Improving Access to Mental Health Care for People with Low Incomes Who Were Pregnant and Gave Birth during the COVID-19 Pandemic

Improving Access to Mental Health Care for People with Low Incomes Who Were Pregnant and Gave Birth during the COVID-19 Pandemic - NCBI Bookshelf An official website of the United States government Here's how you know The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. 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Schaefer , MPH, Leah Ramella , BA, Azure Thompson , DrPH, Josephine Boateng , Martha Zimmermann , PhD, Esther Boama-Nyarko , MPH, Clevanne Julce , MPH, Carolyn Friedhoff , MBE, Linda Brenckle , MS, Amritha Bhat , MD, Deborah Cowley , MD, Debra Glazer , MPH, Wendy Davis , PhD, and Nancy Byatt , DO, MS, MBA. Author Information and Affiliations Authors Thomas I. Mackie , PhD, MPH, 1 Ana J. Schaefer , MPH, 1 Leah Ramella , BA, 1 Azure Thompson , DrPH, 1 Josephine Boateng , 2 Martha Zimmermann , PhD, 2 Esther Boama-Nyarko , MPH, 2 Clevanne Julce , MPH, 2 Carolyn Friedhoff , MBE, 2 Linda Brenckle , MS, 2 Amritha Bhat , MD, 3 Deborah Cowley , MD, 3 Debra Glazer , MPH, 3 Wendy Davis , PhD, 4 and Nancy Byatt , DO, MS, MBA 2 . Affiliations 1 School of Public Health, State University of New York Downstate Health Sciences University, Brooklyn 2 University of Massachusetts Chan Medical School, Shrewsbury 3 Maternal-Child Mental Health Program, Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle 4 Postpartum Support International, Portland, Oregon Washington (DC): Patient-Centered Outcomes Research Institute (PCORI) ; 2023 Oct . Copyright and Permissions Copyright© 2023. SUNY Downstate Health Sciences University. All Rights Reserved. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License which permits noncommercial use and distribution provided the original author(s) and source are credited. (See https://creativecommons.org/licenses/by-nc-nd/4.0/ Structured Abstract Background: Global crises, such as the COVID-19 pandemic, increase the risk of perinatal depression and anxiety. A recent systematic review of 81 cross-sectional studies reported that the prevalence of perinatal depression and anxiety amid the pandemic ranged from 20% to 64% of perinatal individuals. Increased prevalence is understood to reflect several stressors unique to global crises, including self-isolation, living with an affected person, and limited access to routine or emergency health and social care. Medicaid-insured perinatal individuals are also at greater risk than those privately insured for depression and anxiety disorders and confront additional barriers to quality perinatal mental health care. System-level solutions, such as perinatal psychiatry access programs, hold promise in facilitating a population-based response to address the impact of the COVID-19 pandemic. Developed in 2014, access programs provide consultation to tens of thousands of perinatal care professionals, covering approximately 1.9 million of the 3.6 million births across the country. Supported by federal, state, and other funding sources, the 15 access programs implemented nationally at the time of this study build the capacity of perinatal care professionals to address perinatal mood and anxiety disorders through 3 core components: (1) professional-to-professional consultation, (2) resource and referral, and (3) training. This study sought to identify the barriers to accessing perinatal mental health care among low-income individuals amid the pandemic and the promising system-level solutions available to advance health equity among perinatal individuals who are systematically marginalized. Objectives: The objectives of this study are therefore 3-fold: (1) to characterize the response of access programs to the COVID-19 pandemic and related calls to advance health equity, (2a) to understand the factors perceived to increase risk for perinatal mood and anxiety disorders, (2b) to develop a taxonomy on the barriers perceived to decrease perinatal mental health care access among low-income individuals amid the COVID-19 pandemic, and (3) to identify strategies that key community members assess to be both important and effective in advancing health equity. Methods: First, we developed and fielded a survey to a key informant from each of the 15 access programs implemented nationally to identify variation in the strategies employed by access programs to mitigate the impact of the COVID-19 pandemic and to address health inequity. Second, we employed semistructured qualitative interviews with key community members to identify factors reported to (1) increase the risk for perinatal mood and anxiety symptoms amid the COVID-19 pandemic, and (2) influence access to perinatal mental health care amid the pandemic. To elicit the perspective of key community members, we conducted interviews with (1) individuals with lived experience of perinatal mood and anxiety disorders (n = 24), (2) perinatal care professionals (n = 24), and (3) access program team members (n = 33). Our team then developed a taxonomy of factors that influenced access to perinatal mental health care amid the COVID-19 pandemic, by respondent group. Third, we assembled a list of strategies to advance health care equity drawing from a literature review, semistructured interviews with access program team members, and input received from advisory boards. We then conducted a modified Delphi panel, using 2 rounds of RAND appropriateness criteria methods, with members of our 4 advisory boards (n = 38). Survey results were analyzed using descriptive statistics. Results: First, access program key informants reported adopting equity-focused strategies that aimed to (1) improve the program's internal capacity, (2) support quality improvement and evaluation strategies, and (3) initiate new or adapt existing services. Access program team members reported implementing, on average, 4.5 (range, 0-10) strategies in response to the COVID-19 pandemic and, on average, 3.5 equity-focused strategies (range, 0-10). Second, our study found that individuals with lived experience of perinatal mood and anxiety disorders and perinatal care professionals reported that the pandemic increased the risk factors for perinatal depression and anxiety symptoms at the individual, interpersonal, and practice and organizational levels. Both perinatal care professionals and individuals with lived experience reported the pandemic affecting perinatal individuals' emotional (eg, anxiety because of risk of COVID-19 exposure), cognitive (eg, increased awareness of the Black maternal mortality crisis), and physical state (eg, decline in physical health because of change in diet and lack of exercise) in ways that increased risk factors for perinatal depression and anxiety symptoms. Key community partners also reported interpersonal challenges increasing risk of perinatal depression and anxiety symptoms (eg, strain on the partner relationship and the loss of social support). Key community members also emphasized the practice- and organizational-level factors (eg, restrictive clinic visitation policies, lack of consistent child care) increasing risk. Second, individuals with lived experience reported that the pandemic affected not only their own emotional, cognitive, and physical state, but also interpersonal relationships, health care delivery systems, and the sociopolitical context for accessing perinatal mental health care services. Perinatal care professionals reported barriers to perinatal mental health care emerging because of changes in an individual's interpersonal relationships, transformation of the health care delivery system, and the sociopolitical context. Finally, the modified Delphi panels assessed whether equity-focused strategies were promising approaches to address perinatal mental health care disparities amid the pandemic. Conclusions: Individuals with lived experience and perinatal care professionals identified a myriad of multilevel risk factors that they perceived to have influenced the well-documented increase in perinatal depression and anxiety symptoms. Despite elevated need, respondents reported barriers to care that have been exacerbated because of the pandemic. In response, our study suggests that the access programs generate equity-focused strategies that experts rated to hold promise in responding to the call to advance perinatal mental health equity. Limitations: Our exploratory study engaged qualitative methods to build new understandings grounded in the experiences of individuals with lived experience, perinatal care professionals, and access program team members amid the pandemic. The small sample size of our qualitative work limits generalizability to populations outside those interviewed; additional studies to investigate generalizability of findings across relevant populations are warranted. The modified Delphi panel assembles consensus from experts in light of our lacking data on the effectiveness of equity-focused strategies; additional research is needed to assess empirically the comparative effectiveness of equity-focused strategies. Background Perinatal mood and anxiety disorders affect approximately 1 in 4 individuals during the perinatal period, defined as 1 year before and up to 24 months after giving birth, 1 , 2 and are the most common pregnancy complications in the United States. 3 Perinatal mood and anxiety disorders are also associated with longer-term risks for the perinatal individuals and their children. 4-7 Global crises, such as COVID-19, increase the risk of perinatal mood and anxiety disorders. 8 For example, cross-sectional studies have found symptoms of depression in 36% of perinatal individuals compared with a prepandemic prevalence rate of 11% to 17%. 9 Across the 81 studies reviewed in a recent systematic review, reported prevalence of perinatal depression and anxiety amid the pandemic ranged from 20% to 64% of perinatal individuals. 9 Self-isolation, living with an affected person, and limited access to routine or emergency health and social care are all stressors unique to a global crisis that can increase risk of mood and anxiety symptoms. 9 , 10 Rates of perinatal mood and anxiety disorders are even greater among Medicaid-insured perinatal individuals. 11-15 Despite this elevated need, additional barriers to quality perinatal mental health care exist for perinatal individuals who are insured through Medicaid. 16 , 17 The COVID-19 pandemic brought needed attention to the persistence of structural racism in our service delivery system and society and the need for interventions that specifically seek to address the well-documented inequities experienced by minoritized perinatal individuals. As defined by Bailey et al, 18 structural racism “refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources.” To respond to these challenges, additional information is needed to understand the challenges and promising solutions required to respond to the increased prevalence of perinatal mood and anxiety disorders amid the COVID-19 pandemic and calls for health equity. 19 Perinatal Mental Health Care Amid the COVID-19 Pandemic Although perinatal mood and anxiety disorders are widespread illnesses that negatively affect birth, 20 infant, 14 and child outcomes, 15 most individuals go untreated. 21 The global COVID-19 pandemic has rapidly altered obstetric and mental health care systems, the delivery of care by obstetric and other perinatal care professionals, and the lives of the perinatal individuals whom those systems and clinicians serve. 22 , 23 In this report, perinatal care professionals are defined as those who are (1) licensed obstetric clinicians, such as obstetricians/gynecologists, licensed midwives, nurse practitioners (NPs), and other licensed obstetric care practitioners across treatment delivery settings, and (2) other perinatal care professionals, such as doulas. Amid the pandemic, perinatal care professionals have reduced in-person visits and increased use of telemedicine, 24 and they report experiencing their own mental health challenges amid the pandemic. 25 Uncertainty, grueling work hours, debilitating fatigue, and the potential for both the professionals themselves and their families acquiring COVID-19 took a toll on perinatal care professionals, resulting in posttraumatic stress, moral injury, and burnout. 