State social policy interventions for maternal health

Project Summary Poverty is the most widely studied fundamental determinant of maternal mental health, morbidity, mortality, and inequities in the U.S. and worldwide. Low absolute and relative income and low socioeconomic status are associated with financial hardship, food and housing insecurity, discrimination, limited healthcare access, other

social stressors, and subsequent depression during the preconception, perinatal, postpartum, and parenting years; effects are disproportionately adverse for racial and ethnic minority, rural-residing, and other structurally disadvantaged groups of women. Public policies that shape the social conditions in which women live, notably

those that assure economic resources and supports during the early childbearing years, can set life-long trajectories of maternal and child wellbeing. Thus, economic security laws have strong potential as public health interventions for women’s mental health and health equity; yet the most timely and promising state-level

laws within the dynamic, complex policy landscape over the last two decades have not been collectively or rigorously evaluated. The goal of this R01 is to empirically test the effects of six state-level economic security policies targeting low-income women on maternal mental health outcomes and disparities across the U.S. over

the last 20-years. We focus on Paid Family Leave, Paid Medical Leave, Child Care and Development Fund, Earned Income Tax Credits, Minimum Wage, and Temporary Assistance for Needy Families. First, we will use our team’s validated novel legal measurement, analysis, and mapping methods to conduct a detailed state-

year-level policy surveillance study of the six economic policies across all 50 states and Washington D.C. from 2000 to 2023. Second, we will estimate the independent effects of each economic security policy (and specific dimensions of each policy) on a range of mental health indicators spanning the preconception, perinatal,

postpartum, and parenting periods among U.S. women ages 18 to 45. We will use a rigorous quasi- experimental approach (difference-in-differences), exploiting state-year-level policy variation and six different population datasets, to provide causal estimates and maximize statistical power. We will examine differences

in policy effects by race, ethnicity, socioeconomic status, rurality/urbanicity, and age. Third, we will use interaction analyses to test whether combinations of economic security policies have greater impact than each alone and determine which policy combinations have the greatest effects on maternal mental health outcomes

and for which groups. Fourth, we will use mediation analysis to test whether economic outcomes, health care access, psychosocial and behavioral outcomes, and social stressors are mechanisms linking the economic policies to health. This research will substantially advance our understanding of how social policies can be

optimally used for population maternal health promotion. Findings will guide policymakers toward evidence- based policy interventions at a critical time in U.S. history when public health crises of mental health morbidity, maternal mortality, and poverty are colliding for childbearing women of structural disadvantage.