The Financial and Human Cost of Untreated Maternal Mental Health Conditions in Texas

Addressing inequities such as untreated maternal mental health is not only the right thing to do; it is costly not to

Published March 8, 2021

Healthy women are a cornerstone of healthy families, communities, and economies. That’s why investing in women and girls is a key part of our strategy to advance health equity in Central Texas.

The United States has the highest maternal mortality rate of any developed country, and Texas’ high uninsured rate further exacerbates maternal health challenges. So, while we believe women’s health encompasses more than childbirth and postpartum, we see addressing and improving maternal health outcomes—especially for women of color—as an imperative.

In fact, in 2018, we launched Focus on the Fourth, an initiative that supports maternal health during what’s known as the “fourth trimester,” or the year after childbirth. Each year, thousands of women suffer injuries, complications of childbirth, or risk death, with women of color impacted at double the rate as their white counterparts.

A new report released by Mathematica and published in collaboration with St. David’s Foundation and Texans Care for Children examines a crucial part of postpartum health—maternal mental health conditions (MMHCs), and their economic and human costs. These conditions are among the most common complications of pregnancy and childbirth and can have a devastating impact on mothers and children, yet they often go minimized, undiagnosed, and untreated.

In Texas, maternal mental health conditions affect more than 1 in 8 pregnant and postpartum women. In this newly issued report, Mathematica estimated the total monetary cost of untreated maternal mental health conditions in Texas is $2.2 billion.

The largest costs are productivity losses ($610 million), child behavioral and developmental disorders ($556 million), maternal health expenditures ($445 million), and preterm births ($372 million). With many of these costs resulting from untreated conditions, extending coverage to uninsured or underinsured mothers from 60 days to a year after childbirth could be one step to lowering this cost.

But the $2.2 billion doesn’t include the societal cost. When mothers suffer, we all do.

“The human cost, beyond the financial impact quantified in the analysis, ripples across generations. Every year in Texas, untreated MMHCs lead to an additional 7,472 babies being born preterm, 61 cases of SIDS, and nearly 7,000 children growing up with health, emotional, or behavioral challenges. Similarly, untreated MMHCs by definition hurt the mental well-being of moms, in addition to placing them at a higher risk of suicide and health challenges – which impact their families and extended community.” Lourdes Rodriguez, DrPH, Senior Program Officer at St. David’s Foundation

Untreated maternal mental health conditions are common and costly among families of all backgrounds. However, the report shows that families of color—especially Black families—are disproportionately impacted, affecting an estimated 19% of Black mothers in Texas, compared to 15% of Hispanic mothers and 12% of White mothers.

We know that some of the factors contributing to such disparities in maternal health outcomes include implicit bias in the health care system; chronic stress, including the physical toll of stress related to structural racism; social determinants of health, such as housing, food scarcity, and education; and a disproportionate lack of access to health insurance. (Interested? Read more here).

With all this in mind, one thing is clear—for the well-being of mothers, children, and the community, addressing maternal mental health during the postpartum period is crucial. Not only would it save financial costs, but it would also improve and save lives, for generations to come.

“We approach birth equity from an understanding that structural barriers including systemic racism and institutional bias lead to the stark health disparities we see in our community. This research demonstrates that addressing inequities such as untreated maternal mental health is not only the right thing to do, but it is costly not to.” Lourdes Rodriguez, DrPH, Senior Program Officer.

To learn more and review the findings, you can download the issue brief here: Untreated Maternal Mental Health Conditions in Texas: Costs to Society and Medicaid

The Impact of a Diaper: Innovating to Meet Increasing Diaper Need During A Pandemic

Published November 20, 2020

On any given Friday afternoon this past spring, you could find hundreds of families waiting in a drive-through line to pick up diapers from the Austin Diaper Bank. The Diaper Bank would distribute more than 50,000 diapers to over 750 families in just half an hour. This isn’t how they normally operate—the increased need was driven by the start of the COVID-19 pandemic. But responding to the importance and impact of diapers wasn’t anything new to the Austin Diaper Bank.

One in three families experience “diaper need,” or the lack of a sufficient supply of diapers to keep an infant, toddler, or other individual clean, dry, and healthy. Diapers are expensive, and here in Texas, the amount of infants and toddlers living in poverty or low-income households is higher than the national average.

The Austin Diaper Bank, a recipient of St. David’s Foundation’s COVID-19 Recovery Fund, provides diapers to Central Texas families who need a clean, reliable supply of diapers for a healthy and comfortable quality of life. Started in 2013, the Diaper Bank has grown considerably. The organization serves six counties and tens of thousands of families.

