Good afternoon, Chair Louis and Chair Lee and thank you for holding this valuable hearing today. I am Brooklyn Borough President Antonio Reynoso, and maternal health is one of my top priorities. Brooklyn is one of the boroughs that consistently sees the highest rates of pregnancy-related deaths and morbidity, and it is time that we reversed this. Fortunately, 78% of pregnancy-related deaths are preventable, and mental health-related deaths are 100% preventable. It is no coincidence that the first majority female City Council is shining a spotlight on this long-overlooked issue, and I would like to thank my Council colleagues for putting forth these proposals to begin to make the changes we need.
I want to focus on my testimony today on a few key proposals: Intros 912 and 869, and Resolutions 402, 403, 404, and 405. I also want to share concerns about Resolution 299.
Intros 912 and 869:
Intro 912, or the Newborn Navigator Act, which I had the pleasure of working on with Councilmember Gutierrez, calls for the creation of targeted resources to support maternal health and connect people to available services. Currently, there is a lack of readily accessible resources to support expecting and new parents, and diverse levels of linguistic and digital literacy complicate this further. The Newborn Navigator Act will allow for the equitable distribution of resources so that every parent has access to the same information before and after childbirth.
Because mental health supports are critical for new parents, I suggest adding resources focused on mental health screening, identification, care, and treatment. According to the The New York State Report of Pregnancy-Associated Deaths in 2018, mental health conditions are the third leading cause of pregnancy-related deaths statewide, while in New York City, such conditions were among the leading causes of maternal deaths between 2016-2020. Available data regarding pregnancy-associated deaths during this time shows that 23.3% of deaths were attributed to mental health, which the DOHMH defines to include suicide and overdose. For this reason, I also support Intro 869, which would create a public outreach campaign on parental mental health.
Two important provisions of Intro 912 leave implementation to DSS, and I would like to make specific recommendations for them. In consulting with various agencies and community-based organizations to develop materials, it is critical that they include people who have firsthand experiences with birthing people. DOHMH should create a working group to determine the full scope of the materials to be included, including topic-specific sub-committees.
Additionally, the bill includes creation of a searchable database of information on City-contracted community-based organizations supporting maternal healthcare. In addition to what the bill language now requires, this site should incorporate the ability to search for organizations based on payment requirements, and should include hours of operation, contact information, and insurances accepted (if applicable). Parents as well as providers should be able to print each listing into an easy-to-read document, which will also enable providers to provide efficient resource referrals. This website should have language translation in multiple languages and include links to the materials developed as a part of the resource campaign. Users should also be able to create personalized accounts where they can save organization profiles and relevant resources.
Res 402
Implementing a standardized maternal mental health quality management program would expand access to quality care, improve rates for providers, and incentivize providers to expand the available of essential services to pregnant and postpartum New Yorkers.
Ensuring that pregnant and postpartum patients, especially those who have experienced racism, violence, and exclusion at the hands of the medical establishment, are screened and can access quality and affordable care is a necessary step to reducing maternal mortality and morbidity. In 2022, the California state legislature similarly passed SB 1207, requiring health insurance plans to create a measure to promote high quality and affordable care to include screening, diagnosis, treatment and referral for maternal mental health services – including provider training incentives and enrollee outreach – a model that New York State should replicate.
This measure should work hand-in-hand with initiatives to increase Medicaid reimbursement rates for mental health providers and to increase the pool of perinatal psychiatrists and psychiatric nurse practitioners.
Res 403
One of the primary reasons why people who are pregnant or postpartum are not getting the care they need and deserve is the sheer lack of clinicians with prescriptive powers such as perinatal psychiatrists and psychiatric nurse practitioners. According to the American Hospital Association, 75% of birthing people diagnosed with Maternal Mental Health disorders do not receive treatment in part due to the shortage of mental health practitioners who treat pregnant patients.
Another structural issue facing the fields of perinatal psychiatry and psychiatric nursing is a lack of diversity. The maternal mental health crisis is multifaceted and has its roots in historical and contemporary forms of oppression that disproportionately impact Black and Brown birthing people; it is one that can no longer be ignored. Studies indicate that diversity and representation are not simply a matter of affirmation. They have decisive repercussions on the experiences and well-being of individuals and communities.
Despite 2016-2020 maternal mortality review reports showing that an average of 47.36% of maternal deaths were Black, Black psychiatrists make up only 2% of the profession, while only 10.4% of all psychiatrists are Black, Latino, or Native American. The psychiatric nurse practitioner workforce faces many of the same issues with racial and ethnic diversity as psychiatrists. At 77.5% White, 6.7% Latino or Hispanic, 6.3% Asian, and 4.7% Black, the psychiatric nurse practitioner profession is overly homogenous in terms of both New York City’s population and the United States’ population as a whole. Both providers and patients of color seeking mental healthcare services can face a lack of representation, microaggressions, medical racism, unconscious bias, and other forms of discrimination.
Resolution 403 brings attention to the critical lack of perinatal psychiatrists in New York City. There are currently only 19 perinatal psychiatric fellowships in the entire country. New York City houses three of these programs in private institutions, including NYU, Columbia and Weill Cornell, with no programs housed in public institutions. With one in five people experiencing mental health concerns while pregnant or in their postpartum period, the lack of programs leads to deadly outcomes for pregnant people.