24 These challenges confront an already-overtaxed mental health care system. For example, there are national shortages in mental health clinicians for individuals with perinatal mood and anxiety disorders, and even fewer clinicians accept Medicaid reimbursement. 26 , 27 Before this study, our federal and state policymakers, researchers, and patient and clinician partners identified the need to improve the capacity of perinatal care professionals to address perinatal mood and anxiety disorders. Our community partners identified securing access to quality mental health care for perinatal individuals who are Medicaid-insured as a policy priority. 28 The COVID-19 pandemic, however, exacerbated these well-documented challenges in meeting the needs of Medicaid-insured individuals with perinatal mood and anxiety disorders. This enhancement award sought to respond to this evidence gap by investigating (1) how system-level interventions responded to the pandemic, (2) the barriers and facilitators that emerged in accessing quality care for perinatal mood and anxiety disorders amid the COVID-19 pandemic, and (3) promising strategies for system-level interventions to respond. Facilitators and Barriers to Perinatal Mental Health Care Perinatal care professionals and the individuals they serve find that screening for perinatal mood and anxiety disorders is futile when it occurs without a system in place to help them respond to a positive screen. 29-31 Building the capacity of perinatal care professionals to respond appropriately to positive screens and provide evidence-based perinatal mental health care themselves could provide a solution. Despite serving perinatal individuals, perinatal care professionals are often not trained in or comfortable providing mental health care. Obstetric clinicians, for example, report that they want training to address the limited knowledge and skills they have in how to screen, assess, treat, and refer individuals with perinatal mood and anxiety disorders. 32 Although training is critical, training alone does not increase access, especially for perinatal individuals insured by Medicaid. 32 , 33 Perinatal individuals who live below or close to the poverty line, including those insured through Medicaid, experience a myriad of barriers that include lack of access to financial resources, limited insurance coverage, lack of transportation, English as a second language, and geographic barriers. 26 , 27 Finally, there are simply not enough mental health professionals to treat the perinatal individuals who need one; thus, it is critical to provide support and resources to help perinatal care professionals adequately screen, assess, refer, treat, and monitor until symptom remission (when appropriate). 34 There is an urgent need for perinatal care professionals to be trained and supported in ensuring their own mental health care needs are met. In particular, it is important to address the additional barriers experienced by perinatal individuals who are insured through Medicaid. 28 Perinatal Psychiatry Access Programs In response, the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms was established in 2011 to build the capacity of obstetric clinicians to deliver mental health care for perinatal individuals. A multicomponent implementation strategy, MCPAP for Moms supports clinicians in enhancing the delivery of evidence-based mental health care through telephone consultations between perinatal psychiatrists and obstetric clinicians who have clinical questions. 35-37 In addition to telephone consultations, MCPAP for Moms clinicians provide (1) 1-time face-to-face consultation to support the obstetric clinician in providing a diagnostic assessment and treatment recommendations (consultation), (2) training of perinatal care professionals (training), and (3) provision of resources and referral to the perinatal care professional or the perinatal individual directly (resource and referral). The model allows every obstetric clinician in the state to access these services free of charge. Although preliminary studies demonstrate relatively widespread reach across state systems, 35 the objective of the main award of this enhancement, “Comparative Effectiveness of Perinatal Psychiatric Access Program Treatment Engagement,” aims to further elucidate the extent of programmatic reach across 2 statewide access programs in the states of Washington and Massachusetts. Early evidence of the effectiveness of MCPAP for Moms has led to federal legislation 38 , 39 and funding for other states to launch similar programs. 35 , 40-42 In total, 21 states and 1 national-level program have launched perinatal psychiatry access programs based on the original Massachusetts model. 41 , 42 (For an up-to-date list of available access programs, please visit https://www.umassmed.edu/lifeline4moms/Access-Programs.) Responding to local context, priorities, and resources available, the access program model has been adapted in various ways across the nation's programs. Each program includes a mix of the 3 main components (consultations, training, and resource and referral), and several also include a fourth component called technical assistance, which provides screening workflow implementation support directly to local clinical practices. Access programs differ in the eligibility criteria employed for accessing the provided services. For example, some access programs make services available to nonprescribing perinatal professionals (eg, doulas), and others limit eligibility to licensed perinatal professionals with independent prescribing privileges. To coordinate efforts of these programs nationally, the National Network of Perinatal Psychiatry Access Programs (funded by Perigee Fund; principal investigator, N.B.) 43 provides support, coordinates activities, and conducts collaborative research. Collectively, these access programs are available to provide consultation to tens of thousands of perinatal care professionals, covering approximately 1.9 million of the 3.6 million births across the country. 44 They offer a practical and sustainable platform for overcoming the barriers perinatal individuals experience when accessing mental health care during global crises, such as the COVID-19 pandemic. 36 , 45 Access programs have adapted their program components in response to COVID-19 and calls for health equity, which states that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential. 46 , 47 Little was known about these innovations, however, and the relative merits had not been identified before the present study. Identified as a priority area for investigation by members of the National Network of Perinatal Psychiatry Access Programs (hereafter, the National Network of Access Programs), the present study sought to identify how these programs (1) adapted in response to the COVID-19 pandemic and (2) monitored and addressed inequities in perinatal mental health care access and quality. During the National Network of Access Programs meetings, leaders from across the nation's access programs emphasized the need to identify promising strategies that can facilitate responses to both the COVID-19 pandemic and the well-documented and persistent inequities in perinatal mental health care. Study Aims The enhancement award aimed to identify (1) the strategies access programs employed in response to COVID-19 and calls for health equity (aim 1); (2) the factors (including both barriers and facilitators) that influence receipt of perinatal mental health care amid the COVID-19 pandemic, as reported by individuals with lived experience, perinatal care professionals, and access program team members (aim 2); and (3) the relative merits of these strategies, as assessed by an array of key community partners (aim 3). To provide an in-depth understanding across the varied constituencies, we triangulated concepts across respondents and methods to acquire an in-depth understanding of the barriers impeding access to quality perinatal mental health care as well as the opportunities and promise for access programs to mitigate these impacts. In aim 1, we employed surveys to characterize strategies implemented by access program team members across the nation. In aim 2, we employed qualitative methods to build a taxonomy of the potential barriers to care experienced by individuals with perinatal mood and anxiety disorders, their clinicians, and access program team members amid the COVID-19 pandemic. In aim 3, we used the 5 advisory boards assembled for the Evaluating Lifeline for Moms (ELM) Main Research Award (PCORI IHS2019C2-17367-IC) to conduct a modified Delphi panel, engaging the RAND appropriateness criteria methods (modified Delphi panel) to evaluate the importance and effectiveness of the strategies identified to improve equitable perinatal mental health care access. 48 Participation of Patients and other Stakeholders Drawing upon the infrastructure for stakeholder engagement in the ELM Main Research Award, we engaged the expertise and insights of key community partners as co-investigators and advisory board members. First, Wendy David, PhD, executive director, and Carrie Banks, chapters, coordinators, and peer mentoring programs manager at Postpartum Support International (PSI), participated as co-investigators on this COVID-19 Enhancement Award, collaborating throughout on the preparation, implementation, and dissemination of the study findings by providing their own input and convening the PSI Best Practice Committee for Health Equity. We also engaged 4 additional advisory boards assembled for the ELM Main Research Award: 1 national advisory board and 3 state-level advisory boards (Massachusetts, New Jersey, and Washington). Our research was conducted in partnership with PSI, an advocacy and service organization that aims to promote awareness, prevention, and treatment of mental health issues related to childbearing in every country worldwide. This project engaged PSI leadership to inform all aspects of the research design and community engagement efforts. First, PSI reviewed all study protocols and instruments before our research team sharing these materials for advisory board review. PSI also played a central role in developing, implementing, and improving our approach to engagement. PSI recruited, convened, and facilitated the 12-member PSI Best Practice Committee for Health Equity, composed of perinatal care professionals including obstetric clinicians, midwives, doulas, peer support workers, social workers, and psychiatrists. The PSI Best Practice Committee for Health Equity met 6 times in each year to inform various aspects of the (1) study research questions, (2) sampling framework and recruitment procedures, (3) selected measures, and (4) interpretation of the study findings. Although PSI is an international organization, the individuals engaged in this study are all based in the United States. We also routinely convened 4 additional advisory boards to inform our preparation, implementation, and dissemination of study findings. First, the national advisory board comprises 13 representatives from national advocacy and service organizations, professional societies, and the research community. The national advisory board provided key insights into this study's preparation, implementation, and dissemination. In addition to the national advisory board, we convened 3 state-specific advisory boards in Massachusetts, Washington, and New Jersey. The Massachusetts advisory board included 7 representatives, the New Jersey Board included 13, and Washington included 10. Although the specific composition of each board varied by state, the state advisory boards comprised at least 1 representative from each of the following community affiliations: (1) individual with lived experience of perinatal depression; (2) perinatal care professional; (3) relevant community-based programs; (4) health plans; and (5) a relevant state policymaker, whether from the department of health and human services, mental health services, Maternal and child health services, or Medicaid. The state advisory boards met quarterly and informed the development of the (1) research question proposed, (2) sampling framework and recruitment procedures, (3) input on measures, and (4) discussion on the implications of these findings for their respective state systems. Advisory board members were engaged in meetings assembled to inform critical study activities. For example, advisory boards informed the COVID-19 enhancement award's research questions and various aspects of study preparation and implementation, including (1) design and protocols, (2) all 3 interview guide domains, (3) preliminary findings, (4) the protocol for the modified Delphi panel, and (5) dissemination strategy. The advisory board members would be asked to review a prerecorded video and information sheet, approximately 1 hour in length, before the scheduled meeting. The advisory board members would then participate in an hour-long meeting to provide input and feedback on the materials reviewed in advance. Meetings were recorded, and the research team would take careful notes documenting each suggestion made during the meeting. All suggestions were compiled into a single form, referred to as the Feedback Matrix. This form summarized the content area of the feedback received, the specific details of the advisory board members' recommendations, the response and actions taken by the research team, and the impact on the study. The Feedback Matrix would be completed after each meeting, and then be shared with the advisory board with any other preparatory materials before the next meeting. Advisory board members would have an opportunity to provide any concerns or suggestions regarding the summaries offered on the Feedback Matrix. The research team engaged this approach to ensure transparency and accountability throughout the study. Aim 1: Identification of Access Program Adaptations Methods Overview Access programs aim to improve the capacity of perinatal care professionals in meeting the mental health care needs of individuals with perinatal mood and anxiety disorders. 