Suffering in Silence

Mood Disorders Among Pregnant and Postpartum Women of Color

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Suffering in Silence
AP/Scott Eisen

A woman holds her newborn daughter, June 2013.

  • OVERVIEW

    Women of color experiencing perinatal mood disorders often suffer in silence and lack access to mental health care. Mental health stigma must be dismantled and key interventions implemented at the policy and community levels.

  • PRESS CONTACT

Introduction and summary

Pregnancy and childbirth can bring joy and fulfillment to a woman’s life. They can also bring anxiety, depression, and stress. If left untreated, postpartum depression and other mood disorders can grow severe and even fatal for both the mother and her child. The American Psychological Association estimates that 1 in 7 women experience postpartum depression, yet the true statistic is unknown, as most women do not recognize the symptoms associated with the condition.1

According to the World Health Organization, pregnant and postpartum women experiencing severe forms of mental disorders may commit suicide.2 Perinatal mood disorders—including postpartum depression—can affect any woman, yet women of color often face life circumstances that increase their likelihood of experiencing perinatal mood disorders.3 Studies have shown that women of color experience postpartum depression at a rate of close to 38 percent compared with approximately 13 to 19 percent for all postpartum women.4 The racial disparity is vast and mirrors major gaps in both screening and treatment for mood disorders among women.

This report touches upon mood disorders for different groups of women of color, shedding particular light on the unique experiences of black pregnant and postpartum women facing mental health issues. It also draws connections between social, economic, and political adversities and higher rates of perinatal mood disorders. The adversities discussed include lack of access to mental health services, economic insecurity, strong black woman syndrome, gender discrimination, and racism. The personal testimonies of black women affected by perinatal mood disorders can be found in text boxes throughout this report.*

Finally, this report outlines the following recommendations for policymakers, health care providers, researchers, and advocates in order to better address perinatal mood disorders among women of color:

  • Support comprehensive health care coverage under the Affordable Care Act (ACA), including mental health services and maternity care.
  • Improve access to culturally competent and well-trained mental health care providers.
  • Fully fund the MOTHERS Act.
  • Support the integration of mental health screenings into other health care settings.
  • Fund large-scale, culturally appropriate public education campaigns.
  • Conduct additional research on perinatal mood disorders.
  • Develop policies and education campaigns in a way that takes into account the lived experiences of pregnant and postpartum women of color.
  • Educate health care providers, patients, and communities about the importance of mental health care access.
  • Support culture shift efforts.
  • Amplify and support women of color-led organizations.
  • Support policies that improve work-family balance for women in the workplace.

These actions are critical to helping ensure that pregnant and postpartum women of color can stop suffering in silence and can gain access to the necessary supports and services in times when they are experiencing perinatal mood disorders.

Overview of maternal mental health

Maternal mental health is a major public health concern.5 Approximately 10 percent of pregnant women and 13 percent of women in the postpartum period—defined as up to one year after childbirth—grapple with a mood disorder.6 Mood disorders that take place during pregnancy and in the first year after birth can take many forms, some of which include antenatal depression, postnatal depression, anxiety disorder, perinatal obsessive compulsive disorder, postpartum depression, postpartum psychosis, and post-traumatic stress disorder (PTSD).7

Mood disorders experienced by pregnant and postpartum women:

  • Antenatal depression: A form of clinical depression that can affect a woman during pregnancy; also referred to as prenatal depression8
  • Postnatal depression: Depression that can occur in a woman after giving birth9
  • Anxiety disorder: An intense form of anxiety that can interfere with the daily life of a pregnant or postpartum woman10
  • Perinatal obsessive compulsive disorder: Obsessions, compulsions, and anxiety that can be experienced by a woman during pregnancy or after giving birth11
  • Postpartum depression: Moderate to severe depression that can occur in a woman immediately following the delivery of a child or up to a year after giving birth12
  • Postpartum psychosis: A rare psychiatric emergency that can occur in a woman within the first few weeks after giving birth; symptoms can include mania, depression, severe confusion, paranoia, and hallucinations13
  • Post-traumatic stress disorder: A mood disorder caused by real or perceived trauma that is experienced by a woman during the delivery of a child or in the postpartum period14

If left untreated, perinatal mood disorders can be harmful to mothers and to the growth and development of their children. While women of all races, ethnicities, and socioeconomic backgrounds can experience negative maternal mental health outcomes, women of color often suffer simultaneously from distinct and multifactorial effects, which are outlined in this report.