But why diapers? Children require an average of 8-12 diapers a day, averaging around $100 a month or $1200 a year—and that’s just for one child. Families who have trouble affording diapers tend to run short 11-12 diapers each week. Currently, there is only one federal assistance program that exists that can be used to buy diapers, but it also covers basic needs such as rent, transportation, and utilities, leaving little money left for a family in need to spend on diapers (learn more here).

A lack of clean diapers affects a baby’s well-being, leading to an increased risk of infection and sickness for babies. But the connection of diapers to many other issues that impact the health and well-being of children and families goes much further. Diaper rash or discomfort also lead to excessive crying, which is the number one cause of child abuse. Further, most childcare facilities require parents to provide a week’s supply of diapers. No diapers leads to no childcare, and no childcare can lead to missing work or school. In fact, three in five parents report having to miss work or school for this very reason. This can lead to loss of livelihood, further exacerbating diaper need and presenting even more barriers to health.

Over the years, the Diaper Bank has developed an innovative distribution model that has enabled scaled impact and reach. Instead of handing out diapers themselves, the Diaper Bank partners with food pantries, nonprofit organizations, and social service providers that are already connected in the community. By distributing to these partners, families can access diapers right where they are.

“Our model works,” said Holly McDaniel, Executive Director of the Austin Diaper Bank. “Asking a family in poverty to come to us makes no sense. Instead, meet the clients where they are. I don’t want to add anything to their plate, I want this to be easy for them.”

So, why the drive-through diaper line? Many of the Austin Diaper Bank’s community partners are led by volunteers, including many people who at a higher risk for COVID-19. As wide-spread closures started throughout the region and the nation, many of these organizations had to halt any in-person work; while at the same time, factors such as job loss and retail shortages caused diaper need to increase.

Thankfully, as organizations adapted to the pandemic, the Diaper Bank was able to return to their effective distribution model—but not without implementing some key learning and long-term programming shifts.

“One of the things we’re really proud of, considering we’re a really small staff, is the appointments we started. We started doing direct service,” explained McDaniel. “As much as we loved the drive-through, we weren’t making the much needed connections with the families.”

To better understand and meet the needs of families struggling during the pandemic, the Austin Diaper Bank created an online form to set up appointments that occurred in their parking lot. During these 15-20 minute appointments, they got the opportunity to listen to families share their story. Many were newly thrust into poverty and needed help navigating the social services system, and the Diaper Bank was in a perfect position to connect them to countless agencies and organizations.

While diaper distribution has returned to Austin Diaper Bank’s partners, the small team is continuing to serve as a community hub for health and knowledge sharing. Diapers are a tangible, high-priority need for families, which gives the Diaper Bank the opportunity to serve as gatekeepers and way finders to countless assistance programs.

“Yes, we’re giving out diapers, but we’re also supporting families,” said McDaniel. “We can’t do that without looking at them at a holistic level. Everybody needs space to tell their story. Our mission is to support these families by talking to them and sharing knowledge.”

Filling the crucial need of diapers also frees up emotional and mental space for families and caretakers to focus on accessing these services or improving other areas of health.

“When you hand them that diaper, you see the weight lifted and the life come back to their eyes,” said McDaniel. “When you are so focused on the lack of need for a child, you can’t focus on applying for jobs or filling out forms.”

To ensure proper social distancing, the Austin Diaper Bank can only allow three volunteers to work in their warehouse at a time—doing the work of what normally takes 15-20 people. Despite the challenges from this year, they have continued to press on and increase their impact. As of September, the Diaper Bank had already served over 22,000 families in 2020, compared to an average of 15,000 families in years past.

As a relatively new organization in Austin, the Diaper Bank is continuing to build new relationships and increase brand awareness in Central Texas. Growing community needs in the face of the pandemic has given them an opportunity to educate far and wide on diaper need and the impact a diaper can have on a family. Additionally, The Austin Diaper Bank is a member of the National Diaper Bank Network and is an emerging leader in their field, serving as a model for diaper banks throughout the nation.


You can learn more about diaper need and ways to partner with the Austin Diaper Bank at their website:

Facing Two Pandemics: How Black Mamas Community Collective is Combatting Global Health Crises

Published August 26, 2020

Before the COVID-19 pandemic, the Centers for Disease Control and Prevention reported that Black women in America were three times more likely to die of pregnancy- and childbirth-related causes than white women. Now, the pandemic is compounding inequity even further. Recent data reveals that Black and Latino individuals are twice as likely to die of COVID-19 than their white counterparts.1 And from an economic standpoint, COVID-19 has predominately impacted non-white women, skyrocketing unemployment rates for Black and Hispanic women to 16.4% and 20.2%, respectively.2

The unfortunate reality is women of color and their families have long-faced undue barriers to achieve and sustain success in varying aspects of life, including access to critical health care services supporting their emotional, mental and physical wellbeing. That’s why particular focus must be given to support mothers of color during these truly unprecedented times.

