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Mental Health and Maternal Mortality in Colorado: Exploring Connections and Policy Solutions
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Mejía, Melissa
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Denver, CO
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University of Colorado Denver
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English

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Auraria Library
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Running Head: MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 1 Mental Health and Maternal Mortality in Colorado : E xploring Connection s and Policy Solutions Melissa Meja University of Colorado Denver School of Public Affairs

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 2 Capstone Project Disclosures This client based project was completed on behalf of Center for Health Progress and supervised by PUAD 5361 Capstone course instructor Wendy L. Bolyard, PhD, and second faculty reader Todd Ely, PhD . This project d oes not necessarily reflect the views of the School of Public Affairs or the faculty readers. Raw data were not included in this document, rather relevant materials were provided directly to the client. Permissions to include this project in the Auraria Li brary Digital Repository are found as the final Appendix. Questions about this capstone project should be directed to the student author.

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 3 Executive Summary Rates of maternal mortality in Colorado have increased in recent years, and the state has taken some initial measures to address the issue. As an advocate for equitable health care in Colorado, Center for Health Progress , the client for th is capstone proje ct , requested a report exploring the relationship between disparities in mental health care and maternal mortality and providing policy recommendations though a policy case study . To support this effort , a quantitative investigation of Colorado public health data at the region level and a case study of a related public health program were conducted . Statistical correlations of maternal mortality ratios and provider rates did not produce significant findings . Correlation of post natal depressive indicators and maternal mortality rates did produce significant findings. Correlation of racial demographics, maternal mortality, and provider rates did not produce statistically significant findings. Further geospatial examination indicated that there may be more significant relationships between some variables if investigated at the county or individual level. The case study of the Massachusetts C hild Psychiatry Access Program for Moms showed initial improvement in OB/GYN capacity to treat and support per inatal mental health. Translating the programming to Colorado is complicated by the geographic scale . Implementation of the program c ould provide a manageable and lower cost option to address maternal mental health directly and improve the systemic approach to perinatal mental health care . Supporting policy that names maternal mental health specifically helps to focus efforts . Policy that supports ca pacity building programs ensures that they would have the time necessary to be effective and that women would have mental health resources following the already funded screenings.

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 4 Mental Health and Maternal Mortality in Colorado: Exploring Connections and Policy Solutions As awareness of the importance of mental health treatment has increased in recent years , a relationship between mental health care (MHC) and other health outcomes has been illuminated. A complex interaction of diverse factors influences general health outcomes, but mental health has a significant effect ( Kohan, et al. 2019; Roll , et al., 2013) . Improved pathways to care are vital in reduci ng negative outcomes , and racial d isparities in mental health and MHC access have remained persistent. Mental health issues and inadequate care can have severe effects on health outcomes for both mothers and children ( Nguyen & Duderstadt, 2018 ; Surkan, Patel, & Rahman, 2016) . Women of color are more susceptible to mental health issues and thus at higher risk of developing pregnancy related depression and anxiety ( Ertel, et al., 2012 ; Nuru Jeter, et al., 2008 ; Taylor, et al., 2019 ). Incidences of maternal depression have also been loosely linked to mortality rates ( C olorado Dep artment of Public Health and Environment [CDPHE] , 2017 ), making existing disparities a significant threat to the health and life of mothers. In Colorado, high rates of untreated depression in new mothers has been established ( CDPHE , 2017 ), and almost doubled between 2008 and 2013 ( CDPHE , n.d. ) . In Colorado mental health conditions have been found to be one of the leading cause s of maternal mortality, and 80% of total deaths were deemed preventable ( CDPHE , n.d. ). During the spring 2019 legislative session Colorado passed HB19 1122 establishing a maternal mortality review committee through the Department of Public Health and Environment . This move is demonstrative of a statewide willingness to acknowledge and address the issue through policy, and includes language specifying diversity of both the committee and research considerations. While demographic differences have been st atistically shown on a national level , use of

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 5 Colorado data to determine the presence of racial disparit ies in MHC access and maternal mortality help inform more effective future state policy decisions. Implementation of care policy and procedure is a cent ral responsibility of the public administration field . Establishing the problem empirically is crucia l to demonstrating need and directing policy . M aternal mental health is a long term issue that requires sustained intervention in order to improve outcomes , and a single policy change will not be enough without a n extended implementation strategy . The long term development of the best possible interventions and appropriate evaluative methods to assess effectiveness falls to public administrators . Improving maternal mortality outcomes related to mental health can be aided by integrating care, a process which will require decisions on resource allocation and coordination by public administ rators . Access to MHC can be life saving for mothers and families, and facilitation of that access rests on the administrative system and its ability to adequately address existing inequities . A strong voice in state public health advocacy, Center for Health Progress highlights community health concerns to help find policy solutions. As an organization focused on equity in health care, disparities in health outcomes and access to care are of great concern. Center for Health P rogress has worked to establish connections between soc ial issues and health outcomes to both inform the public and influence policy decisions. This project support s their efforts by conducting the necessary research and investigation for Center for Health Progress to publish a short report on maternal mental health access and mortality rates and advocate for more effective policy interventions.

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 6 Statement of Purpose The purpose of this project , completed on behalf of Center for Health Progress , is to investigate potential policy solutions to determine best practices and policy recommendations for the state of Colorado. The greater purpose for the work is to help establish the need for increased and improved access to maternal MHC . Mental health is increasingly understood as a n integral part of holistic human health, and for mothers is highly influential on physical health outcomes for both mother and child. Helping to improve access to needed care for the most vulnerable populations can improve heal th outcomes for mothers and children, and potentially reduce maternal mortality rates. This paper provide s a brief background on the client organization foll ow ed by a review of the existing literature on mental health disparities , MHC access , maternal mental health effects, and integrative MHC . The mixed methods of this investigation are outlined, including data sources and case study framework . S tatistical results and a discussion of their significance are complemented by the findings of the policy case study. The paper conclude s with an overall picture of maternal mental health and mortality in Colorado, accompanied by policy recommendations. Organizational Background Center for Health Progress is involved in policy advocacy, professional development services, and community organizing throughout the state of Colorado. Based on values that include access to health care, a broad definition of health, using research and da ta, and being solution focused, Center for Health Progress is involved in the promotion of health and health care equity at multiple levels. As a part of its advocacy work, Center for Health Progress publishes reports on targeted public health issues eleva ting community needs. These reports are

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 7 public facing, graphic, and accessible to a broad audience. Previous reports have tied prominent 2018. Center for Health Progress is looking to publish such a report, with related policy recommendations, establishing the connection between MHC access disparities and maternal mortality. Center for Health Progress understands that there are multiple fa ctors that influence maternal mortality but believes that disparities in MHC access play a significant role. T he report is intended to highlight the breadth of consequences that arise from disparities in MHC access while providing policy recommendations to address them. Review of the Literature A review of existing literature provides evidence of the significant effects of maternal mental health on infants, disparities in access to care and possible issues with care being provided, and the support for and promise of policy that integrates maternal mental health into existing primary ca re and well child care structures . Demographic D isparities in M ental H ealth Weathering . Discussion of disparities in healt h outcomes related to maternal mental health requires acknowledgement of the role of systemic racism in the mental health of women of color. Women of color, specifically black women , are more susceptible to both adverse medical conditions and mental health complications. Black women have higher levels of allo static load wherein exposure to chronic stressors as the result of systemic racism results in physical and psychological wear and tear, often referred to as weathering ( Nuru Jeter et al., 2008 ). In a n investigation using focus groups of adult women with ch ildren who self identified as African American , Nuru Jeter et al. (2008) highlighted six overall themes identified by

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 8 participants. These themes, including how the women experienced racism and their constant concern for their children experiencing racism in the future, provided a qualitative lens to the concept of weathering (Nuru Jeter et al., 2008 ). Weathering associated risks extend to birth complications, with black women showing higher rates of several pregnancy and birth conditions that have been emp irically shown to be related to chronic stressors , and pregnant women who experience racial discrimination show more depressive symptoms (Ertel et al., 2012 ; Nuru Jeter et al., 2008) . T hemes from the focus groups illustrate exactly what allostatic load loo ks like for women day to day, including carrying the trauma of past racism ( Nuru Jeter et al., 2008 ; Roll et al., 2013) . U nderstanding these social risk factors is vital in providing adequate mental health treatment . Empirically establishing the connection between experiences of racism and discrimination with mental health is often complicated by social factors. Ertel et al. (2012 ) found that women with higher socioeconomic (SES) status were more likely to report racial discrimination , theoriz ing that higher SES women feel more empowered and secure le a d ing to increased comfort in naming and discussing racism. Experienced discrimination ha s been linked to poorer mental health score s using different types of self report measures for racial discrimination, indicating that despite difficulty in measurement the relationship exists ( Kwate & Goodman, 2015; Wallace, Nazroo, & B é cares, 2016) . A study in New York City linked increases in (2012) finding those who more readily named discrimination had fewer baseline poor mental health days (Kwate & Goodman, 2015). women from b oth groups who were able to discuss their experiences reported lower rates of depressive symptoms, highlighting the importance of incorporating an acknowledgement of systemic racism into MHC .

