Maternal Mental Health and Substance Use

Maternal deaths resulting from mental health conditions and substance use have become pervasive across Texas and the nation, prompting responses from federal and state governments. According to the U.S. Department of Health & Human Services, the national “maternal mortality rate is the highest of any developed nation in the world and more than double the rate of peer countries, and most pregnancy-related deaths are considered preventable…For too long, we have allowed preventable deaths, life-altering complications, and untreated mental health and substance use disorders to persist.”1

Varying terms are often used interchangeably throughout literature and discussions: “maternal mental health and substance use” broadly reflects the wide range of challenges during and after pregnancy and birth. Further, “maternal mental health conditions” often encompasses substance use and overdoses.2 “Maternal” centers the woman giving birth and typically encompasses her well-being during pregnancy, childbirth, and postpartum.3 Whereas, “perinatal” is typically descriptive of time relative to the birth, including shortly before, during, and after (or the postpartum period), and “postpartum” refers to the time after birth, typically up to one year.4,5

Maternal health cannot be properly promoted and maternal mortality cannot be prevented without addressing maternal mental health and substance use. It is important decision-makers understand:

  • Maternal mental health conditions and substance use are not uncommon. It is estimated that one in between five to eight women are impacted, but this may be underreported as many women do not receive treatment, nor share their struggles.6,7,8 Research suggests the prevalence in Texas reflects these estimates.9 The most common diagnoses reported for pregnant women and new moms are anxiety and major depressive disorders, followed by obsessive-compulsion, bipolar, and psychosis disorders.10
  • Pregnant women and new moms are not immune to substance use disorders and addiction. In FY 2022, over 1,190 infants were reported by medical professionals with prenatal substance exposure (IPSE) in Texas.11 Further, risk of overdose is highest within the first year after birth.12
  • Both mom and baby will experience negative outcomes from poor maternal mental health and substance use. Unlike other populations experiencing mental health challenges, the substantial impact of perinatal conditions extends beyond the mother to their baby, including high-risk pregnancies and births.13 Women with mental health challenges are twice as likely to experience preterm birth and higher risks of gestational hypertension, hemorrhaging, low birth weight, reduced breastfeeding rates, and outcomes that do not result in a live birth.14,15,16
  • To prevent negative impacts to child’s development, it is imperative to address maternal mental health and substance use early. The severity and persistence of mom’s untreated mental health conditions can impact children’s language and motor development, attachment styles, increase their risk of behavioral problems by age 3, lower mathematic scores, and increase their risk of depression in adolescence.17,18,19,20
  • Maternal mental health conditions can have dire consequences when untreated. Mental health conditions, inclusive of suicide and overdose, is the leading cause of pregnancy-related deaths accounting for almost a quarter of maternal mortality in the U.S.21 Suicide and overdoses are the leading cause of death within the first year of birth.22 These statistics are not a national trend unseen in Texas.

Maternal Mortality

In Texas, mental health conditions are the leading cause of pregnancy-related death.23 The death of a new parent is unfathomable for families and communities; however, these outcomes are not inevitable. Pregnancy-related deaths resulting from untreated mental health conditions and substance use are preventable: these deaths are the leading cause of preventable pregnancy-related deaths.24

Analyses of preventable pregnancy-related deaths from 2008-2019 determine that mental health deaths, inclusive of suicide and overdose, are more preventable than any other cause.25,26 In fact, state Maternal Mortality Review Committees (MMRCs) have determined 100 percent of these deaths are preventable.27 MMRCs determine if there is “no chance”, “some chance”, or “a good chance” death could have been averted by one or more reasonable changes to patient, family, community, provider, or systems factors. Deaths are considered preventable if a reasonable change made to one factor would have resulted in at least “some chance” of the outcome being altered.28

