Data Sets and Scoring Methodology
Risk Factors
The research team identified known factors associated with poor maternal mental health and over two dozen datasets were collected and standardized.
A scoring system was developed to assign a Risk Factors Score (RFS) for each county in the U.S.
The RFS system is composed of tiers in which each data set has been included.
Tier I factors have been associated with poor perinatal mental health in multiple systematic reviews.
I-1: Intimate Partner Psychological Aggression
Source: (2017) National Intimate Partner and Sexual Violence Survey, State Reports 2010-2012
Description: Lifetime Prevalence of Psychological Aggression by an Intimate Partner; State Level
Key Variable: (%) Intimate-Partner Victimization of Any Kind
I-2: Violent Crime Rate
Source: (2022) County Health Rankings & Roadmaps, University of Wisconsin Population Health Institute
Description: Violent Crime; County Level
Key Variable: Violent Crime Rate: Number of violent crimes reported per 100k
I-3: Poor Mental Health Days
Source: (2022) County Health Rankings & Roadmaps, University of Wisconsin Population Health Institute
Description: Poor Mental Health Days; County Level
Key Variable: Average Number of Mentally Unhealthy Days per Month
I-4: Mother Lacks Emotional Support
Source: (2020-2021) National Survey of Children’s Health, Health Resources and Services Administration, Maternal and Child Health Bureau
Description: Mother lacks emotional support; State Level
Key Variable: (%) Answering 'YES'
I-5: Intended Pregnancy
Source: (2016-2020) Centers for Disease Control and Prevention (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS)
Description: Pregnancy: Mistimed, Unwanted, Unsure whether Wanted, Intended; State Level
Key Variable: (%) Pregnancies: Intended
I-6: Children in Poverty
Source: (2022) County Health Rankings & Roadmaps, University of Wisconsin Population Health Institute
Description: Children in poverty; County Level
Key Variable: (%) in poverty (all children)
Tier II factors have a known association with poor perinatal mental health, but with less supporting research.
II-7: Educational Attainment by Fertility Status (gave birth last 12 mo)
Source: (2020)ACS 5-Year Estimates Public Use Microdata Sample
Description: Educational Attainment by Fertility Status (gave birth last 12 mo); State Level
Key Variable: Less than College Degree, Gave birth within past 12 months=Yes
II-8: Children in Single Parent Households
Source: (2022) County Health Rankings & Roadmaps, University of Wisconsin Population Health Institute
Description: Children in single parent households, County Level
Key Variable: (%) of Children in Single-Parent Households
II-9: Households w/Children Age 6 or Younger and At Least 1 Unemployed Parent
Source: (2020)ACS 5-Year Estimates Public Use Microdata Sample
Description: Employment Status of Parents by Household presence and age of Children, State Level
Key Variable: At least one parent unemployed, households w/ children age 6 and under
II-10: Teen Births
Source: (2022) County Health Rankings & Roadmaps, University of Wisconsin Population Health Institute
Description: Teen births, County Level
Key Variable: (#) of births per 1,000 female population ages 15-19
II-11: Cesarean Delivery Rate
Source: (2020) Centers for Disease Control and Prevention (CDC), Center for Health Statistics
Description: Cesarean Delivery Rate, County Level
Key Variable: (%) of all live births that were cesarean deliveries
II-12: Pre-Term Birth Rates
Source: (2017-2019) Health Resources & Services Administration (HRSA), Maternal & Child Health Bureau
Description: Preterm birth rates, County Level
Key Variable: Estimated (%) of live births that are preterm (/> 37 weeks)
Tier III factors include environmental stressors and hazards that are well known, but for which research substantiating a direct link to poor perinatal mental health is currently absent.
