University of Southern California Dissertations and Theses

Maternal mental health matters: Creating FQHC+ to meet the complex needs of perinatal women of color

(USC Thesis Other)

Maternal mental health matters: Creating FQHC+ to meet the complex needs of perinatal women of color

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content Running head: MATERNAL MENTAL HEALTH
1
Maternal Mental Health Matters: Creating FQHC+ to Meet the Complex Needs of Perinatal
Women of Color
Shirley Sotelo
University of Southern California
DSW Cohort 5
Dr. Lewis
SOWK 722
Capstone Project
Doctor of Social Work
December 2019
MATERNAL MENTAL HEALTH 2

Executive Summary
Health care costs continue to rise while the quality of care does not. This health gap
impacts all Americans especially women of color and those of low socioeconomic status.
Specifically, it is during the perinatal period that women of color and of low socioeconomic
status experience the most risk to their physical and mental health and experience poor
pregnancy, health, and life outcomes disproportionally to their Caucasian counterparts.
Maternal depression is the most common complication in pregnancy, behind gestational
diabetes and preeclampsia combined (Byatt, Levin, Ziedonis, Moore, & Allison, 2015), yet it
often goes undiagnosed and untreated due to a myriad of personal, community, and systemic
barriers to care; less than 15% of identified cases receive adequate mental health treatment
(Byatt, Levin, Ziedonis, Moore, & Allison, 2015). Untreated maternal mental health disorders
place women’s lives at risk, are costly, and negatively impact not just mothers and their infants
but also communities, public sectors, and society in general. Living in poverty has been found to
be the greatest predictor of developing a maternal mental health disorder in the United States
(Dolbier, Rush, Sahadeo, & Thorp, 2013).
FQHC+, an innovative clinic, seeks to enhance and expand the current service model for
maternal mental health treatment at Federally Qualified Health Centers (FQHCs). This will be
achieved by addressing the most significant barriers to care experienced by this population such
as poverty, mental health stigma, and provider implicit bias. FQHC+ addresses these barriers
MATERNAL MENTAL HEALTH 3

through the addition/construction of a mother’s milk bank/breastfeeding support center. This
center will provide women with an opportunity to sell their excess breastmilk for a small amount
of income, have access to trained peer support workers, lactation consultants, and receive
behavioral health care from bilingual/bicultural mental health providers.
Main aims of the implementation of FQHC+ include improving maternal depression
symptoms and severity, improving pregnancy outcomes such as birthweight and gestational age
at birth, as well as improving maternal morbidity after birth, and ensuring prevention of maternal
mortality. Future action includes improving the overall state of maternal health at one FQHC
outside of Downtown, Los Angeles with the goal of improving maternal health for all FQHCs
across the country.
Implications of FQHC+ are vast especially if the pilot project yields the expected positive
outcomes in the aforementioned areas. FQHC+’s data could inform the Health and Resources
Services Administration (HRSA) of how this innovation has the potential to improve maternal
health significantly thus mandating that all new FQHC’s have a mother’s milk
bank/breastfeeding support center. HRSA providing additional grant funding to do so, will
greatly change the current landscape of maternal health in public health spaces. This project
takes an innovative step forward beyond a local context as it addresses both physical and mental
health disparities experienced by women of color across the nation.

MATERNAL MENTAL HEALTH 4

Table of Contents

Conceptual Framework ................................................................................................................... 7
Description of Social Problem: Prevalence & Incidence ............................................................ 7
Current Research & Practice ....................................................................................................... 8
Gaps in Care .............................................................................................................................. 11
Proposed Innovation: FQHC+ .................................................................................................. 12
Current Innovations .................................................................................................................. 12
Conceptual Framework & Theory of Change ........................................................................... 13
Problems of Practice and Solutions/Innovations .......................................................................... 15
Explanation of Design ............................................................................................................... 15
Justification of Innovation ........................................................................................................ 18
Goals: Proposed Impact ............................................................................................................ 18
Evidence or Data to Show Impact ............................................................................................ 19
Logic Model .............................................................................................................................. 20
Explanation of How the Proposed Solution Will Improve Grand Challenge Area .................. 20
Feedback from Multiple Stakeholders on Proposed Solution and Feasibility .......................... 21
Analysis of How FQHC+ is Positioned within History, Policy, and Public Knowledge ......... 23
Description of Political, Organizational and Community Allies .............................................. 24
Description of Political, Organizational, and Community Obstacles ....................................... 26
Analysis of Alternative Pathways ............................................................................................. 27
Project Structure, Methodology, and Action Components ........................................................... 27
Implementation Plan and Timeline ........................................................................................... 28
Exploration phase. ................................................................................................................. 28
Preparation phase. ................................................................................................................. 29
Implementation phase. .......................................................................................................... 30
Sustainment phase. ................................................................................................................ 31
Details of Financial Plans and Staging ..................................................................................... 32
Description of Measurement of Outcomes Using Data or Community Input .......................... 33
Plan for Stakeholder Involvement that Includes Relevant Constituencies ............................... 34
Communication Plan and Strategies that will Engage Audiences ............................................ 35
Dissemination Plan for Broader Impact .................................................................................... 35
MATERNAL MENTAL HEALTH 5

Ethical Concerns and Possible Negative Consequences ........................................................... 36
Summary of Project Plans and Conclusions ............................................................................. 36
Conclusion, Actions, & Implications ............................................................................................ 37
Implications of FQHC+: Practice or Policy Improvement ....................................................... 37
Acknowledgement of Limitations and Risks: Recommendations for Future Work ................. 38
Next Steps for Advancing DSW Capstone Project ................................................................... 39
References ..................................................................................................................................... 41
Appendix A ................................................................................................................................... 49
Appendix B ................................................................................................................................... 50
Appendix C ................................................................................................................................... 52
Appendix D ................................................................................................................................... 53
Appendix E ................................................................................................................................... 55

MATERNAL MENTAL HEALTH 6

Maternal Mental Health Matters: Creating FQHC+ to Meet the Complex Needs of Perinatal
Women of Color
Health care costs continue to swiftly rise while improvements in quality of care are much
slower, this creates gaps that impact all Americans, especially those of low socioeconomic status.
Closing the health gap is a grand challenge that is linked to health disparities often experienced
by women, racial/ethnic minorities, and persons of low socioeconomic status. Research suggests
that the aforementioned groups have additional barriers in achieving optimal health and well-
being and thus experience a higher incidence and prevalence of disease as well as a shorter life
span (National Institutes of Health, 2014). Two groups disproportionally impacted are African-
American and Latina perinatal women (period from conception to one year post-partum) and
their babies.
Over 200 million women conceive each year and deliver approximately 140 million
newborns worldwide (Graham et al., 2016). From these births, it is estimated that 10 percent of
these babies will be born premature and face possible disability or death (World Health
Organization, 2012). The United States ranks among the top 10 countries with the highest
number of premature births (World Health Organization, 2012).
National maternal death rates have also been on the rise during the past 20 years,
approximately 700 women die per year from pregnancy or during childbirth (Momsrising.org,
MATERNAL MENTAL HEALTH 7

2017). Women of color and of low socioeconomic status are significantly impacted.
(Reproductiverights.org, 2016). African-American women have been found to be three to four
percent more likely to die and are 60 percent more likely to have a pre-term baby than Caucasian
women (Orchard & Price, 2015). Similarly, Latina women from disadvantaged backgrounds
also have poorer pregnancy outcomes than Caucasian women (Sanchez-Vaznaugh et al., 2016).
However, a significant number of these women die from what are considered
“preventable” causes of death such as preeclampsia and gestational diabetes (World Health
Organization, 2015). Interestingly, the most common complication in pregnancy has been found
to be maternal depression (Fresno, 2015). Thus, the mental health of a perinatal woman cannot
be separated from their physical health when addressing their state of maternal health overall.
Conceptual Framework
Description of Social Problem: Prevalence & Incidence
Under this grand challenge lies the social problem of untreated maternal mental health
disorders resulting in poor pregnancy, health, and life outcomes for mothers and their babies.
Maternal mental health disorders refer to conditions such as postpartum depression, anxiety,
postpartum obsessive-compulsive disorder, among others, experienced during the pregnancy and
postpartum spectrum (American Psychological Association, 2013).
Maternal mental health disorders occur approximately in 10 -20 % of pregnant and
postpartum women worldwide (“Maternal Mental Health”, n.d.) yet they often go undiagnosed
MATERNAL MENTAL HEALTH 8

and untreated due to various barriers such as stigma and lack of access to quality care (Byatt,
Levin, Ziedonis, Moore, & Allison, 2015). Research has found several predictors that increase
the incidence of developing maternal depression such as race/ethnicity and socioeconomic status
(Santoro & Peabody, 2010). African-American women have rates as high as 35% for maternal
depression followed by Latina women (Santoro & Peabody, 2010). Living in poverty has also
been found to be the greatest predictor of developing a maternal mental health disorder in the
United States (Dolbier, Rush, Sahadeo, & Thorp, 2013). Along with depression, a significant
number of women also experience suicidal ideation during this time, thus putting them at risk for
suicide (Gavin, Tabb, Melville, Guo, & Katon, 2011).
Current Research & Practice
Mclemore et al. (2018), found that women of color experience and are exposed to stress
at higher rates than their Caucasian counterparts while receiving prenatal care thus putting them
at higher risk of having a preterm baby. Additionally, research indicates that women of color are
at higher risk for experiencing trauma, violence, and abuse (APA Psychnews, 2017). Women of
color also face challenges in accessing, initiating, and completing mental health treatment for
maternal depression. (Kozhimannil, Trinacty, Busch, Huskamp, & Adams, 2011). These
barriers may be due to the interplay of mental health stigma, implicit bias (unconscious
prejudices, stereotypes, beliefs and/or values), and challenges associated with poverty
MATERNAL MENTAL HEALTH 9

(Kozhimannil, Trinacty, Busch, Huskamp, & Adams, 2011; Zestcott, Blair, Stone, &Kwan,
2016).
Untreated maternal mental health can also prove to be very costly. According to Wilder
Research, “the annual cost of not treating a mother with depression is $7,200 in lost income and
productivity; an additional $15,300 can be attributed to the child, totaling $22,500 per
mother/child dyad” (Diaz & Chase, 2010). Untreated maternal depression can also increase
health care costs as lingering depression past the post-partum stage can contribute to illnesses
such as heart disease, stroke, and type II diabetes (Bowers et al., 2013; Farr et al., 2011; Mezuk
et al., 2008; Pan et al., 2011).
In some cases, untreated mental health can contribute to developing a substance abuse
problem as women with postpartum may be at greater risk for substance use compared with
women without (Chapman & Wu, 2013). Mothers with a substance use disorder are at greater
risk of coming into contact with the child welfare and sometimes the criminal justice system and
potentially having their children enter the foster care system. Pregnant women in or entering the
prison system are at high risk of adverse maternal mental health and negative pregnancy
outcomes.
Over the past 20 years, the number of women in state and federal prisons have increased more
than six times and is growing at a faster rate than that of their male counterparts (Braithwaite,
Treadwell, & Arriola, 2008). A majority of these women come from low socio-economic
MATERNAL MENTAL HEALTH 10

