Within hours of giving birth to her first child, Araceli Aquino-Valdez was engulfed by an intense sadness. She sobbed for days after arriving home, grieving the loss of her life before motherhood and feeling dismissed by her care providers.
Medical professionals had warned the Yuma mother-to-be early in her pregnancy that prior mental health challenges put her at an increased risk of postpartum depression, she said. They’d offered no further information or resources at the time, though, so she didn’t think much of the warning.
When she visited her OB-GYN for the standard six-week postpartum checkup, she shared her ongoing feelings of hopelessness with a different doctor. Again, she said, there was no discussion of possible solutions, referrals to mental health specialists or even a plan to follow up.
Aquino-Valdez turned to online forums, like Reddit, to look for answers her doctors weren’t offering. She got the impression that mothers who lived elsewhere were getting a different standard of care — one she couldn’t access.
“It seemed like postpartum depression was taken seriously in those places,” she told AZCIR. “I thought it would be taken more seriously here.”
Perinatal mental health conditions are among the leading causes of death during or within one year of pregnancy in Arizona, with substance use often emerging as a contributing factor, according to the state’s Maternal Mortality Review Committee. Between 2018 and 2019, the most recent year for which data is available, almost 40% of pregnancy-associated deaths in the state involved a mental health condition — and nearly all of those deaths were deemed preventable.
“Women are not being assessed properly as they should be. We’re not identifying mental health (as a problem) until it becomes an emergency,” said Cara English, CEO of the Arizona-based Cummings Graduate Institute of Behavioral Health Studies. “This is where women die.”
English and other experts said prenatal mental health screenings like the one Aquino-Valdez received can be an effective tool for early intervention. But they contend many maternal care providers, including OB-GYNs, lack the training to correctly administer them, simply opt not to, or fail to provide appropriate resources or follow-up care.
Sometimes, there’s nowhere to refer patients for specialized services — the state has one of the worst shortages of mental health professionals in the country. Mental health providers specifically dedicated to perinatal populations are rarer still, while inpatient psychiatric facilities where mothers can recover with their babies are nonexistent.
In the state’s more rural areas, common logistical problems like a lack of dependable transportation or internet frequently compound limited access to care, and reliance on state-funded insurance can further reduce the number of available providers. Though maternal deaths tripled statewide from 1999 to 2019, more recent data shows increases occurring in rural counties.
The state Legislature and Department of Health recently put forth a flurry of initiatives and funding to address the maternal mortality crisis, including an annual maternal and infant mortality summit, support for community based home-visit organizations, and the review committee, which examines individual cases of pregnancy-associated deaths and recommends actions to improve maternal health outcomes.
So far, though, the impact of these efforts remains unclear. While the review committee is analyzing deaths from 2021, it has only released reports through 2019 — a significant lag that makes it difficult to gauge if interventions are working.
State Rep. Quantá Crews, a Democrat who has become a key voice in support of widespread interventions in maternal health, has a personal investment in the issue. During her third pregnancy, she was in and out of her doctor’s office for a week before her provider identified a complication, even though Crews was certain something was wrong. “I don’t feel like I was heard,” she told AZCIR. Crews also developed postpartum depression, and still sees a counselor a decade later.
Araceli Aquino-Valdez, sitting in her living room with her 11-month-old infant, turned to online forums to look for answers she says her doctors weren’t offering for her postpartum depression.
Though Crews and other advocates for women’s and children’s health acknowledged the steps Arizona has begun taking to address maternal mortality, they said its efforts continues to fall short of the more comprehensive, strategic approach needed. They also want to see more state funding dedicated to the problem, an area where Crews said state lawmakers could intervene.
“Amplifying this issue, I think, is one role of the Legislature,” she said. “And putting our money where our mouth is and supporting programs to end this high rate of maternal mortality.”
Identifying mental health concerns early in mothers is an essential step in preventing maternal deaths, yet OB-GYNs receive little to no formal training in mental health care, experts told AZCIR. A 2019 report indicated that only 20% of OB-GYN residency directors interviewed by researchers felt trainees were entirely prepared to identify psychiatric needs in their patients.
OB-GYN programs that do include mental health training tend to focus on the most severe types of maternal mental health crises, which are far less common than more routine conditions like perinatal mood anxiety disorder, English said. As a result, patients who show up overwhelmed and unsure if what they’re feeling is normal may be left in the lurch.
Stigma around mental health challenges — especially following the birth of a child — can keep mothers from seeking care in the first place, even when they sense something is wrong. New mothers in particular may have been sold a rosy picture of postpartum joy, or warned only about the fleeting “baby blues.”
“A lot of women may not feel comfortable bringing (more serious mental health concerns) up, because they feel like this isn’t supposed to happen,” said Cindy Herrick, editorial and research manager for the nonprofit Policy Center for Maternal Mental Health, a national think tank and advocacy organization. “In actuality, it’s more prevalent than people realize.”
Delayed diagnoses can have devastating consequences. Common treatments like antidepressants, for instance, can take weeks to take full effect, and patients may have to try several before finding one that works. Finding an effective therapist can similarly take weeks, if not longer. All the while, mothers may be losing sleep or struggling to bond with their babies, compounding factors that can exacerbate mental health issues.
The American College of Obstetricians and Gynecologists and the American Psychiatric Association, among other groups, have rallied behind maternal mental health screenings as a tool for early detection. But such screenings are not effective alone.
Some providers, including OB-GYNs, simply administer the tests and file them away, experts told AZCIR, leaving patients like Aquino-Valdez unsure of their next steps. In 2022, a University of Arizona study that assessed the care experiences of 39 pregnant or postpartum patients — women who were either Black or living in rural areas — found that more than half received mental health screenings, but none were referred for follow-up care.
These pitfalls have spurred experts to advocate for a more integrated approach that involves training OB-GYNs and other clinicians in behavioral health or bringing specialists on-site.
Without appropriate, coordinated follow-up care, “you actually might be doing more harm,” Herrick said. “Because now you have a mom that realizes she has a problem, but … she doesn’t know where to get help.”
Most of Arizona lacks enough trained behavioral health professionals to meet the needs of the population, with Mental Health America ranking the state 47th in the country for access to mental health care.
Providers specializing in perinatal mental health care are even harder to find: More than half of Arizona’s 15 counties have zero such specialists.
Review committee member Elizabeth Wood said maternal mental health providers who want to participate in Arizona’s Medicaid program — the Arizona Health Care Cost Containment System, or AHCCCS — have been denied because the agency does not recognize their services as a specialty, instead claiming the network includes enough doctors who focus on depression and anxiety. Less than a quarter of the roughly 200 certified perinatal mental health specialists in the state take AHCCCS, according to Wood, who also chairs the state chapter of Postpartum Support International, a maternal mental health advocacy group.
Substance abuse treatment for women who are pregnant or have recently given birth is also elusive in Arizona, despite the prevalence of maternal deaths involving drugs and alcohol. The review committee found that substance use disorders were involved in 84 of 203 pregnancy-associated deaths between 2016 and 2018. Mental health conditions were present in more than half of those cases.
It was only after Aquino-Valdez developed a reliance on alcohol to cope with her postpartum depression that she finally decided to seek therapy.
“I reached out for help on my own,” she said. “If it wasn’t for me taking that initiative, I definitely would have never received help, I think. I would probably be much worse.”
Project Willow Rebloom, a nonprofit focused on maternal mental health, has announced plans to open an inpatient mental health facility for perinatal patients and their babies in early 2025. No such facility exists in Arizona now, however, leaving those experiencing the most severe mental health crises with limited options for care.
Patients can try one of the state’s general inpatient facilities, but they may be met with thousands of dollars in out-of-pocket costs and a team unequipped to deal with a maternal mental health emergency. Women frequently end up leaving instead, with their families attempting to handle the situation themselves, according to English.