Kay’s story

“The death of my baby girl at birth was by far the worst day of my life. Along with grief I also experienced postpartum depression that went undiagnosed for many months. Once diagnosed, I truly learned the meaning of self-care and that I am most important and that I matter first. On the road to recovery, I created my organization, The Shades of Blue Project, which helps minority women before, during, and after childbirth with mental health advocacy, treatment, and support. We push for changes in maternal mental health so that women all over will understand that it’s OK not to be OK and that they are not alone and we are here to help.”

Addressing mental health during pregnancy and postpartum

Pregnant women of color are underserved by the mental health profession and relevant support services.15 When perinatal mood disorders are left undiagnosed or untreated, the results can be deadly. Suicide is a leading cause of maternal death for women with postpartum depression.16 Women of color are typically unaware that the mental health symptoms they experience are the result of pregnancy or childbirth, which also means that the symptoms often remain unaddressed both by the woman and her medical provider.

When women of color do access mental health care, the services and supports they find are often woefully inadequate.17 Women of color who have experienced postpartum depression report seeing health professionals yet remain undiagnosed, even after multiple visits.18 Some Asian American women have questioned whether or not the lack of diagnosis can be attributed to mythical perceptions about minorities.19 Studies have shown that although approximately 24 percent of Indian American women experience postpartum depression, most are misdiagnosed.20 Mental health care for women of color must be culturally sensitive and culturally appropriate. Large-scale educational campaigns reflecting the lived experiences of women of color are also needed to help them more easily recognize the symptoms associated with mood disorders.

LaShonta’s story

“After the birth of my second child, I found myself in the throes of [postpartum depression]—alone. I continued to care for my children, suffering and learning how to survive while suffering. After my third child was born, I was again alone, and found more moms alone with no help; stigmatized, ostracized—alone. This piqued my passion, and continues to drive A Mother’s Sanctuary’s (AMS) mission of providing a safe environment for women who are suffering from maternal mental health illness. AMS promotes awareness, prevention, and treatment of mental health issues related to pregnancy not only to the mothers but to the family members and friends as well. During my travels and work, I’ve found a striking lack of African American women who have access to care or can admit their circumstances because their additional burden created by societal expectations.”

Black and Hispanic women who experience maternal depression have higher rates of adversities compared with their white counterparts.21 In a nationally representative study of the rates and risks of maternal depression in the United States, these adversities include poverty, employment issues, issues related to personal relationships, and marital problems.22 In addition, adversities such as racism and gender discrimination have been reported by black and Hispanic women. Women of color are also more likely to report experiencing workplace discrimination.23 These women often feel that disclosing a mood disorder could increase the risk of losing a job.

Black and Hispanic women also experience a gender wage gap, making 63 cents and 54 cents, respectively, to every dollar earned by white men.24 Facing racism and gender discrimination in the workplace, in the health care system, and in broader society negatively affects the mental and physical health of women of color while also inhibiting their financial independence. Furthermore, women of color tend to work in jobs that lack structural supports,25 such as paid sick days, paid family leave, and flexible scheduling—all of which are crucial for maintaining one’s mental and physical health and well-being. Without access to these supports, women of color disproportionately lack the time and flexibility required to regularly attend doctor’s appointments, which can be critical for addressing mood disorders. Women in this situation have to choose between neglecting their health because they lack access to these supports—potentially exacerbating health concerns—or losing pay or their jobs as a result of taking time off. 26 Racism—including both overt and covert forms as experienced through structures or institutions—can also affect the mental health of women of color and have a negative impact on pregnant and postpartum women. These conditions can make it extremely difficult for women with mood disorders to parent.

