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Relationship between Depression and Anxiety during Pregnancy, Delivery-Related Outcomes, and Healthcare Utilization in Michigan Medicaid, 2012–2021

Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA
Department of Psychiatry, Michigan Medicine, Ann Arbor, MI 48109, USA
Department of Obstetrics and Gynecology, Michigan Medicine, Ann Arbor, MI 48109, USA
Ambulatory Care Program, Department of Pediatrics, Michigan Medicine, Ann Arbor, MI 48109, USA
Department of Learning Health Sciences, Michigan Medicine, Ann Arbor, MI 48109, USA
Author to whom correspondence should be addressed.
Healthcare 2023, 11(22), 2921;
Submission received: 29 June 2023 / Revised: 25 October 2023 / Accepted: 31 October 2023 / Published: 7 November 2023
(This article belongs to the Special Issue Medicaid and Public Health: Second Edition)


To evaluate associations between depression and/or anxiety disorders during pregnancy (DAP), delivery-related outcomes, and healthcare utilization among individuals with Michigan Medicaid-funded deliveries. We conducted a retrospective delivery-level analysis comparing delivery-related outcomes and healthcare utilization among individuals with and without DAP between January 2012 and September 2021. We used generalized estimating equation models assessing cesarean and preterm delivery; 30-day readmission after delivery; severe maternal morbidity within 42 days of delivery; and ambulatory, inpatient, emergency department or observation (ED), psychotherapy, or substance use disorders (SUD) visits during pregnancy. We adjusted models for age, race/ethnicity, urbanicity, federal poverty level, and obstetric comorbidities. Among 170,002 Michigan Medicaid enrollees with 218,890 deliveries, 29,665 (13.6%) had diagnoses of DAP. Compared to those without DAP, individuals with DAP were more often White, rural dwelling, had lower income, and had more comorbidities. In adjusted models, deliveries with DAP had higher odds of cesarean and preterm delivery OR = 1.02, 95% CI: [1.00, 1.05] and OR = 1.15, 95% CI: [1.11, 1.19] respectively), readmission within 30 days postpartum (OR = 1.14, 95% CI: [1.07, 1.22]), SMM within 42 days (OR = 1.27, 95% CI: [1.18, 1.38]), and utilization compared to those without DAP diagnoses (ambulatory: OR = 7.75, 95% CI: [6.75, 8.88], inpatient: OR = 1.13, 95% CI: [1.11, 1.15], ED: OR = 1.86, 95% CI: [1.80, 1.92], psychotherapy: OR = 172.8, 95% CI: [160.10, 186.58], and SUD: OR = 5.6, 95% CI: [5.37, 5.85]). Among delivering individuals in Michigan Medicaid, DAP had significant associations with adverse delivery-related outcomes and greater healthcare use. Early detection and intervention to address mental illness during pregnancy may help mitigate burdens of these complex yet treatable disorders.

1. Introduction

Pregnant individuals with mental health conditions deliver more than 800,000 infants each year [1]. Up to or exceeding 20% of individuals have depression and/or anxiety during pregnancy (DAP) [2,3,4,5,6], the most underdiagnosed obstetric complication in the United States (US) [7]. Individuals with lower incomes suffer at a higher rate (40–60%) and experience more severe episodes of DAP [7]. The estimated societal financial toll of not treating DAP exceeds $14 billion annually in the US, with healthcare expenditures and cesarean deliveries driving the overall economic burden [8].
The US experiences the worst maternal morbidity and mortality rates of any peer nation [9]. The global maternal mortality rate decreased 43% since 1990, while the US maternal mortality rate increased 16% from 12 to 14 deaths per 100,000 live births [2]. The US maternal mortality rate remains 75% higher than the average maternal mortality rate for high income nations [3]. High cesarean and preterm delivery rates drive severe maternal morbidity (SMM) and maternal death [4], often along socioeconomic and racial lines [10,11]. Disparities further influence utilization patterns as high-risk individuals seek emergency services to supplement inadequate or inaccessible perinatal health care [5].
Literature indicates that maternal depression and anxiety may increase odds of preterm birth, low birthweight, and other poor birth outcomes [6,7]; however, some systematic reviews maintain that the association is inconclusive [8] or reflects complex causal pathways [7]. A recent study using nationally representative survey data found that individuals with depressive symptoms during pregnancy had higher odds of going without routine medical care and using urgent care more frequently compared to delivering individuals without these symptoms [9]. This study will complement and extend that work by comparing associations between individuals with and without diagnosed DAP and the amounts and types of health care utilization in a high-need population of delivering individuals, namely, those with Medicaid health insurance coverage, which funds nearly half of all births [10,11].
We aimed to determine if delivering individuals with DAP had higher rates of suboptimal delivery-related outcomes and greater utilization of health services compared to delivering individuals without diagnosed DAP.

2. Materials and Methods

We conducted a retrospective cohort study to evaluate health care utilization for Michigan Medicaid enrollees aged 15 to 49 who delivered live births between 1 January 2012 and 30 September 2021 [12]. We used de-identified administrative claims from the Michigan Department of Health and Human Services (MDHHS) data warehouse. During the study period, Medicaid served as the primary payer for 40–44% of births in Michigan [13].
Our inclusion criteria required continuous enrollment in Michigan Medicaid for nine months prior to delivery and three months afterward. Although we recognize that not all pregnancies last exactly nine months, we aimed to increase the likelihood that we could observe all health services utilization during pregnancy. Similarly, Medicaid is available to an eligible woman while she is pregnant, including the month her pregnancy ends and during the two calendar months following the month her pregnancy ends (i.e., 2–3 months). Individuals could appear in our dataset more than once if they had more than one delivery during the study period.
An honest broker extracted and created a de-identified study dataset of Michigan Medicaid enrollment and administrative claims data. The eligible population included all deliveries with at least one live birth. For eligible enrollees, the dataset included all paid claims for nine months prior to and up to three months after the delivery date, including visit dates, hospital admission, and discharge dates; International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM and ICD-10) codes (diagnostic and procedure codes); Diagnosis Related Group (DRG) codes; Current Procedural Terminology, 4th edition, codes (procedure codes); Healthcare Common Procedure Coding System codes (supplies and services codes); Revenue codes, Type of Bill codes, HIC3 Specific Therapeutic Codes; and prescription dispense date. Demographic data at the time of delivery included year of birth, race/ethnicity, Medicaid benefit plan, zip codes, and income level (% Federal Poverty Level [FPL]). We did not exclude individuals with third party liability, which comprised less than 3% of the study sample. Appendix A provides cohort and all variable definitions.
The University of Michigan and Michigan Department of Health and Human Services Institutional Review Boards approved this study. We followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines [14].

2.1. Dependent Variables

This study included four delivery-related outcomes and five utilization outcomes during the pregnancy. Delivery-related health outcomes included cesarean delivery, preterm delivery (by diagnosis of gestational age ≤37 weeks), 30-day readmission after delivery, and severe maternal morbidity (SMM) within 42 days as defined by the Centers for Disease Control and Prevention (CDC) [15]. Utilization outcomes included (1) ambulatory care visits (i.e., all outpatient visits including prenatal care); (2) inpatient visits (excluding delivery hospitalization); (3) emergency (ED) and/or observation visits; (4) psychotherapy visits; and (5) substance use disorder (SUD) treatment visits. Utilization variables include visits in the nine months before delivery.

2.2. Independent Variables

For this study, we considered DAP to include any diagnosis of depression or anxiety disorder during pregnancy as the primary independent variable. We included maternal sociodemographic characteristics available in the Medicaid data for time of delivery with plausible associations with outcomes of interest, including age (range 15–49); race/ethnicity (American Indian/Alaskan Native, Asian, Black, Hispanic, Native Hawaiian/Pacific Islander, White, other/unspecified); urbanicity (urban, non-urban/unknown based on zip codes of residence) [16]; and percentage of FPL (0, >0 to ≤50, >50, unknown).
We also included clinical characteristics commonly associated with outcomes of interest using any diagnosis code (not just primary diagnosis), including Bateman Obstetric Comorbidity Index (OBCMI; categorized as 0–1, 2+) [17]; behavioral health diagnoses other than depression and anxiety (serious mental illness, SUD, other behavioral health diagnoses, any of the four preceding diagnosis groups); and psychotropic medication use (antidepressants, anxiolytics, antipsychotics, mood stabilizers, opioid analgesics, medication for opioid use disorder, stimulants, any of the seven psychotropic medication classes).

2.3. Statistical Methods

First, we compared sociodemographic and clinical characteristics among deliveries to childbearing individuals with and without DAP at any time during the study period. Next, we used unadjusted and adjusted odds ratios from generalized estimating equation (GEE) regression in GENMOD models to assess delivery-related and utilization outcomes with delivery as the unit of analysis. We treated deliveries as a repeated measure to account for mothers who had more than one delivery during the study period. We used a compound symmetry assumption (type = cs) for the covariance matrix. We conducted all analyses using SAS 9.4 and used the PROC GENMOD module.

3. Results

The sample included 218,890 deliveries among 170,002 Michigan Medicaid enrollees meeting study criteria during the study period. This included 129,903 (76.4%) with one delivery, 32,629 (19.2%) with two deliveries, 6329 (3.7%) with three deliveries, and 1141 (0.7%) with four or more deliveries. Of those delivering individuals, 15.7% of deliveries had diagnosed DAP during pregnancy. Figure 1 presents the study cohort selection and attrition.
Table 1 compares sociodemographic characteristics and clinical characteristics of childbearing individuals with and without DAP (all p < 0.001). Deliveries with DAP had a higher proportion of White (69.6% versus 50.57%) enrollees than deliveries without DAP, as is consistent with other literature [18]. Deliveries with DAP also had a higher proportion of non-urban (20.3% versus 13.5%) and lower income (60.6% versus 55.8% with income at 0% FPL) enrollees than deliveries without DAP. Individuals with DAP had more obstetric comorbidities than those without DAP (2.07 vs. 1.27). Findings indicated substantially higher rates of other behavioral health diagnoses and psychotropic medication use among those with diagnosed DAP versus those without. Among deliveries with DAP, 49.6% had another behavioral health diagnosis, and 71.7% had any psychotropic medication use. Among those without diagnosed DAP, 8.8% had another behavioral health diagnosis, and 12.5% had any psychotropic medication use during pregnancy and/or postpartum.
Table 2 presents findings on delivery-related outcomes and utilization of health services from adjusted and unadjusted GEE regression models displaying odds ratios. In adjusted analyses, deliveries with DAP during pregnancy versus without DAP had 2% greater odds of cesarean delivery (OR = 1.02, [95% CI: 1.00, 1.05]) and 15% greater odds of preterm delivery (OR = 1.15, [95% CI: 1.11, 1.19]). Women with DAP had 14% greater odds of being readmitted to the hospital within 30 days of delivery (OR = 1.14, [95% CI: 1.07, 1.22]) and 27% greater odds of experiencing SMM within 42 days of delivery (OR = 1.27, [95% CI: 1.18, 1.38]).
Compared with delivering individuals without diagnosed DAP, those with pregnancy-related diagnosed DAP had a higher probability of all five types of utilization assessed during pregnancy, including an almost eight-fold increase in odds of attending an ambulatory visit (OR = 7.75, [95% CI: 6.75, 8.88]), a 13% increase in odds of attending inpatient visits (OR = 1.13, [95% CI: 1.11, 1.15]), and an 86% increase in odds of being admitted for ED/observation (OR = 1.86, [95% CI: 1.80, 1.92]). Unsurprisingly, DAP was associated with 172.8 times greater odds of attending psychotherapy visits (OR = 172.83, [95% CI: 160.10, 186.58]) and 5.61 times greater odds of attending an SUD visit (OR = 5.61, [95% CI: 5.37, 5.85]).

