Health Insurance Status and Mental Health in Alabama Mothers: an Analysis of Prams 2017-2022

Maternal mental health outcomes in the Southern U.S. remain poor, compounded by high uninsured rates among reproductive-aged women. The region's distinct demographic, geographic, and political context further shapes these challenges. However, limited research has examined the intersection of healthcare affordability and perinatal mental health in the South. This dissertation examined the relationship between health insurance status and maternal mental health in two Southern states, taking into account maternal demographics. Specifically, this study explored whether health insurance and Medicaid expansion were linked to pre-pregnancy mental healthcare utilization among mothers with self-reported pre-pregnancy depression. Additionally, the study evaluated whether health insurance was related to self-reported postpartum depressive symptoms (PPDS), and whether postpartum Medicaid coverage differed before and after implementation of the Families First Coronavirus Response Act (FFCRA) among low-income mothers from two Deep South states--Alabama (without Medicaid expansion) and Louisiana (with Medicaid expansion).Using data from the Centers for Disease Control and Prevention (CDC)'s Pregnancy Risk Assessment Monitoring System (PRAMS), this study identified significant disparities across racial, ethnic, and other demographic groups. Using logistic regression models, health insurance was not associated with pre-pregnancy mental healthcare utilization and PPDS. However, low-income younger mothers were less likely to have pre-pregnancy mental health visits. Mothers identifying as Asian, American Indian, Hawaiian/Pacific Islander, or other/multiple races were more likely to report postpartum depressive symptoms (PPDS) than their White and Hispanic counterparts. Alabama mothers had more than twice the odds of losing postpartum Medicaid coverage compared to Louisiana mothers, and this coverage loss was higher before the FFCRA, greater among Hispanic and married mothers, and lower among mothers with less education. These findings carry important policy and clinical implications, underscoring the need for strengthened screening practices, expanded access to care, and efforts to reduce disparities. Future research could further investigate maternal health in the Southern U.S., with particular attention to minority populations, and address systemic barriers to mental health services.