Spotlight on maternal mental health among black women

Black women experience higher rates of depression compared with the general population.27 This is particularly troublesome considering the pervasive stigma around mental health in the black community.28 Mental health stigma often deters black women from seeking much-needed treatment and support services29—that is, if their symptoms are recognized or diagnosed in the first place.

When women experience acute and chronic life stressors during pregnancy, mood disorders can arise. For a host of reasons, single black women are particularly vulnerable to these stressors. Black women are more likely to be the primary or sole head of household, and 72 percent of black mothers are single.30 The added stress of running a household increases the likelihood that single black women will experience postpartum mood disorders.31 In fact, the reported rate of depressive symptoms for single black mothers is six times that of the general population and double the reported rate for black women in general. Issues such as poverty, racism, and gender discrimination are proven factors that can lead to severe depression among black women.32 Increased exposure to violence and trauma—which can begin as early as childhood—can increase the likelihood of perinatal mood or anxiety disorders for black women.33 Due in part to a lack of awareness of these disorders, black women are also less likely to recognize and report symptoms for mood disorders, which translates into lower rates of mental health care utilization.34 Black women are half as likely to receive mental health treatment and counseling as white women.35 They are one of the most undertreated groups for depression in the United States.

Timoria’s story

“Immediately following the birth of my oldest daughter, in 2010, I suffered a postpartum hemorrhage and almost died. I underwent a life-saving surgery and was later diagnosed with PTSD. One year later, I had a miscarriage in a frozen yogurt shop in front of several people, which triggered the difficult emotions from the hemorrhage I suffered the year prior. I realized that there were very few resources for women who had experienced similar birth and pregnancy complications and the lingering psychological effects. I decided to start the conversation publicly and became a maternal health advocate.”

Strong black woman syndrome36

Studies show that black women rarely recognize symptoms of depression and other mental health issues.37 Black women also must grapple with social and cultural perceptions of mental health that perpetuate stigma. Theorists Susan Folkman and Richard Lazarus have highlighted the fact that certain coping mechanisms—such as showing strength in high-stress moments or in the face of adversity—are culturally sanctioned in the black community and are used by black women to cope with depression.38 Many black women internalize expectations of strength, causing them to deny symptoms of depression and forgo appropriate and effective mental health treatment and self-care. Black women are often expected to work through depression and stress, ignoring signs of mood disorders and not allowing those symptoms to interfere with their caretaking responsibilities and jobs. When life circumstances become unbearable, black women are often encouraged to pray or attend church. In a survey of 114 black women, religious coping was reported as the preferred way to address mental health issues.39 An overwhelming number of these women reported avoiding help from a mental health professional. About half of the women who participated in the survey reported seeking mental health care but only as a last resort.40

Because of strong black woman syndrome,41 black women often appear calm and controlled in times of extreme adversity. Efforts to dismantle the stigma and shame associated with mental health must be a priority within communities of color, and professional mental health care should be promoted and supported. Better support for mental health screening and treatment is drastically needed, especially for single black mothers who tend to experience high levels of depression. Praying and attending church can be part of a broader, more comprehensive approach to addressing mood disorders—one that also includes social and emotional support from trusted friends and family as well as professional screening and treatment. Additional research is needed in order to determine how strong cultural and religious foundations can play a positive role in addressing the mental health needs of black women.

Health care policy implications

Under the Affordable Care Act (ACA), maternity care and mental health services are part of the package of essential health benefits (EHBs).42 Despite several failed attempts to repeal the ACA and undermine access to these vital services, their coverage is still required under the current health care law.43 Attempts to repeal the ACA also took aim at the Medicaid program—both the ACA’s expansion and traditional Medicaid—which is a lifeline for low- and middle-income women. Medicaid covers nearly half of all births in the United States and provides many women of color with health care coverage.44 While mental health screening remains an important aspect of the EHBs supported by the ACA, more work needs to be done in order to ensure the accessibility, availability, and affordability of mental health care.