That can lead to emergencies and, ultimately, maternal deaths, “because it is very, very difficult to impossible for a family to provide the 24/7, around-the-clock care that an individual needs,” she said. “Often, this is when women slip out and leave the home and kill themselves.”
Maternal health advocacy groups and experts are working to equip OB-GYNs and other providers who regularly encounter pregnant or postpartum women with more specialized knowledge of perinatal mental health issues. These efforts could eventually spur legislation compelling the AHCCCS network to include a certain number of these professionals, according to Wood, or prompt the state to mandate new mental health training for providers working with the perinatal population.
To avoid costly campaigns and lengthy legislative processes, maternal health advocates have so far prioritized initiatives that don’t require new laws. But a lack of coordination between lawmakers and others can lead officials to duplicate efforts, such as forming multiple committees focused on the same problem.
Araceli Aquino-Valdez says she struggled to find mental health care after experiencing postpartum depression following the birth of her first child.
Crews, the state legislator, said all stakeholders need to “take a step back, look at these issues, write them down, put them in order of priority and start making things happen.”
Aquino-Valdez wonders if her experience might have been different if she’d had more options for an OB-GYN, allowing her to switch to someone with whom she felt more comfortable. Prior to giving birth, she tried to book an appointment with another doctor, but high demand meant she would have had to wait weeks for an appointment. Delivering at Onvida Health, formerly Yuma Regional Medical Center, also felt like a last resort, she said, but it was the only hospital nearby with a delivery unit.
Residents of La Paz, Graham and Cochise counties have even less access to OB-GYNs and hospitals offering obstetric services, according to a March of Dimes report. Greenlee County has no obstetric care whatsoever.
Overall, the report found that only 0.1% of maternity care providers in Arizona practiced in rural areas. Though Arizona has 17 federally recognized critical access hospitals in place to meet some of the vast needs faced by rural communities, only six offer labor and delivery services.
To combat the lack of providers in underserved areas, the Legislature funded scholarships for 100 medical students who committed to practicing in those parts of the state after graduation. Once graduates have put down roots, it could be much easier to convince them to stay, rural health experts said. That, in turn, could go a long way toward building out rural care networks long-term.
Practitioner proximity is another important consideration for women in rural parts of the state. If someone has a negative birth experience and wants to switch hospitals for a subsequent delivery, for example, they may have to drive an extra hour for that luxury. Or, if they suspect a problem during pregnancy, they may ask themselves, “Is it worth even traveling an hour and a half, or should I just stick it out at home and see if whatever the concern is passes?” Crews said.
Telehealth options can help rural residents more easily access providers, but challenges with unreliable internet can complicate this option, too. While the state has allocated more than $1 billion dollars to improving broadband access and equity, an estimated one in 10 Arizonans live in households without a computer or broadband.
Residents of the state’s rural counties are more likely to rely on AHCCCS for coverage, which can limit their provider options. A small provider pool, in turn, can result in longer wait times for patients — particularly in places like Navajo and Apache counties, where about half the population has state insurance.
Nearly three-quarters of pregnancy-associated deaths between 2018 and 2019 involved Arizonans covered by AHCCCS, despite mothers on Medicaid accounting for less than half of all births in the state during that time.
AHCCCS expanded postpartum coverage in 2023 from 60 days to a year to reduce maternal mortality and morbidity. But some providers have opted not to accept state insurance, which reimburses them at a lower rate than private insurers.
That can leave patients with a daunting choice: Pay out of pocket, or keep struggling to find care.
Community-based providers like postpartum doulas and home visitors can provide crucial support for women, but they’re not always covered by insurance, either — public or private. AHCCCS, for instance, will only reimburse patients for care from state-licensed doulas, of which there are only four, according to Health Department data.
Advocates and legislators are optimistic that initiatives like this one will gain traction over time, ultimately building out stronger and more far-reaching networks of care. But until that happens — and barriers to care are substantially reduced — women will continue to fall through the cracks.
“I definitely don’t think I am the same person I once was, ” Aquino-Valdez said of her postpartum experience. “I am struggling between craving and wanting to live my old life (and) having to accept this new life for what it is.”