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 9 Increased r isk. An investigation into postpartum depression in Minnesota found that even with recent increases in MHC coverage , in one county African American women have more than twice the risk of experiencing P ostpartum D epression (PPD) as white women (Tuttle, 2018). Using national and stat e public health data, Tuttle (2018) argues that residential segregation, interpersonal racism, and wealth disparities are all contributing factors to the heightened risk of PPD for African American women in the county. In a recently published national report on maternal mental health, Taylor , Novoa, Hamm, and Phadke (2019) discuss the significantly higher risk women of color, and especially African American women, face for Severe Maternal Morbidity (SMM) defined as significant health consequences result ing from pregnancy . The authors point to the cumulative effects of chronic stress associated with the experience of systemic racism as a significant risk factor in mental health and birth rela ted conditions (Taylor et al., 2019). Taylor et al., (2019) argue that and that policy solutions must consider the effect s of structural racism in order to effectively combat them and reduce mental health disparities (p. 4) . Access to C are D isparities Establishing the existence of MHC disparities in the United S tates first requires defining a n MHC disparity. In their investigation on mental health disparities and policy, McGuire and Miranda (2008) present two established definitions of health care dispa rities. The Agency for Healthcare Research and Quality (AHRQ) considers any difference between population s a disparity is a difference in health care quality no t due to the differences in health care needs or 395). Understanding care disparity as a n unnecessary and

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 10 preventable difference provides for a more nuanced understanding that includes needs, access, and discrimination that may not be captured by a simple difference. Demographic differences . P eople of color have been found to have l ess frequently reported mental health issues but are also more likely to live in areas with inadequate care, terminate care early, and are more susceptible to provider bias and discrimination (McGuire & Miranda, 2008) . These findings indicate that the lower reported rates of mental health issues for people of color as compared to the white population might reflect disparities in quality of care and underdiagnosis combined with social attitudes, but this is not a stance McGuire and Miranda (2008) explicitly state. Influence of underdiagnosis and social attitu des is further supported by the work of Lo, Cheng, and Howell (2014) who found affordability r emaine d a limiting factor for black individuals in accessing MHC , and that when care was accessed , black individuals arrived with more severe symptoms compared to white individuals. Exacerbation of mental health conditions from delayed treatment is a n important risk factor in mental health disparities, e s pecially when considering potential consequences for mothers who do not seek treatment. Differences in access. Using a definition of access to M HC from Millman (1993) of health Snowden & Yamada, 2005 , p. 144 ), Snowden and Yamada (2005) investigated the potential causes of disparities in access to care. Notably, the authors state that access is not a measure of improved health because improving health outcomes requires sustained, effective, and culturally responsive treatment. Snowden and Yamada (2005) also highlight t he demographic differences in accessing MHC that are not seen in access rates of primary care services, presenting an opportunity to integrate MHC into existing services. In a survey of primary care physicians, Cunningham (2009) found that primary care providers identified a shortage of MHC providers as

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 11 one of the more difficult barriers to accessing MHC for their patient s . Concerns about insurance coverage for mental health care raised in the study have largely been a lleviated through recent health care coverage changes at federal and state levels, but access to MHC providers has not necessarily grown at the same rate. Cultural responsiveness. P rovider understanding of cultural differences is integral to effective MHC, and treatment and diagnoses can be influenced by a lack of cultural responsiveness ( McGuire & Miranda , 2008 ; Roll et al. , 2013) . Provider awareness of cultural differences as well as heightened risk factors for women of color are vi t al for effective i nterventions, and a recent report highlight s the need for provider education about disparate MHC access and quality of care ( Nuru Jeter et al., 2008 ; Taylor et al., 2019 ) . E ven with recent changes in coverage and national social attitudes, black mothers ar e still half as likely to receive mental health treatment as white mothers and are still less likely to have access to MHC (Taylor et al., 2019) . Understanding these discrepancies can improve MHC policy and programming, but while cultural responsiveness is highlighted quality of care is not included in care discrepancy literature , despite acknowledgement that lack of understanding may be influential. Maternal M ental H ealth and R isks for W omen and F amilies In an investigation into existing practices surrounding maternal mental health, Engle ( 2009) uses a definition of maternal mental health from the World Health Organization (WHO ): stresses in life, can work productively and fruitfully, and is able to make a contribution to her community (p. 963S). This is a more comprehensive conception o f mental health that goes beyond a simple absence of mental illness and provides a more holistic view of mental health as

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 12 an ability to thrive. Engle (2009) goes on to discuss the growing global conception of mental health as a requirement for general heal th, highlighting that it is not a special interest but an essential part of overall wellbeing. Effects on children. Maternal depression has significant negative effects on child development and health, ranging from consequences of increased cortisol (stress hormone) exposure in utero to diminished nursing practices (Surkan, Patel, & Rahman, 2016) . Maternal depression also leads to reduced rates of health care seeking , and t he resulting delay in or lack of care can jeopardize the health of both mother and child ( Surkan et al. , 2016) . Nguyen and Duderstadt (2018) outline the risks of untreated perinatal mental health issues, including premature birth, low birth weight, and failure to thrive. Health risks for chil dren have been pre mental health generally in order to improve outcomes for all children ( Class et al., 2013; Surkan et al. , 2016) . Effects on women. Women in their third trimester of pregnancy have a higher risk of depression than the general population and suicidal ideation is a primary concern for healthcare providers, a risk that can be compounded by reduced c are seeking (Surkan et al., 2016) . In a more recent report on maternal mental health services in the U.S., Nguyen and Duderstadt (2018) present the prevalence of PPD and the low rates of diagnosis (30.8%) and adequate treatment (6.3%). Women who experience PPD are at high risk of social isolation, self harm, and poor physical health ( Letour neau et al., 2012; Schmied et al., 2016 ) . Consensus of the literature implicate s a strong, significant relationship between maternal mental health an d health outcomes for both mother and infant, making it reasonable to expect that increased mental health issues and decreased access to care should play a role in maternal mortality. Surkan et al. (2016)

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 13 identified the lack of studies and poor quality of data surrounding the relationship between mortality and maternal mental health, justifying a need for further review. Maternal mental health in Colorado. T he Colorado Department of Public Health and Environment (CDPHE) published a 2017 Maternal and Child Health data brief show ing pregnancy related mental health issues are the most common pregnancy complication while nationally remaining the most underdiagnosed, with over 75% of cases going untreated. In Colorado, just under 10% of women report PPD symptoms ( CDPHE , 2017) . The data brief outlines the cumulative effects of life stress that can contribute to an increased risk of PPD and the adverse effects on families including reduced attendance of well c hild visits ( CDPHE , 2017). It connects the occurrence of PPD to increased risk of maternal mortality and finds significant underreporting and access to MHC service by new mothers in Colorado ( CDPHE , 2017). Mental H ealth C are I ntegration Provider s hortage . Access to MHC is currently impacted by a shortage in MHC providers even as MHC coverage by insurance expands. In a recent investigation into who accesses family mental health programs, Hamovitch, Acri, and Bornheimer (2018) found that a shortage of provi ders and service availability does indeed exist as the number of people accessing services increases. In a recent publication from the Colorado Health Institute (2019), local level increases in behavioral health coverage ha ve still not resulted in mental health parity and is partially the result of complications in maintaining enough providers . Integration into existing structures. Embedding MHC into institutions that the target population already frequents has been tested in a few settings, including integration into school structures to reach younger populations. Hamovitch et al. (2018) highlighted the role of mental health screening in schools as increasing access for those who might not otherwise seek out

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 14 treatment, and as a current example of integrative care solutions. In a global study of maternal mental health interventions, Rahman, Surkan, Cayetano, Rwagatare, and Dickson (2013) found success in approaches that integrated maternal MHC into existing structures. The st udy found reduced rates of depression from integration into both child centered and community centered health programs, indicating that the most important factor is meeting people where they already are (Rahman et al., 2013). Ion, Sunderji, Jansz, and Ghav am Rhassoul (2017) found that integrative care approaches have improved access and outcomes, but that empirical evidence around implementation and disaggregated effects of the model are lacking. Through interviews with providers and clients, Ion, et al. (2 017) found that colocation and continuity of care were highly valued and aided in improved care supporting the holistic health conception. Through interviews with postpartum women and providers, Henderson et al. (2016) investigated reactions to integration of maternal care into well child visits. Barriers to accessing maternal postpartum doctor visits identified by the women included complications of time, transportation, and childcare (Henderson et al., 2016), all of which would be barriers to s eeking external MHC as well. While both groups recognized the potential value in integrating care, both were also concerned that i t could lead to less attention for the specific needs of both mothers and children. Rahman, et al. (2013) specifically argue a gainst the idea that combined care will dilute the effectiveness, taking a holistic view of health and arguing that integrated interventions can more completely address mental health issues. Integration is further supported by the finding that screenings l eading only to external referrals without additional support create barriers to follow through that can increase disparities in access to MHC (Selix, et al., 2017) . An investigation from a clinical nursing perspective by Selix, et al. (2017) concluded that integrating care with an