The ACA includes language from a bill that was aimed at ensuring support services for women experiencing postpartum depression and psychosis as well as support for research, treatment, and diagnosis of these mood disorders.45 The Mom’s Opportunity to Access Health, Education, Research, and Support for Postpartum Depression (MOTHERS) Act not only mandated research to better understand postpartum depression, but it also addressed the unique needs of women of color when it comes to culturally competent and evidence-based approaches to treatment. Unfortunately, Congress has yet to officially approve funding allocations for this body of interventions.46

The U.S. Preventive Services Task Force (USPSTF), an independent panel of experts in preventative and evidence-based medicine, recognized the importance of integrating mental health services into primary health care. In 2016, the group issued a recommendation to expand and integrate depression screening into other health care service delivery systems, including the screening of pregnant and postpartum women.47 The USPSTF describes depression as one of the leading causes of disability in people over the age of 15. Because depression is so common among people seeking care in primary health care settings—including pregnant and postpartum women—integration is key to helping to destigmatize mental health and ensure proper screening and treatment. The group’s recommendations have helped inform ACA implementation in regard to the delivery of mental health services, which are offered at no cost under the current health care law.48

While the ACA is still the law of the land, President Donald Trump recently issued an executive order aimed at sabotaging the health care law.49 The order would eliminate cost-sharing reduction payments for low- to moderate-income Americans, roll back protections for people with pre-existing conditions, contribute to the destabilization of the insurance market, and support junk insurance plans with minimal health care coverage.50 On October 27, the Department of Health and Human Services released a proposed rule that would undermine coverage of EHBs, such as mental health services or maternity care, by allowing states to offer bare-bones EHB-benchmark plans with limited benefits.51 The Trump administration has also substantially decreased funding for advertising, promotion, and outreach during the 2017 open enrollment period and has drastically shortened the open enrollment period.52 These changes are designed to undermine access to affordable and comprehensive health care coverage for women of color, who may be in need of mental health screenings and treatment.

Since passage of the ACA, uninsured rates among women of color have significantly decreased. However, single mothers, low-income women, women of color, and immigrant women are still most likely to be uninsured.53 Consequently, these groups of women are most likely to lack access to vital health care services—including mental health services and pregnancy-related care—and are at increased risk of suffering from poorer health outcomes. Any policy change that would repeal or undermine the current health care law would have a disproportionate effect on access to and affordability of mental health care for women, and particularly women of color.

Recommendations

The following recommendations outline a multifactorial approach for policymakers, health care providers, researchers, and advocates to better address perinatal mood disorders, including postpartum depression, among pregnant and postpartum women of color.

  • Support comprehensive health care coverage under the ACA, including mental health services and maternity care as parts of EHBs, as well as robust support for the Medicaid program.
  • Improve access to culturally competent, well-trained mental health care providers for underserved communities, particularly single mothers, low-income women, women of color, and immigrant women.
  • Fully fund the MOTHERS Act, which includes solutions for making maternal mental health treatment more affordable and accessible and for emphasizing the unique needs of women of color.
  • Support the integration of mental health screening into other health care settings for pregnant and postpartum women, as recommended by the USPSTF.
  • Fund large-scale, culturally appropriate public education campaigns that help women recognize their symptoms and empower them to seek the help they need.
  • Conduct additional research on perinatal mood disorders, taking into account the lived experiences of women of color and including information on the immediate and long-term impact on both women and children of color.
  • Develop policies and education campaigns that take into account the lived experiences of pregnant and postpartum women of color as well as the ways that racism and gender discrimination impact their mental health and well-being.
  • Educate health care providers, patients, and communities about the importance of access to and utilization of mental health care among women of color.
  • Support culture shift efforts aimed at dismantling the strong black woman syndrome.
  • Amplify and support women of color-led organizations that are working at the forefront to ensure access to mental health care and maternal justice.
  • Support policies that would improve work-family balance for women in the workplace, including the expansion of access to paid sick days; paid family and medical leave; and fair scheduling.

