BACKGROUND

Current State of Maternal Health in Mississippi

Of its 2.94 million citizens, approximately 581,196 Mississippi (MS) women are of child-bearing age (15-44). According to the Office of Mississippi Physician Workforce, its physician-to-population ratio for overall physicians ranks 50th in the U.S.¹ Mississippi has consistently had one of the highest maternal mortality rates in the country, and racial disparities play a significant role, as African American or Black women in the state have been disproportionately affected by maternal mortality compared to white women.²

Unsurprisingly, Mississippi mothers report poorer mental health functioning compared to the rest of the nation.³ Approximately 22.1% of postpartum women in Mississippi report symptoms of postpartum depression - compared to 13.4% nationally⁴ - and this risk is higher in women who deliver prematurely or experience birthing traumas. Additionally, 5.5% of mothers report experiencing intimate partner violence (IPV) before pregnancy (3.5% nationally). As of 2019, the annual average prevalence of substance use disorder (SUD) in Mississippi was 6.3% or 154,000, and 10% of women report smoking in the last 3 months of pregnancy.⁵

An unequal distribution of social determinants of health (SDOH) worsens health disparities, and inequities that lead to greater downstream risk for behavioral health problems and unmet service needs. Large rates of poverty are present. For example, in 2022, 57.3% of birthing women were insured by Medicaid compared to 41.3% nationally.⁶ Mississippi’s geographically rural nature, low co-location rates of medical and behavioral care providers,⁴ and disadvantaged backgrounds (including minority ethnic/racial backgrounds) are each also well-known factors either correlated with or contributing to negative health outcomes and disparities. Black mothers in the Mississippi Delta experience even higher rates of medical complications/conditions such as preterm birth, diabetes, and obesity, and related factors that contribute to greater disparities in mental health and SUD rates.⁷ These medical conditions are well known to contribute to later mental health problems for mothers with post-partum mood and anxiety disorders or their children (e.g., ADHD, emotional-behavioral difficulties).⁸

Mississippi’s shortage of mental healthcare workforce, particularly those with perinatal expertise, exacerbates these difficulties. Almost all of Mississippi counties (80/82) are Health Resources and Services Administration (HRSA)-designated mental health professional shortage areas, and even fewer areas have access to clinicians trained in perinatal mental health, as only 10 therapists statewide report expertise in this area.⁴ As of 2023, there were no known reproductive psychiatrists in the state. Additionally, 94% of counties include shortages of primary care physicians who practice family medicine, internal medicine, pediatrics, and obstetrics-gynecology who may be responsible for providing medical management of perinatal psychiatric conditions. Furthermore, mothers of color— particularly Black mothers— are disproportionately impacted, and this disparity is exacerbated by the state’s history, including structural barriers of racism.⁹ Given these disparate maternal mental health outcomes and limited workforce, a perinatal mental health access program is necessary to make gradual improvements for maternal health in Mississippi.

Identified Areas of Growth and Expansion Within the Perinatal Period

One model to encourage growth and expansion of resources within the perinatal period is psychiatric access programs (also called mental healthcare access programs), which have proliferated among states in addressing mental health needs of pediatric populations. In short, these programs connect trained mental health specialists to primary care via a teleconsultation model, to support their knowledge in the identification, management, and treatment of mental health conditions. Supporting primary care providers, in turn, provides populations with greater access to knowledge about specialized care in pediatric and perinatal mental health conditions, mitigating workforce gaps. The Health Resources and Services Administration (HRSA) has a vested interest in expanding mental health services across the nation. There are currently 54 pediatric mental health care access programs, including in Mississippi since 2018.¹⁰ Given the success of these program - which are associated with increased access to care, reductions in mental health symptoms, greater provider knowledge, high satisfaction, and potential cost savings - there has been significant expansion of these programs to include maternal mental health.^11–14 With newly incorporated funding, there are now currently 30 perinatal access programs across the nation.¹⁵ While our state has an HRSA-funded pediatric mental health care access program (PMHCA) Child Access to Mental Health and Psychiatry (CHAMP)—we did not have any perinatal programs providing similar peer-to-peer consultation, education, care coordination, and resource sharing to providers of expecting or post-partum mothers. Thus, with seed funding from the United Healthcare Foundation in 2022 and 5-year funding from HRSA beginning in Fall 2023, the CHAMP for Moms program has been established as the first statewide perinatal teleconsultation service network in Mississippi.