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 15 interdisciplinary approach from providers creates an opportunity to both improve outcomes for women and reduce redundancies of care. Maternal Mental Health Policy Relevant policy is most effective when it names maternal mental health specifically, generalized mental or physical health policies have not produced equal results . A focused policy analysis investigating specific law, regulations, a nd practice guidelines in Mexico aimed at maternal mental health by Place, et al. (2016) found that while prenatal care and mental health were both recognized, maternal mental health was not always specified, and where it was specified lacked follow through and support. Similarly, maternal mental health policies in the United States have focused on increasing maternal mental health screening while lending less support to next steps ( Nguyen & Duderstadt , 2018 ; Selix, et al., 2017) . Place, et al. (2016 ) highlight the difference between material and symbolic policy, arguing that having action step s is important for meaningful policy as intent is not influential without associated tangible actions . Policy interventions at the federal level were kick started with the passing of the Melanie Blocker Stokes Postpartum Depression Research and Care Act in 2003 ( Rhodes & Segre, 2013). Intended to increase research on PPD and evaluate programs addressing maternal mental health, the Act has since been renamed and eventually integrated into the Affordable Care Act (ACA) in 2010 (Rhodes & Segre, 2013). In an analysis of current local level policy interventions, Nguyen and Duderstadt (2018) found that incorporating MHC into other mechanisms, like well child visits , could help increase rates of diagnosis and treatment for underserved or harder to reach populations. Screening was specifically identified by both Rhodes and Segre (2013) and then Nguyen and Duderstadt (2018) as an important tool , but not effective in improving mental health outcomes on its own. Addressing the barriers to continued care is necessary to improving

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 16 outcomes and the increased likelihood that mothers will attend rather than their own creates an opportunity to i ntegrate MHC (Nguyen & Duderstadt, 2018) . Summary The literature review shows a relationship between maternal mental health and health outcomes for mother and child. Investigations of disparities in mental health and MHC demonstrate care gaps related to enough providers, quality of care, and systemic racism . Variations in treatment practices and social norms may unduly influence reporting rates of mental health issues for people of color and must be considered when assessing population differences . It is important to understand that demographics do not just affect access to MHC but also the risk and severity of mental health issues , thus exacerbating the negative consequences of disparities in MHC access. The risks of maternal mental health issues, specifi cally PPD, are significant for mothers and families, and the national trends have been detected within Colorado. While some policy interventions exist, the literature demonstrated that specific action steps are necessary in creating real impact and integrating care into existing healthcare systems could increase accessibility and follow through. Interventions must also include integration of cultural responsiveness in order to ensure equitable quality of care across populations. Methodology A mixed method approach was used to both assess the relationship between MHC access and maternal mortality within Colorado and to closely examine a maternal mental health program in Massachusetts . To best address the advocacy needs of Center for Health Progress and the related health needs of the community, this investigation address es the following research questions:

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 17 1. Is there a significant relationship between MHC access , race/ethnicity demographics, maternal depressive indicators, and rates of maternal mortality in the state of Colorado? 2. a. What is the structure of the recently implemented program to improve maternal MHC in M assachusetts ? b. What was the policy /program development and i mplementation process? c. How similar were the conditions in M assachusetts to those presently in C olorado ? Research Question 1 Hypotheses . To address Research Question 1, a quantitative analysis of public health and licensed provider data in Colorado was conducted . The analysis sought to establish a correlation between maternal mortality rates , demographics, and proximity to providers as an indicator of MHC access . Addressing these relationships has been further parsed into five hypotheses: 1. There will be a statistically significant correlation between the number of mental health care providers in a region and the rate of maternal mortality at the p 2. There will be a statistically significant correlation between demographics in a region and the rate of maternal mortality at the p 3. There will be a statistically significant correlation between the demographics in a region and the number of mental health care providers at the p 5 level. 4. There will be a statistical ly significant correlation between the number of mothers who reported p eri partum depression and/or symptoms in a region and the rate of maternal mortality at the p 5. There will be a statistically significant correlation between mothers who had a postpartum checkup in a region and maternal mortality at the p

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 18 Measurement and d ata c ollection . Each hypothesis was tested by conducting a bivariate As the analysis utilize d correlational tests, there is no significance in assigning independent or dependent status to the individual variables ; the analysis indicate d whether they vary together , not whether one directly influences the other. It is a central part of this investigation to assume that no two variables are exclusively related and without influence from external factors. This analysis proposes that t he presence of a relationship betwe en the identified variables indicate s the potential to address that variable to improve mortality outcomes by intervening in the broader variable interactions. A detailed table of the hypotheses, associated variables, and data sources can be found in Appen dix A. The analysis used secondary data f ro m several sources. Open datasets were obtained from The Colorado Health Institute (CHI) and the Census Bureau. Additional datasets were provided upon request by the Colorado Department of Public Health and Environment (CDPHE) . CHI is a nonprofit organization that believes in the use of evidence to inform health policy and provides acce ss to extensive datasets and data workbooks to the public . CDPHE provides an online library of health and environmental data, including datasets, analysis reports, summary tables, and the surveys used in data collection ; raw datasets are not publicly available . D atasets containing sensitive information are restricted, and some topics only provide reports and summaries. Sampling p lan . The rate of MHC care providers by county required compiling six datasets sourced from C HI that each include the rate of one type of provider (i.e. , psychologist ) by county (dated 2017) . The rates were added together to give a complete number of providers per county . Once compiled into the final regional dataset, this number was converted to the number of providers per 1,000 residents ( providers / [ population /1000 ] ) to control for expected

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 19 higher rates in more populous areas. The race/ethnicity rates for each county were sourced from a demographic dataset from C HI (dated 2016) . CDPHE provided two separate datasets fo r this investigation. One dataset included compiled information from the 2015 2017 Pregnancy Risk Assessment Monitoring System (PRAMS) at the county level. PRAMS data are frequently used in investigation s into issues surrounding perinatal health, and the provided dataset included answers to questions regarding mental health and PPD , insurance coverage, and demographics of PRAMS mothers. The second dataset included maternal mortality rat ios by region from 2008 2013 (the most recent available). While the dat a in use are several years old, the process of collecting, compiling , analyzing, and sharing mortality data generally takes a few years and using data from this time frame is in keeping with standard practice. The ratio is determined as a function of the n umber of maternal deaths ( within 1 year of birth) as compared to the number of live births . The calculation of the ratio gives a comparable function across regions that removes the difference attributed to difference in birth rate between region s . Because all other variables are to be compared with the maternal mortality ratio, all data required conversion to regional level . The counties included in each region was based on the makeup of the regions in the datasets provided by CDPHE, s ee appendice s for a table (Appendix B) and a map (Appendix C) of the counties included in each region . Because the unit of analysis is region rather than individual level, the n for n =21. Validity and r eliability . It is important to note that these are multifactored issues , b ut as the literature review demonstrate s connections between occurrences in public health data can serve as indicators of more complex relationships. Thus, the validity of the study is imperfect but in keeping with public health research and is being conducted with full understanding of the limitations of establishing these complex relationships. I t is t herefore assumed that any analysis

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 20 of two variables will not be an isolated relationship. The intent is not to pinp oint a cause , but rather to demonstrate correlation and recommend intervention at one level to improve outcomes. The reliability of the analysis is stronger due to the use of relatively recent datasets . As a state going through continuous population changes in recent years, however, any analysis of data 2 3 years old must be understood as an approximation of the current population and not a perfectly accurate reflection. The data are recent and complete enough, however, to justify its use in establishing relationships and reasoning for policy. Similarly, the research design makes the best use of available data ; t his is a simple correlation and illustration of relationships that is easily replicable with any public health data. Data a nalysis . The data from each of the different datasets were compiled into a single region level dataset in Excel. The dataset will then be exported to STATA to run the correlations. The p value will be set at .05, and a bivariate correlation using all regional data will be run . The process is outlined below: 1. Excel s preadsheet s of available /provided data. 2. Identify best representation of variables 3. Combine provider datasets by county , convert to region 4. Clean and compile data into single set by region 5 . Export to STATA 6 . Use STATA to run correlations and produce scatterplots Research Question 2 To address Research Question 2, a limited c ase s tudy of the Massachusetts Child Psychiatry Access Program (M C PAP) for Moms will be conducted. T he program was implemented in 2014 , C PAP program , in response to a recognized