Conclusion

Pregnant and postpartum women of color are at higher risk for mood disorders and need accessible, affordable, and culturally appropriate mental health care. Symptoms associated with depression, anxiety disorder, and other mood disorders experienced during and after pregnancy are largely underreported by women of color. The ACA has helped make maternity care and mental health services more accessible and has supported integration with other health care services. This has been important in helping to destigmatize mental health and improve maternal and child health outcomes.

Additional work, however, is drastically needed. Approaches to addressing mood disorders among pregnant and postpartum women of color must not only focus on health care delivery, public education, and research; they must comprehensively address the primary sources of stress and adversity in the everyday lives of women of color—both overt and covert forms of racism.

About the authors

Jamila Taylor is a senior fellow at the Center for American Progress. Christy M. Gamble is the director of health policy and legislative affairs at the Black Women’s Health Imperative.

*Authors’ note: These interviews have been edited for clarity. They were conducted by the authors on the following dates: Kay, November 8, 2017; Timoria, November 9, 2017; LaShonta, November 9, 2017.

Endnotes

  1. Katherine L. Wisner and others, “Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum Women with Screen-Positive Depression Findings,” JAMA Psychiatry 70 (5) (2013): 490-498, available at https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1666651.
  2. World Health Organization, “Maternal mental health,” available at http://www.who.int/mental_health/maternal-child/maternal_mental_health/en/ (last accessed November 2017).
  3. Karen A. Ertel, Janet W. Rich-Edwards, and Karestan C. Koenen, “Maternal Depression in the United States: Nationally Representative Rates and Risks,” Journal of Women’s Health 20 (11) (2011): 1609-1617, available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3253390/.
  4. Administrator, “Postpartum Depression and Race: What We All Should Know,” Psychology Benefits Society blog, June 21, 2016, available at https://psychologybenefits.org/2016/06/21/postpartum-depression-in-women-of-color/.
  5. World Health Organization, “Maternal mental health.”
  6. Ibid.
  7. Everyone’s Business, “Maternal Mental Health,” available at http://everyonesbusiness.org.uk/?page_id=6 (last accessed November 2017).
  8. NetDoctor, “Antenatal depression,” available at http://www.netdoctor.co.uk/conditions/pregnancy-and-family/a9293/antenatal-depression/ (last accessed November 2017).
  9. NetDoctor, “Postnatal depression,” available at http://www.netdoctor.co.uk/conditions/depression/a644/postnatal-depression/ (last accessed November 2017).
  10. NetDoctor, “Anxiety disorders,” available at http://www.netdoctor.co.uk/conditions/depression/a624/anxiety-disorders/ (last accessed November 2017).
  11. Royal College of Psychiatrists, “Perinatal Obsessive Compulsive Disorder,” available at http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/perinatalocd.aspx (last accessed November 2017).
  12. MedlinePlus, “Postpartum depression,” available at https://medlineplus.gov/ency/article/007215.htm (last accessed November 2017).
  13. Ian Jones and others, “Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period,” The Lancet 384 (9956) (2014): 1789-1799, available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)61278-2/abstract.
  14. Postpartum Support International, “Postpartum Post-Traumatic Stress Disorder,” available at http://www.postpartum.net/learn-more/postpartum-post-traumatic-stress-disorder/ (last accessed November 2017).
