Many of us supporting evidence-based policymaking got involved with applied research in hopes that our findings might reach decision makers who would then use the evidence to improve people’s well-being. But sometimes it can be hard to know if and how our evidence is driving change. One of my greatest fears is that a report I worked on for years (that a funder spent millions of dollars supporting) will go ignored and unread, gathering dust on a shelf. That’s why I welcomed the opportunity to serve as a panelist at a public forum that took place in October on maternal mental health and employment, where evidence from Mathematica was part of a broader conversation about state and federal policies that support pregnant and recently pregnant workers.
The roundtable was hosted by Women In Government and the U.S. Department of Labor’s Office of Disability Employment Policy. What made the event special was the audience—women state legislators and their staff—as well as the other panelists, including lawmakers from Pennsylvania and Massachusetts who sponsored legislation to protect pregnant workers from discrimination and to allow those workers to recover after a pregnancy, miscarriage, or failed adoption. Fellow panelists Massachusetts State Representative Jamie Belsito and Pennsylvania State Senator Amanda Cappelletti shared how their policy proposals were not only informed by the kind of evidence Mathematica produces, but also by their personal experiences with pregnancy, parenthood, miscarriages, and depression.
“Having lost a baby at almost three months, it was taboo and it was not spoken about…I was devastated and incredibly depressed and expected to go right back to work,” said Representative Belsito.
“I experienced two miscarriages last year back-to-back,” said Senator Cappelletti. “I can’t imagine for…the people that I’ve heard from and the horrible experiences that they’ve had [with] employers not recognizing the physical and mental health trauma that goes along with a pregnancy loss.”
A recent economic analysis from Mathematica found that nine of the many health conditions stemming from or worsened by pregnancy were associated with $6.6 billion in lost worker productivity over the five years following childbirth. State policies that support workers during or after a pregnancy could help reduce those costs associated with lost worker productivity.
“Money walks, money talks,” said Representative Belsito said during the webinar, explaining that money “tends to dictate a lot of our policy decisions and what and how we move forward…in our state and federal legislature.” Mathematica’s analysis also found that maternal mental health conditions such as the depression Representative Belsito described accounted for $14.2 billion in societal costs for the United States between pregnancy and five years post-partum.
There are other methods of accounting for the impacts of not adequately treating maternal health conditions, but measuring financial costs associated with maternal morbidities provides a lens for policy makers and advocates through which they can consider the fiscal benefits of investing in policies and programs to reduce U.S. maternal morbidities and mortality. It’s been gratifying to engage with policymakers like those at the Women In Government event who are looking for the best available information to help them articulate concretely the potential impacts of their policies and programs.
Since 2019, when my Mathematica colleague Kara Zivin led a study that estimated the national costs of perinatal mental health disorders, public agencies and private organizations across the country that want to make the case for investments in maternal mental health have reached out to Mathematica. In the past four years, we have provided state-level estimates on the cost of perinatal mood anxiety disorders in Washington State, Colorado, California, Texas, and Vermont.
Kara has sought to further increase public understanding about the costs of maternal mental health conditions by supplementing Mathematica’s numbers-driven analysis with qualitative and personal evidence. She has spoken publicly about her experiences with maternal mental illness, including at a candlelight vigil in remembrance of mothers who died by suicide. Like my fellow panelists for the Women in Government event, Kara understands that lived experience is another rich source of data, one that can be combined with economic analysis to further inform decision makers’ understanding of maternal health conditions.
Our work in Texas, supported by the St. David’s Foundation, enabled Texans Cares for Children to use Mathematica’s estimated costs of maternal mental health conditions as key evidence when it successfully lobbied the legislature to extend Medicaid postpartum coverage from 2 to 6 months (pending approval from the Centers for Medicare & Medicaid Services). Currently, we are assessing the societal cost of maternal mental health conditions in Vermont, which should inform the state’s participation in Screening, Treatment, and Access for Mothers and Perinatal Partners, a five-year cooperative agreement funded by the U.S. Health Resources and Services Administration to help expand perinatal mental health services in Vermont.
I’m hopeful that these types of state-level economic analyses will become even more relevant as states consider extending post-partum Medicaid coverage beyond two months. Medicaid is the number one payer for mental health services across the country, and a provision in the American Rescue Plan Act of 2021 gives states a five-year window to take advantage of a new option to extend Medicaid coverage for to up to one year after childbirth, even in states that did not choose to expand Medicaid under the Affordable Care Act. As of mid-November 2022, a tracker managed by the Kaiser Family Foundation has found that slightly more than half of states have already implemented the one-year extension. And at least some experts expect more states to extend post-partum Medicaid to address an anticipated surge in demand for pregnancy-related care resulting from state abortion bans that went into effect following the U.S. Supreme Court’s Dobbs decision earlier this year. The societal cost of not insuring and treating mental health conditions for new parents after childbirth, including lost productivity for a state’s workforce, could be a critical piece of information for lawmakers weighing such policy changes.
While I’m optimistic that policy windows will remain open and that the political will exists to continue improvements in maternal mental health, I also recognize that implementing these policies will determine if they have their intended impact. As a researcher, I see another role for evidence as we move beyond policy to enacting systems change and implementing programs. Change initiatives need evidence to determine optimal approaches and where to adjust to achieve the desired impact.
At a recent conference organized by the University of Illinois at Urbana-Champaign, Brown University School of Public Health, and The Rockefeller Foundation, I heard a discussion about the vital role that data and evidence can play in understanding and addressing problems related to the COVID-19 pandemic. Over time, data show where things are getting better and where they are getting worse. They show which responses are working. The more comprehensive your data are, the more comprehensive your response can be. As I listened, I was reminded of how those same lessons apply in maternal health. I hope that data and evidence will continue to guide policy decisions related to maternal health and other health issues that challenge us globally.