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 21 sense of urgency surrounding untreated perinatal depression . MCPAP for Moms was identified during the initial literature review as part of Nguyen and (2018) investigation of current U.S. approaches. The M assachusetts program was selected as a case study because of the recency of its implementation and its specific in tent to increase MHC access for mothers. Outline and p roposition . The outline for the case study is presented in Table 1. Due to limitations in both time and resources, a full case study is not feasible as part of this investigation. The case study has therefore been limited to short term, essential components, including research on the development of the program, implementation mechanisms, the relevant policy, and the challenges and/or successes of the program. Table 1. Outline for Case Study M C PAP for Moms Case Massachusetts Policy/Public Health Approach to Addressing Maternal Mental Health through the M C PAP for moms Program Questions How did Massachusetts address the issue of Maternal Mental Health? What mechanisms did Massachusetts use to address the issue? What policy was passed to enable these changes? What was the outcome of the initial program? Proposition Building capacity in existing avenues of direct care providers will increase screening, identification of perinatal depressive symp toms, and quality and appropriateness of care provided to patients. Case Parameters The case is limited to the state of Massachusetts between the initial policy allowing formation of M C PAP for Moms to the present; including precursors, program developme nt, implementation, and initial impact analysis. Data Sources Archival record statutes/bills ; website; provider resources Documentation journal publications Logical Link; Data to Propositions Archival to substantiate the approach and process in MA to address maternal mental health; to illustrate the program mechanisms Documentation to determine functionality of program and whether it was determined successful why? Analysis Pattern matching How similar is the identified case to the current situa tion in Colorado? How might this affect translation of the program to the Colorado population? Sampling p lan and r eliability . Research will be conducted using the Auraria campus library database and M assachusett s government open data and municipal/program websites . The

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 22 intent of the case study is to determine the most successful parts of the process and the policy, and the similarities and differences between the two state conditions to determine the most effective potential impleme ntation of a similar effort in Colorado. Results Research Question 1: Is there a significant relationship between MHC access, race/ethnicity demographics, and rates of maternal mortality in the state of Colorado? The correlations revealed minimal relationships between most of the selected variables. A total of nine correlations were used to address the five stated hypotheses . H ypothesis 4 was tested with four depression indicators based on availability of data and the complexity of identifying mental health condition as compared with the more concrete rates of providers or demographics. E ach of the other hypotheses was only tested using a single variable pairing. The results of the correlations are presented in Table 2 ; results of hypotheses 2 and 3 related to demographics will be presented separately. Table 2. Results ; Maternal Mortality Variable Pair Correlation Coefficient Significance Level H 0 ; No Relationship H 1 Maternal Mortality Ratio; Provider Rate per 1k res. 0.1952 0.5036 Fail to rejec t H 4 (1) Maternal Mortality Ratio; Healthcare Visit for Depression 0.0107 0.9724 Fail to reject H 4 (2) Maternal Mortality Ratio; 3 mo. Pre Preg. Had Depression 0.5440 0.0443* Reject null; H 4 supported H 4 (3) Maternal Mortality Ratio; Had PPD Symptoms 0.6666 0.0092* Reject null; H 4 supported H 4 (4) Maternal Mortality Ratio; Down/Dep . /Hopeless since baby born 0.5639 0.0357* Reject null; H 4 supported H 5 Maternal Mortality Ratio; 1+ Stressors/ year pre preg. 0.3826 0.1769 Fail to reject H 6 Maternal Mortality Ratio; Had Postpartum Checkup 0.6295 0.0158* Reject null; H 6 supported n = 21 p *= significant

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 23 The H 1 relationship between provider rate and maternal mortality did not demonstrate a statistically significant relationship , further illustrated in F igure 1. While the correlation was negative , indicating that provider rate increases might decrease maternal mor tality, the significance was negligible and lacked a discernible pattern (Figure 1) . Although the regions with the highest mor t ality ratio are on the lower end of provider rates, there is no discernable overall trend in the relationship across regions. There was also no significant relationship found between Maternal Mortality Ratio and a healthcare visit for depression or stressors experienced in the year before pregnancy. Three of the indicators for depression were significant : Had depression during th ree months before pregnancy, had PPD symptoms, and always/often felt down, hopeless, or depressed since the Figure 1. Scatterplot of Maternal Mortality Ratio and Provider Rate by Region

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 24 new baby was born. All three of the relationships were significant at the p <.05 level, with the maternal mortality and PPD symptoms significant at the p <.01 level. All relationships were positive, suggesting th at as the reported depressive measures in PRAMS increased in a region so did the Maternal Mortality Ratio. Scatterplots for the depressive symptoms can be found in Appendix D. The scatterplot for the 3 month indicator shows that there may be a couple outlying regions affecting the significance of the correlation, though the direction of the trend is the same. The other two correlations show a stronger, more directed trend, a difference reflected in the strength of the significance found in the correlation. The correlation coefficient for H 6 , m ortality ratio and having a postpartum checkup , was significant at the p <.05 level, and in this case was a negative relationship indicating that increased postpartum checkup correlated with a reduced mortality ratio. The scatterplot for this measure is presented in Figure 2. There are a couple outlying regions that may have affected the Figure 2. Scatterplot of Maternal Mortality Ratio and Rate of Postpartu m Checkup by Region

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 25 strength of the significance, as most regions are clustered near the higher end of having postpartum checkups (for more, see discussion/Appendix F ). None of the demographics tested demonstrated a significant relationship with either maternal mortality or the provider rate by region, H 2 and H 3 respectively, as show n in Table 3. The demographic categories were limited to White : non Hispanic, Hispanic : any race, and Black/African American based on being the most represented demographics in most regions and Table 3. Correlations Results for Race/Ethnicity White; non Hispanic Hispanic; any race Black/African American H 0 ; No Relationship H 2 Maternal Mortality Ratio 0.2571 ( 0.3748 ) 0.4387 ( 0.1166 ) 0.2771 ( 0.3376 ) Fail to reject H 3 Provider Rate per 1k res. 0.0053 ( 0.9819 ) 0.1769 ( 0.4429 ) 0.1824 ( 0.4286 ) Fail to reject common all significant relationship. It is notable that Hispanic, any race was the only category showing an indication of a positive relationship with mortality ratio and a negative relationship with provider rate by region , but as these relationships were not determ ined to be statistically significant no conclusions can be drawn from this analysis . Research Question 2: a. What is the structure of the recently implemented program to increase maternal MHC in Massachusetts? b. What was the policy/program development and

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 26 implementation process? c. How similar were the conditions in Massachusetts to those presently in Colorado? I dentified sources for the case study are summarized in a table presented in Appendix E . Sources include two statutes, a government report, MCPAP for Moms website and resources, and three journal articles. The most important policy components of MCPAP for Moms include a statu t e enabling mortality research and an act specifically creating a research commissio n of PPD and how to address it. Further policy primarily includes funding for MCPAP for Moms being included in the annual legislative budget, and the empowerment of the Department of Mental Health and the state health commissioner to mandate the ongoing pr ogram . The vital components to answer the identified case study questions are presented in Table 4. Table 4. Components of MCPAP for Moms Initiation Following the 2010 passing of the PPD Act creating a commission empowered to make recommendations to the state, MA saw state government recognition in 2013 that maternal mortality rates had become a pressing issue requiring immediate action. MA passed legi slation to fund the establishment of MCPAP for Moms to address maternal mental health and maternal mortality rates. Existing personal and professional relationships were the primary recruiting channels for provider participants; the establishment of the p rogram relied heavily on the networks and reputations of the founding organizers. Recruitment of provider enrollees included presentations at professional conferences, personal communication with organizer s own networks, contacting professional societies to disseminate information to members, and cold calling identified OB/GYN practices. Related/Relevant Policy Title XVI Chapter 111 Section 24 A & B Empowering public health department commissioner to establish research committees on morbidity and mortality; requiring the sharing of birth records with the commissioner and protecting all relevant public health data 2010 Chapter 313 Ac t addressing PPD directly, establishing a research commission empowered to make recommendations to the state. Implem ent ation Mechanism MCPAP for Moms was modeled on the existing pediatric MCPAP program: Staffing of Central Office Development of Mental Health resource network for referrals Recruitment of participatory providers Provider training (required for enrollment ), including access to toolkits, recommended screening schedules, and treatment algorithms Once providers become members:

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 27 Screening of all postpartum patients at three specified intervals, four for high risk or history of depression, over one year postpart um When a patient with risk factors is identified, calls for a consult with MCPAP for Moms using toll free number Intake information is taken by a care coordinator, and the on call psychiatrist calls the provider within 30 min.; while patient is still at the office. Psychiatrist provides consultation to provider about next steps, including decision making about treat ment, referrals to mental health resources matched to patient needs, or if needed scheduling a consult with the patient themselves (when a referral appointment cannot be made within a satisfactory time frame). MCPAP for Moms is not intended to be a direct service provider, but if needed mothers can call the central office or use the website for resources and assistance in finding accessible and appropriate MHC. Implement ation Administration MCPAP for Moms is administered through the Massachusetts Behavio ral Health Partnership (MBHP), a private company under Beacon Health Options. There are three MCPAP for Mom locations with professional teams (psychiatrists and resource/referral specialists) spread out around MA, all embedded into existing psychiatry depa rtments at academic healthcare facilities: Baystate Medical Center University of Massachusetts Memorial Medical Center MCPAP for moms is payer blind and universally accessible. The MHC database was developed and maintained by William James College INTERFACE and is designed to aid in matching resource options with patient needs. Funding Sources Because MCPAP for Moms is a resource and training support system integrated into existing care structures, the total cost for the prog ram in 2017 18 was $750,000. Costs incurred by the institutions housing the MCPAP for Moms offices are reimbursed through annual contracts. MCPAP for Moms is supported with funding through the MA department of mental Health. As of 2015 program funding has been incorporated as a line item in the legislative budget to ensure it appropriation for the program. Partial funding comes from surcharges to commercial insurers in proportion to their use of MCPAP for Moms programs. Because services are payer blind, t hese surcharges help to cover the cost that would have normally been covered by insurance through conventional methods. Target Population Programming The direct programming of MCPAP for Moms targets healthcare providers rather than patients directly. The program is intended to build capacity of frontline providers with existing contact and relationships with mothers to not just screen for depression but to have knowledge and expertise to initiate next steps in seeking or providing treatment. The progra m targets OBGYN practices and midwives, while also supporting pediatric and family medicine providers who have contact with mothers during the perinatal period. As of 2017: 145 enrolled practices, 70% of obstetric practices in MA 1,174 providers, who accou nt for ~80% of MA deliveries (~72,000 annually)

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 28 Target Population Impact In recognizing that providing screening is not sufficient to address perinatal depression, MCPAP for Moms creates a network and resources to increase the providers mothers come into contact with who can provide support for depressive symptoms, as well as increasing and improving the avenues available to seek and support further treatment. This increased access to mental health supports will increase the detection and treatment of dep ression in mothers leading to improved outcome for both maternal and infant morbidity and mortality. As of 2017: 3,699 women served, 9.9% of 37,275 women with presumed depression in MA (at est. 15% rate of depression) Most telephone consultations included questions about medication or resources, indicating that patients were receiving more informed and complete care than they would have without the MCPAP for Moms program. Because of the delay on maternal mortality statistics and the recency of the program , statistical analysis of the programs impact on maternal mortality rates in MA is needed. The most recent report uses mortality rates ending in 2014; the year MCPAP for Moms launched. The rapid growth and rate of access of MCPAP for Moms has made it a recognized national model, and several states have begun the process of adopting it . Despite the national impact on rates of maternal depression and mortality is limited by th e recency of the program . A source included in the case study did provide an initial analysis of the first three and a half years concluding that the focus on targeting providers has been largely successful . While the number of women accessing and impacted by the program increases steadily , the number of women accessing care is still a small percentage of the estimated number of women in need of perinatal MHC in M assachusetts . To examine part c of Research Question 2, The basic characteristics of the two states were complied in Table 5. The quantifiable characteristics are intended to aid in analysis of similarity of conditions and associated challenges in implementing MCPAP for Moms type programming in Colorado.

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 29 Ta ble 5. Relevant Characteristics of Massachusetts and Colorado M assachusetts Colorado Population 6,547,629 Population 5,029,196 Pop per Sq. Mile 839.4 Pop per Sq. Mile 48.5 Sq. Miles 7,800.06 Sq. Miles 103,641.89 Pop. Female 51.5% Pop. Female 49.7% White, non Hispanic 72.2% White, non Hispanic 68.3% Black/African American 8.8% Black/African American 4.5% Hispanic/Latino 11.9% Hispanic/Latino 21.5% Average Annual Births (2015 17) 71,168 Average Annual Births (2015 17) 65,854 Demographics: 2010 Census ; Birth sources: CoHID; National Vital Statistics Reports Total Fertility Rates by State and Race and Hispanic Origin: United States, 2017 ; Massachusetts Department of Public Health: Massachusetts Births 2016 Report Discussion The data established a statistically significant relationship between perinatal depressive symp toms and maternal mortality in Colorado regions, supporting the need for improved intervention in perinatal depression. Risk factors alone, specifically experien cing stress and having had a healthcare visit for depression in the past, were not significantly correlated with maternal mortality. Signs of existing maternal depression correlating with maternal mortality is not surprising given the research on the link established in the literature review , but it is important to recognize that this trend is happening on a geographic level in Colorado, and that some regions may need more support tha n others to address the recent maternal mo rtality trends. While there were region outliers for some variables, these findings help establish the link locally, and can help to identify where further research might provide a more detailed picture. When the outliers are removed from the two correlati ons in which they were identified, H 4(2) and H 6 , the results were no longer statistically significant. This does not necessarily indicate that the relationships identified are irrelevant, but more likely underscore the need for more detailed data that woul d separate the outlying regions into 4 6 separate counties (figures in Appendix F) . Access to data a t a more detailed level, such as county rather than region, would potentially

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 30 reveal changes in the relationships and possibly provide more insight into areas that have a stronger need. While no relationship was found using demographic data, the initial trends indicate that more detailed data might reveal a more significant relationship. Location Based Analysis While the expected relationship between the rate of providers by region and maternal mortality was not stati sti cally significant , a nuanced analysis can begin to answer why. Information for selected correlational relationships was put into Tableau Public to map the results and compare geospatially. When provider rate and maternal mortality ratios are mapped together, as seen in Figure 3 , we can begin to understand why the absence of statistical significance may have occurred and why access to a more detailed maternal mortality dataset Figure 3 . MHC Providers and Maternal Mortality in Colorado might yield different results. The two regions with the highest maternal mortality ratio are in southern Colorado and in the southern end of the mountain range, significantly removed from the metropolitan areas and showing a relatively low provider rate. S everal regions

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 31 with a low maternal mortality ratio but varied provider rates are clustered close together, indicating that the varied geographic size of the regions and their proximity to each other ma y impact the statistical significance o f the findings. The comparison between provider rates and maternal mortality is further illustrated by single variable maps in Appendix G . The potential trends , despite lack of statistical support, are further illustrated by map ping maternal mor t ality and the size of the Hispanic population in each region seen in Figure 4 . Region 8 clearly shows a lower provider Rate (Figure 3), a high maternal mortality ratio, and one of the highest Hispanic population ratios in the state. Despite not showing any statistic al significance in demographics, a closer look demonstrates that there are other indications of potential relationships. The clustering Figure 4 . Maternal Mortality and Hispanic Populations in Colorado of regions in the Front Range is likely skewing the findings at the region level and masking concentration of MHC providers. Further investigation of individual or county level data could influence statistical findings and help more accurately identify variable relationships and areas of

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 32 need . Regional level data made it difficult to determine whether relationships were not found due to the small sample size . T he geographic illustrations suggest the likelihood of a stronger relationship with more detailed data, especially considering that even regional level data produced statistically significant relationships. Mental Health Care I nterventions The relationship between p ostpartum checkup s and mortality was statistically significant, though did include outliers and might need more detailed data to establish a stronger relationship. The significant findings do, however, support the premise that inc orp o rating MHC into existing care structure might not only improve access but increase the existing benefits of postpartum care . The case study on MCPAP for Moms provides a framework of how to improve the mental health aspects of these postpartum visits, poten tially increasing their value as an effective intervention for maternal mortality. As of 2017 , Colorado has allowed for up to three screenings in the first year post pregnancy and allows the screening to be billed to the Medicaid to help fill the gap for mothers without insurance coverage ( CDPHE , 2017) . This is a valuable step in ensuring women have access to screening, but screenings are not effective in improving maternal mental health without subsequent supportive steps ( Place, et al. , 2016 ; Selix, et al., 2017). MCPAP for Moms is based on the premise that post screening support is vital to improvement in maternal MHC and designed the program to address improvement of follow up treatment. MCPAP for Moms approach of increasing capacity of the providers that have existing contact and relationships with mothers minimizes the expansion required to increase access and takes advantage of the infrastructure that already exists rather than creating new care pathways . The 2017 18 cost of running MCPAP for Moms of $750,000 is low for a statewide public health program . further