  15. Robert H. Keefe, Carol Brownstein-Evans, and Rebecca S. Rouland Polmanteer, “Having our say: African-American and Latina mothers provide recommendations to health and mental health providers working with new mothers living with postpartum depression,” Social Work in Mental Health 14 (5) (2016): 497-508, available at http://www.tandfonline.com/doi/abs/10.1080/15332985.2016.1140699.
  16. Kate Rope, “New Study Reveals Disturbing PPD Statistics,” Seleni Institute, March 15, 2013, available at https://www.seleni.org/advice-support/article/largest-postpartum-depression-study-reveals-disturbing-statistics.
  17. ADriane Nieves, “Women of Color and Maternal Mental Health: Why Are We So Underserved?”, Postpartum Progress, January 8, 2015, available at http://www.postpartumprogress.com/women-color-maternal-mental-health-underserved.
  18. Pooja Makhijani, “Here’s Why Postpartum Depression Is Even Harder When You’re Not White,” BuzzFeed, December 7, 2015, available at https://www.buzzfeed.com/poojamakhijani/we-can-save-one-anothers-lives?utm_term=.jld471ORx#.lyRx1z4kX.
  19. Yanan Wang, “Asian Americans speak out against a decades-old ‘model minority’ myth,” The Washington Post, October 20, 2015, available at https://www.washingtonpost.com/news/morning-mix/wp/2015/10/20/asian-americans-speak-out-against-a-decades-old-model-minority-myth/?utm_term=.1fcaaba15ead.
  20. Deepika Goyal, Susan O. Murphy, and Jayne Cohen, “Immigrant Asian Indian women and postpartum depression,” Journal of Obstetric, Gynecologic, and Neonatal Nursing 35 (2006): 98-104, available at https://www.ncbi.nlm.nih.gov/pubmed/16466357.
  21. Ertel, Rich-Edwards, and Koenen, “Maternal Depression in the United States: Nationally Representative Rates and Risks.”
  22. Ibid.
  23. Keefe, Brownstein-Evans, and Rouland Polmanteer, “Having our say: African-American and Latina mothers provide recommendations to health and mental health providers working with new mothers living with postpartum depression.”
  24. Kate Bahn, “Economics of Misogyny,” Center for American Progress, September 28, 2017, available at https://www.americanprogress.org/issues/women/news/2017/09/28/439953/economics-of-misogyny/.
  25. Jocelyn Frye, “The Missing Conversation About Work and Family” (Washington: Center for American Progress, 2016), available at https://www.americanprogress.org/issues/women/reports/2016/10/03/145208/the-missing-conversation-about-work-and-family/.
  26. Ibid.
  27. Nia Hamm, “High Rates of Depression Among African-American Women, Low Rates of Treatment,” HuffPost, September 25, 2014, available at https://www.huffingtonpost.com/nia-hamm/depression-african-american-women_b_5836320.html.
  28. National Alliance on Mental Illness, “African American Mental Health,” available at https://www.nami.org/Find-Support/Diverse-Communities/African-Americans (last accessed November 2017).
  29. Nia Hamm, “High Rates of Depression Among African-American Women, Low Rates of Treatment,” HuffPost, September 25, 2014, available at https://www.huffingtonpost.com/nia-hamm/depression-african-american-women_b_5836320.html.
  30. Jessica Dickerson, “72 Percent Documentary Confronts The Black Community’s Single Parent Epidemic,” HuffPost, August 5, 2014, available at https://www.huffingtonpost.com/2014/08/05/72-percent-black-fatherhood_n_5648759.html.
  31. Rahshida Atkins, “Coping with Depression in Single Black Mothers,” Issues in Mental Health Nursing 37 (3) (2016): 172-181, available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4887600/.
  32. Maigenete Mengesha and Earlise C. Ward, “Psychotherapy with African American Women with Depression: Is it okay to Talk about Their Religious/Spiritual Beliefs?”, Religions, 3 (1) (2012): 19-36, available at http://www.mdpi.com/2077-1444/3/1/19.
  33. Tula Karras, “PMADs – Such as PPD and Anxiety – in African American Moms,” Seleni Institute, available at https://www.seleni.org/advice-support/article/pmads-such-as-ppd-and-anxiety-in-african-american-moms (last accessed November 2017).
  34. Hamm, “High Rates of Depression Among African-American Women, Low Rates of Treatment.”
  35. Atkins, “Coping with Depression in Single Black Mothers”
  36. BlackDoctor, Inc., “The New Face of Depression: The ‘Strong’ Black Woman,” available at http://blackdoctor.org/462194/black-women-depression/ (last accessed November 2017).
  37. Atkins, “Coping with Depression in Single Black Mothers.”
  38. Susan Folkman and Richard S. Lazarus, “An Analysis of Coping in a Middle-Aged Community Sample,” Journal of Health and Social Behavior 21 (3) (1980): 219-239, available at https://www.jstor.org/stable/2136617?seq=1 – page_scan_tab_contents.
  39. Earlise C. Ward and others, “African American Men and Women’s Attitude Toward Mental Illness, Perceptions of Stigma, and Preferred Coping Behaviors,” Nursing Research 62 (3) (2013): 185-194, available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4279858/.
  40. Ibid.
  41. BlackDoctor, Inc., “The New Face of Depression: The ‘Strong’ Black Woman.”
  42. Sam Berger and Emily Gee, “Senate Health Care Bill Could Drive Up Coverage Costs for Maternity Care and Mental Health and Substance Use Disorder Treatment,” Center for American Progress, June 20, 2017, available at https://www.americanprogress.org/issues/healthcare/news/2017/06/20/434670/senate-health-care-bill-drive-coverage-costs-maternity-care-mental-health-substance-use-disorder-treatment/.
  43. Rachel Roubien, “Timeline: The GOP’s failed effort to repeal Obamacare,” The Hill, September 16, 2017, available at http://thehill.com/policy/healthcare/other/352587-timeline-the-gop-effort-to-repeal-and-replace-obamacare.
  44. Christy M. Gamble and Jamila Taylor, “Maternity Care Under ACA Repeal” (Washington: Center for American Progress, 2017), available at https://www.americanprogress.org/issues/women/reports/2017/08/07/437116/maternity-care-aca-repeal/.
  45. Postpartum Support International, “Legislation,” available at http://www.postpartum.net/professionals/legislation/ (last accessed November 2017)
  46. Ibid.
  47. U.S. Preventive Services Task Force, “Final Recommendation Statement,” available at https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1 (last accessed November 2017).
  48. Centers for Medicare and Medicaid Services/The Center for Consumer Information and Oversight, “Affordable Care Act Implementation FAQs – Set 18,” available at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs18.html (last accessed November 2017).
  49. Tami Luhby and Kevin Liptak, “Trump begins Obamacare dismantling with executive order,” CNN, October 12, 2017, available at http://www.cnn.com/2017/10/12/politics/trump-obamacare-executive-order/index.html.
  50. Center for American Progress, “STATEMENT: CAP’s Topher Spiro Says Executive Order Creates ‘Junk Plans’,” Press release, October 12, 2017, available at https://www.americanprogress.org/press/statement/2017/10/12/440704/statement-caps-topher-spiro-says-executive-order-creates-junk-plans/.
  51. Katie Keith and Timothy Jost, “The 2019 Proposed Payment Notice, Part 2: Consumer-Facing Provisions,” Health Affairs, October 28, 2017, available at http://www.healthaffairs.org/do/10.1377/hblog20171028.887269/full/.
  52. Ashley Lopez and April Dembosky, “With Federal Funds Cut, Others Must Lead Health Insurance Sign-Up Efforts,” NPR, October 28, 2017, available at http://www.npr.org/sections/health-shots/2017/10/28/560225509/with-federal-funds-cut-others-must-lead-health-insurance-sign-up-efforts.
  53. The Henry J. Kaiser Family Foundation, “Women’s Health Insurance Coverage,” available at https://www.kff.org/womens-health-policy/fact-sheet/womens-health-insurance-coverage-fact-sheet/ (last accessed November 2017).

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