Parents are mentally and physically healthy, with particular attention paid to the perinatal period.

Parents’ physical and mental health affects their ability to care for their children and engage in the warm, responsive interactions that infants and toddlers need for long-term healthy development. Yet parents often do not have the resources they need to care for themselves adequately as they care for their children, particularly during the perinatal period, which can pose unique health challenges to families. For example, between 7% and 15% of postpartum women experience depressive symptoms.1,2 However, not all mothers get the help they need. A study by the Centers for Disease Control found that among women who had recently given birth, one in eight reported that they had not been asked about depression during postpartum visits.3

Due to the social determinants of health—defined by the World Health Organization as “the conditions in which people are born, grow, live, work and age”—parents who experience substantial adversity are at higher risk of facing physical and mental health challenges.4 These risks perpetuate disparities in children’s health outcomes. For example, due to barriers such as lack of insurance, not all women receive adequate prenatal care, which is critical to ensuring healthy birth outcomes, and women of color are least likely to receive adequate prenatal care.5 The effects of COVID-19 are exacerbating these racial and socioeconomic disparities. Data show that rates of hospitalization for people who are Hispanic, American Indian or Alaska Native, or Black are 4 to 5 times higher than among White people.6 Other effects of the health crisis, such as stress due to job insecurity and challenges with securing child care, also pose a threat to the mental and physical health of parents who are trying to care for young children.

Because physical and mental health are intertwined, interventions that help relieve parents’ stress also can improve physical health outcomes. Some policies—such as expanded income eligibility for health insurance, paid family leave, and higher state minimum wage—impact parental health indirectly by increasing financial resources. Other strategies, such as group prenatal care, directly affect parental health by helping parents build social support. In working toward this goal, states can measure progress by tracking outcomes, such as maternal mental health and parenting support, particular to children ages 0 to 3.

Two outcome measures illustrate parents’ health and wellbeing: (1) maternal mental health and (2) parenting support. These outcomes vary considerably across states, and parenting support varies by race and ethnicity, as well.

Both outcome measures were calculated intentionally in the negative direction to demonstrate where states have room for improvement and to help states prioritize the PN-3 policy goals that are lagging. Out of 51 states, the worst state ranks 51st, and the best state ranks first. The median state indicates that half of states have outcomes that measure better than that state, whereas half of states have outcomes that are worse.

 

OUTCOME MEASURE: POOR MATERNAL MENTAL HEALTH
% of children under age 3 whose mother reports fair or poor mental/emotional health
Median state value: 4.3%

Maternal mental health is a strong predictor of healthy child development. In the five worst states, 8% to 10% of children under age 3 have a mother who has mental health concerns, compared to approximately 2% of children in the five best states. Although rates of maternal mental health vary substantially across states, rates do not vary as substantially by race and ethnicity.

See the Prenatal-to-3 State Policy Roadmap Appendix for a table of state variation in Parental Health and Emotional Wellbeing outcomes and corresponding ranks for each state.
Source: 2016-2018 National Survey of Children’s Health (NSCH); for additional information, please refer to Methods and Sources.

 

OUTCOME MEASURE: LOW PARENTING SUPPORT
% of children under age 3 whose parent lacks emotional parenting support
Median state value: 14.4%

In the five worst states, approximately one-quarter of children under age 3 have a parent who reports that they do not have anyone they can turn to for emotional support with parenting, compared to less than 10% in the five best states. Rates of low parenting support vary substantially by race and ethnicity, with nearly one-third of Hispanic children, over 20% of Black children, and less than 10% of White children under age 3 living with a parent who lacks emotional support.

Source: 2016-2018 National Survey of Children’s Health (NSCH); for additional information, please refer to Methods and Sources.

Effective policies have a demonstrated positive impact on at least one prenatal-to-3 goal, and the research provides clear guidance on legislative or regulatory action that states can take to adopt and implement the policy. By contrast, effective strategies have demonstrated positive impacts on prenatal-to-3 outcomes in rigorous studies, but the research does not provide clear guidance to states on how to effectively implement the program or strategy statewide.

EXAMPLES OF IMPACT

Effective state policies and strategies to impact Parental Health and Emotional Wellbeing

Effective Policies Examples of Impact on Parental Health and Emotional Wellbeing
Expanded Income Eligibility for Health Insurance
  • Medicaid expansion had both positive and null effects on mental distress (L, H, K)
Paid Family Leave
  • Access to paid family leave led to a 7 to 17 percentage point increase in mothers reporting very good or excellent mental health and a 3 to 5 percentage point increase in mothers reporting coping well with day-to-day demands of parenting (C)

  • Access to paid family leave led to an 8.2 percentage point decline in the risk of being overweight and a 12 percentage point decline in any alcohol consumption (P)
State Minimum Wage
  • A $1 increase in the minimum wage resulted in a 3.4% to 5.9% reduction in adult (non-drug) suicides (T)