communities and have experienced high incidences of violence and abuse (Ferszt & Clarke,
2012). There are no national standards of care for pregnancy in jails and prisons. Additionally,
pregnant women suffer from substandard treatment such as heavy workloads, poor nutrition, and
even shackling during delivery and birth. There is limited research on the subject of maternal
health of incarcerated women and on the long-term effects and costs of their untreated mental
health.
Costs for the infant, immediately after birth and long-term can also be very high as there
is an increased likelihood that infants born to depressed women are also more likely to be
premature (Li, Liu, & Odouli, 2009; Orr, James, & Blackmore Prince, 2002) and are at greater
risk of being small for gestational age (U.S. Department of Health and Human Services, Office
of Women’s Health, 2009). Both of these conditions may lead to the infant needing the NICU.
One analysis estimated that the cost of a night in the NICU was nearly 2.4 times the cost of a
regular nursery night (Adams et al., 2002).
Children who experience these conditions may also be at higher risk of experiencing
developmental delays as well as an insecure parent-child bond (Cummings, Schermerhorn,
Keller, & Davies, 2008; Elgar et al., 2007; Goodman & Gotlib, 1999; Lim et al., 2008) thus
needing costly early intervention and special education services in the future. Women who may
already have limited resources and support along with maternal depression may not be as
MATERNAL MENTAL HEALTH 11

emotionally and psychologically present to be able to provide their child with the attention and
time necessary for their development thus possibly creating conditions of neglect.
Access to adequate care and treatment is essential however there exist many barriers such
as lack of universal health screening, culturally competent assessments, as well healthcare
provider shortages. The most frequently cited barriers to treatment for women of low
socioeconomic status are lack of childcare, lack of transportation, lack of insurance, high out of
pocket expenses, lack of health literacy, and lack of financial flexibility (Abrams, Dornig, &
Curran, 2009). Additionally, women face issues related to the way in which care is delivered to
them in already familiar spaces.
Gaps in Care
The places where perinatal women of color and of low income receive care on public
health insurance, such as Medicaid and Medicare, is often limited to community clinics and/or
Federally Qualified Health Centers (FQHCs). Historically, FQHCs can be traced back to the
creation of community health centers during President Johnson’s war on poverty (Strelnick,
2005). Their initial purpose was to provide a safety net for those uninsured as well as indigent
including minorities and those of low socioeconomic status.
They have experienced much of their growth and expansion during the Obama
administration through the passing of the Affordable Care Act (ACA) with the idea that the
healthcare professionals providing care be individuals from the community that “resembled”, in
MATERNAL MENTAL HEALTH 12

ethnicity and cultural experience, those they provide care to. While these FQHCs are able to
provide invaluable care to the neediest of individuals and are located in underserved
communities, at present they are ill equipped to meet the complex needs of marginalized
populations such as the target population for this innovation. Additionally, a majority of health
care providers are not reflective of the community they serve, carry implicit bias, and often
experience a high turnover rate.
Proposed Innovation: FQHC+
The main aim of FQHC+, the innovation, is to enhance the current service delivery model
of maternal health treatment in an FQHC to improve health outcomes for women and their
babies. FQHC+ will accomplish this by addressing the complex unmet needs experienced by
perinatal women of color and of low income. It will work to reduce the barriers posed by
poverty, mental health stigma, and implicit bias through the addition of a mother’s milk bank/
breastfeeding support center. This center will provide breastfeeding education/lactation support,
formally trained peer support, culturally aware behavioral health counseling, and the opportunity
for women to sell their excess breastmilk in exchange for income.
Current Innovations
FHQC+ compares to a community program in Winter Garden, Florida by licensed
midwife Jennie Joseph. Ms. Joseph’s program stresses the importance of access and quality care
for women of color and of low socio-economic status. Her program, like FQHC+, does not turn
MATERNAL MENTAL HEALTH 13

women away for lack of insurance and/or payment and uses peer educators to establish
therapeutic relationships that guide them through their pregnancy journey and beyond. However,
FQHC+, is different as it provides formally trained peer educators as well as multidisciplinary
treatment from licensed healthcare professionals.
There are also similarities between FHQC+ and a breastfeeding support program at
Kaiser Permanente. This program identifies postpartum women, especially those with preterm
and/or low-birth weight babies and provides lactation support and increases the ability for them
to feed their babies. FHQC+ is unique in that it would provide access to women of color, of low
socioeconomic status, that do not have private insurance. Additionally, the practice of
breastfeeding through FQHC+ would be communal and encourage the natural exchanges and
dialogue between women that could prove to be extremely supportive during this delicate time
where many women who are depressed may isolate. This sense of community is a unique
feature that may draw in perinatal women of color. However, focus groups with both African-
American and Latina women will be held to explore attitudes, beliefs, practices around
breastfeeding and using breastmilk for monetary profit.
Conceptual Framework & Theory of Change
The theory of change behind this innovation is that an FQHC is an ideal setting to serve
this target population as research suggests that women of color already struggle to access,
initiate, and complete mental health treatment (Kozhimannil, Trinacty, Busch, Huskamp, &
MATERNAL MENTAL HEALTH 14

Adams, 2011). Interventions located in spaces where women are already receiving prenatal
services and are familiar and comfortable would increase the chances of their participation. This
innovation will also be effective because offering peer support is closely in line with
interventions that have shown success with Latina women in decreasing preterm births and low
birth weight of their newborns (Bill, Hock-Long, Mesure, Bryer, & Zambrano, 2009).
Theory of change for FQHC+ is grounded in the collaborative health model as it works
well when focusing on population care, is evidence-based, and currently used in integrated health
settings. Furthermore, this model is closely in-sync with healthcare’s “triple aim” of improving
health outcomes, improving quality of health, and reducing costs (Unutzer, Harbin, Schoenbaum,
& Druss, 2013). Outcomes expected from this innovation are reduced rates of depression (both
duration and intensity of symptoms) along with increased rates of full-term and “healthy” weight
babies.
On the innovation continuum, this intervention would be somewhere in between
incremental and disruptive as it will take at least a couple of years to run a pilot program and be
able to see positive outcomes. This capstone innovation will disrupt the societal norm that we do
not talk about our mental health for fear of judgment or being misunderstood. Research suggests
that African-American and Latina women experience an even higher level of stigma when it
comes to disclosing their mental health symptoms (Julion, 2018).
MATERNAL MENTAL HEALTH 15

FQHC+ is innovative for three reasons; one, being that at present there is no FQHC with
an attached mother’s milk bank. Second, because it will utilize (formally trained) peer support
as a targeted intervention to decrease mental health stigma among pregnant women and new
mothers and third, because it will also provide income for pregnant women and mothers through
selling of their breastmilk.
Problems of Practice and Solutions/Innovations
Explanation of Design
FQHC+ is a community-based clinic with innovative programs and multi-disciplinary in
its approach to improve pregnancy outcomes for both mothers and their babies. It would meet
the complex needs of perinatal women by providing “physical health” care by licensed medical
providers, “mental health” care by licensed behavioral health specialists, “socio-emotional” care
through formally trained and curriculum led peer support and socialization activities,
“nutritional” through lactation consultants, and “financial” through the mother’s milk bank
center. All providers will utilize an updated/enhanced electronic health record system (EHR)
and have the ability to cross-communicate, chart/document, complete assessments with patients
and make needed referrals as needed. Additionally, cultural humility training will be provided to
all health care providers with an aim to reduce implicit bias.
There will be multiple points of entry and all patients will be informed of in-house
services by intake/registration staff. During the intake process, demographics will be collected
MATERNAL MENTAL HEALTH 16

with special attention being placed on perinatal women’s resources and/or sources of income
along with their biopsychosocial functioning. Patients will be provided with clinic materials that
describe the different service locations and hours of service.
The implementation of FQHC+ will be facilitated through use of the Expert
Recommendations for Implementing Change (ERIC) project strategies. These strategies are
evidence-based, support adoption of innovations in the health care industry, and have been
agreed upon by both practitioners and researchers (Powell et al., 2015). Additionally, these
strategies have been categorized into nine clusters that serve to target important areas to be aware
of when trying to implement “change”.
The first phase of the project will consist of finding a local and existing FHQC that has a
need to improve current maternal health treatment and pregnancy outcomes, as well as a
significant number of the target population (perinatal women of color). The cluster strategy of
using evaluative and iterative strategies will be a primary focus during this time due to needing
to understand the context (FQHC) as well as the community that will promote the desired change
of improving health indicators and outcomes for the target population. This is also a phase were
all stakeholders including patients, consumers, and family members will voice their needs,
concerns, and ideas for change as the innovation is proposed. This will be achieved through use
of focus groups, formal meetings, and community outreach events. Feedback from these
MATERNAL MENTAL HEALTH 17

stakeholder groups will be continuous and frequent throughout implementation and sustainability
phases as quality improvement to meet the needs of the target population will be essential.
The second phase of the project will consist of the senior leadership team mandating the
change throughout the clinic and presenting data and feedback from the needs assessment, focus
groups, and stakeholder meetings. There will also be a focus on infrastructure modification of
the current FQHC will includes the addition of the mother’s milk bank support center, the
expansion of the current electronic health record system, and development of additional quality
monitoring systems. Identifying and training new leadership, champions, and all health care
providers and staff will also be an effective strategy before full operation begins.
The third phase of the project includes clinician support cluster strategies that will
provide real time data of their provided services and milk bank support activities, continued
training and supervision, along with engaging patients to increase use and satisfaction of
services. Essentially, this implementation phase is vital to the innovation’s sustainability.
The fourth phase of the project will utilize a majority of ERIC cluster strategies which include
using evaluative and iterative strategies, further engagement of patients, and working with
stakeholders as well as beginning to work with an educational institution. During this stage,
there should be sufficient data to show the impact of the innovation on improving pregnancy and
health outcomes. Moreover, FQHC+, will be able to serve as a model for other FQHCs in the
MATERNAL MENTAL HEALTH 18

county. The use of an expanded collaborative model as proposed with FQHC+ could also inform
future social work and medical education curriculum.
Justification of Innovation
FQHC+ is the best solution for this social problem in an FQHC setting as it would
directly target the issues of mental health stigma, implicit bias, and poverty which continue to go
unaddressed or underserved for the target population. Given that living in poverty may be the
greatest predictor of developing a maternal mental health disorder in the U.S. (Children’s
Defense Fund, 2011), this innovation providing women with a source of income will yield
immense benefits. Furthermore, this innovation will be brought to the target population versus
the target population having to explore and/or travel new unfamiliar spaces. Lastly, facilitators
for this innovation include readily available data of health disparities at current FQHCs and other
community clinics as well as available funding through the Health and Resources Services
Administration (HRSA) with a focus on improving the care for this population.
Goals: Proposed Impact
Initially, the goal of this innovation is to improve health indicators for pregnant women
of color and their babies given that they are experiencing great disparities with their Caucasian
counterparts. Specifically, the proposed impact is also to normalize conversations around
maternal mental health and increase access/reduce barriers to care. Alongside this goal, lies the
component of addressing the implicit bias of health care providers in the provision of perinatal
MATERNAL MENTAL HEALTH 19

services through the use of cultural humility training. Thus, the overall proposed impact of this
innovation is not just to improve metrics but to change the current culture in FQHCs and to
empower perinatal women of color through a combination of education, emotional support,
mental health intervention, and increased income.
Evidence or Data to Show Impact
The initial scope of the project will be a 21-month pilot in order to capture the outcomes
and impact of this program from the time a woman conceives up to one year postpartum. During
this pilot, key benchmarks will be the following: at end of three months at least 160 lactation
classes will have been provided to perinatal women, 15 socialization activities, and 18 support
group sessions. At end of six months health symptoms for perinatal women will have been
reduced by almost 50% and women will have had their income increase by at least 25% through
the selling of their breastmilk. At the end of one year, women’s pregnancy outcomes will have
improved by 20%. Overall program success metrics will be the following: 85% reduction in
pregnancy complications, 90% reduction in maternal deaths, 85% reduction in preterm and low-
birth weight babies, and 60% sustained reduction in mental health symptoms.
MATERNAL MENTAL HEALTH 20