35 , 36 Our team aimed to identify the ways in which the nation's access programs had developed new strategies to respond to the COVID-19 pandemic and calls to advance health equity. In aim 1, we conducted a survey to collect information systematically about the strategies that access program team members engaged in response to the COVID-19 pandemic and calls to advance health equity. Study Design To characterize the extent of adaptations employed by the access programs, an initial survey was sent to 1 key informant from each of the nation's 15 access programs. Our team engaged a survey to identify variation in the strategies employed amid the COVID-19 pandemic and opportunities to identify promising strategies. The IRB at Rutgers University reviewed and approved the aim 1 research protocol and study instruments. Setting Access program team members completed the online Research Electronic Data Capture (REDCap) survey in March and April 2021. When our research initiated this study, 15 access programs were in existence across the United States. We successfully recruited at least 1 key informant from each of the nation's 15 access programs, resulting in a 100% response rate. As of July 2022, there are now 19 state-level access programs and 1 national-level access program. Participants and Sampling Framework Our team engaged a key informant sampling framework, in which respondents were selected for their knowledge on the subject of inquiry. 49 Respondents were leadership from each of the 15 access programs, selected because of their comprehensive and in-depth knowledge of their respective access program. 49 Sample Size One key informant from each of the nation's 15 access programs participated. Respondents could indicate whether they were not confident answering any section of the survey. If they were not confident in the answers to a particular section, the respondent could indicate a colleague who was better positioned to answer the questions. No respondents indicated the need for a colleague to respond to a section of the survey for the findings reported in this report. Evaluation Measures The development of the survey measures presented here was informed by structured conversations that took place during a peer learning initiative sponsored by the National Network of Access Programs in June 2020. Our team conducted 6 structured conversations with access program team members who participated in the annual meeting of the network. The structured conversations were facilitated by members of our team at University of Massachusetts Chan Medical School and Downstate Health Sciences University. These conversations were structured by questions on (1) the access program model and (2) adaptations made by access programs in response to the COVID-19 pandemic. Notes were taken and themes summarized. The interdisciplinary research team further consulted the extant literature and access program experts to develop an in-depth survey tool. The survey aimed to (1) characterize the access program model and its rollout and funding, (2) characterize the access program response to the COVID-19 pandemic, and (3) identify initiatives implemented to advance health equity in perinatal mental health care. The resulting survey tool included approximately 300 items that queried on multiple domains of interest—for example, (1) the access program model itself, including funding sources and the implementation timeline; (2) the various program components (consultation, resource and referral, and training); (3) strategies and adaptations made in response to the COVID-19 pandemic; (4) initiatives implemented to advance health equity; and (5) the sociodemographic characteristics of each respondent. Questions specific to strategies engaged by access programs in response to COVID-19 and health inequities are provided in the aim 1 “ Results ” section. Relevant sections of the survey tool can be found in Appendix A . Data Collection Methods The leadership of the National Network of Access Programs collaborated with the research team to recruit key informants from across the nation's access programs. The network sent an initial invitation for program leadership to opt in to learning more about the study. Access program leadership identified an appropriate key informant given the topics of the survey. The identified key informants received an invitation to complete the survey through REDCap, 50 a secure, electronic data capture tool. Participating program key informants received and signed an informed-consent form and were offered a $40 gift card for remuneration. Survey recruitment resulted in a key informant completing the survey from each of the 15 access programs (100% response rate). Data Analysis We conducted descriptive statistics using Stata statistical software (StataCorp) 51 to characterize the sociodemographic characteristics and strategies implemented across the nation's access programs. Changes to the Original Study Protocol No changes were made to the submitted COVID-19 enhancement award study protocol. Results Sample Characteristics As detailed in Table 1 , 15 key informants from access programs across the United States participated in the survey. Table 1 Characteristics of the PCORI ELM Enhancement Award Aim 1 Survey Participants. Strategies to Adapt to and Mitigate the Impact of the COVID-19 Pandemic As detailed in Table 2 , access program team members reported both adapting and strengthening programmatic services in response to the COVID-19 pandemic. Team members from all 15 of the access programs (100%) reported their respective program implementing at least 1 strategy to address the COVID-19 pandemic. One respondent indicated that their respective program did not adapt an existing strategy because the program itself launched amid the pandemic. Instead, this program incorporated the strategies listed here into the initial design and implementation of the access program. The denominator for these estimates of strategies responding to the COVID-19 pandemic are adjusted to include only those access programs that offer the relevant program component. Table 2 National Survey Findings of Perinatal Psychiatry Access Program Initiatives Amid the COVID-19 Pandemic as Reported by Access Program Team Members. Access program team members reported implementing, on average, 4.5 (range, 1-10) strategies in response to the COVID-19 pandemic. Team members most frequently reported training perinatal care professionals on aspects of the COVID-19 pandemic generally (9 of 12 access programs that provide trainings [75.0%]) and on the provision of trauma-informed care (7 of 12 access programs that provide training [58.3%]). Strategies implemented in response to calls for health equity As detailed in Table 3 , access program team members reported implementing strategies to promote health equity amid the COVID-19 pandemic. Respondents reported that 13 of the 15 (86.7%) access programs implemented at least 1 strategy to promote health equity. The access program implemented, on average, 3.5 strategies (range, 0-10) to advance health equity. Our findings suggest that programs implemented (1) strategies to build internal program and perinatal care professional capacity, and (2) adaptations to core program elements. Additional analyses and detailed descriptions of the specific response to calls for perinatal mental health care equity that state programs made and their distribution across the United States have been published by the research team elsewhere. 45 Please see Appendix B for the full publication. Table 3 National Survey of Findings of Perinatal Psychiatry Access Program Initiatives to Promote Health Equity Amid the COVID-19 Pandemic as Reported by Access Program Team Members. Discussion Initially designed to improve access to perinatal mental health care for all populations, 36 our findings suggest, the access program model holds the potential to evolve as a platform for additional strategies to address the barriers to perinatal mental health care that emerged amid the pandemic. 52 This survey provides a first step toward understanding how access programs are expanding their work in response to the COVID-19 pandemic and calls to advance health equity. The survey also identifies opportunities for future research to investigate the comparative effectiveness of these innovations. The present study was not without its limitations. First, the survey tool used was piloted and received extensive interdisciplinary review. The individuals who completed the survey may have interpreted questions differently, however. Therefore, variability may exist in what respondents thought “counted” as a strategy implemented in response to the COVID-19 pandemic or calls for health equity. In addition, the current study sought to identify the strategies implemented by access programs amid an unprecedented circumstance but does not investigate whether these adaptations were effective or useful. Additional analyses are warranted to investigate the impact of the strategies reported on specific outcomes of interest (eg, perinatal mental health care access). Nonetheless, this study presents the preliminary work necessary to facilitate such future studies on effectiveness. Finally, we designed the survey in collaboration with a subset of advisors from the National Network of Access Programs. These advisors did, in some cases, participate in the survey as representatives for their access programs. The sample of survey respondents comprised leaders from across the nation's access programs. The lack of diversity among the sample surveyed demonstrates opportunities for creating pathways for minoritized individuals to be in leadership positions across the nation's access programs. The list of potential adaptations generated by this advisory group may not be representative of all the initiatives being implemented by access programs nationally. Our use of a structured survey and “check all that apply” value set allowed for broad characterization of access program innovations nationally, however. The survey itself did not include an open-text response for additional strategies that had not been identified by the Advisory Board; however, during the semistructured interviews conducted in aim 2 we were able to identify any additional strategies that access programs used in response to the COVID-19 pandemic. Future research in this area would benefit from additional qualitative inquiries to understand in greater depth the strategies reported in the present study. Future research on the barriers to and facilitators of implementing change