  • A $1 increase in the minimum wage led to a 7% decline in smoking during pregnancy (Q)
Effective Strategies Examples of Impact on Parental Health and Emotional Wellbeing
Group Prenatal Care
  • Group prenatal care decreased the likelihood of excessive weight gain (M, P)

  • Group prenatal care reduced depressive symptoms, especially among high-stress women (C, H)

Early Intervention Services
  • Mothers of low birthweight infants who received EI services scored significantly higher on scales of maternal self-confidence and maternal role satisfaction than control groups (D, H)

Note: The letters in parentheses in the tables above correspond to the findings from strong causal studies included in the comprehensive evidence reviews of the policies and strategies. Each strong causal study reviewed has been assigned a letter. A complete list of causal studies can be found in the Prenatal-to-3 State Policy Roadmap Appendix. Comprehensive evidence reviews of each policy and strategy, as well as more details about our standards of evidence and review method, can be found at in the Prenatal-to-3 Policy Clearinghouse.

 

POLICY VARIATION ACROSS STATES

Have states adopted and fully implemented the effective policies to impact Parental Health and Emotional Wellbeing?

Expanded Income Eligibility for Health Insurance

37 states have adopted and fully implemented the Medicaid expansion under the Affordable Care Act (ACA) that includes coverage for most adults with incomes up to 138% of the federal poverty level (FPL).

Sources: As of October 1, 2020. Medicaid state plan amendments (SPAs) and Section 1115 waivers.

Paid Family Leave

5 states have adopted and fully implemented a paid family leave program of a minimum of 6 weeks following the birth, adoption, or the placement of a child into foster care.

Sources: As of October 1, 2020. State statutes and legislation on paid family leave.

State Minimum Wage

19 states have adopted and fully implemented a minimum wage of $10 or greater.

Sources: As of October 1, 2020. State labor statutes and State Departments of Labor.

 

STRATEGY VARIATION ACROSS STATES

Have states made substantial progress toward implementing the effective strategies to impact Parental Health and Emotional Wellbeing?

Group Prenatal Care

10 states have supported the implementation of group prenatal care financially through enhanced reimbursements for group prenatal care providers.

Sources: As of June 8, 2020. State health department websites and proposed and passed state legislation.

Early Intervention Services

5 states have moderate or broad criteria to determine eligibility and serve children who are at risk for later delays or disabilities.

Sources: As of June 2020. IDEA Infant and Toddler Coordinators Association 2018, state regulations retrieved from state legal statutes, health department regulations, and Early Intervention program websites.

Note: Some states in the “no” category for Policy Variation Across States have adopted a policy, but they have not fully implemented it, or they do not provide the level of benefit, indicated by the evidence reviews, necessary to impact the PN-3 goal. Many states in the “no” category for Strategy Variation Across States have implemented aspects of the effective strategies, but states are assessed relative to one another on making substantial progress. For additional information, go to the State Data Interactives.

Beyond the policies and strategies proven effective by the current research, states also are pursuing other approaches that hold promise for improving parental health and wellbeing. States can look to these approaches as potential models for policy innovation, and they should support ongoing research in these areas to better understand impacts on parents’ health and to determine the most effective way to employ these approaches.

Perinatal mental health programs: A variety of efforts at the state and local levels have emerged to address parents’ and families’ mental health needs during and after pregnancy. For example, MCPAP (Massachusetts Child Psychiatry Access Program) for Moms helps primary care providers build their capacity to serve pregnant and postpartum women and their children.7 The organization’s goal is to prevent, identify, and help patients manage mental health and substance use concerns. Funded primarily by the Massachusetts Department of Mental Health, the program provides practitioners with training and toolkits, consultation and care coordination services, and linkages to community resources.

Based in New Haven, Connecticut, another initiative focused on parental mental health is the Mental health Outreach for Mothers Partnership (known as the MOMS Partnership).8 This initiative connects mothers with resources and social supports, including therapy, stress management classes, and parenting support. Elevate—a policy lab based in the Yale School of Medicine—is currently scaling up the MOMS program to five new sites (in Connecticut, Kentucky, District of Columbia, New York, and Vermont).9 A multigenerational impact evaluation is planned for each site, and results will demonstrate the potential effectiveness of this initiative for improving parental health and emotional wellbeing.10 This effort will include a comparative analysis of impacts across program sites. These and other emerging efforts may serve as models for states that are developing policies to improve parental health and emotional wellbeing.

Targeted screenings: Both comprehensive and targeted health screenings promote optimal long-term child development and family wellbeing by allowing medical professionals to assess a patients’ health risks before problems develop.11 In contrast to comprehensive screenings—which allow a practitioner to identify a wide range of potential risks and health needs that a patient may have—targeted screenings allow assessment of a patient’s risk for a specific issue that can impact health and wellbeing. For example, challenges during the perinatal and postpartum periods that can be identified in targeted screenings, such as maternal depression and developmental delays among children, affect a substantial number of families. Research suggests that 9% of pregnant women12 and between 7% and 15% of postpartum women experience depressive symptoms.13 Without screenings, less than a quarter of postpartum depression cases are identified.14

As the map below shows, approximately half of states recommend that mothers receive a screening for maternal depression during a well-child visit, and six states currently require it (out of 43 states reporting policy status). For child developmental screenings, approximately half of states (shown in the map) have Medicaid programs that reimburse for and require these screenings as part of a well-child visit.