Logic Model

Explanation of How the Proposed Solution Will Improve Grand Challenge Area
FQHC+ is uniquely poised to be in line with the grand challenge of closing the health
gap. Specifically, FQHC+ will improve the pregnancy outcome disparities between perinatal
women of color and Caucasian perinatal women. It will address gaps caused by socioeconomic
differences; FQHC+ will have a direct impact on increasing the income available to perinatal
women of color. In addition, FQHC+ will improve the quality of overall health care received by
perinatal women of color, which remains a significant gap in the public health care system.
MATERNAL MENTAL HEALTH 21

Moreover, advocacy work will take place with HRSA to require FQHCs to integrate the
FQHC+ model as part of their routine care around the country. As HRSA is the primary funder
for an FQHC, this upstream disruption will ensure the replicability and scaling of the current
project. FQHC+ will provide a set manual and curriculum and be available for technical
assistance for further consultation.
Feedback from Multiple Stakeholders on Proposed Solution and Feasibility
Primary research interviews with local perinatal women and medical providers
demonstrated that it is very difficult to find supportive programs in the community for perinatal
women. Women reported that they would be more likely to participate in services that were in
the clinic they received care or was nearby as transportation would not be an added barrier
(Sotelo, 2018). Thus, FQHC+ with its emphasis on all services under one roof and being a
familiar space is surely to contribute to decreasing barriers to care for the target population.
Internal stakeholders include the board of directors, administration/leadership members,
and staff consisting of health care providers and their support staff as well as patients. Each of
these groups individually and collectively have the potential to affect FQHC+ positively and
negatively. The board of directors can impact the intervention positively in that it would be able
to see “the big picture” of the aims of the innovation with improving pregnancy, health, and life
outcomes for the perinatal population. It would also be able to exert accountability, follow-
through, and evaluation of effectiveness of the program. On the other hand, if the board of
MATERNAL MENTAL HEALTH 22

directors is not aligned with the intervention, they may want to set financial limits and be more
conservative with staffing and programming.
Health care providers and their support staff will often want to place the needs of the
patients above else. This will be positive in gaining initial “buy-in” for FQHC in terms of them
encouraging patient participation and in decreasing barriers for them to access the intervention
services. However, on the negative side, they may go back to working in their “silos” after the
initial pilot study or may experience a lot of turnover whereby essential staff that was
knowledgeable of the interventions are no longer there to provide the much-needed pipeline and
referrals for the intervention.
Key external stakeholders are government and state funders such as HRSA & Medi-Cal
as well as non-governmental funders, community members and residents. Government funders
could be supportive financially as they currently are in FQHCs as well as positive impact the
intervention if they felt the intervention was closely in line with their ultimate goal of reducing
health care costs while improving the lives of individuals and populations. Government funders
will also place constraints as to how funds may be spent, which type of staff may be hired, and
be focused on sustainability plans for the interventions but overall, they may be the primary
funder for the intervention until the for-profit portion of the intervention is successful.
Community members & residents could also have a positive and negative influence on
the innovation. Community members from organizations that have served as partners in the past
MATERNAL MENTAL HEALTH 23

may want to solidify relationships in order for FHQC+ to provide services that would help them
meet their own goals. Given the focus and growth of health neighborhood initiatives in Los
Angeles County, community members may see the value of investing their own funding or
advocating on behalf of FQHC+ for funding via the Department of Mental Health and/or the
California Endowment. On the other hand, community members who do not see the value of
FQHC+ or view it as competition may decrease their support and participation and/or play a role
in deterring patients from enrolling in services.
Residents of the community could have a positive influence on the intervention if they
were to become patients through their participation and satisfaction of services. If they are not
patients they could have a family member or a friend be a member and thus form an opinion on
the value of the innovation. Residents have voting power and can influence local legislation to
support or abandon investing in a local community clinic, like an FQHC.
Analysis of How FQHC+ is Positioned within History, Policy, and Public Knowledge
Maternal health has been identified as a global public health issue that is closely aligned
with the sustainable development goals (SDGs) set forth by the United Nations (Graham et al.,
2016) to reduce inequities such as poverty and disease. While there are no federal mandates
regulating maternal mental health screenings in the United States, several states have adopted
legislation to require screening, awareness campaigns, and task forces focused on maternal
mental health (Rhodes & Segre, 2013). At the federal level, the Patient Protection and
MATERNAL MENTAL HEALTH 24

Affordable Care Act, provides support for screening, improved service delivery, and research on
postpartum conditions (Santoro & Peabody, 2010).
National research has also found that “the annual cost of not treating a mother with
depression is $7,200 in lost income and productivity” (Diaz & Chase, 2010). Untreated maternal
depression has also been found to increase health care costs as lingering depression past the post-
partum stage can contribute to illnesses such as heart disease, stroke, and type II diabetes
(Bowers et al., 2013; Farr et al., 2011; Mezuk et al., 2008; Pan et al., 2011). These are examples
of public knowledge driving changes in legislation and legislation, in turn, influencing public
knowledge. FQHC+ is positioned to increase public knowledge of pregnancy health disparities
and bring further awareness to mental health stigma. Moreover, FQHC+ will provide valuable
administrative data that may also increase support for further policy changes and mandates for
FQHCs, community clinics, and other health spaces to recognize cost saving interventions that
can improve health.
Description of Political, Organizational and Community Allies
The current political climate is positive for this type of innovation at the federal and state
level. In 2016, the Bringing Postpartum Depression Out of the Shadows Act passed authorizing
the HRSA to manage $5 million for state grants to “establish, improve, or maintain” programs
aimed at screening, increasing access and treatment of maternal mental health. More recently,
California passed three bills mandating mental health screening by obstetrician (OB) providers,
MATERNAL MENTAL HEALTH 25

mental health training to clinical staff in hospitals, and improved maternal care via public health
departments.
Currently, California Senator Kamala Harris and New York Senator Kirsten Gillibrand
have introduced two bills focusing on maternal health. Ms. Harris’s bill specifically targets the
health disparities experienced by pregnant African-American women and women on Medicaid.
This bill, currently in the House of Representatives, if passed, would support FHQC+.
Initial collaborators would include federal, state, and community partners such as HRSA’s
Maternal and Child Health Bureau; Centers for Medicaid and Medicare Services (CMS); The
Administration of Children and Family; FQHCs; California Task Force on The Status of
Maternal Mental Health Care; California Primary Care Association; Community Clinic
Association of Los Angeles County; Public Health Department and Women, Infants, and
Children (WIC) program. Most of these partners have the same goal for providing positive
health outcomes however there may be differences as to how they go about doing so.
Specifically, most medical settings that serve low-income patients such as those that use
Medicaid and Medicare often have high productivity standards (number of patient visits per day)
for their providers which usually translate to very little time to spend with patients during their
visits. This is especially detrimental for pregnant women as they require a higher level of care
and screening for mental health conditions. FQHC+ would provide additional interventions
needed for this population that medical providers would be unable to give.
MATERNAL MENTAL HEALTH 26

Description of Political, Organizational, and Community Obstacles
One obstacle at the political level is lack of federal legislation requiring perinatal mental
health screenings. As of 2018, only five states have legislation to mandate screening of perinatal
mental health disorders/maternal mental health disorders (Yu & Sampson, 2016). A second
barrier is inconsistent monitoring and review. A majority of American health plans utilize the
Healthcare Effectiveness Data and Information Set (HEDIS) as a tool to measure performance on
various health measures such as diabetes, hypertension and cervical cancer, however, there are
no measures on perinatal mental health screening and treatment per trimester. This creates a lack
of incentive for medical providers, primary care clinics, and hospitals to prioritize maternal
mental health.
One barrier in the organizational context is role specialization. FQHC+ needs lactation
consultants and formally trained peer support workers as part of the intervention. At this time,
lactation consultants and peer support workers are not typically on staff at FQHCs. Furthermore,
how well peer support workers may be able to integrate to a team with medical providers may be
more difficult than expected due to differences in level of education and socioeconomic status.
An obstacle at the community level may be the unfamiliarity of breast milk banks as they
do not typically exist as part of the local health system. This lack of knowledge and exposure
may translate into lack of trust for the target population. Additionally, the novelty of a breast
MATERNAL MENTAL HEALTH 27

milk center/mother’s milk bank may also be a barrier when wanting to create partnerships in the
community.
Analysis of Alternative Pathways
Community education and participation is a key piece to this innovation being successful.
If lack of engagement and participation become an issue, focus groups with both African-
American and Latina women will be held to explore attitudes, beliefs, practices around
breastfeeding and using breastmilk for monetary profit. Community education through outreach
efforts will also work dispel myths, social stigmas, and/or uncomfortable feelings surrounding
the selling/buying of breastmilk as well as to ensure women that all safeguards have been taking
to ensure the breastmilk is free of any harmful substances to their newborns.
Since the overall goal of FQHC+ is to improve the pregnancy, health and life
outcomes of women and their babies, an alternative pathway could be to increase focus on
reducing the implicit bias of health care professionals and their support staff. This could include
a variety of different training modalities as well as working to improve the overall culture of the
FQHC. One alternative could be to utilize the peer support role in a variety of different ways
such as an advocate in “real time” when the perinatal woman attends her OB appointment. This
could increase the comfort level of the patient while also serving as a cultural interpreter for the
health care professional.
Project Structure, Methodology, and Action Components
MATERNAL MENTAL HEALTH 28

Implementation Plan and Timeline
Implementation of FQHC+ is not only guided by the aforementioned ERIC project
strategies but also by the Exploration, Preparation, Implementation, & Sustainment (EPIS)
framework developed by Aarons, Hurlburt, & Horwitz in 2011. In this conceptual model, four
phases (Exploration, Preparation, Implementation & Sustainment) are analyzed at two main
levels, the inner and outer context. The outer context explores important factors such as federal
legislation and sociopolitical funding outside of the FQHC while the inner context explores
factors within the FQH such as climate, culture, and leadership.
It is through the analysis of both contexts that barriers and/or facilitators for
implementation are identified. The EPIS framework is an ideal choice for this innovation as this
model has been used to implement new practices in medical settings (Aarons, Hurlburt, &
Horwitz, 2011; Becan et al. 2018). An EPIS model table (Appendix A) and a Gantt chart
(Appendix B) are included to illustrate steps needed to be performed at each stage of
implementation over the course three years.
Exploration phase.
This first stage of implementation is focused on organizational challenges while
exploring new strategies, approaches, and/or innovations that would improve current practices to
obtain desired health outcomes (Aarons, Hurlburt, & Horwitz, 2011). This phase would begin at
the start of the project in 2019 and end in December of that year. During this time period, the
MATERNAL MENTAL HEALTH 29

implementation team would conduct a local/community needs assessment of an existing FQHC
who has identified health disparities within the target population along with an assessment inside
the organization to determine readiness for change along with barriers and facilitators.
Additional steps during this phase include involving patients, health care providers, and other
essential stakeholders to give them a voice in choosing the FQHC+ innovation.
Preparation phase.
This second stage of implementation refers to when a decision has been made to adopt a
certain intervention, strategy, or approach (Aarons, Hurlburt, & Horwitz, 2011). At this stage,
FQHC+ would have been chosen as the optimal intervention for improving maternal mental
health outcomes. During this phase, FQHC leadership mandating change throughout the agency
would be the first step towards implementation. Additionally, identifying and preparing a
champion within the OB/GYN department would be extremely important as this individual will
be an influencer of the project with other medical providers.
This would also be a time of significant physical restructuring as the breastmilk support
center would be built, new clinical teams would be created to include an OB provider, a licensed
clinical social worker, a lactation consultant, and a peer support worker, and initial funding
through HRSA would be applied to support construction and the hiring of additional staff. The
electronic health record system would also undergo expansion as new workflows are created and
new indicators identified for tracking purposes. Educational materials would be created for
MATERNAL MENTAL HEALTH 30