to advance health equity is a critical line of inquiry needed to advance the scalability and tailoring of these strategies to diverse contexts. Aim 2: Factors that Influence Access to Perinatal Mental Health Care AMID The Covid-19 Pandemic Methods Study Design In aim 2, we employed semistructured qualitative interviews to identify perceptions of (1) factors increasing the perceived risk for perinatal mood and anxiety symptoms amid the COVID-19 pandemic and (2) factors influencing access to perinatal mental health care amid the COVID-19 pandemic. Sample Aim 2 was conducted with a national sample, drawn from across the United States, of (1) individuals with lived experience of perinatal mental health concerns amid COVID-19, (2) perinatal care professionals, and (3) access program team members. Participants and Recruitment Study participants and sampling framework are provided below for each aim 2 sample. Two CONSORT diagrams ( Figures 1 and 2 ) for recruitment of perinatal individuals and perinatal care professionals, composed of obstetric clinicians and doulas, are included in each of the respective sections below. Access program team members included key informants from the survey participants in aim 1. Figure 1 Individuals With Lived Experience of Perinatal Mood and Anxiety Disorder CONSORT Diagram. Figure 2 Perinatal Care Professional CONSORT Diagram. Individuals with lived experience To facilitate a national sample of individuals with lived experience, we engaged our partners at PSI. PSI distributed recruitment materials via its social media outlets on Facebook, Instagram, and Twitter. The flyer included general information about the study and a link to a REDCap eligibility screening survey. Individuals were eligible if they (1) were 18 years of age or older; (2) could read, understand, and speak English or Spanish; (3) had access to a telephone to complete the interview; (4) had access to the internet to complete enrollment; (5) had received prenatal care since March 15, 2020, or delivered a baby since May 15, 2020; (6) reported having sought access to mental health care since March 15, 2020; and (7) selected at least 1 indicator of low-income status (eg, health insurance status, food insecurity, housing insecurity, participation in the Special Supplemental Nutrition Program for Women, Infants, and Children or Head Start). Individuals were not required to have received services from an access program or live in a state with an access program. If individuals were eligible, they were able to enter their contact information and consent to being contacted by study staff. Study staff then contacted individuals with lived experience to receive consent, screen for study eligibility, collect demographic information, and schedule the semistructured interview. See Figure 1 for the Individuals with Lived Experience CONSORT diagram. Perinatal care professionals To facilitate a national sample of perinatal professionals, social media posts, including information about the study and a link to the eligibility survey, were distributed through PSI and the American College of Obstetrics and Gynecology. Perinatal professionals engaged included 2 distinct samples: (1) obstetric clinicians and (2) doulas. Our study initially was going to interview only obstetric clinicians who are licensed perinatal care professionals (eg, obstetricians, physician assistants, NPs, and midwives). Following feedback from our advisory boards, we expanded the sample to include doulas. Perinatal care professionals were eligible if they (1) were 18 years of age or older; (2) could read, understand, and speak English; (3) had access to a telephone to complete the interview; (4) had access to the internet to complete enrollment; and (5) had provided perinatal care since March 15, 2020. If eligible, perinatal care professionals were able to enter their contact information and consent to be contacted by study staff. See Figure 2 for the perinatal care professional CONSORT diagram. Access program team members To recruit access program team members, our team first contacted the program leadership and expanded the sample of survey respondents to additional key informants where complementary understandings were necessary given the additional topics covered in the interview guide. All respondents were selected because of their comprehensive and in-depth knowledge of their respective access program. 49 Each of the 15 access programs had between 1 and 5 individuals participate in the semistructured interview (100% response rate). Because the states of Massachusetts and Washington are part of our main study, we were able to use additional interviews conducted with individuals in these states for the main award. We do not include a CONSORT diagram for the access program team members because all of the respondents that were recruited participated in the study. See Figure 3 , which provides a map of which access programs participated in the study. Figure 3 Map of States With Perinatal Psychiatry Access Programs That Participated in Study. Sample Size Interviews were conducted with 24 individuals with lived experience, 24 perinatal care professionals (including obstetric clinicians and doulas), and 28 access program team members. Consistent with standards in qualitative research, interviews were conducted until thematic saturation was reached for each of the 3 samples. 53 , 54 Recruitment ceased once theoretical saturation was reached in articulation of facilitators and barriers experienced. The respondents' quotes drawn in Tables 5 through 12 later in this report were chosen as representative and illustrate saturated themes. Prior methodological studies suggest the number of interviews required to achieve saturation will vary depending upon complexity of the topic and data collected; qualitative researchers have previously suggested a minimum of 12 interviews to achieve thematic saturation. 55 Evaluation Measures Given the unique role of each key community member, separate semistructured interview guides were developed for (1) individuals with lived experience; (2) perinatal care professionals, including (2a) obstetric clinicians, and (2b) doulas; and (3) access program team members. At the recommendation of our advisory boards, separate interview guides were developed and fielded for obstetric clinicians and doulas given the differences in services provided. Each interview guide explored a common set of domains on (1) the impact of COVID-19 on the mental health of perinatal individuals, (2) experiences of perinatal mental health care amid the pandemic, and (3) the impact of delivery system transformation amid the pandemic (eg, telehealth, mask mandates). All semistructured interview guides were based on the extant literature 56 and given in consultation with an interdisciplinary team, including individuals with lived experience, perinatal psychiatrists, obstetricians, health services researchers, psychologists, and medical sociologists. After the domains and guides were initially developed, interview guide domains and questions received review from the assembled advisory boards. In addition to the interview guides, we also fielded surveys to ascertain sociodemographic information of the samples. The demographic survey and interview guide are available in Appendices C through F for all samples. Data Collection Methods Two members of the research team conducted semistructured 60-minute telephone or Zoom-based interviews. Interviews with individuals with lived experience were conducted in English or Spanish. Perinatal care professional and access program team member interviews were offered only in English, as we did not feel that a Spanish-speaking sample for professionals and access program team members was necessary—these professionals are most often bilingual. After the interview, respondents from each of the 3 samples were offered a $40 gift card for remuneration. Data Analysis Individuals with lived experience and perinatal care professionals Interviews conducted with individuals with lived experience and perinatal care professionals were analyzed using “coding consensus, co-occurrence, and constant comparison.” 57 First, recordings were sent for verbatim transcriptions and subsequently checked by a trained research team member for accuracy and deidentified. Second, the analysts familiarized themselves with the data, listening to recordings and reading transcripts. Third, an interdisciplinary research team reviewed transcripts employing emergent, data-based, and a priori codes. A priori codes are those that are predetermined 58 and in our analyses included the application of domains aligned with the research questions posed, specifically the perceived (1) impact of COVID-19 on the risk of perinatal depression and anxiety symptoms, (2) factors influencing obstetric care, and (3) factors influencing access to perinatal mental health care. Two or more trained investigators performed line-by-line coding of each transcript using the developed codebook. The codes were then reconciled against each other, arriving at consensus on the codes line by line. The coded data were then entered into Dedoose, 59 a qualitative software program used to organize data. Access program team members Access program team member interviews were analyzed using an a priori and deductive coding structure, referred to as framework analysis. 60 Framework analysis involved 7 steps that facilitate the organization and systematic analyses of qualitative data. First, recordings were sent for verbatim transcriptions and subsequently checked by a trained research team member for accuracy and deidentified. Second, the analysts familiarized themselves with the data, listened to recordings, and read transcripts. Third, an interdisciplinary research team reviewed transcripts employing emergent and a priori codes. Emergent codes were inductively identified arriving from the textual data analyzed through a process of open coding and team review. 58 A priori codes included codes that arrived from the structure of the research questions posed and corresponding interview questions, 58 resulting in codes that were applied systematically to assess (1) the impact of COVID-19 on the risk factors associated with perinatal mental health concerns, (2) factors influential to obstetric care, and (3) factors influential to accessing perinatal mental health care. A priori and emergent codes were assembled into a codebook that delineated each code and an operational definition and illustrative example for each. The final codebook was then reviewed by an interdisciplinary team. Two or more trained investigators performed line-by-line coding of each transcript using the developed codebook. The codes were then reconciled against each other to arrive at consensus for each coded excerpt. Analysts were instructed to consult a senior member of the research team at any time if consensus was not reached. Analysts then used Dedoose, 59 a software program that allows for the organization of qualitative data. In step 4, we developed a matrix to index codes thematically and facilitate a summary of established codes. The matrix was then analyzed to identify the similarities and differences articulated across respondents, lending unique insights into the barriers and facilitators that emerged amid the pandemic and in response to calls to advance health equity. Across all samples, we present findings in tables that summarize the thematic area, the sample for whom the finding arose, and an illustrative quote that exemplifies the thematic finding. Consistent with standards for presentation of qualitative data, 61 we selected quotes that the research team considered to illustrate most comprehensively a given theme to increase the trustworthiness of the analyses presented and to amplify the words and experiences of participants themselves in the presentation of our findings. 