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 33 investigation of the Colorado budget and state funding for public health programs could hi gh impact program. The program is still in early stages, and it is difficult to assess its effectiveness without more recent public health data. The drawbacks identified in the quality assessment include provider discomfort and hesitation surrounding mental health and associated treatment (Byatt, et al., 2018) . This sugge s t s that it is not only a general cultural shift around mental health but a healthcare provider attitudinal shift that might be required to reach the program s full potential. The training and resources supplied to providers can aid in this process, but attitudinal change that leads to improved care will take time . Provider discomfort and lack of confidence with mental health might also be influencing comfort in reporting symptoms, potentially a factor in MCPAP for Moms still only se rving a fraction of the estimated population of need. Despite measurement challenges at this stage, MCPAP for Moms has demonstrated rapid growth and strong program utilization numbers , providing a MHC option that c ould address location issues face d by OB/GYN providers and mothers in rural areas of Colorado. Current Local Conditions and Programs Colorado has taken some initial policy steps similar to those that enabled the establishment of MCPAP for Moms. The 2019 expansion of the state maternal mortality review committee positions local legislators to make the kind of program recommendations that initiated MCPAP for Moms. Curr ently, Beacon Health Options supports Colorado Psychiatric Access & Consultation for Adults and Kids (C PAC) in southern Colorado. The program is modeled on the original MCPAP program and provides resource and consultation support to providers in regions 1, 5 (75%), 6, 7, 8, 13, and 18 ( http://www.cpack.org/where we re located/ ) . Services are similar to MCPAP but less extensive and designed for general adult and pediatric providers that choose

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 34 to enroll. The program is not currently targeted toward reachin g mothers. T h is investigation indicates that Colorado could benefit greatly from targeted maternal support , and that this targeting is an important piece of improving maternal mental health outcomes . Scaling the project to Colorado will present significant logistical challenges. The population of Colorado is slightly smaller than Massachusetts, as seen in Table 5, but the difference in population per square mile between the state s is extreme. This had been one of the challenges to expanding care in the state, and would require extending resources across a more expansive area to achieve results similar to MCPAP for Moms. The reduced population density and potentially further distance f rom MHC resources makes care coordination in Colorado more complex, and even help with resources cannot necessarily address the need for providers in areas where they a re currently lacking. This issue might be addressed by incorporation of telepsychiatry i nto a MCPAP for Moms type framework but has not yet been tested by MCPAP for Moms as a strategy (John & Schuman , 2018). The number of births in Colorado is lower, however, and so the cumulative need for maternal MHC resources is also lowered . The m ost important component w ould be developing a detailed database . This process w ould take time up front due to geographic sprawl , but once put into practice the providers ability to consult with care coordinators who are familiar with the database could re duce the effects of geographic location as a barrier to care . Limitations As indicated thus far, this analysis was limited by the availability of data. Although common for public health data, the recency of data available makes it difficult to address the current state of maternal mortality and mental health. Results from this analysis must be understood to be an approximati on , as the maternal mental health indicators are from 2017, while

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 35 the maternal mortality rate data is 6 10 years old. Moreover, the us e of data at region level weakened the dataset and minimized the likelihood of finding statistical significance. More detailed data at the county level would increase the sample size and strengthen potential findings ; the fac t that statistical significance was found at the region level indicates that relationships are strong enough to transcend the weaker sample size and should be investigated further. The case study portion of this investigation was extremely limited by time a nd resources. A more rigorous case study w ould have included a comprehensive review of Massachusetts public health data, interviews with policy process participants, and budgetary analysis. Future research should include budgetary comparisons between Color ado and Massachusetts and between the cost of MCPAP for Moms and similar programming in Colorado . Recommendations This investigation intended to identify maternal mental health policies that have been put in to practice and asse s s their effectiveness and transferability to Colorado. In identifying a program for the case study, it became clear that many of the initial policy steps other states have taken to address mental health ha ve been recently implemented locally . Incorporating maternal PPD screening in to Medicaid coverage began less than two years ago; a significant step that other states have taken but too recent in Colorado to assess its impact . Maternal m ortality review boards have been a vital step in states understanding maternal mortality and the role of mental health, as well as developing and supporting related programming. Colorado recent review board updates are potentially stronger than many of its predecessors due to the inclusion of equity language, but again its passage in May 2019 makes it much to o recent to have had an impact. The required data sharing included in the bill should enable a more detailed and accurate assessment of the relationship between maternal mortality and demographics.

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 36 The most effective steps in seeing real change for maternal mental health for Colorado will be less related to initial policy changes and should focus instead on persuading those who have be e n empowered through the policies to develop programming that increases the capacity of existing health systems. Based on the findings of communities in need and the effectiveness of the MCPAP for Moms program, the following actions are recommended: 1. Advocating for a statewide intervention program targeted at ma ternal mental health support ; specifically including a detailed database of providers throughout the state , offices in several regions that can specialize knowledge to local populations , and intentional support directed at geographically isolated areas and southern Colorado. 2. Advocating for increasing the capacity of frontline providers in assessing mental health, conducting screenings , identifying warning signs, and ability to treat moderate mental health issues. This should include ongoi ng training to reduce provider discomfort with discussing and addressing mental health. 3. Advocating for specific policy support for programming ( inclusion in statute , similar to the updates to the maternal mortality review committee) to ensure that the inte rventions have the extended time period necessary to develop effective resources , establish vital relationships, and address cultural challenges . Translating MCPAP for Moms type program ming to Colorado w ill require broader reach and significantly more offices than was necessary in Massachusetts . The ability to connect over the phone and a well researched MHC resource database would be incredible assets to more isolated areas and would not necessarily require large amounts of long term funding. C urrent

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 37 legislative efforts to understand and address maternal mortality can help illuminate new approaches and access to new resources that would improve outcomes for all mothers . I ncreasing the capacity of current frontline providers to address maternal mental h ealth give us a way to take advantage of a system already in place and lay the groundwork for a more comprehensive healthcare system that would be more supportive of other mental health measure s in the future. A program like MCPAP for Moms not only improve s the quality of care in a more immediate way than an entirely new program would be able to, but it offers an opportunity t o improve cultural attitudes of both patients and providers toward mental health. a more comprehensive maternal mortality review committee puts lawmakers in a position to recommend a similar program and seek state supported funding. putting Colorado in a potentially better position to ensure that the program addresses racial disparities in care and outcomes. Because the outcomes of this kind of programming are long term and thus may take a long time to establish, having a policy that ensures the program s longevity is vital to ensuring that it can be promoted properly and allowed to permeate existing healthcare practices. Colorado has already taken steps to increase screenings, ensuring that policies support what comes after screenings is the next step in a ddressing the growing rate of maternal mortality. Conclusion Maternal mortality r ates in Colorado have been increasing in recent years and the problem has been identified as a priority for state lawmakers. The issue has been linked to maternal mental health conditions, and the statistical analysis conducted by this investigation found a significant relationship between perinatal depressive symptoms and maternal mortality

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 38 by Colorado region. Despite not producing a significant correlative relatio nship, maternal mortality and the rate of providers in a region shows a potential relationship, specifically for areas that are more geographically isolated. MCPAP for Moms has had success in Massachusetts increasing capacity of direct care providers to ad vise and treat perinatal mental health issues for women and connect them to appropriate and attainable care. The program provides a promising framework for Colorado in addressing barrier s to care such as distance from MHC providers and lack of follow throu gh with depression screenings. The unequal impact of race on mental health requires that any program implementation must include culturally responsive considerations in order to best serve the highest risk maternal population. Future research should focus on scaling down correlative data to identify patterns at the county or individual level . Policies to empower the establishment of the identified programming have recently been passed, but the effectiveness and longevity of such a program should be supported by policy naming maternal mental health specifically and establishing state funding for the program.