The most recent data also highlights one in three pregnancy-related deaths were violent.29 In addition to cause of death, manner of death should inform discussions and solutions to the maternal mortality crisis across Texas. The determination of how the cause leads to death is categorized under five manners: natural, accident, suicide, homicide, and undetermined. Violent pregnancy-related deaths with a manner of death by suicide or homicide represent 27 percent of deaths, most frequently by airway restriction, overdose, and firearms.30 Partners were most likely to be responsible for homicide.31

Insufficient Systems of Support

Lack of mental health and substance use support and high rates of mortality can be attributed to a complex number of factors. An interplay between individual, family, community, providers, and systems factors influences maternal mental health and well-being. Various non-medical drivers of health (i.e., education, health care, socioeconomic status, neighborhood, etc.) affect risk of experiencing perinatal mental health conditions and subsequent care. Additional psychosocial risk factors include ongoing conflict with the partner, poor social support, and ongoing stressful life events.32

Despite preventable deaths and treatable conditions, many women do not receive adequate mental health and/or substance use support during or after their pregnancies. Further, most women are not screened and those who are, rarely receive services. Less than half of women are screened for depression during or after their pregnancy, and only 22 percent of those who screen positive, receive mental health treatment.33,34 More broadly, only one out of four women with maternal mental health or substance use concerns receive adequate treatment.35 More can be done to ensure prevention, detection, and early intervention efforts are pursued and implemented uniformly and wholly throughout healthcare and communities.

Other Risk Factors

Access to mental health care and rates of maternal mortality resulting from mental and substance use are strongly associated with these various non-medical drivers of health, which are often disparate among groups. These risk factors are known to disproportionately impact communities of color, rural communities, and those facing systemic inequities.36

Research and data show that where someone resides impacts risk for maternal mental health conditions and substance use, as well as access to resources. National analysis found Texas is one of the top six states to be considered in the “Maternal Mental Health Dark Zone.” This zone encompasses states with the highest number of counties with the highest number of birthing-age women at high-risk of experiencing maternal mental health disorders and counties lacking sufficient maternal mental health resources.37 Moreover, over 46 percent of Texas counties are defined as a “maternity care desert,” compared to the 32.6 percent in the United States.38 In rural areas across Texas, 28.4 percent of women live over 30 minutes from a birthing hospital compared to 3.8 percent of women living in urban areas.39

From 2012-2021, a consistently larger percentage of White women received prenatal care in the first trimester of pregnancy compared to all other racial and ethnic groups.40 In 2021, over 77 percent of White women received prenatal care compared to 64 percent of Hispanic mothers and 60 percent of non-Hispanic Black mothers.41 Additionally, the Texas Maternal Mortality and Morbidity Review Committee found that while the average of pregnancy-related mortality ratio (PRMR) decreased, disparities still persist among racial groups. While the PRMR rates for both non-Hispanic Black and White women decreased, the PRMR rates for non-Hispanic Black women are 1.5 times greater than that for non-Hispanic White women.42 Further, the PRMR for Hispanic women and women in the non-Hispanic Other race group have increased over time.43 The most recent data in Texas also highlights discrimination contributed to more than one in 10 pregnancy-related deaths.44

Stigma

As a significant barrier, stigma’s impact on help-seeking should not be overlooked. Internal beliefs by women, as well as messages received from others can have lasting effects. Research shows help-seeking is heavily influenced by stigma, shame, and the fear of being labelled “mentally ill.”45 For example, researchers have found that individuals believe unpreparedness for, or not coping with parenthood, are causes for women to experience postpartum depression (PPD).46,47 Further, perinatal women have reported being told that “good mothers don’t feel depressed after having a baby” or felt judgement by their partner.48,49

Maternal Substance Use and DFPS

Doctors and nurses are required by mandatory reporting laws to report suspected child abuse and neglect if they have reasonable cause to believe the child has been abused as defined by statute.50 Definitions of child abuse in Texas law include “the current use of controlled substances by an adult in a manner or to the extent that the use results in physical, mental, or emotional injury to a child.”51 DFPS Statewide Intake advances any reports of substance-exposed infants for an investigation. During the investigation, a child assessment, parental assessment, holistic family assessment, safety planning, and the development of initial services occur.

