I’m electric!” “I am beautiful!” “I can do hard things!” “My feelings matter!”
Then Wilder gives the group their homework: a week of affirmations, journaling about what they feel and what the impact is on their mood.
“Don’t just throw it off to the side,” she says. “Put it somewhere and think of all the good, positive things.”
The group chuckles, then promises they’ll keep the mirrors and cards with affirmations handy.
When reflecting on the program, Wilder said it has given the entire organization a boost. She said she hopes this model of support is something other organizations can adopt to support pregnant Texans through the ups and downs of their first year of parenting.
“Sometimes I'm like, OK, this will be a short lesson and then we're still here two hours,” she said. “For me, it was confirmation that it’s needed. It was also confirmation that our team needed something, too. Even though we showed up to help someone else, it's helping us and so for me, that's a win.”
This is the third in a series of stories investigating maternal and pregnancy health in Texas. Read previous stories on pregnancy Medicaid and tips on how to apply for state health programs.
Got a tip? Email Elena Rivera at erivera@kera.org. You can follow Elena on Twitter @elenaiswriting.
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