62 Changes to the Original Study Protocol When presenting the sampling approach for perinatal care professionals to the advisory boards on this project, our team received feedback that doulas hold an important role in relation to the mental health of individuals throughout the perinatal period. In response to their input, the sample of perinatal care professionals was expanded to include doulas. To respond to the unique role of doulas during the birthing process, the advisory board also recommended the research team develop an interview guide for doulas. The present study included a sample of doulas and administered an interview guide specifically developed to capture the unique experiences of doulas. Results Sample Characteristics Table 4 describes the characteristics of respondents who participated in the semistructured interviews across the 3 samples. Table 4 Characteristics of PCORI ELM Aim 2 Semistructured Interview Participants. Impact of COVID-19 on the Mental Health of Perinatal Individuals Individuals with lived experience, perinatal care professionals, and access program team members reported that the COVID-19 pandemic affected the risk of perinatal depression and anxiety symptoms. Grounded in the social-ecological framework, respondents across all 3 samples reported factors increasing risk of depression and anxiety symptoms at the individual, interpersonal, and organizational levels. (See Table 5 .) In contrast, only individuals with lived experience and doulas reported factors that decreased risk at the interpersonal and sociopolitical levels amid the COVID-19 pandemic. (See Table 6 .) The reported barriers and facilitators are reviewed in the sections that follow. Table 5 Factors Perceived to Increase Risk of Perinatal Depression and Anxiety Symptoms Amid COVID-19, as Reported by Individuals With Lived Experience, Perinatal Care Professionals (Obstetric Clinicians and Doulas), and Access Program Team Members. Table 6 Factors Perceived to Decrease Risk of Perinatal Depression and Anxiety Symptoms Amid COVID-19, as Reported by Individuals with Lived Experience, Perinatal Care Professionals (Obstetric Clinicians and Doulas), and Access Program Team Members. Factors perceived to increase the risk of perinatal depression and anxiety symptoms Factors increasing the perceived risk of perinatal depression and anxiety symptoms amid COVID-19 were reported by all respondents, including individuals with lived experience, obstetric clinicians, doulas, and access program team members as reported in Table 5 . Factors perceived to decrease the risk of perinatal depression and anxiety symptoms As detailed in Table 6 , only individuals with lived experience and doulas identified factors that were perceived to reduce the risk of perinatal depression and anxiety symptoms amid the pandemic. Impact of COVID-19 on Access to Quality Perinatal Mental Health Care Individuals with lived experience, obstetric clinicians, doulas, and access program team members reported factors influential to an individual's access to perinatal mental health care amid the pandemic. As reported by one respondent: I think it [the pandemic] changed access for all parents expecting peanuts. The access is just a lot more difficult now; even with providers scrambling to increase access, it's not keeping up with the demand. Individuals with lived experience Individuals with lived experience reported both barriers and facilitators to their access to quality perinatal mental health care amid COVID-19 across levels of the social-ecological framework. 63 Reported barriers and facilitators were identified at the individual, interpersonal, practice and organizational, and sociopolitical level. Individuals with lived experience reported their perception of efforts to facilitate access to perinatal mental health care amid the pandemic more frequently than any other sample. The barriers and facilitators reported by individuals with lived experience are reviewed in turn below. Barriers to accessing quality perinatal mental health care reported by individuals with lived experience As shown in Table 7 , barriers were reported by individuals with lived experience at the individual, interpersonal, practice and organizational, and sociopolitical levels. Table 7 Barriers in Access to Perinatal Mental Health Care Amid COVID-19 as Reported by Individuals With Lived Experience of Perinatal Mood and Anxiety Disorders. Facilitators to accessing perinatal mental health care reported by individuals with lived experience As shown in Table 8 , facilitators were reported by individuals with lived experience across the social-ecological framework, including at the individual, interpersonal, practice and organizational, and sociopolitical levels. Table 8 Facilitators to Accessing Perinatal Mental Health Care Amid COVID-19 as Reported by Individuals With Lived Experience of Perinatal Mood and Anxiety Disorders. Perinatal Care Professionals Perinatal care professionals reported both barriers and facilitators to an individual's access to perinatal mental health care amid COVID-19 across the social-ecological framework. Reported barriers and facilitators were identified at the interpersonal, practice and organizational, and sociopolitical level. Reported facilitators were identified at the practice/organizational and sociopolitical level. The sample of perinatal care professionals included (1) obstetric clinicians such as obstetricians, physician assistants, NPs, and midwives; and (2) doulas. Given the distinct role of these perinatal care professionals, the barriers and facilitators to perinatal mental health care access are differentiated by respondent group. Barriers to an individual's access to perinatal mental health care reported by perinatal care professionals As shown in Table 9 , perinatal care professionals reported interpersonal-level barriers, practice-level and organizational-level barriers, and sociopolitical-level barriers. Table 9 Barriers to Individuals' Accessing Quality Perinatal Mental Health Care Amid COVID-19 as Reported by Perinatal Care Professionals. Facilitators to an individual's access to perinatal mental health care reported by perinatal care professionals As shown in Table 10 , perinatal care professionals reported practice/organizational- and sociopolitical-level facilitators. Table 10 Facilitators to Accessing Perinatal Mental Health Care Amid COVID-19, as Reported by Perinatal Care Professionals. Access program team members Access program team members reported both barriers and facilitators to an individual's access to quality perinatal mental health care amid COVID-19 across the social-ecological framework. Barriers to accessing perinatal mental health care reported by access program team members As described in Table 11 , access program team members reported individual, interpersonal, and practice and organizational barriers to perinatal mental health care access amid the COVID-19 pandemic. Table 11 Barriers to Accessing Perinatal Mental Health Care Amid COVID-19 as Reported by Access Program Team Members. Facilitators to accessing perinatal mental health care reported by access program team members As shown in Table 12 , access program team members reported individual and practice/organizational facilitators. Table 12 Facilitators to Accessing Perinatal Mental Health Care Amid COVID-19 as Reported by Access Program Team Members. Discussion In aim 2, our study team sought to create a taxonomy of factors that influence perinatal individuals' access to perinatal mental health care amid COVID-19. We conducted a series of one-time semistructured interviews with key informants from 3 sample groups: (1) individuals with lived experience, (2) perinatal care professionals (obstetric clinicians and doulas), and (3) access program team members. From these interviews, we intended to expand existing knowledge of facilitators and barriers to perinatal mental health care, particularly for individuals from communities that are marginalized by health care systems. Our findings suggested that facilitators and barriers existed at multiple levels of the social-ecological framework, with facilitators and barriers reported at the individual, interpersonal, organizational, and sociopolitical levels. Although there were differences in reported facilitators and barriers across respondent groups, all 3 reported a perceived increase in perinatal mood and anxiety symptoms during COVID-19. This confirms much of what is reported in the literature — that COVID-19 negatively affected the mental health of perinatal individuals. 2 All 3 groups also noted a general increase in awareness and acknowledgment of mental health symptoms during COVID-19, with some respondents pointing to general media discussions of the issue and others noting that there was general recognition that the pandemic negatively affected mental health, and therefore also perinatal mental health. Although it was less frequently reported by individuals, perinatal care professionals and access program team members noted an increase in intimate partner violence and the difficulty in addressing this concern amid COVID-19, particularly in light of telehealth visits occurring in the home and with a potential partner present. Perinatal care professionals and access program team members noted that patients were asked to complete tasks previously required of the perinatal professional (eg, blood pressure monitoring). At the same time, some individuals with lived experience reported that perinatal professionals provided little attention to them amid COVID-19. Individuals expressed a general sense of dismay that their perinatal care professionals were often focused on completing perinatal visits in an expedited manner. Individuals expressed scant concern for perinatal mental health concerns and even less follow-up of concerns than before the pandemic. Individuals reported multiple barriers that reflected multiple ways in which systems of oppression hindered access to quality mental health care. More specifically, individuals with lived experience reported having encountered racism and discrimination based on their health insurance, non–native English speaker status, and financial situation. These reports amplify the many forms of oppression that exist for perinatal individuals accessing perinatal mental health care in normal times. Aim 2 of our study has limitations. For example, our findings represent conclusions that can be drawn from the national sample of perinatal individuals with low income, the perinatal care professionals (including obstetric clinicians and doulas) who serve these individuals, and access program team members in the United States. Our findings therefore should not be extrapolated to understandings of perceived barriers among populations who are from middle- or high-income standing or to contexts outside of the United States. Our samples also do not represent the diversity of the communities who require perinatal mental health care access nor the professionals who serve them. To advance health equity, additional research is needed to ensure the experiences of minoritized perinatal individuals and professionals are also understood. Although outside of scope for the present study, questions about the applicability of our findings to these populations present an opportunity for further research. At the same time, we recognize that limitations persist in the generalizability of findings among the heterogeneous composition of the experiences of low-income individuals and the perinatal care professionals who serve low-income individuals across the United States. We hope our qualitative findings provide new insights into the experience of perinatal individuals and perinatal care professionals in this under-studied area. Future research would benefit from the development of a survey that would be better positioned to assess the generalizability of the qualitative findings presented in the present study. In addition, other models to explain mental health services utilization could be applied to our data. For example, the Andersen-Aday model for the study of access to health care highlights factors that are (1) predisposing (eg, education, gender/sex, marital status), (2) enabling (eg, income/financial status, insurance), and (3) need (eg, health status, perceived health). Although our analyses grounded in the data led us to use a different framework, future research might investigate ways to operationalize influential factors relevant to other frameworks commonly employed in health services research. 64 Aim 3: Prioritization of Access Program Strategies in Response to Covid-19 and Health Inequities Methods Overview Delphi panels, broadly defined as a convening of experts to review a question or consider a problem, 65 are used frequently in health services research to provide expert insights on relevant health care issues. 