The birth of a substance-exposed infant does not result in an automatic removal of that child, nor an automatic disposition of child abuse or neglect. Each family’s specific circumstance is assessed; DFPS works closely with partners who provide substance use intervention or treatment services to parents who engage in substance use.52 In some cases, the parent has sufficient support and/or engaged in treatment services, thereby eliminating the need for further DFPS involvement beyond investigation. Other parents may be assisted in development of a plan and access to services during the investigation stage of services, or a Family-Based Safety Services (FBSS) stage may be opened to provide ongoing services without removal. Where safety cannot be assured, DFPS will seek removal of the infant.53 While it is unclear how often an infant is being removed due to substance use in Texas, the research is clear: mom and baby together is better. Integrated treatment programs, allowing children to reside with their mother while seeking treatment, are associated with preventing out-of-home child placements, treatment completion, and maternal substance use, while also reducing child abuse and improvements in child’s physical and emotional development.54

Child Removals

During the 86th legislative session, Texas passed SB 195 (Perry/Parker) which directed DFPS to collect and report data each year on children testing positive for alcohol or controlled substances at birth, what controlled substances were present in these positive results, children removed as a result and have also been diagnosed with a disability or chronic health condition, and parents who test positive for controlled substances during a DFPS-investigation of abuse or neglect.55 In 2022, DFPS reported lack of funds resulted in an inability to update their current information management system, so the data would not be able to be collected.56 Months later, DFPS reported funds from existing appropriations would be used and updates were scheduled for FY 2023.57

Current Efforts Across Texas

The prevalence of mental health and substance use-related conditions and maternal mortality in Texas has been met with efforts across the state to support new moms, families, and babies. Both common sense and innovative steps have been taken to ensure new parents and babies can thrive.

12-month Medicaid expansion

In Texas, the Parkland Community Health Plan found that prior to statewide implementation, women who remained on Medicaid for 12 months postpartum sought mental health and substance use treatment at a rate three times that of women who lost coverage after two months. Those with continuous coverage also needed 37 percent fewer services in the first postpartum year following subsequent pregnancies.58

Passed during the 88th Texas Legislative session, HB 12 (Rose/Kolkhorst) provides 12 months of continued Medicaid coverage for mothers following the birth of their child, making Texas the 43rd state to extend this coverage. Enacted on March 1, 2024, Governor Greg Abbott’s office projects approximately 137,000 women will benefit from 12-months postpartum coverage in fiscal year 2025.59

Texas Perinatal Psychiatry Access Network (PeriPAN)

Housed with the Texas Child Mental Health Care Consortium, the Texas Perinatal Psychiatry Access Network (PeriPAN) is statewide program that offers clinicians and other health professionals evidence-based, clinician-to-clinician support to provide perinatal mental health care to patients. PeriPan offers peer-to-peer consults with multidisciplinary mental health professionals, including reproductive psychiatrists by phone, vetted and personalized referrals and resources, and behavioral health CMEs.60,61 PeriPan began as a pilot program with COVID-19 relief funds based off the Child Psychiatry Access Network (CPAN), the existing pediatric program in Texas. Texas PeriPAN and similar networks are based on Lifeline for Moms and Massachusetts Child Psychiatry Access Program (MCPAP) for Moms, supported by the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG).62 As a result of its success, the Texas Legislature funded the program in order for statewide expansion beginning in September 2023.63

The program created The PeriPAN Mental Health OB Toolkit resource “for perinatal care providers with actionable information to build capacity for preventing, identifying, treating, and monitoring perinatal mood and anxiety conditions,” including guidance, resources, and materials to support clinicians. More information on the Texas Child Mental Health Care Consortium is in the THECB section of the Guide.