dissemination by administrators, medical providers, as well as patients. The chief financial
officer would be in charge of working with the billing department to place the innovation on a
new fee for service list. Overall, an initial and formal implementation blueprint would be created
and shared among all sectors of the organization. This phase would cover the entirety of the year
2020.
The preparation phase would also include the building of a coalition composed of
members from the FQHC, other community member, community clinic association management
and service providers, along with milk banking experts/advisors. These partnerships will support
the innovation through the implementation stage and beyond. They will also be an essential part
of resource sharing and supporting with quality assurance monitoring.
Implementation phase.
This third phase of EPIS is marked by active implementation of the innovation and tests
the factors identified during preparation (Aarons, Hurlburt, & Horwitz, 2011). At this stage, the
attached breastmilk bank center would be fully operational and adequately staffed with a
significant number of the target population enrolled in services. At this point, additional funding
through Bringing Postpartum out of the Shadows Act would be applied for, along with the Title
V Maternal and Child Health block grant, and initial revenue from reimbursable visits and would
be utilized for additional scale up. This period would also mark a time where FQHC+ may have
MATERNAL MENTAL HEALTH 31

bought a significant amount of breastmilk from postpartum women that it would engage in
selling to other clinics and milk banks for additional revenue.
Clinician support and additional/ongoing training is also an essential component of this
phase as demand for services grow. The marketing department would be responsible for
promoting the innovation through use of mass media including social applications. Most
importantly, it is during this phase that initial outcomes of the implementation could be analyzed
and adjustments/adaptions could be made to further meet the needs of the target population. This
phase also encompasses the majority of the year 2020 into 2021.
Sustainment phase.
The fourth and final phase of EPIS includes the “continued use and/or maintenance” of
the innovation in the organization (Aarons, Hurlburt, & Horwitz, 2011). At this stage, the pilot
would have ended and outcomes for at least one cohort of the population receiving the
innovation would have graduated from the program. Implementation steps in this phase would
take place in year 2020 and 2021. At this stage, health care providers that are part of this
innovation would be provided incentives. Patient feedback would also continue to be an
important component in this phase as we would want to address any additional barriers to care.
Promoting adaptability is an important activity during this stage as the innovation
continues to be refined. Also, given that outcomes are positive and close to what they are
expected informing local opinion leaders and other community clinics in the county would be
MATERNAL MENTAL HEALTH 32

highly beneficial for continued funding and promotion. A long-term aim of FQHC+ could be
collaboration with educational institutions whereby health care providers such as medical
doctors, nurse practitioners, physician assistants, and licensed clinical social workers could do
their internships/practicums at FQHC+ and thus increase a workforce that is trained in this
innovation model.
Details of Financial Plans and Staging
The foundation of FQHC+’s financial plan is a line budget format with an annual fiscal
year that starts in October and ends in September. During the pilot year, revenue will consist of
$1.5 million from the California Endowment (Appendix C). This funding will be essential in
order to hire qualified personnel, remodel clinic space for the addition of a functional breastmilk
bank, as well as expand the electronic health record system to accommodate new workflows and
data collection. Additionally, it is during the pilot year that additional fundraising and
partnerships will be created to obtain additional funding for the full operation of FQHC+.
During the fully operational fiscal year of 2021 (Appendix D), additional revenues will
come from donor contributions, a grant from HRSA, a government contract with the Women,
Infants, and Children (WIC) program, as well as revenues from fee-for-service Medi-Cal visits
and breastmilk sales. It is expected that as the target population increases participation and
utilizes the services of the mother’s milk bank that revenues will continue to increase.
MATERNAL MENTAL HEALTH 33

Moreover, as FQHC+ gains trust and visibility among other community clinics and hospitals;
breastmilk sales will also increase from the projected $125,000.
If funding is not able to be secured from the Maternal and Child Health Block Grant,
FQHC+ will proceed with partial innovation to include the additional formally trained peer
support workers and lactation consultants. A focus would then be to increase revenue via
billable visits as well as through the California Endowment and private donors. Subsequently,
another HRSA grant would be applied to in order to collect funds for the addition of the mother’s
milk bank/ breast feeding support center.
Description of Measurement of Outcomes Using Data or Community Input
Depression treatment outcomes will be measured with a Patient Health Questionnaire-9
(PHQ-9). This validated screening tools is routinely used in primary medical clinics and includes
the minimum five symptoms of depression needed to make a diagnosis of Major Depressive
Disorder in the DSM-5 (Spitzer, Kroenke, & Williams, 1999). This tool will be used every two
weeks from the beginning of participation in the program up to one year post-partum. Pregnancy
outcomes will also be measured from data collection in the Electronic Health Record (EHR)
system. Specific pregnancy outcomes are newborn birth weight and length of pregnancy defined
as 37 weeks’ gestation.
Quantitative data such as depression score, newborn birthweight, and gestational age at
birth will be analyzed before and after FQHC+ participation. Significant findings would be 50%
MATERNAL MENTAL HEALTH 34

overall reduction in depression score and pregnancy outcomes i.e. higher birth weights and full-
term babies. Initially, a pilot study that follows a perinatal woman from the first trimester up to
one year post-partum will lend important data for further analysis of the complex interplay of
race, gender, and perinatal care. Anticipated longer term impacts of FQHC+ will include an 85%
reduction in pregnancy complications, a 90% reduction in maternal death, an 85% reduction in
preterm births and low-birth weight babies, and a 60% (sustained) reduction in mental health
symptoms for the target population receiving the innovation. The collection of qualitative data
will also be explored through the creation and administration of patient satisfaction surveys and
input from focus groups. Semi-structured interviews with different members of the care team
with also provide additional input.
Plan for Stakeholder Involvement that Includes Relevant Constituencies
Ideally, multiple stakeholders from various levels of participation including the
organization and the community would be able to share data, anecdotal information, and have a
platform for much needed advocacy for the target population through neighborhood council
meetings. These meetings would be spearheaded by the local health consortium and FQHC+ and
take place on a bi-monthly basis. Consumers of the program would be welcomed into the group
and their participation encouraged. Feedback would be gathered through online surveys, in-
person discussion, and ongoing recommendations for quality assurance and quality
improvement.
MATERNAL MENTAL HEALTH 35

Communication Plan and Strategies that will Engage Audiences
Communication plans will occur at all major phases of the innovation. During the pre-
phase of implementation, a needs assessment will be conducted along with consumer meetings.
Flyers would be distributed among patients of the FQHC as well as community partners.
Internally, FQHC+ would hold meetings with health care professionals proposing the innovation
and encourage them to provide their readiness for change and their willingness to undergo
additional training and multidisciplinary collaboration.
During the second phase of communication, funding would have been secured and
feedback from the aforementioned stakeholders would have been assimilated. A coalition made
up of FQHC+ health care professionals and administration members would have been formed at
this point as well as an ethics advisory board in order to guide implementation. It is also during
this phase that real time problem-solving would take place and consumer feedback would be
essential.
The third phase of communication, involves sustainability. At this point, program
evaluation would have taken place at FQHC+ and data could be shared with local opinion
leaders, the Community Clinic Association of Los Angeles County, as well as HRSA. This
period is marked by scaling of the innovation beyond the local community into the National
landscape. Multiple forms of media campaigns will be utilized to spread the innovation.
Dissemination Plan for Broader Impact
MATERNAL MENTAL HEALTH 36

National efforts to spread the innovation would include publishing program evaluation
results in peer reviewed journals, submitting Op-Eds, attending national conferences, and
beginning to cross national geographical boundaries. At the international level, social media
campaigns could prove powerful in reaching even the most remote of places. The uniform
message that would be stressed would be that every mother counts and maternal mental health
matters not just for mothers and babies but for all citizens of the world. Building a strong
relationship with the World Health Organization would be vital as well as reframing maternal
mental health and women’s rights as a human rights issue.
Ethical Concerns and Possible Negative Consequences
Possible ethical concerns include perinatal women feeling their bodies are being
exploited for profit and/or perinatal women may endanger their own newborn by selling breast
milk for profit. In order to prevent such actions and to ensure participation and utilization of
these services, there will be several safeguards such as an ethics advisory board, a health
committee, informed consent, licenses regulating handling, collection, and distribution of breast
milk required by the State of California and the Human Milk Banking Association of North
America. There will also be an overall emphasis that breast milk bought by FQHC+ will firstly
be made available to other underserved communities in Los Angeles and neighboring counties.
Summary of Project Plans and Conclusions
MATERNAL MENTAL HEALTH 37

The process of innovation and implementation is an iterative one. While frameworks
such as EPIS and strategies from the ERIC project are useful and guide the implementation
process, innovations that target underserved and marginalized populations must have flexibility
and adaptability to meet the unmet needs of these patients. Innovators and practitioners should
also strive to include the voices of these patients in order to instill ownership and true
participation. It is important to note that innovations do not happen in vacuums and they have
the potential to bring about many changes in a community. FQHC+’s vision is to go beneath the
surface of health disparities and target the socioeconomic inequalities experienced by perinatal
women of color.
Conclusion, Actions, & Implications
Implications of FQHC+: Practice or Policy Improvement
Health inequities and gaps in maternal mental health treatment are not only detrimental to
the mother and fetus but are also an issue of social justice. Untreated maternal mental health
disorders place women at higher risk of developing substance abuse disorders, having a higher
likelihood of contact with the child welfare and criminal justice systems, as well as prevents
them from fully participating in society. Untreated maternal mental health disorders are also
very costly to communities, States, and the Nation and have lasting negative effects on women,
their children, and their families.
Federal legislation is lacking in setting a universal mandate to require the screening,
MATERNAL MENTAL HEALTH 38

reporting, monitoring, and treatment of maternal mental health conditions thereby allowing
medical insurance companies, including Medicaid and Medicare, to continue operating without
prioritizing maternal mental health treatment. FQHC+ has the potential to positively impact
legislation as well as the centers for Medicaid and Medicare (CMS) and HRSA to improve
overall practice. The possibilities to impact global maternal mental health care is also vast
through partnership with the World Health Organization as overall maternal health has been
identified as an area of focus.
Acknowledgement of Limitations and Risks: Recommendations for Future Work
FQHC+ has various limitations in its concept and implementation. The concept of
selling breastmilk may be too novel for the target population thus eliciting fear or mistrust. This
of course must be acknowledged and validated. One specific way to garner trust would be
through a media campaign composed of perinatal women’s “testimonies” as to how breastmilk,
both the buying and selling, has been beneficial and even life-saving for their premature babies.
A limitation of implementation would be not being able to move the project forward with
all three important constituents which include clinic administration, health care providers, and
the patients themselves. Clinic administrators often have to be balance quality versus revenues;
if FQHC+ does not have cost benefit it may not be allowed to move forward. Health care
providers would also need to be on board in order to want to take part in the implementation
process and lastly the patient’s must believe that the intervention can be beneficial for them.
MATERNAL MENTAL HEALTH 39

Moving forward with implementation would thus require careful consideration and engagement
of all three groups in the process.
One of the strongest foundations for FQHC+ will be its ability to provide patients care
from providers that are bicultural and bilingual. This is very challenging as there are limited
mental health providers of color especially African-American. This highlights a bigger
challenge that could be addressed with training and graduate programs of these providers to start.
Furthermore, FQHC+’s limitation lies in that it is an innovation in the public sector
versus the private sector. While poverty is one of the greatest predictors of developing a
maternal mental health disorder, these disorders also occur in populations of perinatal women of
higher socioeconomic classes. A recommendation for future work is to continue identifying and
creating methods, innovations, and practices that reduce the overall mental health stigma that
maternal mental health disorders carry. If perinatal women do not feel comfortable enough to
speak up the method of intervention may not have as much of an impact as initially intended.
Next Steps for Advancing DSW Capstone Project
Advancing FQHC+ will consist of a series of steps such as contacting the local FQHC
located in the Pico-Union area of Los Angeles, County. This location has been identified due to
the large presence of the target population of perinatal women of color and of low
socioeconomic status. Administration and leadership of this local FQHC will be contacted in
order to propose the innovation. Materials provided to them will include this paper, an in-person
MATERNAL MENTAL HEALTH 40

presentation, and a prototype in the form of a grant proposal (Appendix E) to a local healthcare
organization.
Upon review and approval to move forward. The prototype/grant proposal will be
submitted for initial funding of the pilot project. The pilot year will consist of the addition of the
physical structure that is the mother’s milk bank/ breastfeeding support center. Additionally, the
hiring of staff such as a lactation consultant, milk bank laboratory techs, and peer support
workers. After the pilot project yields positive and expected outcomes, FQHC+ will grow in
capacity as well as ensuring its sustainability.