66 , 67 In aim 3, we convened our 3 state advisory boards and 1 national advisory board to conduct a modified Delphi panel to evaluate the importance and ability to advance health equity of access program–reported adaptations implemented to promote health equity. 48 We conducted a 2-round modified electronic Delphi process to identify and attain consensus on a comprehensive and conceptually distinct list of access programs' adaptations and to elicit prioritization according to importance and ability to advance health equity. 65 We used multiple approaches to generate the list of strategies implemented by access programs to advance health equity. The list of strategies and adaptations was developed using the following approach: Conduct semistructured interviews with access program team members. As outlined in aim 2, our team fielded semistructured interviews with access program team members (n = 33) from across 15 of the nation's access programs. We conducted semistructured interviews to acquire in-depth information on the strategies implemented by access programs to advance health equity. The specific individuals with whom we spoke at each access program were selected because of their knowledge about their respective program's strategies to advance health equity and were not selected at random. PCORI ELM research team members interviewed the access program team members between May 2021 and January 2022. Review the literature. Our team conducted a literature review to identify and summarize strategies used in population-level initiatives and institutions (eg, academic medical centers) to address racism and other systems of oppression. Acquire expert review of identified strategies. The list of strategies was reviewed by an array of relevant experts, including individuals with lived experience, perinatal and mental health professionals, health systems administrators, advocates, access program team members, and other researchers. Respondents provided input to clarify the operational definition of each strategy and policy implementation strategies used. Our approach yielded multiple strategies to advance health equity through the access program platform, including (1) building the internal capacity of the access program itself, and (2) developing new initiatives for the HCPs and patients served. Based on the research methods and tools outlined above, we included specific strategies engaged to build the internal organizational capacity, including (1) hiring and training staff, and (2) quality improvement and evaluation as well as various strategies added to existing programmatic components. See Table 13 for the complete list of strategies. The additional information provided to participants to prepare for the modified Delphi panel is available in Appendix G . Table 13 Strategies to Promote Perinatal Mental Health Equity. Study Design The modified Delphi panel was conducted to evaluate strategies identified to advance health equity. Engaging our 4 advisory boards, our team had each advisory board assess the potential strategies access programs could implement to advance health equity. Strategies were assessed by members of the advisory boards based on 2 criteria: (1) their importance and (2) their ability to advance perinatal mental health care equity. Study Procedures and Evaluation Measures Each advisory board met independently for a 60-minute virtual meeting in March 2022. The research team asked each board to review and discuss strategies reported by access programs across the nation to advance and promote perinatal mental health care equity in aim 1 of the PCORI ELM study. The list of strategies was developed in response to a particular policy window and political movement, including COVID-19 and the racial reckoning. We surveyed the access programs (aims 1 and 2), and then provided a summary to identify the most promising strategies across the country. All board members were provided with the list of strategies before the meeting and were asked to consider 4 questions during this first meeting: (1) What role do access programs have in promoting perinatal mental health equity? (2) Are the strategies described clear? If not, where would additional clarification be helpful? (3) Do the categories used to organize these data make sense to you? If not, why not? And (4) What, if any, additional services could access programs offer to advance health equity? The feedback during this first meeting was then used to develop the domains and the questions for the modified Delphi panel tool described below. Additional strategies proposed in these meetings, but not reported by access programs in the aim 1 survey, were also added to the list of potential strategies. A list of strategies is available in Appendix H . The second virtual 60-minute convening of each advisory board occurred in May 2022. Before this meeting, all participants were provided with a detailed overview of the survey that would be completed during the meeting. Participants convened and completed the anonymous survey during the first 20 minutes of this second session. Advisory board members were asked to rate strategies in each domain based on 2 factors: (1) importance and (2) ability to advance perinatal mental health care equity . A strategy is considered “important” when implementation should be prioritized even when resources are limited. A strategy demonstrates the “ability to advance perinatal mental health care equity” if it meaningfully addresses a difference in perinatal mental health care access or quality because of structural racism or other forms of oppression. For each of these scales, respondents scored the characteristics of the respective strategy by scoring the extent to which each characteristic of the scale is represented, ranging from “not at all” (which equated to a 1) to “present, but not critical” (which equated to a 4) to “critically important” (which equated to a 9). The group then engaged in a facilitated discussion about the domains and proposed strategies in terms of importance to promote health equity and ability to advance health equity. Each participant was provided with a second link to the same survey approximately 3 to 5 days after the final May meeting. The modified Delphi panel advisory board meetings were facilitated by the same facilitator and notetakers to ensure consistency across all 4 advisory boards. A diagram of the modified Delphi panel process is illustrated in Figure 4 . Figure 4 Diagram of the Modified Delphi Panel Process. Participants and Sampling For the modified Delphi panel, members and other key informants of our 4 advisory boards (Massachusetts, New Jersey, Washington state, and national) convened virtually in 2 meetings in March 2022 and May 2022. We purposefully sampled from the state and national advisory boards on this study to acquire perspectives specific to the context of each state system (New Jersey, Massachusetts, Washington) while obtaining the national perspectives necessary in consideration of potential scale-up. Although Delphi panels often vary in number of expert participants, review of the literature suggests that Delphi panels that consist of 20 or more respondents yield stable consensus results. 66 , 68 For aim 3, our sample of 38 respondents is consistent with standards of Delphi panels, facilitating breadth in respondent orientation. Our participants are all considered “experts” in the area of perinatal mental health care and represent a myriad of views and opinions on how to best promote and advance health equity in perinatal mental health care. Data Collection Data collection occurred during the second convening of the 4 advisory board meetings in May 2022. Every participant in each of the 4 modified Delphi panels received a secure link to complete the survey via Qualtrics, a secure data collection tool. In round 1 of the modified Delphi panel, respondents completed the survey in the first part of the facilitated discussion convening in May 2022. After completion of this round 1 survey, participants convened and discussed their results with a facilitator guiding the questions for consideration. Approximately 3 to 5 days after this convening, each respondent received a secure invitation via email to complete the survey for a second time, where they would rate all strategies on a scale of 1 to 9. The round 2 survey included the exact same questions and same choices for strategies to rate in terms of importance and ability to advance perinatal mental health equity. Participants were allowed up to 2 weeks to complete this final survey round of the modified Delphi panel. More than 90% of participants completed both the first and second surveys. Data Analysis To analyze the results of our 4 modified Delphi panels, we employed descriptive characteristics to understand the factors leading to consensus around the strategies to promote health equity. 69 For each item on the survey, we reviewed (1) mean importance and mean ability to advance health equity for each domain, (2) SD associated with each mean for each domain (a smaller SD would indicate a higher degree of consensus), (3) overall ranking based on mean, and (4) ranking within the domain based on mean, median, and range. We collected and reviewed the results of the survey from both round 1 and round 2 of each advisory board's questionnaire. This analysis allowed us to understand consensus on priority strategies with respect to their importance for health equity and their ability to advance health equity. It also allowed our research team to understand the differences in consensus between these 2 factors and to consider what parallels, if any, were apparent in expert responses. Changes to the Original Study Protocol The original study protocol aimed to focus on adaptations to address COVID-19. During the semistructured interviews, however, we found that the major adaptations that have been accommodated during the COVID-19 pandemic were focused on addressing perinatal mental health equity. Therefore, we shifted the modified Delphi panel to include approaches taken to promote perinatal mental health equity amid the COVID-19 pandemic. In addition, we have opted not to present the findings of the inter-percentile range because of the ceiling effect that we had as advisory boards rated the strategies. Results Sample Characteristics Thirty-eight members of the 3 state and 1 national advisory boards participated in 4 separate modified Delphi panels for the study. Complete demographics for each advisory board are included in Table 14 . Many members of our advisory boards, however, span multiple roles and identities. For example, some identify as both a perinatal care professional and someone with lived experience. Many are also part of more than 1 community listed in our survey ( Table 14 ). Table 14 Characteristics of PCORI ELM Aim 3 Modified Delphi Panel Participants. Strategies to Advance Perinatal Mental Health Equity The results reported here represent the consensus strategies from the round 2 responses to the questionnaire. The primary goal of aim 3 was to generate a consensus-driven list of access program strategies prioritized by relevant community members in response to the COVID-19 pandemic. The modified Delphi panels of each advisory board varied in their final top 5 rankings, in terms of both importance and ability to advance perinatal mental health equity. Ranking of strategies to advance perinatal mental health equity Based on the mean score for each strategy, an overall rank was provided to that strategy. Table 15 provides a list of the top 4 ranked strategies for (1) importance; and (2) ability to promote perinatal mental health equity for each advisory board. A complete table of overall rank, within domain rank, mean (SD), median, and range can be found in Appendix H . Table 15 Advisory Boards' Ranking of Strategies to Promote Perinatal Mental Health Equity. Discussion As explored in aim 1 of our study, access programs responded to COVID-19 and the alarming increase in health inequities during the pandemic through several internal and programmatic adaptations. Many of the adaptations and initiatives developed to promote perinatal mental health equity were novel, however, and little evidence exists as to their effectiveness for advancing perinatal mental health equity. To develop consensus on which strategies were important for promotion of perinatal mental health equity and which strategies could advance perinatal mental health equity, we convened our 4 advisory boards in a series of modified Delphi panels. Each advisory board identified different strategies to be most important and able to advance perinatal mental health equity. Rather than achieve consensus, our findings suggest that strategies to advance perinatal mental health care equity will need to be selected and customized based upon community priorities, available resources, and extant initiatives. Our application of the modified Delphi panel has notable limitations. First, experts who reviewed materials and attempted to achieve consensus were doing so on a novel question with a limited evidence base. 70 Second, our Delphi panel process included 2 rounds of rating, which may have limited achieving ultimate consensus on the list strategies. Delphi panels may include 3 or more iterations. 