TexasAIM

DSHS partners with the Alliance for Innovation on Maternal Health (AIM) and various other organizations to implement the TexasAIM program.64 TexasAIM supports birthing hospitals implementing AIM maternal safety bundles with technical assistance and collaborative learning. Safety bundles are multidisciplinary, evidence-based, and clinical condition-specific best practices across five domains that lead to improved outcomes for mothers and birth safer.65,66 These domains include Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful Care.67

To address the leading and most preventable causes of maternal mortality in Texas, TexasAIM began with maternal patient safety bundles for obstetric hemorrhage, severe hypertension, and opioid and other substance use disorders.68 From 2017-2020, DSHS partnered with the AIM multi-state collaboration to develop and pilot the Obstetric Care for Women with Opioid Use Disorder (OUD) Patient Safety Bundle in 10 hospitals. Based on learnings from other states, a new Care for Pregnant and Postpartum with Substance Use Disorders Bundle (CPPSUD) was created in October 2021.69,70

Incorporating AIM’s CPPSUD Patient Safety Bundle elements, DSHS launched the Obstetric Care for Women with Opioid and other Substance Use Disorder Innovation and Improvement Learning Collaborative (OSUD IILC) in August 2023.71 The learning collaborative includes nine pilot hospitals, including hospitals from the original OUD pilot, through 2024. After the pilot, DSHS expects to expand the program statewide for full implementation.72

Moving Forward

While steps have been taken, there is ample space for Texas to shift and reimagine how it supports pregnancies before, during, and after birth, inclusive of mental health and well-being. Some opportunities for Texas to build off current work, and revisit missed opportunities include:

References

  1. The White House. (2022). White House blueprint for addressing the maternal health crisis. https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf ↩︎
  2. Centers for Disease Control and Prevention. (2022, September 19). Four in 5 pregnancy-related deaths in the U.S. are preventable [Press release]. https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html ↩︎
  3. Texas Health and Human Services. (2023). Maternal depression strategic plan for Fiscal Years 2021-2025: Fiscal Year 2023 update. https://www.hhs.texas.gov/sites/default/files/documents/hb253-postpartum-depression-strategic-plan-update-oct-2023.pdf ↩︎
  4. Clake, D.E., De Faria, L., Alpert, J.E., the Perinatal Mental Health Advisory Panel, & the Perinatal Mental Health Research Team. (2023). Perinatal mental and substance abuse disorders. American Psychiatric Association and the Centers for Disease Control and Prevention Foundation. https://www.psychiatry.org/getmedia/344c26e2-cdf5-47df-a5d7-a2d444fc1923/APA-CDC-Perinatal-Mental-and-Substance-Use-Disorders-Whitepaper.pdf ↩︎
  5. Graham, W. J., Cairns, J., Bhattacharya, S., Bullough, C.H., Quayyum, Z., & Rogo, K. (2006). Maternal and perinatal conditions. In D. T. Jamison, J. G. Breman, A.R. Measham, G. Alleyne, M. Claeson, D. B. Evans, P. Jha, A. Mills & P. Musgrove (Eds.), Disease control priorities in developing countries (2nd ed.). Oxford University Press. https://www.ncbi.nlm.nih.gov/books/NBK11742/ ↩︎
  6. Policy Center for Maternal Mental Health. (2023). Maternal mental health.  https://www.issuelab.org/resources/42983/42983.pdf ↩︎
  7. Fitzgerald, L., McNab, S., Njau, P., Chandra, P., Koyiet, P., Levine, R., Hardtman, P., & Stalls, S. (2024). Beyond survival: Prioritizing the unmet mental health needs of pregnant and postpartum women and their caregivers. PLOS global public health, 4(2), 2782. https://doi.org/10.1371/journal.pgph.0002782 ↩︎
  8. Webb, R., Uddin, N., Ford, E., Easter, A., Shakespeare, J., Roberts, N., Alderdice, F., Coates, R., Hogg, S., Cheyne, H., Ayers, S., & MATRIx study team (2021). Barriers and facilitators to implementing perinatal mental health care in health and social care settings: a systematic review. The lancet. Psychiatry, 8(6), 521–534. https://doi.org/10.1016/S2215-0366(20)30467-3 ↩︎
  9. Ibid. ↩︎
  10. Clake, D.E., De Faria, L., Alpert, J.E., the Perinatal Mental Health Advisory Panel, & the Perinatal Mental Health Research Team. (2023). Perinatal mental and substance abuse disorders. American Psychiatric Association and the Centers for Disease Control and Prevention Foundation. https://www.psychiatry.org/getmedia/344c26e2-cdf5-47df-a5d7-a2d444fc1923/APA-CDC-Perinatal-Mental-and-Substance-Use-Disorders-Whitepaper.pdf ↩︎
  11. Children’s Bureau. (2022). Child Maltreatment 2022. U.S. Department of Health & Human Services. https://www.acf.hhs.gov/sites/default/files/documents/cb/cm2022.pdf ↩︎
  12. Centers for Disease Control and Prevention. (2022, September 19). Four in 5 pregnancy-related deaths in the U.S. are preventable [Press release]. U.S. Department of Health & Human Services. https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html ↩︎
  13. Fitzgerald, L., McNab, S., Njau, P., Chandra, P., Koyiet, P., Levine, R., Hardtman, P., & Stalls, S. (2024). Beyond survival: Prioritizing the unmet mental health needs of pregnant and postpartum women and their caregivers. PLOS global public health, 4(2), 2782. https://doi.org/10.1371/journal.pgph.0002782 
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10843059/ ↩︎
  14. Stephanie Green. (2023). Maternal mental health crisis undermines moms’ health. National Partnership for Women & Families. https://nationalpartnership.org/wp-content/uploads/2023/02/maternal-mental-health-crisis.pdf ↩︎
  15. Texas Department of State Health Services. (2023). Maternal and child health epidemiology: 
    2022/2023 healthy Texas mothers and babies data book. 
    https://www.dshs.texas.gov/sites/default/files/healthytexasbabies/Documents/2022%20-%202023%20Healthy%20Texas%20Mothers%20and%20Babies%20Data%20Book.pdf ↩︎