No rigorous research has yet examined the impacts of these legislative strategies. Studies have found that legislation to allow reimbursement for targeted screenings is associated with higher rates of identification of needs and subsequent initiation of services,15,16 but study design limitations preclude firm conclusions. Current research also does not provide guidance on a clear threshold for the optimal reimbursement rate for child developmental screenings, and no available studies have examined which well-child visits are ideal for administering screenings or which screening tools may be best for identifying needs or delays. More research will help provide guidance on these matters.

Medicaid Treatment of Maternal Depression Screenings During Well-Child Visits

Source: As of March 2020. National Academy for State Health Policy. For additional information, please refer to Methods and Sources.

 

Medicaid Requires and Reimburses Child Development Screenings

Source: As of July 23, 2019. National Academy for State Health Policy. For additional information, please refer to Methods and Sources.

 

  1. Committee on Obstetric Practice. (2015). ACOG Committee opinion: Screening for perinatal depression. The American College of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression
  2. Yawn, B. P., Olson, A. L., Bertram, S., Pace, W., Wollan, P., & Dietrich, A. J. (2012). Postpartum depression: screening, diagnosis, and management programs 2000 through 2010. Depression Research and Treatment2012. https://pubmed.ncbi.nlm.nih.gov/22900157/
  3. Bauman, B. L., Ko, J. Y., Cox, S., D’Angelo, D. V., Warner, L., Folger, S., Tevendale, H. D., Coy, K., C., Harrison, L., Barfield, W. D. (2020, May 15). Vital signs: Postpartum depressive symptoms and provider discussions about perinatal depression – United States, 2018. Morbidity and Mortality Weekly Report, 69(19);575–581. Centers for Disease Control. https://www.cdc.gov/mmwr/volumes/69/wr/mm6919a2.htm?s_cid=mm6919a2_w
  4. Braveman, P., & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 129(Suppl 2): 19-31. https://doi:10.1177/00333549141291S206
  5. Novoa, C. (2020). Ensuring Healthy births through prenatal support. Center for American Progress. https://www.americanprogress.org/issues/early-childhood/reports/2020/01/31/479930/ensuring-healthy-births-prenatal-support/
  6. Centers for Disease Control. (2020, June 25). COVID-19 in racial and ethnic minority groups. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html
  7. Massachusetts Child Psychiatry Access Program. (n.d.). Overview, vision, history. https://www.mcpap.com/About/OverviewVisionHistory.aspx
  8. Center on the Developing Child. (n.d.) MOMS Partnership. https://developingchild.harvard.edu/innovation-application/innovation-in-action/moms/
  9. Yale School of Medicine. (n.d.). Welcome to Elevate: A policy lab to elevate mental health and disrupt poverty. https://medicine.yale.edu/psychiatry/elevate/
  10. Elevate. Findings from six MOMS Partnership goals & needs assessments. (2019). Yale School of Medicine. https://medicine.yale.edu/psychiatry/elevate/our-work/scaling/GNA%20Findings%20From%20Six%20Sites_383295_284_47060_v1.pdf
  11. Office of Disease Prevention and Health Promotion. (n.d.). Get screened. U.S. Department of Health and Human Services. https://health.gov/myhealthfinder/topics/doctor-visits/screening-tests/get-screened#text=Screenings%20are%20medical%20tests%20that,can%20do%20for%20your%20health.
  12. Committee on Obstetric Practice. (2015). ACOG Committee opinion: Screening for perinatal depression. The American Colege of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression
  13. Committee on Obstetric Practice. (2015). ACOG Committee opinion: Screening for perinatal depression. The American Colege of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression
  14. Wilkinson, A., Anderson, S., & Wheeler, S. B. (2017). Screening for and treating postpartum depression and psychosis: A cost-effectiveness analysis. Maternal and Child Health Journal, 21(4), 90-914. https://link.springer.com/article/10.1007%2Fs10995-016-2192-9
  15. King, T. M, Tandon, S. D., Macias, M. M., Healy, J. A., Duncan, P. M, Swigonski, N. L., Skipper, S. M. & Lipkin, P. H. (2010). Implementing developmental screening and referrals: Lessons learned from a national project. Pediatrics, 125(2), 350-360
  16. Schonwald, A., Huntington, N., Chan, E., Risko, W., & Bridgemohan, C. (2009). Routine developmental screening implemented in urban primary care settings: More evidence of feasibility and effectiveness. Pediatrics, 123(2).