Impacts of Telehealth Policies on Inequities in Perinatal Behavioral Health Care Access and Outcomes - Project Abstract: Suicide is now the leading cause of death during the perinatal period, and nearly a quarter of maternal deaths are attributable to behavioral health (BH) conditions. As with maternal mortality and morbidity overall, poor perinatal BH outcomes disproportionately affect historically marginalized communities of color. Despite the prevalence and life-threatening nature of perinatal BH conditions, only 11% of individuals with these conditions during pregnancy or postpartum receive needed care, and individuals from marginalized and under-resourced populations are less likely to be screened or treated for BH conditions. Telehealth has enormous potential to address the maternal morbidity and mortality crisis by improving access to perinatal BH care. It has been shown to increase health care access and reduce missed appointments for BH care, particularly among individuals from underserved communities. Research overwhelmingly finds comparable efficacy between in- person and telebehavioral health (TBH) care. Finally, telehealth can help overcome particularly salient barriers for pregnant and postpartum people. Few studies have examined TBH in the perinatal period, but evidence suggests that TBH services for pregnant and postpartum people provide equivalent benefit to those delivered in-person. Importantly, pregnant and postpartum individuals from historically marginalized populations, (e.g., Medicaid-insured; those living in rural areas; those with disabilities; and members of racial and ethnic minority groups), face additional health care barriers, including structural racism, language barriers, and provider shortages. The extent to which TBH diminishes or amplifies these specific barriers and reduces BH disparities is unknown. Recently, the COVID-19 pandemic accelerated policy changes to make telehealth services more widely available. However, state-level Medicaid policies are not uniform, and not all states retained pandemic- era expansions in their reimbursement policy. As policies influencing availability of telehealth continue to evolve, quantifying policy impacts on perinatal BH care access and outcomes, and better understanding the mechanisms driving those impacts, are critical to using TBH more effectively to address maternal morbidity and mortality from untreated perinatal BH conditions. To fill these gaps, this mixed-methods study will (1) Develop a detailed, longitudinal dataset describing the evolution of state-level telehealth policies with relevance to perinatal behavioral healthcare for individuals insured by Medicaid; (2) Use event-time modeling to estimate the relationship between telehealth policies of interest and key behavioral health outcomes (e.g., emergency department visits, overdoses, and suicide) and maternal-infant outcomes (e.g., maternal morbidity, preterm delivery), with a focus on identifying inequities by race/ethnicity, rural residence, and disability status; and (3) Apply the Consolidated Framework for Implementation Research in a series of in-depth interviews with patients and providers to explain the quantitative findings through an examination of factors that influence telehealth policy implementation and associated health outcomes.