  16. Davenport,M.H., Meyer,S. Meah, V.L., Strynadka, M.C., & Khurana, R. (2020). Moms are not ok: COVID-19 and maternal mental health. Frontiers in Global Women’s Health, 1(1). https://doi.org/10.3389/fgwh.2020.00001 ↩︎
  17. Fitzgerald, L., McNab, S., Njau, P., Chandra, P., Koyiet, P., Levine, R., Hardtman, P., & Stalls, S. (2024). Beyond survival: Prioritizing the unmet mental health needs of pregnant and postpartum women and their caregivers. PLOS global public health, 4(2), 2782. https://doi.org/10.1371/journal.pgph.0002782 ↩︎
  18. Quevedo, L. A., Silva, R. A., Godoy, R., Jansen, K., Matos, M. B., Tavares Pinheiro, K. A., & Pinheiro, R. T. (2012). The impact of maternal post-partum depression on the language development of children at 12 months. Child: care, health and development, 38(3), 420–424. https://doi.org/10.1111/j.1365-2214.2011.01251.x ↩︎
  19. Netsi, E., Pearson, R. M., Murray, L., Cooper, P., Craske, M. G., & Stein, A. (2018). Association of persistent and severe postnatal depression with child outcomes. JAMA Psychiatry, 75(3), 247. https://doi.org/10.1001/jamapsychiatry.2017.4363 ↩︎
  20. Sanger, C., Iles, J. E., Andrew, C. S., & Ramchandani, P. G. (2015). Associations between postnatal maternal depression and psychological outcomes in adolescent offspring: a systematic review. Archives of women’s mental health, 18(2), 147–162. https://doi.org/10.1007/s00737-014-0463-2 ↩︎
  21. Centers for Disease Control and Prevention. (2022, September 19). Four in 5 pregnancy-related deaths in the U.S. are preventable [Press release]. https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html ↩︎
  22. Clarke, D.E., De Faria, L., Alpert, J.E., the Perinatal Mental Health Advisory Panel, & the Perinatal Mental Health Research Team. (2023). Perinatal mental and substance abuse disorders. American Psychiatric Association and the Centers for Disease Control and Prevention Foundation. https://www.psychiatry.org/getmedia/344c26e2-cdf5-47df-a5d7-a2d444fc1923/APA-CDC-Perinatal-Mental-and-Substance-Use-Disorders-Whitepaper.pdf ↩︎
  23. Texas Health and Human Services. (2023). Addendum – Texas maternal mortality and morbidity review committee and department of state health services joint biennial report 2022. https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/Addendum-2022-MMMRC-DSHS-Joint-Biennial-Report.pdf ↩︎
  24. Trost, S. L., Beauregard, J. L., Smoots, A. N., Ko, J. Y., Haight, S. C., Simas, T. A. M., Byatt, N., Madni, S. A., & Goodman, D. (2021). Preventing pregnancy-related mental health deaths: Insights From 14 US Maternal Mortality Review Committees, 2008–17. Health Affairs, 40(10), 1551-9. https://doi.org/10.1377/hlthaff.2021.00615 ↩︎
  25. Ibid. ↩︎
  26. Trost, S., Beauregard, J., Chandra, G., Nije, F., Berry, J., Harvey, A., & Goodman, D.A. (2022). Pregnancy-related deaths: Data from Maternal Mortality Review Committees in 36 US states, 2017–2019. Centers for Disease Control and Prevention, US Department of Health and Human Services. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html ↩︎
  27. Ibid. ↩︎
  28. Texas Health and Human Services. (2022, December). Texas maternal mortality and morbidity review  
    committee and department of state health services joint biennial report 2022. https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/2022-MMMRC-DSHS-Joint-Biennial-Report.pdf ↩︎
  29. Thompson, M. (2024, March 15). Texas task force that reviews pregnancy-related deaths losing advocate role. The Austin Chronicle. https://www.austinchronicle.com/news/2024-03-15/the-texas-task-force-that-reviews-pregnancy-related-deaths-is-losing-its-sole-advocate-position/ ↩︎
  30. Texas Health and Human Services. (2023, October 25). Addendum – Texas maternal mortality and morbidity review committee and department of state health services joint biennial report 2022. https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/Addendum-2022-MMMRC-DSHS-Joint-Biennial-Report.pdf ↩︎
  31. Ibid. ↩︎
  32. Ibid. ↩︎