Many organizations like Black Mamas Community Collective (BMCC), a local nonprofit committed to providing Black mothers access to the resources and education needed to have healthy pregnancies, birthing and postpartum experiences, are creating their own support networks to action meaningful change. Their work began long before the pandemic but has grown increasingly more critical during the virus’ sustained spread.

A Socially Distant Safe Haven

Like many, BMCC has experienced drastic change in the past five months. At the beginning of the pandemic, BMCC’s services, such as its prenatal and postpartum community circles, transitioned from weekly in-person gatherings and appointments to virtual Zoom meetings to adhere to social distancing regulations. The organization’s doula program, which pairs a certified doula with a Black mother to support her through pregnancy, childbirth and the first year postpartum, also transitioned its weekly home visits to virtual Zoom meetings and telehealth check-ins. Nakeenya Wilson, BMCC’s Executive Director, said this has led to an increase in consistent participation by mothers thanks to expanded service access via technology. She also noted how both services have become even more valued and critical because they provide a safe, consistent space for mothers to connect with one another and express the challenges experienced in a socially distanced world, including round-the-clock care, parenting and schooling.

Going Above & Beyond

While BMCC made these quick pivots to support short-term needs, the team also prepared for the long-term impacts of the virus. According to a study by Texans Care for Children, “maternal mental health challenges – sometimes called postpartum depression or maternal depression – are one of the most common complications of pregnancy, affecting 1 in 7 Texas women.” This has only been exacerbated by the isolation and increased responsibility placed on mothers while navigating this “new normal.”

BMCC recognized this growing need and applied for a St. David’s Foundation COVID-19 Recovery Fund Grant in late April to expand it social services support. In June, the Foundation awarded BMCC with a grant to support the hiring of a licensed social worker. This will equip the organization with the resources needed to provide intensive case management and culturally relevant, trauma-informed, individual and group mental health services for the mothers of BMCC. Going forward, the organization also plans to focus on developing and expanding long-term partnerships with fellow nonprofits, as well as grow their volunteer base to continue to up level the support they provide “Black Mamas of ATX.”

From Surviving to Thriving

It’s said that a happy, healthy mother is the foundation of a household and their child’s success – from birth to the early formative years and beyond. The intermediate and long-term impacts of the coronavirus pandemic on Central Texas women of color aren’t yet fully realized. However, both the pandemic and recent race relations have reignited the conversations around racial justice. As a result, BMCC has received an influx of donations enabling the organization to serve more women and enhance and expand their current services. BMCC asks for continued support alongside fellow nonprofits, such as Mothers Milk Bank, Keep Austin Fed, and Undoing White Supremacy, to ensure support is sustained, as well as to foster growth of women’s health services in this region.

Prior to receiving a St. David’s Foundation COVID-19 Recovery Fund grant, BMCC was an existing grant partner of St. David’s Foundation’s Focus on the Fourth Women’s Health Initiative, a campaign aimed at improving postpartum access and outcomes during the “fourth trimester,” the first year of a baby’s life. The Foundation is committed to health equity across all its goals and principles and is dedicated to advancing women’s health to ensure there are no avoidable, systemic or social determinants preventing health care access for women in the Central Texas Community.

If you’re interested in learning more about St. David’s Foundation’s Focus on the Fourth Initiative and its partners, click here. To learn more about or get involved with Black Mamas Community Collective, please click here.

  1. Source: The Fullest Look Yet at the Racial Inequity of Coronavirus as reported by the New York Times on July 5, 2020.
  2. Source: Why Some Women Call This Recession a ‘Shecession’ as reported by the New York Times on May 9, 2020.

Focus on the Fourth: A Commitment to Maternal Health & Equity

By Lourdes Rodriguez, DrPH, Senior Program Officer

Published July 20, 2020

Understanding The Fourth Trimester

I vividly remember the births of my first and second children; the third one, however, I remember painfully. Each birthing story is unique and deeply personal, each bringing its moments of joyful highs and challenging lows. I was already in my thirties when I became pregnant the first time. I quickly found that no number of years in formal training on maternal, child or public health would prepare me for the necessary – and at times dull – journey of prenatal care. I found myself being disappointed. I longed for more than simply being monitored from a clinical standpoint by my doctor and her staff. While the care I received was the standard model, I was expecting more. What truly prepared me for birthing and motherhood – and complemented my clinical care – were the powerful experiences of mothers, doulas, midwives, the first-hand accounts of relatives and friends, and the unwavering support of my partner. Through this, I became a better everything after I became a mother: a better public health practitioner, a better neighbor, a better friend to other pregnant women.

Before experiencing this personally, I simply did not have the words to describe what I can now recognize as the fourth trimester – a crucial period in the months following the birth of my children where the need for support, community and access to healthcare is at its most critical. After nine months of such diligent and high-touch care as an expectant mom, I quickly found myself navigating a whole new world for my child and me with much less formal support. My motherhood journey had just begun and here I was with little context of what to expect physically, emotionally and mentally now that my child had arrived.

Recognizing Others’ Disproportionate Experiences
After my first pregnancy, I recall returning to work and connecting with a colleague who had been pregnant at the same time. I asked about her birth, eager to share my positive experience, only to see her face drop when she shared that her baby boy had died shortly after birth. Since that day 15 years ago, similar questions were met with the same painful and heartbreaking news – more than I’d like to count. Each story was shared with me by a woman of color, like me, who had experienced a miscarriage or who was only able to hold their newborn for a few brief days or months. I stopped asking new moms about their births and newborns and now wait until people show their baby pictures.

Despite all the advancements we’ve made in medical care in the United States over the last half century, a shocking fact remains: the U.S. has the highest maternal mortality rate of any other developed country. Each year, thousands of women suffer injuries or complications from childbirth, with women of color twice to three times as likely to suffer pregnancy-related issues than their white counterparts according to 2019 CDC data.

Decreasing maternal mortality and morbidity are within our reach

I keep the women who shared their stories with me and the countless others in my heart as I join St. David’s Foundation overseeing the work in our Women’s Health Program. I am eager and grateful to continue the work started by my predecessor to raise awareness about the critical importance of the fourth trimester. Unlike diseases for which we have no cure, the answers to decreasing maternal mortality and morbidity are within our reach. We have an opportunity to build awareness and think about how we organize clinical care and work to reduce barriers and stressors for women experiencing the greatest health inequities.

My work at the Foundation began as the COVID-19 pandemic turned our world upside down and inside out. As a community scholar, public health practitioner and Latina, I already had a front row seat to the health inequities that exist and are fueled by systems and structures that value and serve people differently based on racial and ethnic background, education, social and financial standing. The current coronavirus pandemic has served as a magnifying glass for inequities as evidenced by the disproportionate number of people of color who are impacted by the crisis. In April, the CDC analyzed COVID-19 patient information of individuals for whom race and ethnicity information was available. Data shows 33% of patients were black compared to 18% in the community. And race and ethnic information for New York deaths indicate the death rates of Black and Latino individuals were significantly higher than those of white counterparts, at 92.3 deaths per 100,000 population and 74.3 respectively.

While schools, businesses and places of worship have closed to stem the virus, pregnancies do not wait for a more convenient time. Now more than ever, we must ensure that we not only meet the needs of women to improve maternal health outcomes, but also maintain the early traction and progress we have made on the importance of good mental health during pregnancy and postpartum.

Deepening Our Commitment to Empowering Women
As part of this work, St. David’s Foundation has launched the Focus on the Fourth initiative to support maternal health during the “fourth trimester,” the year after childbirth, for women experiencing the greatest health disparities, especially women of color. To date, the initiative has funded grants to 10 organizations totaling more than $2 million. We believe that healthy women are the cornerstone of healthy families, communities and economies, and the Foundation is committed to enabling access to services that help women care for their health and well-being, as well as their families. We work alongside our grant recipients and community partners to empower women to attain good health, advance health equity, breakdown the social determinants of health preventing care, and build capacity within community-based organizations to help more women and babies stay healthy through their first year.

Amidst this time of uncertainty and social distancing, this work is even more vital as mothers are cut off from the support they can typically rely on from friends and relatives. You can learn more about St. David’s Foundation Focus on the Fourth initiative here and read the stories of the organizations working to provide care and support to Central Texas women. We will also be hosting the Advancing Women’s Health in Central Texas: From Data, to Analysis – to Action webinar on August 5, 2020 where we will explore and discuss three recent studies on maternal health disparities in Central Texas. Learn more and register here.



The Path to Healthier Texas Mothers and Babies

It’s been almost two years since we launched Focus on the Fourth, our funding opportunity with a specific focus on improving maternal health during the year after childbirth for women experiencing the greatest health disparities, especially women of color. Every day, there are more critical uncertainties and opportunities to keep the issue and importance of women’s health top of mind. We recently put together a panel on maternal mortality for SXSW and are so inspired by members of the community and recipients of our Focus on the Fourth grants that have come together to build collaboratives like Black Mamas ATX and create calls to action.