MATERNAL MENTAL HEALTH 41

References

Aarons, G., Hurlburt, M., & Horwitz, S. (2011). Advancing a Conceptual Model of Evidence-
Based Practice Implementation in Public Service Sectors. Administration and Policy in
Mental Health and Mental Health Services Research, 38(1), 4–23
Abrams, L., Dornig, K., & Curran, L. (2009). Barriers to Service Use for Postpartum Depression
Symptoms Among Low-Income Ethnic Minority Mothers in the United
States. Qualitative Health Research, 19(4), 535-551.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Becan, J., Bartkowski, J., Knight, D., Wiley, T., DiClemente, R., Ducharme, L., Welsh, W.,

Bowser, D., McCollister, K., Hiller, M., Spaulding, A., Flynn, P., Swartzendruber, A.,

Dickson, M., Fisher, J., Aarons, G. (2018). A model for rigorously applying the

Exploration, Preparation, Implementation, Sustainment (EPIS) framework in the design

and measurement of a large-scale collaborative multi-site study. Health & Justice, 6(1),

1–14.

Bill, D. E., Hock-Long, L., Mesure, M., Bryer, P., & Zambrano, N. (2009). Healthy Start

Programa Madrina: A Promotora Home Visiting Outreach and Education Program to

Improve Perinatal Health among Latina Pregnant Women. Health Educator, 41(2), 68-

76.
MATERNAL MENTAL HEALTH 42

Braithwaite, R. L., Treadwell, H. M., & Arriola, K. R. J. (2008). Health Disparities and
Incarcerated Women: A Population Ignored. American Journal of Public
Health, 98(Suppl 1), S173–S175.
Bowers, K., Laughon, S. K., Kim, S., Mumford, S. L., Brite, J., Kiely, M., & Zhang, C. (2013).

The association between a medical history of depression and gestational diabetes in a

large multi-ethnic cohort in the United States. Pediatric and Perinatal Epidemiology,

27(4), 323–328.

Byatt, N., Levin, LL., Ziedonis, D., Moore, Simas TA, & Allison, J. (2015, November).

Enhancing participation in depression care in outpatient perinatal care settings: A

systematic review. Obstetrics & Gynecology, 126(5), 1048-1058.

Chapman, D., Whitfield, C., Felitti, V., Dube, S., Edwards, V., & Anda, R. (2004). Adverse
childhood experiences and the risk of depressive disorders in adulthood. Journal of
Affective Disorders, 82(2), 217-25.
Cummings, E. M., Schermerhorn, A. C., Keller, P. S., & Davies, P. T. (2008). Parental
depressive symptoms, children’s representations of family relationships, and child
adjustment. Social Development, 17, 278–305.
Diaz, J. Y., & Chase, R. (2010). The cost of untreated maternal depression. St. Paul, MN: Wilder

Research.

Dolbier, C., Rush, L., Sahadeo, T., Shaffer, E., & Thorp, L. (2013). Relationships of Race and
MATERNAL MENTAL HEALTH 43

Socioeconomic Status to Postpartum Depressive Symptoms in Rural African American

and Non-Hispanic White Women. Maternal and Child Health Journal, 17(7), 1277-

1287.

Elgar, Frank J., Mills, Rosemary S. L., McGrath, Patrick J., Waschbusch, Daniel A., &
Brownridge, Douglas A. (2007). Maternal and Paternal Depressive Symptoms and Child
Maladjustment: The Mediating Role of Parental Behavior. Journal of Abnormal Child
Psychology, 35(6), 943-955.
Farr, S., Hayes, D., Bitsko, R., Bansil, P., & Dietz, P. (2011). Depression, diabetes,

and chronic disease risk factors among US women of reproductive age. Preventing

Chronic Disease, 8(6), A119.
Ferszt, G., & Clarke, J. (2012). Health care of pregnant women in U.S. state prisons. Journal of
Health Care for the Poor and Underserved, 23(2), 557-569.
Fresno, U. (2015). The American College of Obstetricians and Gynecologists Committee

Opinion no. 630. Screening for perinatal depression. Obstetrics and gynecology, 125 5,

1268-71.

Gavin, A., Melville, J., Rue, T., Guo, Y., Dina, K., & Katon, W. (2011). Racial differences in the
prevalence of antenatal depression. General Hospital Psychiatry, 33(2), 87–93.
MATERNAL MENTAL HEALTH 44

Goodman, S. H., & Gotlib, I. H. (1999). Risk for psychopathology in the children of depressed
mothers: A developmental model for understanding mechanisms of transmission.
Psychological Review, 106(3), 458–490.
Graham, Woodd, Byass, Filippi, Gon, Virgo, Singh. (2016). Diversity and divergence: The
dynamic burden of poor maternal health. The Lancet, 388(10056), 2164-2175.
Julion, W. (2018, January 11). Black mothers are dying: the toll of racism on maternal health.
Statnews.com. Retrieved from https://www.statnews.com/2018/01/11/racism-maternal-
health-erica-garner/?utm_campaign=rss.
Kozhimannil, K., Trinacty, C., Busch, A., Huskamp, H., & Adams, A. (2011, June). Racial and

Ethnic Disparities in Postpartum Depression Care Among Low-Income

Women. Psychiatric Services, 62(6), 619–625.

Li, D., Liu, L., & Odouli, R. (2009). Presence of depressive symptoms during early pregnancy
and the risk of preterm delivery: A prospective cohort study. Human Reproduction,
24(1), 146–153.
Lim, J., Wood, B. L., & Miller, B. D. (2008). Maternal depression and parenting in relation to
child internalizing symptoms and asthma disease activity. Journal of Family Psychology,
22, 264–273.
MATERNAL MENTAL HEALTH 45

Many Women Do Not Disclose Postpartum Mood Symptoms, Survey Finds. (2017, August 17).
APA Psychiatric News. Retrieved from:
https://static1.squarespace.com/static/56d5ca187da24ffed7378b40/t/59b8bc24268b96a33
7f932cd/1505279012952/Many+Women+Do+Not+Disclose+Postpartum+Mood+Sympt
oms+Survey+Finds.pdf
Maternal mental health. (n.d.). Retrieved February 11, 2018, from World Health Organization
Website: http://www.who.int/mental_health/maternal-child/maternal_mental_health/en/
Mclemore, M., Altman, M., Cooper, N., Williams, S., Rand, L., & Franck, L. (2018). Health care

experiences of pregnant, birthing and postnatal women of color at risk for preterm

birth. Social Science & Medicine, 201, 127–135.

Mezuk, B., Eaton, W. W., Albrecht, S., & Golden, S. H. (2008). Depression and type-2 diabetes

over the lifespan: A meta-analysis. Diabetes Care 31, 2383–2390.

National Institutes of Health. (2014). Health disparities. Retrieved from http://www.nhlbi.nih

.gov/health/educational/healthdisparities

Orchard, J., & Price, J. (2017). County-level racial prejudice and the black-white gap in infant
health outcomes. Social Science & Medicine, 181, 191–198.
MATERNAL MENTAL HEALTH 46

Orr, S. T., James, S. A., & Blackmore Prince, C. (2002). Maternal prenatal depressive symptoms
and spontaneous preterm births among African-American women in Baltimore,
Maryland. American Journal of Epidemiology, 156, 797–802.
Pan, A., Sun, Q., Okereke, O. I., Rexrode, K. M., & Hu, F. B. (2011). Depression and risk of
stroke morbidity and mortality: A meta-analysis and systematic review. Journal of the
American Medical Association, 306, 1241–1249.
Powell, B. J., Waltz, T. J., Chinman, M. J., Damschorder, L. J., Smith, J. L., Matthieu, M. M., &
Kirchner, J. E. (2015). A refined complication of implementation strategies: results from
the Expert Recommendations for Implementing Change (ERIC) project. Implementation
Science, 10, 21.
Raising Our Voices for Maternal Health. (2017). Retrieved from
https://s3.amazonaws.com/s3.momsrising.org/images/Birth_Story_Book_Feb_2017.pdf

Rhodes, A. M., & Segre, L. S. (2013). Perinatal depression: A review of US legislation and law.
Archives of Women’s Mental Health, 16(4), 259-
270. doi: http://dx.doi.org/10.1007/s00737-013-0359-6
MATERNAL MENTAL HEALTH 47

Sanchez-Vaznaugh, E., Braveman, P., Egerter, S., Marchi, K., Heck, K., & Curtis, M. (n.d.).
Latina Birth Outcomes in California: Not so Paradoxical. Maternal and Child Health
Journal, 20(9), 1849–1860
Santoro, K., & Peabody, H. (2010, June). Identifying and Treating Maternal Depression:
Strategies & Considerations for Health Plans(Issue Brief). Retrieved from
https://d3n8a8pro7vhmx.cloudfront.net/camaternalmentalhealth/pages/53/attachments/ori
ginal/1434943734/FINAL_MaternalDepression6-7.pdf?1434943734
Spitzer, R., Kroenke, K., & Williams, J. (1999). Validation and Utility of a Self-Report
Version of PRIME-MD. JAMA, 282(18), 1737-1744.
Sotelo, S. (2018). Innovation brief. Unpublished paper submitted for SOWK 723, Innovation
Laboratory II, Summer 2018, DSW Curriculum, University of Southern California.
Unutzer, J., Harbin, H., Schoenbaum, M., Druss, B. (2013, May). The Collaborative
Care Model: An Approach for Integrating Physical and Mental Health Care in Medicaid
Health Homes. Retrieved from
https://www.chcs.org/media/HH_IRC_Collaborative_Care_Model__052113_2.pdf
Strelnick, A. (2005). Increasing access to health care and reducing minority health disparities: a
brief history and the impact of community health centers.(Increasing Access to Health
Care: Methods to Address the National Crisis). New York University Journal of
Legislation and Public Policy, 8(1 2).
MATERNAL MENTAL HEALTH 48

U.S. Department of Health and Human Services, Office of Women’s Health. (2009). Depression
during and after pregnancy fact sheet. As of June 12, 2017:
http://www.womenshealth.gov/publications/our-publications/fact-sheet/depression-
pregnancy.html
World Health Organization. (2012). Born Too Soon: The Global Action Report on Preterm
Birth.Retrieved from
https://www.who.int/pmnch/knowledge/publications/preterm_birth_report/en/index3.htm
l
Zestcott, C., Blair, I., Stone, J., & Kwan, V. (2016). Examining the presence, consequences, and
reduction of implicit bias in health care: A narrative review. Group Processes &
Intergroup Relations, 19(4), 528–542.
Yu, M., & Sampson, M. (2016). Closing the Gap between Policy and Practice in Screening for
Perinatal Depression: A Policy Analysis and Call for Action. Social Work in Public
Health,31(6), 549-556.