  33. Policy Center for Maternal Mental Health. (November 2023). Maternal mental health.  https://www.issuelab.org/resources/42983/42983.pdf ↩︎
  34. Burkhard, J., & Britt, R. (2022, November 14). U.S. maternal depression screening rates released for the first time through HEDIS. Policy Center for Maternal Mental Health. https://www.2020mom.org/blog/2022/11/14/us-maternal-depression-screening-rates-released-for-the-first-time-through-hedis ↩︎
  35. Griffen, A., McIntyre, L., Belsito, J. Z., Burkhard, J., Davis, W., Kimmel, M., Stuebe, A., Clark, C., & Meltzer-Brody, S. (2021). Perinatal mental health care in the United States: An overview of policies and programs. Health Affairs (Project Hope), 40(10), 1543–1550. https://doi.org/10.1377/hlthaff.2021.00796 ↩︎
  36. Burkhard, J., Britt, R., Murphy, C., & Childers, A. (n.d.). 2023 maternal mental health provider shortages & population risk report. Policy Center for Maternal Mental Health. https://www.2020mom.org/us-maternal-mental-health-dark-zones-revealed ↩︎
  37. Ibid. ↩︎
  38. Fontenot, J., Lucas, R., Stoneburner, A., Brigance, C., Hubbard, K., Jones, E., & Mishkin, K. (2023). Where you live matters: maternity care deserts and the crisis of access and equity in Texas. March of Dimes. 
    https://www.marchofdimes.org/peristats/assets/s3/reports/mcd/Maternity-Care-Report-Texas.pdf ↩︎
  39. Ibid. ↩︎
  40. Texas Department of State Health Services. (2023). Maternal and child health epidemiology: 
    2022/2023 healthy Texas mothers and babies data book. https://www.dshs.texas.gov/sites/default/files/healthytexasbabies/Documents/2022%20-%202023%20Healthy%20Texas%20Mothers%20and%20Babies%20Data%20Book.pdf ↩︎
  41. Ibid. ↩︎
  42. Texas Health and Human Services. (2023). Addendum – Texas maternal mortality and morbidity review committee and department of state health services joint biennial report 2022.  https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/Addendum-2022-MMMRC-DSHS-Joint-Biennial-Report.pdf ↩︎
  43. Ibid. ↩︎
  44. Thompson, M. (2024, March 15). Texas task force that reviews pregnancy-related deaths losing advocate role. The Austin Chronicle. https://www.austinchronicle.com/news/2024-03-15/the-texas-task-force-that-reviews-pregnancy-related-deaths-is-losing-its-sole-advocate-position/ ↩︎
  45. Daehn, D., Rudolf, S., Pawils, S., & Renneberg, B. (2022). Perinatal mental health literacy: Knowledge, attitudes, and help-seeking among perinatal women and the public – A systematic review. BMC Pregnancy and Childbirth, 22(1). https://doi.org/10.1186/s12884-022-04865-y ↩︎
  46. O’Hara, M. W., & Wisner, K. L. (2014). Perinatal mental illness: definition, description and etiology. Best practice & research. Clinical obstetrics & gynecology, 28(1), 3–12. https://doi.org/10.1016/j.bpobgyn.2013.09.002 ↩︎
  47. Thorsteinsson, E. B., Loi, N. M., & Moulynox, A. L. (2014). Mental health literacy of depression and postnatal depression: A community sample. Open Journal of Depression, 3(03), 101–111. https://doi.org/10.4236/ojd.2014.33014 ↩︎
  48. Abrams, L. S., Dornig, K., & Curran, L. (2009). Barriers to service use for postpartum depression symptoms among low-income ethnic minority mothers in the United States. Qualitative health research, 19(4), 535–551. https://doi.org/10.1177/1049732309332794 ↩︎
  49. Thorsteinsson, E. B., Loi, N. M., & Moulynox, A. L. (2014). Mental health literacy of depression and postnatal depression: A community sample. Open Journal of Depression, 3(03), 101–111. https://doi.org/10.4236/ojd.2014.33014 ↩︎
  50. Tex. Fam. Code § 261.101(b) ↩︎
  51. Tex. Fam. Code § 261.001(1)(I) ↩︎
  52. Texas Children’s commission. (2023. Texas child protection law bench book. http://benchbook.texaschildrenscommission.gov/library_item/gov.texaschildrenscommission.benchbook/252?print=1 ↩︎
  53. Ibid. ↩︎
  54. Neo, S.H.F., Norton, S., Kavallari, D., & Canfield, M. (2021). Integrated treatment programmes for mothers with substance use problems: A systematic review and meta-analysis of interventions to prevent out-of-home child placements. Journal of Child and Family Studies, 30, 2877-2899. https://link.springer.com/article/10.1007/s10826-021-02099-8 ↩︎