III-13: Mental Healthcare Providers
Source: (2022) County Health Rankings & Roadmaps, University of Wisconsin Population Health Institute
Description: Mental Health Providers; County Level
Key Variable: Mental health provider rate per 100k
III-14: Income Inequality – Income Ratio (80pct/20pct)
Source: (2022) County Health Rankings & Roadmaps, University of Wisconsin Population Health Institute
Description: Income Inequality; County Level
Key Variable: Income Ratio (80th percentile/20th percentile)
III-15: Reproductive Age, % white
Source: (2019) CDC WONDER Single-Race Population Estimates
Description: Reproductive Age, % white, County Level
Key Variable: (%) of Women 15-44 Years of Age by Race - White
III-16: Reproductive Age, % Hispanic or Latina
Source: (2019) CDC WONDER Single-Race Population Estimates
Description: Reproductive Age, % Hispanic, County Level
Key Variable: (%) of Women 15-44 Years of Age by Ethnicity - Hispanic or Latina
III-17: Lack of Insurance Coverage
Source: (2022) County Health Rankings & Roadmaps, University of Wisconsin Population Health Institute
Description: Lack of insurance coverage, County Level
Key Variable: (%) of Uninsured (adults)
III-18: Severe Housing Problems
Source: (2022) County Health Rankings & Roadmaps, University of Wisconsin Population Health Institute
Description: Severe housing problems, County Level
Key Variable: (%) with Severe Housing Problems
III-19: Food Insecurity
Source: (2022) County Health Rankings & Roadmaps, University of Wisconsin Population Health Institute
Description: Food insecurity, County Level
Key Variable: (%) with Food insecurity
Finally, the RFS system considers several direct measures of maternal mental healthcare needs, including survey data covering general mental health status.
DMN-20: Poor Mental Health Among Mothers
Source: (2020-2021) National Survey of Children’s Health, Health Resources and Services Administration, Maternal and Child Health Bureau
Description: Poor mental health among mothers, State Level
Key Variable: (%) with 'Fair or poor' status
DMN-21: Mothers Not Coping Well with Raising their Child
Source: (2020-2021) National Survey of Children’s Health, Health Resources and Services Administration, Maternal and Child Health Bureau
Description: Mothers not coping well with raising their child, State Level
Key Variable: (%) answering 'Very well'
DMN-22: Fertility Rates for Reproductive Age Women
Source: (2021) Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS), National Vital Statistics System
Description: Births and birth rates, by county for reproductive age women
Key Variable: Number of Births Divided by Number of Females aged 15-44 years
The RFS map is a choropleth that reveals numerous patterns and conditions characterizing the general state of maternal mental healthcare In the U.S.
Our findings include:
The highest RFS levels were concentrated in the ‘Deep’ South. Severe conditions were identified in the Mississippi Delta region, the Gulf Coast, greater Appalachia, and New Mexico & Arizona. Common themes present in all of these areas surround poverty, social instability, and isolation.
Higher RFS levels tend to be associated with rural and less populated regions. In contrast, most major metropolitan areas in the U.S. tend to have comparatively moderate to lower risk factor scores. The urban/rural divide may be accounted for in part by a tendency for stronger social infrastructure within urban areas. Social services networks providing food vouchers, housing assistance, and intimate partner violence intervention typically are well funded in urban areas and may play a significant role in mitigating risk.
A small number of cities, regions, and states, including Minnesota, the Atlanta Metropolitan Region, and the Northeast Corridor, exhibit relatively low risk factor scores and may serve well as models.
Resource Methodology
With the RFS levels established, we shifted the focus to resources and conducted a survey of maternal mental healthcare practitioners and community-based organizations focused on perinatal treatment. We found that the majority of service providers are clustered in major metro areas such as Cook County, IL, and Los Angeles County, CA, while many US counties have no qualified providers available. Overlaying the RFS choropleth, we superimposed a bubble diagram showing the concentration of maternal mental healthcare providers for each county.
Finally, we developed an estimate of the “Provider Shortage Gap,” or the estimated number of additional providers needed in order to meet the needs of the current population in each county. The geographic distribution of providers is at odds with the tendency toward higher RFS levels in rural areas, as the greatest number of providers happen to be in the areas with the lowest RFS levels. However, the number of births taking place annually in urban counties greatly exceeds births taking place in rural counties, so much so that urban areas still represent the greatest need for additional providers.