MATERNAL MENTAL HEALTH 49

Appendix A

EPIS Model for Implementation of FQHC+

First Phase Second Phase Third Phase Fourth Phase
Exploration Preparation Implementation Sustainment
Outer
Context-
Barrier(s)
• Legislation
• Monitoring &
review
• Federal
Legislation
• Local
enactment
• Sustained fiscal
support
• Contracting
arrangements
• State
initiatives
• Local
service
system
Outer
Context-
Facilitator
(s)
• Monitoring &
Review
• Client
Advocacy
• National
advocacy

• Support tied
to federal and
state policies
• Intervention
developers
• Professional
associations
• State
initiatives
• Leadership
Inner
Context –
Barrier(s)
• Policies
• Monitoring &
review
• Role
specialization
• Culture
embedding
• Priorities/goals
• Readiness for
change
• Staff
selection
criteria
• Validated
selection
procedures
Inner
Context-
Facilitator
(s)

• Leadership
• Climate
• Knowledge/s
kills/expertis
e
• Championing
adoption
• Adaptability
• Attitudes
toward EBP
• Leadership
• Social
network
support
MATERNAL MENTAL HEALTH 50

Appendix B

GANTT Chart: FQHC+
Phases Implementation Activities 2019 2020 2021
First Conduct local needs assessment
Conduct local consensus discussions
Assess for readiness and identify barriers and facilitators
Involve patients consumers and family members
Conduct educational meetings
Second Mandate change
Identify and prepare champions
Conduct educational outreach visits
Recruit, designate, and train for leadership
Create new clinical teams
Access new funding
Change physical structure and equipment
Change service sites
Change record systems
Develop educational materials
Develop and organize quality monitoring systems
Develop resource sharing agreements
Build a coalition
Develop a formal implementation blueprint
Place innovation on fee for service lists
Prepare patients to be active participants
Third Fund and contract for the clinical innovation
Alter patient fees
Use capitated payments
Create a learning collaborative
MATERNAL MENTAL HEALTH 51

Centralize technical assistance
Use an implementation advisor
Organize clinician implementation team meetings
Use mass media
Stage implementation scale up
Audt and provide feedback
Obtain and use patients and family feedback
Develop and implement tools for quality monitoring
Increase demand
Provide clinical supervision
Purposely reexamine the implementation
Use train-the-trainer strategies
Fourth Conduct ongoing training and consultation
Alter incentive/allowance structures
Capture and share local knowledge
Inform local opinion leaders
Intervene with patients to ehnace uptake and adherence

Promote adaptability
Tailor strategies
Use advisory boards and workgroups
Work with educational institutions

MATERNAL MENTAL HEALTH 52

Appendix C
Budget- Pilot-FY 2020

Revenue
Gov’t Grants 1,500 California Endowment Grant
Total Revenue 1,500

Expenses
Personnel/Salaries
Management 110 1.0 FTE Behavioral Health Director
Lactation Consultant 42 0.5 FTE
Peer Support Staff 18 0.5 FTE
Lab Technician 30 0.7 FTE
Lab Assistant 33 1.0 FTE
Op’s Staff 30 1.0 FTE Case Manager
Sub-Total 263
Benefits 78.9 @ 30 % of salaries
Total Personnel 341.9

Operating Exp
Construction/Remodeling 500 Breastmilk Center
Rent 60 $5k/mo
Technology 120 Expansion of Electronic Health Record Sys
Prof Srvc’s 125 Consultation services (National Human Milk
Bank Association
Matl’s/Supplies 100 $8,333/mo.
Fundraising/Travel 20 Across LA area
Total Op’s Exp. 925

Total Expenses 1,266.9

Surplus/Deficit +233.1 Contingency/Reserve

MATERNAL MENTAL HEALTH 53

Appendix D
Budget- FY 2021

Revenue
Contributions 40 Local donors
Foundation Grants 200 California Primary Care Association
Gov’t Contracts 100 WIC
Gov’t Grants 1,000 HRSA funding & Title V Maternal and Child
Health Block Grant
Visits 50 Billable visit reimbursements
Sales 125 Breastmilk

Total Revenue 1,515

Expenses
Personnel/Salaries
Management 125 1.0 FTE Behavioral Health Director
Clinicians 140 2.0 FTE LCSWs
Lactation Consultant 168 2.0 FTE
Peer Support Staff 108 3.0 FTE
Lab Technician 135 3.0 FTE
Lab Assistant 66 2.0 FTE
Op’s Staff 140 2.0 FTE Case Manager; 1.0 Clinical
Manager (80)
Sub-Total 882
Benefits 264.60 @ 30 % of salaries
Total Personnel 1,146.6

Operating Exp
Rent 100 $8,333/mo
Technology 20 Training/recertification
Evaluation 25
Matl’s/Supplies 80 $6,666/mo
Fundraising/Travel 5 Across LA area
Total Op’s Exp. 205
MATERNAL MENTAL HEALTH 54

Total Expenses 1,376.6
Surplus/Deficit +138.4 Contingency/Reserve

MATERNAL MENTAL HEALTH 55

Appendix E

FQHC+ Grant Proposal

Shirley Sotelo

University of Southern California

Dr. Lewis

SOWK 722

MATERNAL MENTAL HEALTH 56

Project Description

FQHC+ is a Federally Qualified Health Center with a mission of providing safety net
primary care services and innovative health programs to residents of Pico-Union in Los Angeles,
California. FQHC+ is applying for California Endowment funding to support additional
infrastructure to enhance the current service model for maternal health treatment services.
FQHC+ aims to improve health disparities and increase access to mental health treatment for
African-American and Latina women. In order to address their complex needs, FQHC+ will
work to reduce the barriers of poverty, mental health stigma, and provider implicit bias
(unconscious prejudices, stereotypes, beliefs and/or values) through the addition of a mother’s
milk bank/ breastfeeding support center. This center will provide breastfeeding
education/lactation support, peer support, behavioral health counseling, and the opportunity for
women to sell their excess breastmilk for a small amount of income.
Objectives
Objective 1: By end of 6 months from start of program, 200 perinatal women’s depression score
will have improved by at least 50% from start of program.
Objective 2: By end of 6 months from start of program, 125 perinatal women’s income will have
increased by 25 % through breastmilk sales.
Objective 3: By end of the first year from start of program, 250 perinatal women’s pregnancy
outcomes will have improved by 20%.
MATERNAL MENTAL HEALTH 57

Objective 4: By end of pilot program, there will have been 85% reduction in pregnancy
complications for 300 perinatal women, 90% reduction in maternal deaths for 400 perinatal
women, 85% reduction in preterm and low-birth weight babies, and 60% sustained reduction in
mental health symptoms for 200 perinatal women.
Need for Assistance
Scope & Nature of Problem
Over 200 million women conceive each year and deliver approximately 140 million
newborns worldwide (Graham et al., 2016). From these births, it is estimated that 10 percent of
these babies will be born premature and face possible disability or death (World Health
Organization, 2012). The United States ranks among the top 10 countries with the highest
number of premature births (World Health Organization, 2012).
During the past 20 years, national rates of maternal death have also risen with
approximately 700 women dying per year from pregnancy or during childbirth (Momsrising.org,
2017). Women of color and of low socioeconomic status are significantly impacted.
(Reproductiverights.org, 2016). African-American women have been found to be three to four
percent more likely to die and are 60 percent more likely to have a pre-term baby than Caucasian
women (Orchard & Price, 2015). Similarly, Latina women from disadvantaged backgrounds
also have poorer pregnancy outcomes than Caucasian women (Sanchez-Vaznaugh et al., 2016).
MATERNAL MENTAL HEALTH 58

A significant number of these women die from what are considered “preventable” causes
of death such as preeclampsia and gestational diabetes (World Health Organization, 2015).
Interestingly, the most common complication in pregnancy has been found to be maternal
depression (Fresno, 2015). Thus, the mental health of a perinatal woman cannot be separated
from their physical health when addressing their state of maternal health overall.
Untreated maternal mental health disorders result in poor pregnancy, health, and life
outcomes for mothers and their babies. Maternal mental health disorders refer to conditions such
as postpartum depression, anxiety, postpartum obsessive-compulsive disorder, among others,
experienced during the pregnancy and postpartum spectrum (American Psychological
Association, 2013). Maternal mental health disorders occur approximately in 10 -20 % of
pregnant and postpartum women worldwide (“Maternal Mental Health”, n.d.) yet they often go
undiagnosed and untreated due to various barriers such as stigma and lack of access to quality
care (Byatt, Levin, Ziedonis, Moore, & Allison, 2015). Along with depression, a significant
number of women also experience suicidal ideation during this time, thus putting them at risk for
suicide (Gavin, Tabb, Melville, Guo, & Katon, 2011).
Research has found several predictors that increase the incidence of developing maternal
depression such as race/ethnicity and socioeconomic status (Santoro & Peabody, 2010). African-
American women have rates as high as 35% for maternal depression followed by Latina women
(Santoro & Peabody, 2010). Living in poverty has also been found to be the greatest predictor of
MATERNAL MENTAL HEALTH 59

developing a maternal mental health disorder in the United States (Dolbier, Rush, Sahadeo, &
Thorp, 2013). In 2016, 21.4% of African-American women and 18.7 % Latina women were
found to be living in poverty

(National Women’s Law Center, 2016).
Mclemore et al. (2018), found that women of color experience and are exposed to stress
at higher rates than their Caucasian counterparts while receiving prenatal care thus putting them
at higher risk of having a preterm baby. Additionally, research indicates that women of color are
at higher risk for experiencing trauma, violence, and abuse (APA Psychnews, 2017). Women of
color also face challenges in accessing, initiating, and completing mental health treatment for
maternal depression. (Kozhimannil, Trinacty, Busch, Huskamp, & Adams, 2011). These
barriers may be due to the interplay of mental health stigma, implicit bias, and challenges
associated with poverty (Kozhimannil, Trinacty, Busch, Huskamp, & Adams, 2011; Zestcott,
Blair, Stone, &Kwan, 2016).
Untreated maternal mental health can also prove to be very costly. According to Wilder
Research, the annual cost of not treating a mother with depression is $7,200 in lost income and
productivity; an additional $15,300 can be attributed to the child, totaling $22,500 per
mother/child dyad (Diaz & Chase, 2010). Untreated maternal depression can also increase
health care costs as lingering depression past the post-partum stage can contribute to illnesses
such as heart disease, stroke, and type II diabetes (Bowers et al., 2013; Farr et al., 2011; Mezuk
et al., 2008; Pan et al., 2011).
MATERNAL MENTAL HEALTH 60

Children who are born premature and/or of low birth weight and are born to depressed
mothers may also be at higher risk of experiencing developmental delays as well as an insecure
parent-child bond (Cummings, Schermerhorn, Keller, & Davies, 2008; Elgar et al., 2007;
Goodman & Gotlib, 1999; Lim et al., 2008) thus needing costly early intervention and special
education services in the future. Women who may already have limited resources and support
along with maternal depression may not be as emotionally and psychologically present to be able
to provide their child with the attention and time necessary for their development thus possibly
creating conditions of neglect. Access to adequate care and treatment is essential however
women face issues related to the way in which care is delivered to them in already familiar
spaces such as Federally Qualified Health Centers (FQHCs).
Historically, FQHCs can be traced back to the creation of community health centers
during President Johnson’s war on poverty (Strelnick, 2005). Their initial purpose was to provide
a safety net for those uninsured as well as indigent including minorities and those of low
socioeconomic status. They have experienced much of their growth and expansion during the
Obama administration through the passing of the Affordable Care Act (ACA) with the idea that
the healthcare professionals providing care be individuals from the community that “resembled”,
in ethnicity and cultural experience, those they provide care to. While these FQHCs are able to
provide invaluable care to the neediest of individuals and are located in underserved
communities, at present they are ill equipped to meet the complex needs of marginalized
MATERNAL MENTAL HEALTH 61

populations such as the target population for this innovation. Additionally, a majority of health
care providers are not reflective of the community they serve, carry implicit bias, and often
experience a high turnover rate.
Currently, the FQHC located in the Pico-Union area lacks culturally responsive services
even though they serve an ethnically marginalized community. This neighborhood lies just
outside of Downtown Los Angeles and is composed of a highly densely populated area (~26,000
per square mile) with a population of approximately 45,000 residents of which 84% are Latino
and 3 % African-American

(Los Angeles Times, 2017). The median household income is
approximately $26,000 with an average household size of 4

(Los Angeles Times, 2017).