  55. Texas Department of Family and Protective Services. (n.d.). Senate Bill 195_86R: Collection and reporting of alcohol and controlled substance statistics. Retrieved May 8, 2024 from  https://www.dfps.texas.gov/About_DFPS/Reports_and_Presentations/CPS/documents/2022/2022-11-01_SB195_Alcohol_and_Controlled_Substance_Statistics.pdf ↩︎
  56. Ibid. ↩︎
  57. Travis, A. (2022, November 29). Texas finds funding to start tracking impact of substance abuse on foster children. KXAN News. https://www.kxan.com/investigations/texas-finds-funding-to-start-tracking-impact-of-substance-abuse-on-foster-children/ ↩︎
  58. Texas 2036. (n.d.). Retrieved May 8, 2024 from https://texas2036.org/blog/?policy_area=health-and-healthcare&type=&expert=&date= ↩︎
  59. Office of the Texas Governor. (2024, January 24). Governor Abbott, HHSC announce Medicaid, CHIP postpartum coverage extension to 12 months [Press release]. https://gov.texas.gov/news/post/governor-abbott-hhsc-announce-medicaid-chip-postpartum-coverage-extension-to-12-months#:~:text=%E2%80%9CTwelve%20months%20of%20postpartum%20coverage,effect%20on%20March%201%2C%202024. ↩︎
  60. Texas Child Mental Health Care Consortium. (2024). Peripan perinatal: Mental health toolkit  
    for obstetric clinicians. https://tcmhcc.utsystem.edu/wp-content/uploads/2024/03/CPAN_PeriPAN-Toolkit_FINAL.pdf ↩︎
  61. Texas Child Mental Health Care Consortium. (n.d.). Perinatal Psychiatry Access Network (PeriPAN). Retrieved May 8, 2024 from https://tcmhcc.utsystem.edu/perinatal-psychiatry-access-network-peripan/ ↩︎
  62. Texas Child Mental Health Care Consortium. (2024). Peripan perinatal: Mental health toolkit  
    for obstetric clinicians. https://tcmhcc.utsystem.edu/wp-content/uploads/2024/03/CPAN_PeriPAN-Toolkit.pdf ↩︎
  63. Alvarez-Hernandez, J. (2024, February 19). Perinatal psychiatry access network offers real-time mental health consultations. UT Health San Antonio. https://news.uthscsa.edu/perinatal-psychiatry-access-network-offers-real-time-mental-health-consultations/ ↩︎
  64. Maternal and Child Health. (n.d.). TexasAIM. Texas Department of State and Health Services. Retrieved February 27, 2024 from https://www.dshs.texas.gov/maternal-child-health/programs-activities-maternal-child-health/texasaim ↩︎
  65. The Alliance for Innovation on Maternal Health. (n.d.). Patient safety bundles. Retrieved February 27, 2024 from https://saferbirth.org/patient-safety-bundles/#what-are-psbs ↩︎
  66. Texas Department of State and Health Services. (2022). Maternal health and safety initiatives biennial report 2022. https://www.dshs.texas.gov/sites/default/files/legislative/2022-Reports/Maternal-Health-Safety-Initiatives-Biennial-Report-2022.pdf ↩︎
  67. Ibid. ↩︎
  68. Ibid. ↩︎
  69. Maternal and Child Health. (n.d.). TexasAIM obstetric care for women with opioid and other substance use disorders. Texas Department of State and Health Services. Retrieved February 27, 2024 from https://www.dshs.texas.gov/maternal-child-health/programs-activities-maternal-child-health/texasaim/obstetric-care-women-opioid ↩︎
  70. The Alliance for Innovation on Maternal Health. (2023). Care for pregnant and postpartum people with substance use disorder patient safety bundle. https://saferbirth.org/wp-content/uploads/U2-FINAL_AIM_Bundle_CPPPSUD.pdf ↩︎
  71. Maternal and Child Health. (n.d.). TexasAIM obstetric care for women with opioid and other substance use disorders. Texas Department of State and Health Services. Retrieved February 27, 2024 from https://www.dshs.texas.gov/maternal-child-health/programs-activities-maternal-child-health/texasaim/obstetric-care-women-opioid ↩︎
  72. Ibid.  ↩︎
  73. Texas Department of State Health Services. (n.d.). Substance use service locations. Retrieved May 8, 2024 from https://txdshsea.maps.arcgis.com/apps/webappviewer/index.html?id=f2fb359d9a4249f289cd8d241c3b78de ↩︎

Updated on December 16th, 2024



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