 

PERINATAL ACCESS PROGRAM GOALS

The mission of CHAMP for Moms will be to apply the telepsychiatry access model to ensure mothers and their partners receive integrated, evidence-based, and timely care access. Access programs like CHAMP for Moms typically have five programmatic components: (1) Telephone consultation via a warm-line (601-984-2080); (2) one-time patient-facing consultation (often via telehealth); (2) provision of resource and referral services to assist in care coordination; (3) training for perinatal professionals; and (5) practice-level technical assistance to help integrate evidence-based and culturally responsive screening, assessment, and treatment practices for mental health (MH) and SUD. Several additional community partners will assist in program implementation and linkage to community supports across Mississippi in coordination with the University of Mississippi Medical Center (UMMC). Specifically, partners will include Mom.ME, Mississippi Public Health Institute (MSPHI), and Families as Allies (FAA). Mom.ME is a non-profit organization based in Jackson, Mississippi, that assists women, particularly women of color, who are new and/or current mothers in need of additional supports as they navigate the ever-changing journey of motherhood. Their services range from providing mentoring groups, specialized community events, and offering a warm-line for women to call when they just need to feel connected. Mom.ME will support this project with advocacy efforts, promoting the program, collaborating as a community partner, participating in the Project ECHO series, and engaging with the Advisory Council. Mississippi Public Health Institute promotes public health through projects in policy evaluation, community health, data analysis, and health access. Mississippi Public Health Institute will provide training, education, and information to front-line maternity care providers on maternal mental health and SUDs. These trainings will include evidence-based, trauma-informed, and culturally and linguistically appropriate screening; brief intervention; treatment; referrals for treatment; follow-up support services; and linkages to community-based resources and will be offered in-person and online. Families as Allies is Mississippi’s only statewide organization run by and for families of children with mental health challenges. They support families and work together to improve outcomes for children. They are the SAMHSA-designated Statewide Family Network for Mississippi and state chapter of the National Federation of Families. Families as Allies will assist the project in providing the following: local and community resources; pilot training for patient advocacy in situations of positive substance use screening and the need for Child Protective Services; support for CHAMP for Moms and other community partner peer support, based on a nationally recognized model; monitoring and advocacy for policy changes at the state level; consultation for long-term sustainability; use all of their communication platforms and venues to support the project; and participation in project evaluation activities. Together, CHAMP for Moms will link with maternity care providers in a collaborative consultation model to provide access to psychiatric services in a rapid fashion that reduces barriers and improves responsiveness to the needs of front-line providers and patients, ultimately connecting to community supports.

The principal goal of CHAMP for Moms will be to deploy an integrated perinatal telehealth psychiatric consultation service to maternity care providers (e.g., OB/GYN; doulas; lactation consultants; pediatrician/family medicine providers) across the entire state. We have begun a phased rollout beginning with UMMC’s Obstetrics and Gynecology (OB/GYN) department to include their Maternal Fetal Medicine clinics in the Jackson-metro area (i.e., Jackson and Flowood, MS) to hone the program in 2023 and early 2024, before scaling statewide in late 2024. This initial catchment area/population was chosen due to the high rates of MH and co-occurring SUD problems in these high-risk populations, as well as poverty and minoritized groups. Additionally, pregnant mothers with the highest risk - incarcerated or hospitalized with severe mental illness or SUD - are treated by UMMC’s High-Risk Pregnancy Care Clinic. Over the 5-year grant period, CHAMP for Moms will establish, maintain and progressively expand the network of participating maternity care practices and providers that participate and rely on consulting and referral services. Once CHAMP for Moms is scaled statewide, our scope will cover approximately 581,000 expecting and postpartum women representing 20% of the state’s population.

No-cost provider education activities in evidence-based screening, assessment, intervention, and referral practices for perinatal MH and SUD concerns will also be core to the CHAMP for Mom’s mission. Specifically, MSPHI will provide training, education, and information to front-line maternity care providers on maternal mental health and SUDs. These trainings will include evidence-based, trauma-informed, and culturally and linguistically appropriate screening; brief intervention; treatment; referrals for treatment; follow-up support services; and linkages to community-based resources. We will offer both in-person and online activities through synchronous (live trainings, webinars) and asynchronous (module-based trainings) methods. In addition, we will leverage our existing professional education success from our pediatric mental health care access (PMHCA) program to develop a Perinatal Project ECHO (Extension for Community Healthcare Outcomes) series to provide real-time teleconsulting to maternity-care providers. This perinatal ECHO - Maternal Awareness for Mental Health And Substance use disorders (MAMHAS ECHO) - will be comprised of an interdisciplinary team of experts located at UMMC and in the community (Mom.ME; MSPHI; FAA), including reproductive and adult psychiatry, clinical psychology, OB/GYN, perinatal mental health therapists, and peer support. Additionally, our partner advocacy group Families as Allies will conduct provider advocacy trainings in maternal mental health and SUDs. Lastly, we will provide real-time consultation via an embedded peer support specialist in OB/GYN clinics who serves high-risk patients (e.g., UMMC High-Risk Pregnancy Care).