This is
also a very young and undereducated population with a median age of 27 and with a high
percentage of residents without a high school diploma

(Los Angeles Times, 2017).

Additionally,
the majority of this population consists of immigrants from various regions of Mexico and
Central America. While these immigrants can identify as Latino they are quite heterogeneous
and may speak languages other than Spanish as well as have very unique cultural practices.
This neighborhood is serviced by two major hospitals, four community medical clinics,
one Women, Infants, and Children (WIC) office. There is very little collaboration among these
entities thus providing fragmented services for perinatal women. Additionally, services being
located at different locations can also exacerbate existing transportation issues.

MATERNAL MENTAL HEALTH 62

Approach & Goals
FQHC+ utilizes an innovative approach to enhance and expand the current service model
of maternal health treatment through the following services: perinatal medical care by licensed
medical providers trained in cultural humility to reduce implicit bias, perinatal mental health care
by licensed and bicultural behavioral health specialists to reduce depression rates, socio-
emotional care through formally trained peer support workers to decrease mental health stigma,
nutritional support through lactation consultants, and financial care by providing a source of
income for women that sell their excess breast milk. The overall goal of FQHC+ is to reduce
poverty, improve maternal mental health symptoms, as well as improve health outcomes for
newborns related to birthweight and gestational age. These goals will be achieved by directly
addressing mental health stigma, implicit bias, and poverty via the aforementioned services.
Plan of Activities
The plan of activities over time including building, developing, and implementing this
enhanced service delivery model. Initially, the creation of the mother’s milk bank/breastfeeding
support center structure, staffing the program, and oversight by the behavioral health director is
vital. The FQHC+ logic model (Appendix A) depicts the basic process of implementing this
innovation, highlights main program activities, and identifies measures of processes and
expected outcomes. Implementation of FQHC+ will begin with two main resources of existing
MATERNAL MENTAL HEALTH 63

FQHC space and grant funding from the California Endowment. These funds will be essential
towards the remodeling and addition of the breastmilk center which will house lactation support,
formally trained peer support, mental health services, as well as provide opportunity for women
to sell their breastmilk and earn income.
Initial activities will also include inreach and outreach activities with a goal to enroll at
least ten perinatal women of color per month. For those women enrolled in the program they
will have access to lactation classes, socialization activities, and individualized behavioral health
treatment sessions. They will also be able to sell their breastmilk for $2/ounce which could
amount to approximately $500 -$800/month in income. It is the belief that these aforementioned
services will yield positive initial outcomes such as increased engagement and supportive
relationships, earlier identification of maternal mood disorder, a 50% reduction in depressive
symptoms, and an increase in income.
Appendix B depicts the overall implementation plan broken down into four stages.
The first stage consists of work conducted prior to obtain grant funding while the second stage
depicts work after funds are obtained. It is during the third stage that implementation of the new
program takes place. Hiring the “right” personnel will be one of the most important factors to
achieve the aforementioned desired outcomes. Firstly, a full-time behavioral health director will
be hired. Qualities of this behavioral health director will be an individual that is familiar with the
FQHC setting, has extensive supervisory experience, and has strong administrative and
MATERNAL MENTAL HEALTH 64

organizational skills. The desired educational level will be at least a master’s degree in social
work or a doctorate in psychology or social work with an active license to practice in the State of
California. Ideally, this candidate will have a strong understanding of culture and the interplay
of race, poverty, and health. The main role of the behavioral director will be to oversee the
FQHC+ program and serve as a liaison with medical providers and staff.
Under the leadership of the behavioral health director, 2 full-time Licensed Clinical
Social Workers (LCSWs) will be hired. One of these clinicians will be bilingual in Spanish and
bicultural in order to work with the Latina population. Both LCSWs will supervise peer support
staff under them. There will be a total of three full-time peer support staff; their diversity will be
essential, with at least one of the peer support workers being of African-American descent and
the other of Latina descent. Having peer support staff that can relate to the target population is a
vital component for instilling trust with the target population. They will also be women that are
familiar with the pregnancy experience and have a background of low socio-economic status.
Peer support staff will undergo formal training led by the lead LCSW. This training will
consist of safety and risk assessments, customer service, and ethical and professional boundaries.
Peer support staff will utilize curriculum created by the behavioral health director which will
include psychoeducation on maternal mental health, the perinatal experience, and challenges
surrounding birth and the postpartum experience. A case manager will also be hired to serve as a
resource to both patients and staff. The case manager will hold a bachelor’s degree in social
MATERNAL MENTAL HEALTH 65

work or psychology and have at least two years of professional work experience and/or
internships. Duties of the case manager will also be enrollment, tracking of the target population
within utilization of each service, and linkage and referral.
Mother’s milk bank staff will consist of two full-time lactation consultants that will be
recruited in partnership with the Women, Infants, and Children (WIC) program. One lactation
consultant will be bilingual in Spanish and bicultural. These staff will hold at least a bachelor’s
degree and be fully credentialed in the State of California with at least 4 years of professional
work experience. They will be supervised by one full-time clinical manager. The clinical
manager will be a master’s level nurse practitioner with professional work experience in the area
of women’s health and obstetrics and preferably with experience working with a human milk
bank. This manager will also be responsible for quality assurance measures within the
breastmilk center and provide guidance to laboratory personnel.
The laboratory at the breastmilk center will be operated with three full-time lab
technicians and two full-time lab assistants. These technicians will be responsible for the
preparation, distribution, inventory and management of human milk. Technicians will have at
least a bachelor’s level education with a certificate as a human milk technician. Two lab
assistants will work under the supervision of their lead lab technician and will hold at least a high
school diploma and have graduated from an accredited State of California laboratory assistant
program.
MATERNAL MENTAL HEALTH 66

Budget
Two budgets have been created for FQHC+. Appendix C illustrates an initial budget for
the pilot year of 2020 with limited diversity of revenue, high operating expenses, and only
essential personnel. Appendix D, on the other hand, illustrates expenses for FY 2021, the first
full operating year of FQHC+. The first full operating year has various sources of revenue, all
necessary personnel, and operating expenses needed for the intervention to run smoothly.
Initially, the revenue will come primarily from the California Endowment. For the first
year and to support the pilot program, a sum of $1.5 million dollars will be needed for
remodeling/attaching the mother’s milk bank, hiring initial and essential staff, and expansion of
current electronic health record systems. After the pilot, FQHC+ will demonstrate that it can
decrease long-term health costs, improve pregnancy and health outcomes, as well as increase the
engagement and participation of perinatal women of color. At that point, financial focus will
shift to the mother’s milk bank as a for-profit entity to support overall sustainability. Breast milk
could be sold locally, nationally, and perhaps internationally. Selling breast milk to hospitals
will be explored further. It is expected that an increase in “reimbursable” visits for case
management and behavioral health treatment at FQHC+ will also increase revenues.
Overall, FQHCs already receive a significant portion of funding via Health and
Resources Services Administration (HRSA). However, FQHC+ will apply for the Maternal and
Child Health Block Grant through HRSA after the first year in order to continue with expansion
MATERNAL MENTAL HEALTH 67

and the hiring of additional staff. Given that FQHC+ will be able to demonstrate a mechanism
for sustainability, this will improve the possibility of obtaining HRSA grant funds.
Evaluation
Depression treatment outcomes will be measured with a (PHQ-9). These screeners have
been found to validated in primary clinic settings and include the minimum five symptoms
including anhedonia and depressed mood to make a diagnosis of Major Depressive Disorder in
the DSM-5
8
. This tool will be used every two weeks from the beginning of participation in the
program up to one year post-partum. Pregnancy outcomes will also be measured from data
collection in the Electronic Health Record (EHR) system. Specific pregnancy outcomes that will
be reviewed will be newborn birth weight and length of pregnancy with a full-term pregnancy
being 37 weeks’ gestation.
Outcomes
Quantitative data such as depression score, newborn birthweight, and gestational age at
birth will also be collected and analyzed. Significant findings would be at least a 50% reduction
in depression score and at least a 50 % improvement i.e. higher birth weights and full-term
babies. Initially, a pilot study that follows a perinatal woman from the first trimester up to one
year post-partum will lend important data for further analysis of the complex interplay of race,
gender, and perinatal care. Anticipated longer term impacts of FQHC+ will include an 85%
reduction in pregnancy complications, a 90% reduction in maternal death, an 85% reduction in
MATERNAL MENTAL HEALTH 68

preterm births and low-birth weight babies, and a 60% (sustained) reduction in mental health
symptoms. The collection of qualitative data will also be explored through the creation and
administration of patient satisfaction surveys and input from focus groups. Input from the many
different members of the collaborative care team will also complete semi-structured interviews.

MATERNAL MENTAL HEALTH 69

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Bowers, K., Laughon, S. K., Kim, S., Mumford, S. L., Brite, J., Kiely, M., & Zhang, C. (2013).

The association between a medical history of depression and gestational diabetes in a

large multi-ethnic cohort in the United States. Pediatric and Perinatal Epidemiology,

27(4), 323–328.

Byatt, N., Levin, LL., Ziedonis, D., Moore, Simas TA, & Allison, J. (2015, November).

Enhancing participation in depression care in outpatient perinatal care settings: A

systematic review. Obstetrics & Gynecology, 126(5), 1048-1058.

Cummings, E. M., Schermerhorn, A. C., Keller, P. S., & Davies, P. T. (2008). Parental
depressive symptoms, children’s representations of family relationships, and child
adjustment. Social Development, 17, 278–305.
Diaz, J. Y., & Chase, R. (2010). The cost of untreated maternal depression. St. Paul, MN: Wilder

Research.

Dolbier, C., Rush, L., Sahadeo, T., Shaffer, E., & Thorp, L. (2013). Relationships of Race and

Socioeconomic Status to Postpartum Depressive Symptoms in Rural African American

and Non-Hispanic White Women. Maternal and Child Health Journal, 17(7), 1277-

1287.