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 39 References Byatt, N . , Biebel, K., Simas, T. A. M., Sarvet, B., Ravech, M., Allison, J., & Straus, J. (2016). Improving perinatal depression care: The Massachusetts child psychiatry access project for moms. General Hospital Psychiatry, 40 , 12 17. doi:10.1016/j.genhosppsych.2016.03.002 Byatt, N., Straus, J., Stopa, A., Biebel, K., Mittal, L., & Simas, T. A. M. (201 8).Massachusetts child psychiatry access program for moms: Utilization and quality assessment. Obstetrics & Gynecology, 132 (2), 345 353. doi:10.1097/AOG.0000000000002688 Class, Q. A., Khashan, A. S., Lichtenstein, P., Långström, N., & D'Onofrio, B. M. (201 3). Maternal stress and infant mortality: The importance of the preconception period. Psychological Science, 24 (7), 1309 1316. doi:10.1177/0956797612468010 Colorado Department of Public Health and Environment. (2017, August). Maternal and c hild h ealth d ata b rief: Pregnancy r elated depression and anxiety in Colorado . Retrieved from https://www.colorado.gov/pacific/sites/default/files/LPH_MCH_Pregnancy_Related_% 2 0Depression.pdf Colorado Department of Public Health and Environment. (2017, September ). Provider b ulletin ; Reference: B1700403 . Retrieved from https://www.colorado.gov/pacific/sites/default/files/Bulletin_0917_B1700403.pdf Colorado Department of Public Health and Environment . (n.d.). Findings from the Colorado Maternal Mortality Review Commit tee: 2008 2013 . Retrieved fro m h ttps://www.colorado.gov/pacific/sites/default/files/PF_Findings_Maternal_Mortality_C o mmittee_2008 2013.pdf

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 40 Colorado Health Institut e. (2019, March). Parity remains a work in progress for Colorado . Retrieved from https://www.coloradohealthinstitute.org/sites/default/files/file_attachments/SUD.pdf Cunningham, P. J. (2009). Beyond parity: Primary care physicians' perspectives on access to mental health care. Health Affairs, 28 (3), w490 w501. doi:10.1377/hlthaff.28.3. w490 Engle, P. L. (2009). Maternal mental health: Program and policy implications. The American Journal of Clinical Nutrition, 89 (3), 963S 966S. doi:10.3945/ajcn.2008.26692G Ertel, K . A., James Todd, T . , Kleinman, K., Krieger, N., Gillman, M . , Wright, R . , & Rich Edwards, J. (2012). Racial discrimination, response to unfair treatment, and depressive symptoms among pregnant black and African American women in the U nited S tates. Annals of Epidemiology, 22 (12), 840 846. doi:10.1016/j.annepidem.2012.10.001 Hamo vitch, E. K., Acri, M. C., & Bornheimer, L. A. (2018). Who is accessing family mental health programs? D emographic differences before and after system reform. Children and Youth Services Review, 85 , 239 244. doi:10.1016/j.childyouth.2017.12.027 Henderson, V., Stumbras, K., Caskey, R., Haider, S., Rankin, K., & Handler, A. (2016). Understanding factors associated with postpartum visit attendance and contraception choices: Listening to low income postpartum women and health care providers. Maternal and Child Health Journal, 20 (S1), 132 143. doi:10.1007/s10995 016 2044 7 House Bill 19 1122 . ( Colorado Department of Public Health and Environment Maternal Mortality Review Committee ) Seventy second General Assembly . First Regular Session . (Colorado 2019) Ion, A., Sunderji, N., Jansz, G., & Ghavam Rassoul, A. (2017). Understanding integrated mental health care in "real world" primary care settings: What matters to health care providers

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 41 and clients for evaluation and improvement? Families, Systems & Health: The Journ al of Collaborative Family Healthcare, 35 (3), 271. doi:10.1037/fsh0000294 John, K. S., & Schuman, A. J. (2018). Improve mental health access collaboration, integration, and telepsychiatry. (PRACTICE: Improvement: OPTIMIZE YOUR BUSINESS SAVVY). Contemporary Pediatrics, 35 (9), 46 49. Kohan, E. M., Hill, J. R., Schwabe, M., Aleem, A. W., Keener, J. D., & Chamberlain, A. M. (2019). The influence of mental health on patient reported outcomes measurement information system (PROMIS) and traditional outcome instrum ents in patients with symptomatic glenohumeral arthritis. Journal of Shoulder and Elbow Surgery, 28 (2), e40 e48. doi:10.1016/j.jse.2018.07.033 Kwate, N. O. A., & Goodman, M. S. (2015). Cross sectional and longitudinal effects of racism on mental health among residents of black neighborhoods in N ew York C ity. American Journal of Public Health, 105 (4), 711 718. doi:10.2105/AJPH.2014.302243 Letourneau, N. L., Dennis, C., Benzies, K., Duffett Leger, L., Stewart, M., Tryphonopoulos, P. D., Es te, D ., & Watson, W. (2012). Postpartum depression is a family affair: Addressing the impact on mothers, fathers, and children. Issues in Mental Health Nursing, 33 (7), 445 457. doi:10.3109/01612840.2012.673054 Lo, C. C., Cheng, T. C., & Howell, R. J. (2014 ). Access to and utilization of health services as pathway to racial disparities in serious mental illness. Community Mental Health Journal, 50 (3), 251 257. doi:10.1007/s10597 013 9593 7 Massachusetts Child Psychiatry Access Program (MCPAP) for Moms, Boston. (2017). Gold award: Building the capacity of frontline providers to treat mental and substance use

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 42 disorders among pregnant and postpartum women. Psychiatric Services, 68 (10), e1 e3. doi:10.1176/appi.ps.681001 McGuire, T. G., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: Policy implications. Health Affairs, 27 (2), 393 403. doi:10.1377/hlthaff.27.2.393 Nguyen, M. H., & Duderstadt, K. G. (2018). Access to maternal mental health services: Trends in state legislation. Journal of Pediatric Health Care, 32 (6), 644 647. doi:10.1016/j.pedhc.2018.08.007 Nuru Jeter, A., Dominguez, T. P., Hammond, W. P., Leu, J., Skaff, M., Egerter, S., Jones, C.P., Braveman, P. (2009). " I t's the skin you're in": African American women talk about their experiences of racism : A n exploratory study to develop measures of racism for birth outcome studies. Maternal and Child Health Journal, 13 (1), 29. doi:10.1007/s10995 008 0357 x Place, J. M. S., Billings, D. L., Frongillo, E. A., Bla ke, C. E., Mann, J. R., & deCastro, F. (2016). Policy for promotion of women's mental health: Insight from analysis of policy on postnatal depression in M exico. Administration and Policy in Mental Health, 43 (2), 189. doi:10.1007/s10488 015 0629 x Rahman, A., Surkan, P. J., Cayetano, C. E., Rwagatare, P., & Dickson, K. E. (2013). Grand challenges: Integrating maternal mental health into maternal and child health programmes. PLoS Medicine, 10 (5), e1001442. doi:10.1371/journal.pmed.1001442 Rhodes, A. M., & Se gre, L. S. (2013). Perinatal depression: A review of US legislation and law. Archives of Women's Mental Health, 16 (4), 259 270. doi:10.1007/s00737 013 0359 6

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 43 Roll, J. M., Kennedy, J., Tran, M., & Howell, D. (2013). Disparities in unmet need for mental hea lth services in the U nited S tates, 1997 2010. Psychiatric Services, 64 (1), 80 82. doi:10.1176/appi.ps.201200071 Schmied, V., Langdon, R., Matthey, S., Kemp, L., Austin, M., & Johnson, M. (2016). Antenatal psychosocial risk status and Australian women's use of primary care and specialist mental health services in the year after birth: A prospective study. BMC Women's Health, 16 (1), 69 69. doi:10.1186/s12905 016 0344 0 Selix, N., Henshaw, E., Barrera, A., Botcheva, L., Huie, E., & Kaufman, G. (201 7). Interdisciplinary collaboration in maternal mental health. MCN, the American Journal of Maternal/Child Nursing, 42 (4), 226 231. doi:10.1097/NMC.0000000000000343 Snowden, L. R., & Yamada, A. (2005). Cultural differences in access to care. Annual Review of Clinical Psychology, 1 (1), 143 166. doi:10.1146/annurev.clinpsy.1.102803.143846 Surkan, P. J., Patel, S. A., & Rahman, A. (2016). Preventing infant and child morbidity and mortality due to maternal depression. Best Practice & Research: Clinical Obstetri cs & Gynaecology, 36 , 156 168. doi:10.1016/j.bpobgyn.2016.05.007 Taylor, J., Novoa, C., Hamm, K., Ph adke, S. ( 2019, May). Eliminating r acial d isparities in m aternal and i nfant m ortality: A c omprehensive p olicy b lueprint . Center for American Progress: AmericanProgress.org Tuttle, M. (2018). Disproportionate rates of postpartum depression: Too many African American mothers are affected in Ramsey County . Public Health Review, 1 ( 1 ) . Retrieved from https://pubs.lib.umn.edu/index.php/phr/article/view/1574

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 44 Wallace, S., Nazroo, J., & Bécares, L. (2016). Cumulative effect of racial discrimination on the mental health of ethnic minorities in the United Kingdom. American Journal of Public Health, 106 (7), 1294 1300. doi:10.2105/AJPH.2016.303121

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 45 Appendix A. Research Q uestion 1 Measurement Table Hypothesis Variables Measure Level of Measurement Data Source 1. There will be a statistically significant correlation between the number of mental health care providers in a region and the rate of maternal mortality at the p level. Number of mental health care providers Maternal mortality Rate of licensed providers in region Regional maternal mortality rat io Interval/ratio Interval/ratio C O Health Institute : licensed provider data CDHPE provided maternal mortality dataset 2. There will be a statistically significant correlation between demographics in a region and the rate of maternal mortality at the p Race/ethnicity representation Maternal m ortality Rate of race/ethnicity in region Regional maternal mortality rat io Interval/ratio Interval/ratio CO Health Institute CDHPE provided maternal mortality dataset 3. There will be a statistically significant correlation between the demographics in a region and the number of mental health care providers at the p 5 level. Race/ethnicity representation Number of mental health care providers Rate of race/ethnicity in region Rate of licensed providers in region Interval/ratio Interval/ratio CO Health Institute C O Health Institute : licensed provider data 4. There will be a statistically significant correlation between mothers who reported p eri partum depression symptoms and the rate of maternal mortality at the p level. (Calculated depression; Healthcare visit for depression; in 3 mo. Pre Preg. Had Depression ; Down/Depressed/Hopeless since new baby was born ) Mothers reporting p eri partum depressive symptoms Maternal mortality Rate of mothers with symptoms / diagnosis in specified area Regional maternal mortality rat io Interval/ratio Interval/ratio CHDPE provided PRAMS dataset CDHPE provided maternal mortality dataset 5. There will be a statistically significant correlation between mothers who experienced stress in the year pre pregnancy and maternal mortality at the p level. Mothers reporting 1+ stressors in year pre preg. Maternal mortality Rate of mothers who report stressors in region Regional maternal mortality rat io Interval/ratio Interval/ratio CHDPE provided PRAMS dataset CDHPE provided maternal mortality dataset 6. There will be a statistically significant correlation between mothers had a postpartum checkup and maternal mortality at the p Mothers who receive postpartum care Maternal mortality Rate of mothers who report post partum checkup in region Reg ional maternal mortality rat io Interval/ratio Interval/ratio CHDPE provided PRAMS dataset CDHPE provided maternal mortality dataset

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 46 Appendix B. Counties that comprise each identified region (table) Region Counties 1 Logan, Morgan, Philips, Sedgwick, Washington, Yuma 2 Larimer 3 Douglas 4 El Paso 5 Cheyenne, Elbert, Kit Carson, Lincoln 6 Baca, Bent, Crowley, Huerfano, Kiowa, Las Animas, Otero, Prowers 7 Pueblo 8 Alamosa, Conejos, Costilla, Mineral, Rio Grande, Saguache 9 Archuleta, Dolores, La Plata, Montezuma, San Juan 10 Delta, Gunnison, Hinsdale, Montrose, Ouray, San Miguel 11 Jackson, Moffat, Rio Blanco, Routt 12 Eagle, Garfield, Grand, Pitkin, Summit 13 Chaffee, Custer, Fremont, Lake 14 Adams 15 Arapahoe 16 Boulder, Broomfield 17 Clear Creek, Gilpin, Park, Teller 18 Weld 19 Mesa 20 Denver 21 Jefferson

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 47 Appendix C. Counties that comprise each identified region (map) Colors to easily differentiate counties not otherwise significant Colorado Regions with Labeled Counties

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 48 Appendix D. Statistically Significant Depressive Measure Scatterplots

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 49

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 50 Appendix E . Case Study Source Table Source Type Source ; Name Description Archival Statute ; Title XVI Chapter 111 Section 24A & B 1997 A: Reduction of Morbidity and Mortality; Establishment of Program; Information and Reports Empowers commissioner to authorize research on morbidity and mortality Protects all data provided for this purpose from being shared/used outside of the authorized research, including publication or as evidence B: Birth Information; Statistical Purposes Requires the submission of child and parental information for all births to the commissioner for administrative, statistical, and research purposes. Preve nts sharing of submitted information, requires researchers to submit requests and adhere to confidentiality. Statute ; Chapter 313 2010 An Act Relative to Postpartum Depression. Empowers the Department of Public Health to consult with experts to develop measures, measurement standards, and issue regulations to address postpartum depression. Requires the Commissioner of Public Health to issue an annual summary Establishes a special commission to investigate postpartum depression; assessment of research, current policies, development of educational materials, support application for federal funding. Provide guidance to governor on best practices and recommended policy; file annual report. Website ; MCPAP for Moms Access to program components and informat ion, Resources and Toolkits, Contact phone number for providers, provider enrollment information, reports and publications, direct resources for mothers and families including support groups. Provider Resources ; Adult Provider Toolkit, Pediatric Provider Toolkit, Substance Use Toolkits, Webinars and past presentations, Brochures and Resource Cards Available via website; include guides for provider decision making: Assessment tools and decision making algorithms to assist providers in identifying n eeds and best courses of action, specifically for depression and antidepressant medication. Links to toolkits and resources related to maternal substance use, particularly alcohol and opioids. Webinars provide options for continued and specialized educatio n for providers, and print materials can aid providers still adjusting to how to talk about mental health with

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 51 their patients to start conversations and create safe space. Government Report ; Maternal Mortality and Morbidity Review in Massachusetts: A bu lletin for Health Care Professionals 2018 Substance Use among Pregnancy Associated Deaths Massachusetts, 2005 2014 Presentation of state data regarding perinatal substance abuse, specifically related to the opioid epidemic. Includes background on the es tablishment of the Massachusetts Maternal Mortality and Morbidity Review committee. Documentation Journal Article ; Gold Award: Building the Capacity of Frontline Providers to Treat Mental and Substance Use Disorders Among Pregnant and Postpartum Women 2017 Extensive outline of development of MCPAP for Moms. Initiation of program and modeling on existing successful MCPAP program for children. Description of funding sources and mechanisms, details of daily program functionality, history of the programs development and early implementation strategies, current enrollment rates, and the type of guidance given to providers. Journal Article ; Improving perinatal depression care: the Massachusetts Child Psychiatry Access Project for Moms 2016 Overview of project details, funding and state budget appropriations, the development of the program and costs of running. Includes information on organizational partnerships, program staffing, and service provision process details. Outline of data c ollection and methods of program analysis, with an initial 18 month analysis of program reach and effectiveness. Journal Article ; Massachusetts Child Psychiatry Access Program for Moms: Utilization and quality assessment 2018 Investigation into effecti veness of MCPAP for Moms at the 3 ½ year mark using focus groups of both provider and patient participants. Includes details on birth and program use statistics in MA alongside a brief history. The focus group are used to highlight challenges and future im provements, as well as the most beneficial program characteristics. Particularly, providers reported a lack of confidence in MHC related decision making because it is not there are of expertise but reported improvement in understanding and comfort as use i ncreased, as well as a cultural change in provider offices to a more open attitude surrounding conversations about MHC. Some patients reported that their providers still appeared uncomfortable and rushed when discussing mental health, indicating that provi der attitude is willingness to seek MHC assistance. Overall the results indicate that establishing the program is a good first step but developing provider comfort levels with the processes will impro ve effectiveness but may take some time to cultivate.

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 52 Appendix F. Correlations with Outliers Removed Maternal Mortality Ratio Coefficient Significance H 4(2) During 3 mos. before pregnancy had depression ( region 13 removed) 0.2872 0.3414 H 6 Had postpartum checkup (regions 13 and 8 removed) 0.0608 0.8511

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 53

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MENTAL HEALTH AND MATERNAL MORTALITY IN COLORADO 54 Appendix G . Single Variable Maps for Maternal Mortality and Provider Rates

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Description Area This is a non-exclusive grant of permissions for on-line and off-line use for an indefinite term. Off-line uses shall be consistent either for educational uses, with the terms of U.S. copyright legislation's "fair use" provisions or, by the University of Colorado Denver and/or Auraria Library, with the maintenance and preservation of an archival copy. Digitization allows the University of Colorado Denver and/or Auraria Library to generate imageand text-based versions as appropriate and to provide and enhance access using search software. This grant of permissions prohibits use of the digitized versions for commercial use or profit. Signature Your Name Aubrey Hill Date 7/22/2019 Email Address aubreyhill@gmail.com ATTENTION Description Area Grant of Permissions is provided to: Auraria Digital Library Program / Matthew C. MarinerAuraria Library1100 Lawrence | Denver, CO 80204matthew.mariner@ucdenver.edu303-556-5817

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Description Area This is a non-exclusive grant of permissions for on-line and off-line use for an indefinite term. Off-line uses shall be consistent either for educational uses, with the terms of U.S. copyright legislation's "fair use" provisions or, by the University of Colorado Denver and/or Auraria Library, with the maintenance and preservation of an archival copy. Digitization allows the University of Colorado Denver and/or Auraria Library to generate imageand text-based versions as appropriate and to provide and enhance access using search software. This grant of permissions prohibits use of the digitized versions for commercial use or profit. Signature Your Name Melissa Mejia Date 7/23/2019 Email Address melissa.mejia@ucdenver.edu ATTENTION Description Area Grant of Permissions is provided to: Auraria Digital Library Program / Matthew C. MarinerAuraria Library1100 Lawrence | Denver, CO 80204matthew.mariner@ucdenver.edu303-556-5817