CONSULTATION MODEL DESCRIPTION

Overview. The University of Mississippi Medical Center (UMMC) will provide telehealth and in-person consultations, care coordination and linkages to maternal mental health, and substance use treatment referrals for maternity care providers. Consultations concerning diagnosis, medication management, and therapy options for expectant or post-partum women are expected to be the most likely. Dedicated telephone and video consulting warm-lines operating within normal business hours five days a week will be staffed by an interdisciplinary mental health team including psychiatrists—including the state’s first reproductive psychiatrist—, perinatal mental health therapists, nurse practitioner, peer support specialist, resource coordinator and a project director/clinician. Initially in Year 1, this team will service UMMC clinics that will serve the areas of highest need and then roll out to other providers in the state with the goal of a statewide reach beginning in Year 2 (though all consultations will be taken). Community providers may contact the CHAMP for Moms team via phone (601-984-2080), online (http://champms.org), or HIPAA-compliant videoconferencing for rapid, same-day consultation services. We will provide scheduled or return consults on request. We will also embed a peer support specialist in a clinic serving mothers at high-risk for maternal mental health and/or substance use concerns.

Enrollment. Enrollment of providers is planned for two phases. The initial roll-out of CHAMP for Moms will include maternity care providers at UMMC in OB/GYN and Maternal Fetal Medicine. Once appropriate maternity care providers are identified, the team will conduct a survey of these 11 physicians (6 OB/GYNs; 5 Maternal Fetal Medicine) of their maternal mental health and substance use consultation needs to seek their preferences for receiving consultation, training, and technical assistance. Next, in approximately Fall 2024, we will expand our outreach and target statewide enrollment. We aim to leverage relationships with several statewide and community partners including the Mississippi’s section of the American College of Obstetricians and Gynecologists (ACOG) and community partners (Mom.ME; MSPHI; Healthy Moms Healthy Babies, Mississippi State Department of Health, Home Visitors). As some providers are already registered with our PMHCA (i.e., family medicine physicians and pediatrician), we will approach each enrolled provider to re-register them for CHAMP for Moms. Although our primary focus is physicians or other medical providers (e.g., Nurse Practitioners), we will also target and enroll additional frontline providers who interface with mothers in the perinatal period, including doulas; lactation consultants; and home visitors. Enrollment will not be necessary to obtain services or training.

Service Delivery. CHAMP for Moms will offer several services to enrolled maternity-care providers. These include (1) immediate clinical consultation via telephone; (2) immediate provider-to-provider videoconferencing consultation; (3) care coordination for helping facilitate referrals to local community-based resources in maternal mental health and/or substance use care; (4) expedited one-time, in-person psychiatric assessment for mothers (i.e., for mothers with more complex psychiatric conditions or SUD concerns) provided in-person or via one of UMMC’s multiple statewide telehealth offices; and (5) ongoing continuing education for primary-care providers via in-person and webinar-based trainings (i.e., Project ECHO, MSPHI Screening, Brief Intervention, and Referral to Treatment (SBIRT) trainings).

Unique to perinatal psychiatric access programs in the United States, it is possible that the program will be the first to embed a peer support specialist with lived experience with postpartum mental health and/or SUD within the UMMC High-Risk Pregnancy Care clinic to provide real-time, in-person consultation services and assist in care coordination to facilitate referrals to community-based resources. Critically, we chose this clinic as it serves some of the highest-risk women in the state and will ultimately serve as a model for future roll-out of integrated peer-support for women with mental health and substance use concerns within the maternity care medical setting.

For care coordination and resource support, we will maintain two key activities. First, CHAMP for Moms will maintain an online directory of all potential local maternal mental health and substance use service providers ranging from social workers, licensed professional counselors, allied supports, psychiatrists, support groups, and substance use treatment providers. This resource and referral directory will be publicly available on our website (http://champms.org). This directory will be reviewed ongoingly and shared with maternity care providers to facilitate their knowledge of statewide maternal mental health and substance use resources. For referrals, we will coordinate with maternity-care personnel during the enrollment visits to determine whether follow-up calls will be provided by local staff or the CHAMP for Moms clinician, peer support specialist, or resource coordinator. If CHAMP for Moms assumes this role, we will provide follow-up phone calls to ascertain progress in engagement with maternal mental health and/or substance use resources. The CHAMP for Moms program will also benefit from interacting with existing services at UMMC, such as the Addiction Psychiatry service, which is a clinical service line devoted to providing compassionate, research-based assessment, treatment (including medication assisted treatment), and referral services for adults troubled by alcohol and/or drug use.

It is important to recognize that our community partners – namely MSPHI and Mom.ME - will provide efficient and streamlined mechanisms for the referral to community and maternal mental health and substance use resources. Specifically, Mom.ME will serve as a community referral organization and provide peer support services related to maternal mental wellness, including individual and group support, and ongoing support to mothers with mental health concerns. They also operate the Mom.ME warm-line that mothers have access to 24/7 via call or text messaging. Mississippi Public Health Institute has an existing database of substance use treatment and resources and strong connections with both the Mississippi State Departments of Health and Mental Health.

SUSTAINABILITY

The period of federal funding for this program is an opportunity to demonstrate the operational and financial benefits of the program to effectively approach long-term funding sources towards sustainability. Operationally, our program will work within the existing community of providers and provider support organizations to deliver efficient and effective behavioral health education and support that will benefit mothers and families throughout the state. This type of program, a perinatal mental health access program, has demonstrated itself to be a model population health initiative.¹⁶ These programs have found an increase in general maternity-care providers addressing perinatal mood disorders.¹⁷ Therefore, it is imperative to equip maternity-care providers with the necessary resources to treat perinatal mood and anxiety disorders (PMADs).

It has been shown that untreated PMADs could accrue $14 billion dollars nationally.¹⁸ While the financial impact is not well known for Mississippi, we will develop financial justification for the program in a similar manner to the work we have done with our HRSA-supported PMHCA program CHAMP. In our PMHCA program, we worked closely with Managed Care Organizations (MCOs) to analyze claims data to evaluate changes in prescriptions of psychotropic medications fulfilled by pediatric patients of primary care providers (PCPs) enrolled in the CHAMP program. We have already demonstrated that CHAMP consults decrease the cost of psychotropic medication claims and costs when compared to non-psychotropic medication claims and that this reduction comes both by decreasing the average cost to fill a prescription and by reducing the number of prescriptions filled. Notably, greater providers consultation use was linked to greater reduction.¹⁹ Similarly, an evaluation goal will be to partner with Medicaid and MCOs to examine the impacts of CHAMP for Moms on costs and increased, timely access to evidence-based care.

In order to sustain such efforts, it is imperative that the program work closely with a host of partners from maternity care providers, community supports, legislative stakeholders, insurance providers, and advocates to disseminate the potential financial and population health improvements that investments in such a program as CHAMP for Moms can create.

CONCLUSION

Mississippi is a rural and significantly underserved state in several health domains, including maternity care, perinatal mental health care, substance abuse treatment, and SDOH. Mississippi’s mothers face many risk factors for poor mental health and related difficulties, including outcomes that place downstream risk to their children. Such need juxtaposed with a limited available workforce requires substantially new models be deployed. CHAMP for Moms is one such model and will increase health care providers’ capacity to screen, detect, treat, and refer pregnant and postpartum women to services using consultation, training, and resource support that will increase access to mental health support and recovery services. We will rely upon our strong, existing infrastructure of telehealth access programs and community partnerships to accomplish this goal and are laying multiple pathways towards understanding its sustainability and impact on the health system and Mississippi mothers.

 

Contact Information

If you are interested in learning more about the CHAMP for Moms program or enrolling for free in one of our various programs as a Maternity Care Provider, members of our team would be happy to talk with you. If you are interested in learning more about our partners, we have provided links to their websites below. Please submit an inquiry regarding the program to Courtney Walker at cwalker7@umc.edu.

Project Partners

Mississippi Public Health Institute: https://mentalhealthms.com/mississippi-public-health-institute/

Mom ME: https://www.momme.rocks/

Families as Allies: https://www.faams.org/

Child Access to Mental Health and Psychiatry: https://champms.org/

CHAMP for Moms Consult Line: (601) 984-2080

Acknowledgements

The CHAMP for Moms team would like to thank the following partners for their contributions and feedback on the development of the HRSA grant proposal. We are very appreciative to the following partners: Mom.Me, Families as Allies, Mississippi Public Health Institute, Mississippi Chapter of American College of Obstetricians and Gynecologists, University of Mississippi Medical Center’s Maternal Fetal Medicine, Mississippi Chapter of American Academy of Pediatrics, and Six Dimensions.

Funding Disclosure

The authors were supported during the preparation of the manuscript by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $4,134,300 with 10 percent financed with nongovernmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.