MATERNAL MENTAL HEALTH 70

Elgar, Frank J., Mills, Rosemary S. L., McGrath, Patrick J., Waschbusch, Daniel A., &
Brownridge, Douglas A. (2007). Maternal and Paternal Depressive Symptoms and Child
Maladjustment: The Mediating Role of Parental Behavior. Journal of Abnormal Child
Psychology, 35(6), 943-955.
Farr, S., Hayes, D., Bitsko, R., Bansil, P., & Dietz, P. (2011). Depression, diabetes,

and chronic disease risk factors among US women of reproductive age. Preventing

Chronic Disease, 8(6), A119.
Fresno, U. (2015). The American College of Obstetricians and Gynecologists Committee

Opinion no. 630. Screening for perinatal depression. Obstetrics and gynecology, 125 5,

1268-71.

Gavin, A., Melville, J., Rue, T., Guo, Y., Dina, K., & Katon, W. (2011). Racial differences in the
prevalence of antenatal depression. General Hospital Psychiatry, 33(2), 87–93.
Goodman, S. H., & Gotlib, I. H. (1999). Risk for psychopathology in the children of depressed
mothers: A developmental model for understanding mechanisms of transmission.
Psychological Review, 106(3), 458–490.
Graham, Woodd, Byass, Filippi, Gon, Virgo, Singh. (2016). Diversity and divergence: The
dynamic burden of poor maternal health. The Lancet, 388(10056), 2164-2175.
Kozhimannil, K., Trinacty, C., Busch, A., Huskamp, H., & Adams, A. (2011, June). Racial and
MATERNAL MENTAL HEALTH 71

Ethnic Disparities in Postpartum Depression Care Among Low-Income

Women. Psychiatric Services, 62(6), 619–625.

Lim, J., Wood, B. L., & Miller, B. D. (2008). Maternal depression and parenting in relation to
child internalizing symptoms and asthma disease activity. Journal of Family Psychology,
22, 264–273.
Los Angeles Times. (2017). Mapping LA: Pico Union. Retrieved from
http://maps.latimes.com/neighborhoods/neighborhood/pico-union/
Many Women Do Not Disclose Postpartum Mood Symptoms, Survey Finds. (2017, August 17).
APA Psychiatric News. Retrieved from:
https://static1.squarespace.com/static/56d5ca187da24ffed7378b40/t/59b8bc24268b96a33
7f932cd/1505279012952/Many+Women+Do+Not+Disclose+Postpartum+Mood+Sympt
oms+Survey+Finds.pdf

Maternal mental health. (n.d.). Retrieved February 11, 2018, from World Health Organization

Website: http://www.who.int/mental_health/maternal-child/maternal_mental_health/en/

Mclemore, M., Altman, M., Cooper, N., Williams, S., Rand, L., & Franck, L. (2018). Health care

experiences of pregnant, birthing and postnatal women of color at risk for preterm

birth. Social Science & Medicine, 201, 127–135.
MATERNAL MENTAL HEALTH 72

Mezuk, B., Eaton, W. W., Albrecht, S., & Golden, S. H. (2008). Depression and type-2 diabetes

over the lifespan: A meta-analysis. Diabetes Care 31, 2383–2390.

National Institutes of Health. (2014). Health disparities. Retrieved from http://www.nhlbi.nih

.gov/health/educational/healthdisparities

National Women’s Law Center. (2016). National Snapshot: Poverty Among Women &
Families, 2016 [Fact Sheet]. Retrieved from https://nwlc.org/wp-
content/uploads/2017/09/Poverty-Snapshot-Factsheet-2017.pdf
Orchard, J., & Price, J. (2017). County-level racial prejudice and the black-white gap in infant
health outcomes. Social Science & Medicine, 181, 191–198.
Pan, A., Sun, Q., Okereke, O. I., Rexrode, K. M., & Hu, F. B. (2011). Depression and risk of
stroke morbidity and mortality: A meta-analysis and systematic review. Journal of the
American Medical Association, 306, 1241–1249.
Raising Our Voices for Maternal Health. (2017). Retrieved from
https://s3.amazonaws.com/s3.momsrising.org/images/Birth_Story_Book_Feb_2017.pdf

Sanchez-Vaznaugh, E., Braveman, P., Egerter, S., Marchi, K., Heck, K., & Curtis, M. (n.d.).
Latina Birth Outcomes in California: Not so Paradoxical. Maternal and Child Health
Journal, 20(9), 1849–1860
MATERNAL MENTAL HEALTH 73

Santoro, K., & Peabody, H. (2010, June). Identifying and Treating Maternal Depression:
Strategies & Considerations for Health Plans (Issue Brief). Retrieved from
https://d3n8a8pro7vhmx.cloudfront.net/camaternalmentalhealth/pages/53/attachments/ori
ginal/1434943734/FINAL_MaternalDepression6-7.pdf?1434943734

Strelnick, A. (2005). Increasing access to health care and reducing minority health disparities: a
brief history and the impact of community health centers. (Increasing Access to Health
Care: Methods to Address the National Crisis). New York University Journal of
Legislation and Public Policy, 8(1 2).
U.S. Department of Health and Human Services, Office of Women’s Health. (2009). Depression
during and after pregnancy fact sheet. As of June 12, 2017:
http://www.womenshealth.gov/publications/our-publications/fact-sheet/depression-
pregnancy.html
World Health Organization. (2012). Born Too Soon: The Global Action Report on Preterm
Birth.Retrieved from
https://www.who.int/pmnch/knowledge/publications/preterm_birth_report/en/index3.htm
l
MATERNAL MENTAL HEALTH 74

Zestcott, C., Blair, I., Stone, J., & Kwan, V. (2016). Examining the presence, consequences, and
reduction of implicit bias in health care: A narrative review. Group Processes &
Intergroup Relations, 19(4), 528–542.

MATERNAL MENTAL HEALTH 75

Appendix A

MATERNAL MENTAL HEALTH 76

Appendix B

GANTT Chart: FQHC+
Phases Implementation Activities 2019 2020 2021
First Conduct local needs assessment
Conduct local consensus discussions
Assess for readiness and identify barriers and facilitators
Involve patients consumers and family members
Conduct educational meetings
Second Mandate change
Identify and prepare champions
Conduct educational outreach visits
Recruit, designate, and train for leadership
Create new clinical teams
Access new funding
Change physical structure and equipment
Change service sites
Change record systems
Develop educational materials
Develop and organize quality monitoring systems
Develop resource sharing agreements
Build a coalition
Develop a formal implementation blueprint
Place innovation on fee for service lists
Prepare patients to be active participants
Third Fund and contract for the clinical innovation
Alter patient fees
Use capitated payments
Create a learning collaborative
Centralize technical assistance
Use an implementation advisor
Organize clinician implementation team meetings
MATERNAL MENTAL HEALTH 77

Use mass media
Stage implementation scale up
Audt and provide feedback
Obtain and use patients and family feedback
Develop and implement tools for quality monitoring
Increase demand
Provide clinical supervision
Purposely reexamine the implementation
Use train-the-trainer strategies
Fourth Conduct ongoing training and consultation
Alter incentive/allowance structures
Capture and share local knowledge
Inform local opinion leaders
Intervene with patients to ehnace uptake and adherence

Promote adaptability
Tailor strategies
Use advisory boards and workgroups
Work with educational institutions

MATERNAL MENTAL HEALTH 78

Appendix C
Budget- Pilot-FY 2020

Revenue
Gov’t Grants 1,500 California Endowment Grant
Total Revenue 1,500

Expenses
Personnel/Salaries
Management 110 1.0 FTE Behavioral Health Director
Lactation Consultant 42 0.5 FTE
Peer Support Staff 18 0.5 FTE
Lab Technician 30 0.7 FTE
Lab Assistant 33 1.0 FTE
Op’s Staff 30 1.0 FTE Case Manager
Sub-Total 263
Benefits 78.9 @ 30 % of salaries
Total Personnel 341.9

Operating Exp
Construction/Remodeling 500 Breastmilk Center
Rent 60 $5k/mo
Technology 120 Expansion of Electronic Health Record Sys
Prof Srvc’s 125 Consultation services (National Human Milk
Bank Association
Matl’s/Supplies 100 $8,333/mo.
Fundraising/Travel 20 Across LA area
Total Op’s Exp. 925

Total Expenses 1,266.9

Surplus/Deficit +233.1 Contingency/Reserve

MATERNAL MENTAL HEALTH 79

Appendix D

Budget- FY 2021

Revenue
Contributions 40 Local donors
Foundation Grants 200 California Primary Care Association
Gov’t Contracts 100 WIC
Gov’t Grants 1,000 HRSA funding & Title V Maternal and Child
Health Block Grant
Visits 50 Billable visit reimbursements
Sales 125 Breastmilk

Total Revenue 1,515

Expenses
Personnel/Salaries
Management 125 1.0 FTE Behavioral Health Director
Clinicians 140 2.0 FTE LCSWs
Lactation Consultant 168 2.0 FTE
Peer Support Staff 108 3.0 FTE
Lab Technician 135 3.0 FTE
Lab Assistant 66 2.0 FTE
Op’s Staff 140 2.0 FTE Case Manager; 1.0 Clinical
Manager (80)
Sub-Total 882
Benefits 264.60 @ 30 % of salaries
Total Personnel 1,146.6

Operating Exp
Rent 100 $8,333/mo
Technology 20 Training/recertification
Evaluation 25
Matl’s/Supplies 80 $6,666/mo
Fundraising/Travel 5 Across LA area
Total Op’s Exp. 205
MATERNAL MENTAL HEALTH 80

Total Expenses 1,376.6

Surplus/Deficit +138.4 Contingency/Reserve

MATERNAL MENTAL HEALTH 81

Abstract (if available)

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

The Universal Record Data Sharing System

PDF

Mental health advocacy and navigation partnerships: the case for a community collaborative approach

PDF

Mental Health First

PDF

Myths and taboos: deconstructing patriarchy through intimate partner violence awareness

PDF

Game over concepts, mental-health support for college student-athletes

PDF

Stigma-free pregnancy: a recruitment and retention strategy for healthcare systems to engage pregnant women with substance use disorder in collaborative care

PDF

The Women and Girls Center for Maternal Health intergenerational approaches to address the Black maternal health crisis

PDF

From “soul calling” to calling a therapist: meeting the mental health needs of Hmong youth through the integration of spiritual healing, culturally responsive practice and technology

PDF

Inter professional education and practice in the health care setting: an innovative model using human simulation learning

PDF

Unleashing prevention and reaching the masses with a positive mental wellness museum

PDF

The Arukah Project: collaborating with the Church to improve African American mental health

PDF

Full spectrum transition assistance: preventing loneliness and social isolation in military members during moves

PDF

Brazos Abiertos: addressing mental health stigma among the Latino Catholic community

PDF

Integration of behavioral health outcomes into electric health records to improve patient care

PDF

Reducing the prevalence of missed primary care appointments in community health centers

PDF

Empowering and building resilience with youth in congregate care

PDF

Transdisciplinary education approach for collaborative health

PDF

Behavioral Health for All Kids

PDF

Impact of change in sexual identity on mental health risks among sexual minority adolescents

PDF

Closing the health gap

Asset Metadata

Creator Sotelo, Shirley (author)

Core Title Maternal mental health matters: Creating FQHC+ to meet the complex needs of perinatal women of color

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 12/11/2019

Defense Date 11/22/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag breastmilk,FQHC,maternal health,maternal mental health,mother's milk bank,OAI-PMH Harvest,perinatal women of color

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Lewis, Jennifer (committee chair), Arrarian, Karla (committee member), Islam, Nadia (committee member)

Creator Email sotelomsw@gmail.com,sotelos@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-251715

Unique identifier UC11675191

Identifier etd-SoteloShir-8043.pdf (filename),usctheses-c89-251715 (legacy record id)

Legacy Identifier etd-SoteloShir-8043.pdf

Dmrecord 251715

Document Type Capstone project

Rights Sotelo, Shirley

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA