Improving maternal health services: Characterizing risks and measuring program and policy impacts.

摘要

This dissertation characterizes the relationship between two common perinatal conditions and measures effects of specific programs and policies on prenatal and delivery services (in the Philippines) and maternal mental health care (in the United States).The first paper examines the impacts of a national health insurance program and a franchise of midwife clinics on achievement of minimum standards for prenatal and delivery care in the Philippines using data from Demographic and Health Surveys. Scaleup of the insurance program was associated with increased odds of receiving 4 prenatal visits, including care in the first trimester of pregnancy. Exposure to midwife clinics did not affect prenatal outcomes. While both programs were associated with slight increases in the odds of delivery in a health facility, these were not statistically significant. Expansion of an insurance program was associated with increases in achievement of minimal standard prenatal care among Filipina women.The second and third papers use claims data from New Jersey's Medicaid program and focus on maternal mental health among low-income women. The second paper characterizes the association between diabetes and depression during pregnancy and the postpartum period. Women with diabetes compared with those without diabetes had nearly double the odds of experiencing depression during the perinatal period. A similar relationship was shown among women with no indication of depression during pregnancy. Pre-pregnancy or gestational diabetes was independently associated with perinatal depression, including new onset of postpartum depression.The final paper investigates the effects of New Jersey's statewide postpartum depression initiative on mental health care following delivery. Interrupted time series and patient-level longitudinal models are used to estimate policy impacts on initiation, follow-up, and receipt of guideline-consistent depression care. Fewer than 7% of mothers initiated treatment in the 6 months following delivery. Of those who initiated care, 60% received some follow-up, and less than half received guideline-consistent care. There were no policy-associated changes in the level or trends for treatment initiation or follow-up, but there was an increasing trend in receipt of guideline-consistent care following implementation. Postpartum depression is under-recognized and under-treated among low-income women.