Members of Black Mamas ATX at the Texas State Capitol.

On Mother’s Day, the Austin American-Statesman published an op-ed penned by our Senior Program Officer for Women’s Health, Elizabeth Krause, which highlighted the importance of a full year of care for women following childbirth. Link: Austin American-Statesman: “Let’s Give Texas Mothers a Lifeline”. 

“Healthier women are healthier mothers, and healthier mothers lead to healthier Texas infants and families.” – Senior Program Officer Elizabeth Krause

Last week, we were honored to host Jennie Joseph, the inspiring midwife leader of Commonsense Childbirth and creator of the JJ Way, to join us for a breakfast discussion on health equity. We had a packed room for the event, which brought together local doulas, midwifes, safety net clinic staff and representatives from area nonprofits, all of whom are focused on improving maternal outcomes for women.

Jennie Joseph presents to a packed room of maternal health leaders at St. David’s Foundation


We were inspired by Jennie and the simplicity of her message: “All women want and deserve a healthy baby.” She stressed that there are a multitude of barriers keeping underserved women, especially women of color, from having the healthy and empowered pregnancy they deserve, from the neighborhoods where they live, to bureaucracy and increasingly strict, confusing Medicaid restrictions.

“We can spend a lot of time and money being in the stats, but people and mothers populate the statistics.” – Jennie Joseph


Access, knowledge and empowerment, she said, are the ways we get to the best possible outcomes for mothers and their babies. We know there is a long path ahead of us, not just in Texas, but across the US, and we’re so grateful that we have leaders like those that were in the room as Jennie spoke, who are making strides to make sure every mother has the best birth outcome possible.

St. David’s Foundation Senior Program Officer Elizabeth Krause, Jennie Joseph of Commonsense Childbirth and Paula X. Rojas of Mama Sana Vibrant Woman


Read more about our Women’s Health Strategy

Link to Jennie Joseph’s Commonsense Childbirth Page

A Guide for Texas Women: Accessibility, Eligibility and Barriers to Pre- and Postnatal Care

Our Focus on the Fourth Grantees

SXSW Panel: Maternal Mortality in America: What’s Going On

Focus on The Fourth: Our First Women’s Health Grantees

Congratulations to the recipients of our first women’s health RFP grants, focused on aiding low-income and underserved women in Central Texas in receiving timely and effective postpartum support services. In total, $2,000,000 in grants were given to groups working to make a difference in the health of Central Texas women. The postnatal period represents a vital window to help women and babies reap health benefits that can pay dividends for years to come. Through this opportunity, the Foundation is funding projects aimed at improving postpartum access and outcomes for underserved women during the “fourth trimester,” the year following delivery.

Our Focus on the Fourth Postpartum Health Grant Recipients!

Congratulations to all the recipients of our Focus on the Fourth grants, which fund programs that provide postpartum support to women. The ladies of Mama Sana Vibrant Woman are ready to celebrate! #focusonthefourth

Posted by St. David's Foundation on Thursday, January 25, 2018


Cardea Build capacity of Women, Infants and Children (“WIC”) and FQHC sites for opioid screening, intervention, and referral.  $ 300,000
Hand to Hold More effectively serve African-American NICU moms with attention to depression, breastfeeding, and peer support  $ 150,000
Mama Sana Vibrant Woman Institute structured postnatal program with home visiting, support groups, social support, and yoga for moms of color.  $ 169,405
Texans Care for Children Analyze provider readiness to implement new TX postpartum depression screening benefit and substance abuse services.  $ 86,000
Austin Recovery Produce action plan to provide postpartum care to high risk new moms in Family House residential treatment.  $ 273,281
El Buen Samaritano Culturally and linguistically competent outreach to increase postpartum visit adherence among Latina moms.  $ 125,000
Lone Star Circle of Care Employ nurse care coordinator to engage patients in mom-baby teams and work across providers to improve outcomes.  $ 186,681
People’s Community Clinic Improve current postpartum care model to better serve women who experienced prenatal health complications.  $ 200,000
Texas State School of Nursing Translational research using an SMS text messaging and group chat platform to inform, educate, and connect underserved women in Hays County with services and information.  $ 209,633
UT Steve Hicks School of Social Work Engage African-American women in community-based participatory research and strategic planning to tackle maternal mortality disparities.  $ 300,000
 Total Grants  $ 2,000,000