Requiring all accredited psychiatry residency programs to offer a one-year, post-residency fellowship program focused on Perinatal Mental Health would be a positive first step in ensuring access to highly-needed, specialized training. However, there are several related considerations that I would like to highlight for any potential legislation:
- Financial Sustainability – The State should create a plan for dedicated and sustained investment to ensure that fellows have a strong compensation and benefit structure allowing for pay parity with their peers in existing programs. (Currently, Weill Cornell’s Perinatal and Infant Psychiatry Fellowship offers a base salary of $145,000.)
- Diversity – The fellowship should incorporate measures to increase diversity among applicants from racial, ethnic, and linguistic backgrounds reflecting the communities most impacted by maternal mortality.
- Post-Fellowship Employment – To meaningfully address maternal mortality and morbidity, the legislation should build in provisions to ensure that fellows completing the program work in communities that are most disproportionately impacted by the crisis, namely Black and Brown neighborhoods. This can include strengthening the psychiatrist employment and residency pipeline within our public hospital system, as well as offering other employment incentives.
- Infrastructure – There are currently only three general psychiatric residencies in Health + Hospitals, which limits the opportunities for building a fellowship pipeline from the public hospital system. In order to do so, more funding must be invested in Health + Hospitals to increase the number of psychiatrists, and therefore psychiatric preceptors, to train psychiatric residents who can understand the nuanced needs of diverse and historically underserved communities.
- Reporting – Fellowship programs should incorporate reporting on fellow demographics and post-employment statistics, including the communities where fellows work.
Another consideration is expanding access to perinatal mental health training for Psychiatric Nurse Practitioners (pych NPs) through similar fellowship programs; unfortunately, data on the number of psychiatric nurse practitioners who center their work on pregnant and postpartum populations is not publicly available, which makes it difficult to identify the number of psych NPs focusing on maternal health.
Res 404 and 405
In 2018, the New York State Maternal Mortality Review Board deemed that all pregnancy associated deaths due to mental health problems were preventable. According to the 2020 Healthcare Effectiveness and Information Set (HEDIS) analysis, nationally, less than 20% of privately insured and Medicaid patients were screened for prenatal and postnatal maternal mental depression, with only 16% of Medicaid patients screened and given follow-up care during pregnancy and 17% in postpartum. This disparity leads to the majority, between 50% and 70%, of maternal mental health disorders remaining undiagnosed, making preventative intervention more difficult.
Res 404 and 405, which call for integrating maternal mental health screenings into routine OB/GYN perinatal care and Medicaid to cover those screenings, along with proper reporting of depression screening data, would ensure that preventative measures are provided throughout the pregnancy and the postpartum period. Together with the NYS legislature’s recent passage of S.2039-B/A.2870 to require the NYS Health Commissioner, in consultation with stakeholders, to release guidance and standards for incorporating maternal depression screenings into routine perinatal care, there is a clear focus on centering screenings related to prenatal and postpartum depression. While perinatal depression occurs in 10-15% of prenatal and postpartum women, perinatal mood and anxiety disorders also affect approximately 20% of pregnant women and new mothers. Depression and anxiety disorders are highly comorbid, with over 40% of individuals experiencing depression and an anxiety disorder at the same time. Anxiety can also be a symptom of major clinical depression or lead to depression at a later time. Therefore, in addition to ensuring the incorporation of depression screenings into perinatal visits, the resolutions should also call for the incorporation of anxiety screenings such as the GAD-7 into routine perinatal visits, with the appropriate reporting and Medicaid coverage.
Res 229
High-quality midwifery birth centers enable a birthing process that emphasizes respect, autonomy, and informed decision-making in a community setting. According to a Giving Voices to Mothers survey, women and birthing people cared for at birth centers have starkly better experiences, including more time spent and less cases of medical mistreatment; they were also 14 times more likely to report having enough time for prenatal visits. Midwifery birth centers improve autonomy, improve prenatal care outcomes, and reduce c-section rates for lowrisk women and birthing people when proper measures are put in the place to ensure high-quality care, safe and proper staffing, safe birthing environments, and proper hospital transfers when needed.
However, I do not support Res 229 because I am concerned that it reverses the original intention of the amended midwifery center bill (S.1414-A/A.259-A of 2021), which was to create a more robust licensure review process, by removing Commission for the Accreditation of Birth Centers (CABC) as the singular pathway to obtaining a license. This bill not only ensures that national, evidence-based standards of care are met through CABC accreditation, but that by undergoing a Certificate of Need (CON) review process, the facility meets New York State standards for safe and high-quality healthcare facilities and is eligible for Medicaid billing, increasing access for lowincome communities. It is important to ensure that facilities for out-of-hospital births exercise best practices to ensure that the environment is safe and clinical staff are experienced and highly qualified to create a safe birthing experience; patient safety cannot be compromised for efficiency.
This resolution should be discussed in partnership New York Midwives and NYC Midwives, who have been spearheading efforts to open up safe and high-quality midwifery birth centers on the state level. I also support a resolution to call for a midwife to be appointed to serve on the Public Health and Health Planning Council (PHHNC), especially if they will review midwifery birth center CONs; currently membership and vacancies do not include midwives.
Thank you again for the opportunity to testify and for this Council’s work in reversing the maternal mortality crisis. It is important that we continue to assess the recommendations from the New York City and New York State Maternal Mortality and Morbidity Review Committees’ annual and five-year reports to develop evidence-based policy changes. My Maternal Health Taskforce and I look forward to continuing working with you to make Brooklyn — and NYC — the safest place to give birth.