U.S. counties that have shortages of mental health care providers and higher rates of long-term unemployment also have higher rates of neonatal abstinence syndrome, or NAS, according to research published in JAMA.
“What is clear when I take care of infants and talk to their mothers is that while NAS isn’t particularly clinically complex, it can be socially complex,” Stephen W. Patrick, MD, MPH, assistant professor of pediatrics and health policy at Vanderbilt University and director of the Vanderbilt Center for Child Health Policy, told Infectious Diseases in Children. “The stories I hear from pregnant women are long stories of trauma and violence. This study was our first attempt to try to see what is happening beyond the hospital walls. Sometimes, we focus in on what’s happening at the bedside, but so much of NAS occurs outside of the hospital.”
Patrick and colleagues conducted a retrospective, repeated cross-sectional study that assessed birth and economic data collected between 2009 and 2015 from 580 counties in Florida, Kentucky, Massachusetts, Michigan, New York, North Carolina, Tennessee and Washington. Additionally, the researchers examined the county-level 10-year unemployment rate and the availability of mental health and primary care clinicians.
During the study period, 6,302,497 children were born and 47,224 NAS diagnoses were made (median rate = 7.1 cases per 1,000 hospital births; interquartile range [IQR] = 2.2-15.8).
Patrick and colleagues calculated that the 10-year unemployment rate was 7.6% (IQR = 6.4%-9%), and nearly every year in every county (83.9%) had a partial or complete mental health care provider shortage.
Further analyses revealed that NAS rates were higher in counties with mental health care provider shortages (unadjusted rates = 14 per 1,000 live births vs. 10.6 per 1,000 live births; adjusted incidence rate ratio [IRR] = 1.17; 95% CI, 1.07-1.27). The shortage of mental health care providers most affected the rate of NAS cases diagnosed in metropolitan counties (aIRR = 1.28; 95% CI, 1.16-1.40).
Patrick said that there is a known correlation between untreated mental health disorders and opioid use. He suggested that improving access to mental health care providers may be “a way to help prevent NAS for years to come.”
The researchers said there was no relationship between NAS rates and primary care provider shortages, but they did find that NAS rates were correlated with long-term unemployment (unadjusted rate = 20.1 per 1,000 births vs. 7.8 per 1,000 live births; aIRR = 1.34; 95% CI, 1-1.23). This association had the greatest impact on remote, rural counties (aIRR = 1.34; 95% CI, 1.05-1.70).
“For clinicians, I think we need to step back and not just think about the mother’s opioid or drug exposure but the broader context,” Patrick said. “For me, this resonates when I think about how to do trauma-informed care with pregnant women and how I can connect them to other resources that may be beneficial. This can feel completely overwhelming, and I think part of the goal of our paper was not to only focus on the medicine, but to begin the conversation to think about social determinants of health care.”