65 The 4 advisory boards varied in the strategies prioritized, and some advisory boards rated several strategies as top choices rather than clearly selecting a smaller number as most critical. Despite these limitations, there are several key strengths to our modified Delphi panel process. The first is the interactive nature of the Delphi panel process itself, 67 which in our case included initial discussions to understand and refine the research question and the list of identified strategies. A second strength of the Delphi panel was the ability to complete the survey anonymously, which may allow participants to freely select their opinion and prevent dominance of one group or one set of opinions on a topic. 70 The use of these modified Delphi panels also allowed our team to quickly evaluate and analyze round 1 results, which then guided our facilitated discussion before the participants completed the round 2 survey. This rapid evaluation and the intragroup discussions allowed our team to achieve results for aim 3 of the study on the required timeline. Finally, the sample of experts that we convened included leaders in several fields, and this diversity of thought across advisory boards allowed our research team to consider a broad array of strategies to advance perinatal mental health equity. Discussion Given the unprecedented nature of the pandemic, our study engaged qualitative methods to build new understandings of how the global pandemic affected access to quality care for perinatal individuals with depression and anxiety disorders. Our study also brings new understandings on how the nation's perinatal psychiatry access programs responded to these challenges amid the pandemic and associated calls to advance health equity. Our findings suggest that the access program model is well positioned to support the perinatal care professional workforce in responding to both the COVID-19 pandemic and related calls to advance health equity. Summary of Results Our study found that key community members, including individuals with lived experience, obstetric clinicians, and doulas, reported that the pandemic exacerbated risk factors for perinatal depression and anxiety symptoms at the individual, interpersonal, and practice and organizational levels. First, respondents reported factors related to the individual's emotional (eg, anxiety because of risk of COVID-19 exposure), cognitive (eg, increased awareness of the Black maternal mortality crisis), and physical state (eg, decline in physical health because of change in diet and lack of exercise) during the pandemic. Second, individuals with lived experience emphasized the pandemic-related interpersonal challenges that increased the risk of perinatal depression and anxiety disorders, including strain on the partner relationship and the loss of social support amid the pandemic. Third, key community members emphasized the practice- and organizational-level barriers that the pandemic worsened, including clinic visitation policies and lack of consistent school-based care. Individuals with lived experience and doulas did identify factors that they perceived to decrease risk of perinatal depression and anxiety symptoms amid the pandemic, including increased partner involvement in child care and financial support from the government. Key community members also reported a multitude of barriers (at the individual, interpersonal, practice and organizational, and sociopolitical levels) for perinatal individuals seeking to access quality mental health care amid the pandemic. Taken together, these findings provide data important to identifying patient- and stakeholder-centered understandings for the well-documented increase in perinatal depression and anxiety disorders amid the pandemic. 2 Our study triangulated these findings by interviewing perinatal care professionals (obstetric clinicians and doulas) and access program team members to understand their respective perceptions of the barriers experienced by perinatal individuals with depression and anxiety disorders amid the pandemic. Obstetric clinicians and doulas identified barriers that focused at the interpersonal, practice and organizational, and sociopolitical levels, and did not locate barriers with the characteristics of the individuals themselves. Our interpretation of this finding is that the perinatal care professionals were inclined to identify the interpersonal and structural barriers that confronted perinatal individuals amid the pandemic rather than locating barriers to care with aspects of the patients themselves. Perinatal care professionals and access program team members identified barriers associated with the radical transformations in health care and the sociocultural landscape that occurred amid the pandemic. Therefore, our use of these multiple samples generated a more comprehensive picture of the multiple barriers to care than any one respondent group might have yielded itself. Our study also sought to characterize and prioritize the strategies implemented by access programs to respond to the double pandemic of COVID-19 and our nation's racial reckoning and related calls to advance health equity. Our study found that the access program model provides a platform that has been used to respond both to the COVID-19 pandemic and calls to advance perinatal mental health equity. Strategies sought to improve the internal capacity of the access program model while also adapting existing and adopting new strategies in the services made available to both perinatal care professionals and the patients served. Key community partners across our national advisory board and 3 state advisory boards (New Jersey, Massachusetts, Washington) participated in a modified Delphi panel to identify promising strategies. Promising strategies were operationally defined as those deemed to be both important and effective in advancing health care equity. Generally, advisory board members assessed the identified strategies to be both important and able to advance health care equity. In reflecting on the activity during our meetings, advisory board members expressed significant difficulty setting priorities among the strategies selected. Board members generally reported finding all of the strategies to be important but expressed uncertainty about their potential value. Therefore, no 2 panels ranked the same 4 strategies in the same order of potential effectiveness or importance, suggesting that the perinatal psychiatry access program model provides a viable platform for advancing perinatal mental health care equity that requires further investigation to establish effectiveness. Subgroup Analyses/Heterogeneity of Treatment Effects In the present study, our research team conducted analyses both qualitatively and quantitatively across relevant subgroups to assess the variations observed. In aim 1, our analyses summarized findings on the variation in strategies implemented by perinatal psychiatry access programs in response to COVID-19 and calls to advance perinatal mental health equity. Our findings suggested that all of the established programs implemented at least 1 new strategy in response to the COVID-19 pandemic. The access programs implemented, on average, 4.5 strategies (range, 1-10) in response to the COVID-19 pandemic. Across the programs, reported strategies ranged from improving the capacity of their own access program to provide trauma-informed care (n = 3 [20%]) to strengthening the capacity and mitigating the moral injury among the perinatal workforce through new offerings like peer-to-peer support sessions for perinatal professionals (n = 2 [13.3%]) to supporting the care of perinatal individuals with mood and anxiety disorders by modifying services provided through consultation, training, and resource and referral (n = 15 [100%]). Respondents reported that 13 of the 15 (86.7%) access programs implemented at least 1 strategy to promote health equity. The access programs implemented, on average, 3.5 strategies (range, 0-10) to advance health equity. In aim 2, qualitative analyses were conducted by sample and subgroup within sample where appropriate. Our analyses investigated factors perceived to increase the risk of perinatal depression and anxiety amid the pandemic. Investigating across individuals, perinatal professionals, and access program team members, our findings suggest that samples converged in identifying factors across multiple levels that affected risk of perinatal depression and anxiety, including on the individual (eg, altering conceptions of motherhood and birthing, increased anxiety because of health risks), their interpersonal relations (eg, the strain in partner relationship, loss of social support), and available services (eg, lack of child care or school-based care, change of visitation policies). Individuals with lived experience uniquely reported the impact of racism and increased anxiety with awareness of Black maternal mortality rates on risk factors for perinatal depression and anxiety. Doulas also reported the decline in exercise and physical health generating increased risk for perinatal depression and anxiety. Taken together, diverse perspectives generated important insights for future studies to consider the role of intrapersonal, interpersonal, and available social and clinical services, as well as the role of structural racism, in influencing risk for perinatal depression and anxiety disorders. Drawing on these understandings of factors that increase risk for perinatal depression and anxiety offer valuable opportunities for additional study and potential intervention to address the perceived risk factors. In aim 2, our study also examined the factors, including both barriers and facilitators, that influence quality perinatal mental health care amid the COVID-19 pandemic as reported by individuals with lived experience, perinatal professionals who serve them (obstetric clinicians and doulas), and the access program team members. Across all samples, we engaged the social-ecological framework to investigate factors that emerged at the individual, interpersonal, practice and organization, and sociopolitical levels during the COVID-19 pandemic. Given the vantage points of these samples, responses of perinatal individuals were most robust in articulation of the (1) individual-level and (2) interpersonal-level factors influencing their ability to access quality mental health care. These factors include (1a) challenges in acknowledging their own mental health concerns, (1b) negative prior mental health care experiences, (1c) lacking resources to access perinatal mental health care, (2a) discrimination and bias in the patient-perinatal professional relationship, (2b) lack of communication in the patient-perinatal professional relationship, and (2c) lack of supportive social networks. Whereas perinatal individuals with lived experience recognized many system-level factors influencing their access to quality care, perinatal professionals and access program team members provided perspective on the transformative impact of the pandemic on health care systems, highlighting, for example, the substantive impact of transitions to telehealth. Perinatal care professionals and access program team members reported more barriers and concerns associated with the transition to telehealth than perinatal individuals. Barriers reported by professionals and team members ranged from the inability to connect with their patients to concerns about being unprepared to assess mental health symptoms as effectively through telehealth as they once did in person. Although individuals also noted some barriers, they overwhelmingly indicated the transition to telehealth as a facilitator that opened up access to care in a myriad of ways. Individuals also noted that telehealth relieved a number of logistical burdens for them, such as finding child care or transportation to attend telehealth appointments. Patients, professionals, and team members reported challenges in finding a private space for telehealth appointments, a notable barrier to accessing perinatal mental health care. Quantitative analyses of modified Delphi panel results were analyzed separately by board to ensure that the unique panel-specific process for consensus-seeking was captured in our final analyses. Analyses attended to investigating subgroups as appropriate given the goals of this research study to build new understanding (and not test hypotheses). Our findings report the top 4 ranked strategies to advance health equity across 3 state advisory boards and a national advisory board. Although all strategies generally ranked high across boards in both their importance and ability to advance health equity, the variation observed in those rated highest suggests that the Washington and national advisory boards found building capacity of the program itself to be both important and effective in advancing health equity. Strategies included ensuring equal pay for comparable positions, building a strategies leadership committee to develop and implement action plans, strengthening community relations, and creating an advisory council to reflect the diversity of patients served. In contrast, the New Jersey advisory board gave higher rankings to strategies that sought to improve the services delivered to perinatal professionals and the patients that they serve, including offering free mental health assessments and ensuring materials reflected the diversity of patient populations served. Finally, the Massachusetts advisory board prioritized among the top 3 a combination of strategies that emphasized (1) the need for capacity building in the access program itself (eg, ensuring people of color are in leadership positions), (2) modification of existing services (eg, ensuring resource and referral materials represent the diversity of individuals served), and (3) evaluation to detect and respond to health inequities (eg, development of new metrics to measure inequities in program utilization). Study Limitations In the “Discussion” section for each aim, we describe the limitations for the respective study aims. In this section, we highlight 1 limitation for each aim of the study. First, our sample of key informants from the nation's access program includes individuals from 15 access programs. Since we completed data collection, 6 additional access programs have emerged. Accordingly, our understanding of strategies only holds for programs established at the time of our study. At the same time, opportunities exist for the findings of this research study to inform the development of these new programs. Second, our national sample of perinatal individuals, professionals, and access program team members provided a broad array of factors influencing perinatal mental health and health care amid the pandemic; however, additional study is necessary to test the generalizability of these findings to specific subpopulations. Third, the results of the modified Delphi panel suggest that prioritization of strategies to advance health equity depends in part on the local context, the communities being served, and resources available. The generally high scores received across domain areas demonstrate the need to consider all these strategies in setting priorities. Such efforts would likely benefit from engagement with relevant community partners, including those individuals with lived experience who arrive from communities marginalized because of racism and other systems of oppression. Future Research Our use of both qualitative and quantitative inquiry to investigate the under-studied area of the impact of COVID-19 on perinatal mental health and perinatal mental health care leads to myriad opportunities for future research. First, our research findings identified a wide range of factors perceived by both individuals with lived experience and perinatal care professionals to increase or decrease risk of perinatal depression and anxiety symptoms. Opportunities exist to test hypotheses on whether the perceived risk factors impact the prevalence of perinatal depression and anxiety disorders. Such investigations would provide valuable opportunities for understanding the relative contributions of factors potentially influential at the individual, interpersonal, organizational, and sociopolitical levels. In addition, opportunities also exist to investigate the prevalence of barriers identified for individuals living in specific jurisdictions. Such efforts could provide valuable information for understanding how to mitigate these barriers through programmatic or policy intervention. Our study also identified strategies implemented by access programs to mitigate the impact of COVID-19 and to advance health equity. Our efforts to prioritize specific strategies through a modified Delphi panel demonstrated their value, as measured by importance in our surveys administered, to an array of community partners. Participants, however, reported being challenged in assessing the effectiveness of the strategies identified. Therefore, a critical next step is to build an evidence base on the effectiveness of the strategies identified to advance perinatal mental health care equity. Conclusions The findings of our enhancement award bring new evidence on both the perceived barriers to perinatal mental health care for individuals with depression and anxiety disorders amid the pandemic and the strategies available to perinatal psychiatry access programs to respond to these challenges. Given the unprecedented nature of the pandemic, our study engaged qualitative methods to build new understandings of how the global pandemic affected access to quality care for perinatal individuals with depression and anxiety disorders. Key community members, including individuals with lived experience, reported that the pandemic affected the perinatal individual, their interpersonal relationships, practice and organizational settings, and sociopolitical context in ways that increased their risk factors for perinatal depression and anxiety symptoms. Triangulating data across 3 samples (individuals with lived experience, perinatal care professionals, and access program team members), our study also identified barriers to perinatal mental health care access that emerged because of the pandemic. These included the emotional, cognitive, and physical impact of the pandemic on perinatal individuals, but also the impact on interpersonal relationships, the health care delivery system, and changes in health care policy. 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We also extend our thanks and gratitude to the participants who completed interviews for study and would like to recognize in particular those individuals with lived experience who were willing to share their experiences with our team. Finally, we are deeply grateful to MCPAP for Moms and its Diversity, Equity, and Inclusion Committee for their leadership in promoting antiracist programming among access programs. We are especially grateful for the work of Leena Mittal, MD, and Gina Gallagher, MEd, LACD I, PMH-C, for their leadership as co-chairs of the MCPAP for Moms Diversity, Equity, and Inclusion Committee. We also are grateful to our ongoing partnership and meaningful collaborations with the Washington Perinatal Psychiatry Consult Line, the Partnership for Maternal and Child Health of Northern New Jersey, the Central Jersey Family Health Consortium, and the Southern New Jersey Perinatal Cooperative. Finally, we would like to extend our appreciation for the opportunity to conduct this research in partnership with the National Network of Perinatal Psychiatry Access Programs (Lifeline for Moms Network) and PSI. We are also grateful to the Perigee Fund, which funds the Lifeline for Moms Network. Research reported in this report was funded through a Patient-Centered Outcomes Research Institute® (PCORI®) Award (IHS-2019C2-17367-IC). Further information available at: https://www.pcori.org/research-results/2020/comparing-three-programs-increase-access-mental-health-care-pregnant-and-postpartum-patients#section_covid Appendices Appendix A. Evaluating Lifeline for Moms Access Program Team Member Survey (PDF, 366K) Appendix B. A National Survey on Adaptations by Perinatal Psychiatry Access Programs to Promote Perinatal Mental Health Care Equity (PDF, 279K) Table 1. Perinatal Psychiatry Access Programs' reported adaptations to promote health equity by level of racism targeted (PDF, 118K) Table 2. National survey findings of Perinatal Psychiatry Access Program initiatives to address health inequity as reported by Access Program team members a (PDF, 51K) Appendix C. Draft of Semistructured Interview Guide and Demographic Survey for Individuals With Lived Experience (PDF, 370K) Appendix D. Draft of Semistructured Interview Guide and Demographic Survey for Prescribing Perinatal Professionals (PDF, 365K) Appendix E. Draft of Semistructured Interview Guide and Demographic Survey for Doulas (Aim 2) (PDF, 336K) Appendix F. National Program Administrator COVID-19 and Health Equity Interview Guide (PDF, 414K) Appendix G. Access Program Team Member Respondents by State (PDF, 136K) Appendix H. The Perinatal Psychiatry Access Programs (PDF, 268K) Table 1. Perinatal Psychiatry Access Programs' strategies to advance health equity (PDF, 176K) Appendix I. Rating of Importance for Strategies to Advance Perinatal Mental Health Care Equity by Advisory Board (PDF, 278K) Original Project Title: Comparative Effectiveness of Perinatal Psychiatry Access Programs on Treatment Engagement COVID-19 Enhancement PCORI ID: IHS-2019C2-17367-IC Suggested citation: Mackie TI, Schaefer AJ, Ramella L, et al. (2023). Improving Access to Mental Health Care for People with Low Incomes Who Were Pregnant and Gave Birth during the COVID-19 Pandemic. Patient-Centered Outcomes Research Institute (PCORI). https://doi.org/10.25302/10.2023.IHS.2019C217367IC Disclaimer The [views, statements, opinions] presented in this report are solely the responsibility of the author(s) and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute® (PCORI®), its Board of Governors or Methodology Committee. Copyright © 2023. SUNY Downstate Health Sciences University. All Rights Reserved. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License which permits noncommercial use and distribution provided the original author(s) and source are credited. (See https://creativecommons.org/licenses/by-nc-nd/4.0/ Bookshelf ID: NBK620249 PMID: 41529128 DOI: 10.25302/10.2023.IHS.2019C217367IC Share Views PubReader Print View Cite this Page Mackie TI, Schaefer AJ, Ramella L, et al. Improving Access to Mental Health Care for People with Low Incomes Who Were Pregnant and Gave Birth during the COVID-19 Pandemic [Internet]. Washington (DC): Patient-Centered Outcomes Research Institute (PCORI); 2023 Oct. doi: 10.25302/10.2023.IHS.2019C217367IC PDF version of this title (3.2M) In this Page Background Participation of Patients and other Stakeholders Aim 1: Identification of Access Program Adaptations Aim 2: Factors that Influence Access to Perinatal Mental Health Care AMID The Covid-19 Pandemic Aim 3: Prioritization of Access Program Strategies in Response to Covid-19 and Health Inequities Discussion Conclusions References Related Publications Acknowledgments Appendices Other titles in this collection PCORI Final Research Reports Related information NLM Catalog Related NLM Catalog Entries PMC PubMed Central citations PubMed Links to PubMed Recent Activity Clear Turn Off Turn On Improving Access to Mental Health Care for People with Low Incomes Who Were Preg... 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