4. Discussion

This study demonstrates the magnitude of the excess healthcare use associated with DAP among delivering individuals with Medicaid. Delivering individuals with diagnosed DAP had higher rates of comorbid mental health and substance use diagnoses, higher use of psychotropic medication, higher rates of adverse delivery-related outcomes, and higher utilization than their counterparts without diagnosed DAP. Although higher rates of adverse delivery-related outcomes may be driven by associations with other characteristics besides DAP status, healthcare utilization rates remained higher for those with DAP in adjusted models, even for non-behavioral health-related services.
Although this study indicated that those with DAP had higher healthcare utilization, some of that excess utilization may represent appropriate and beneficial care, whereas other utilization may have included inappropriate or low value treatment. Individuals with DAP may need more services; however, we cannot determine from this analysis whether the care received represented the right amount and mix or type of services. Ideally, individuals with DAP would receive necessary and high value care as appropriate to their conditions; their utilization patterns would not necessarily match those for individuals without DAP.
These findings are consistent with existing literature, which consistently identifies an association between depression and/or anxiety and preterm birth [6,7,8]. However, the literature on cesarean delivery is decidedly more mixed. One systematic review found an overall null association between antenatal anxiety and cesarean delivery [6]. These null results may reflect heterogeneity within patients with DAP, as untreated DAP increased risk of cesarean delivery, while treated DAP decreased risk of cesarean delivery. Our study did not control for treatment status, but Medicaid recipients are less likely to receive postpartum mental health treatment than privately insured individuals [19], which may also occur in the antenatal population. We did not identify literature associating DAP with SMM or 30-day rehospitalization. The prevalence of both SMM and DAP has increased over the past decade [20,21], and our findings may indicate that these increases are linked.
These findings correspond with other literature on the higher healthcare utilization among those with behavioral health conditions compared to those without these conditions in delivering and non-delivering populations [9,22,23,24,25]. A five-year retrospective cohort study of Medicaid-insured individuals in South Carolina found that eligible individuals who received group visits had a reduced risk of premature birth, low birthweight, and neonatal intensive care unit stays [26]. Another study suggests establishing routine care and decreasing acute care in this population [9]. Future interventions, including repeated screening throughout pregnancy and postpartum, could also assist in the early detection and management of DAP.
This study documents high rates of comorbidity within and across behavioral health conditions, including SUD, and higher use of SUD treatment among those with DAP. Given the overlap of these conditions in this and in other studies [27,28], this finding also reiterates the importance of both early detection and appropriately tailored treatment that addresses needs of those with multiple behavioral health comorbidities.


Diagnoses represent detected illness, yet DAP frequently goes undiagnosed, especially in non-White individuals; furthermore, race/ethnicity groups may approach treatment for DAP differently [29,30]. Systemic racism can also yield barriers for non-White individuals to accessing perinatal physical and mental health care [31,32]. This creates heterogeneity in under-diagnosis, which may skew our results. Residual bias may have also occurred such that we could not account for all possible confounding influences on the relationship between DAP and outcomes. Imperfect timing of diagnoses in claims data during healthcare visits relative to onset of illness may also have influenced study findings. Claims data can only indicate current diagnoses and may not accurately reflect symptom onset, severity of symptoms, or remission.
This study used a retrospective, observational design, which cannot establish causality. This study included individuals with continuous enrollment, yet Medicaid churn for postpartum individuals remains pervasive [33,34]. More than half of the individuals originally identified in our study population did not meet criteria for continuous enrollment. Therefore, the true extent of the impact of their DAP on healthcare utilization remains unknown and hard to accurately quantify. Individuals enrolled in Medicaid may have higher and more severe rates of DAP; findings may not necessarily generalize to non-Medicaid populations; however, individuals without continuous coverage may have higher rates of DAP than those with continuous coverage. Further, findings may not generalize to Medicaid populations in other states, as each state may handle access to care and coverage differently. For all these reasons, we anticipate that these findings represent an underestimate of the impact of DAP. We focused this study on DAP; individuals experiencing mental health conditions during pregnancy have an increased risk of maintaining or developing those conditions postpartum compared to people without DAP.

5. Conclusions

Accounting for sociodemographic and clinical characteristics, we found that childbearing individuals with DAP with Medicaid insurance coverage in Michigan had higher rates of adverse birth outcomes and healthcare utilization compared to those without DAP. Given the well-established negative intergenerational effects of inadequate care for childbearing individuals on outcomes for their infants, early detection and tailored, appropriate treatment of DAP may help mitigate the health burdens associated with these complex yet treatable disorders.

Author Contributions

Conceptualization, K.Z., X.Z., A.T., S.J.C. and S.V.H.; methodology, K.Z., X.Z. and A.T.; validation, X.Z. and A.T.; formal analysis, X.Z. and A.T.; data curation, X.Z. and A.T.; writing—original draft preparation, K.Z. and X.Z.; writing—review and editing, K.Z., S.J.C. and S.V.H.; funding acquisition, K.Z. All authors have read and agreed to the published version of the manuscript.


This project received funding support from the Center of Medicare and Medicaid Services through the Michigan Department of Health and Human Services (MDHHS).

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the University of Michigan Institutional Review Board (IRB) under HUM00148854 and by the MDHHS IRB Log #: 201811-10-EA-(R1).

Informed Consent Statement

Patient consent was waived by both the University of Michigan IRB and MDHHS IRB as permitted under 45 CR 46.116(d).

Data Availability Statement

The data that support the findings of this study are available from the MDHHS Data Warehouse. Restrictions apply to the availability of these data, which were used under license for this study and thus are not publicly available. Data from the MDHHS Data Warehouse for this study was made available through a Data Use Agreement with MDHHS by program sponsors Michigan Pregnancy Risk Assessment Monitoring System, Medical Services Administration, Behavioral Health and Developmental Disabilities Administration, and Vital Records.


We would like to acknowledge Rebecca Brownlee, Acham Gebremariam, Amy Schroeder, and Erin Miller in the technical support of this manuscript.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript’ or in the decision to publish the results.

Appendix A. Cohort and Variable Definitions

Delivery Codes
VariableICD Diagnosis CodeICD Procedure CodeDRGCPT/HCPCS
Cesarean-740, 741, 742, 744, 7499; 10D00Z0, 10D00Z1, 10D00Z2370, 371, 765, 766, 540, 5401, 5402, 5403, 540459510, 59514, 59515, 59618, 59620, 59622
Vaginal 10D07Z3, 10D07Z4, 10D07Z5, 10D07Z6, 10D07Z7, 10D07Z8, 10E0XZZ372, 373, 374, 375, 767 768, 774, 775, 541, 542, 560, 5411, 5412, 5413, 5414, 5421, 5422, 5423, 5424, 5601, 5602, 560359400, 59409, 59410, 59610, 59612, 59614
Preterm BirthO601, O6010, O6010X0, O6010X1, O6010X2, O6010X3, O6010X4, O6010X5, O6010X9, O6012, O6012X0, O6012X1, O6012X2, O6012X3, O6012X4, O6012X5, O6012X9, O6013, O6013X0, O6013X1, O6013X2, O6013X3, O6013X4, O6013X5, O6013X9, O6014, O6014X0, O6014X1, O6014X2, O6014X3, O6014X4, O6014X5, O6014X9
Mental Health Disorder Codes
VariableICD Diagnosis Code
Depression and/or Anxiety (DAP)Anxiety300.xx, 308.xx, 313.xx, 293.xx, F06.xx, F40.xx, F41.xx, F42.xx, F43.xx, F48.xx, R45.xx
Depression311.xx, 296.xx, 300.xx, F32.xx, F33.xx
Other Behavioral Health ConditionsMental Health Disorders, excluding DAP312.xx, 314.xx, 313.xx, F90.xx, F91.xx, R46.xx, R46.xx, R46.xx, R46.xx, 309.xx, 309.xx, F43.xx
Psychotropic Medication Classification Codes
Medication classHIC 3 Specific Therapeutic Code
AntidepressantH24, H2H, H2J, H2K, H2N, H2S, H2U, H2Y, H7B, H7C, H7D, H7E, H7I, H7J, H7K, H7L, H8P, H8S, H8T, H8Z
Antidepressant/antipsychoticH2W, H7A
Antidepressant/anxiolyticH2X, H7M
AntipsychoticH2G, H2I, H2L, H2O, H7O, H7P, H7Q, H7R, H7S, H7T, H7U, H7V, H7X, H7Z, H8N, H8W
AnxiolyticH20, H2F, H2P, H8A, H8K
Mood stabilizerH2M
Opioid/narcotic analgesicH30, H3A, H3B, H3H, H3J, H3M, H3N, H3Q, H3R, H3U, H3X, H3Z, S7G
Opioid/narcotic antagonistH3T, H3W, H3Y, H33
Opioid/narcotic antitussiveB4F, B4N, B6C, B6I, B6U
StimulantH2V, H7Y, H8M, H8Q, J5B
Visit Codes
Visit TypeICD Diagnosis CodeICD Procedure CodeCPT/HCPCSRevenueBill Type
Ambulatory CareZ00.00, Z00.01, Z00.121, Z00.129, Z00.3, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9, Z76.1, Z76.2, V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99461, 99483, G0463, T1015, G0402, G0438, G0439, S0620, S0621, 98966, 98967, 98968, 99441, 99442, 99443510, 511, 512, 513, 514, 515, 516, 517, 519, 520, 521, 522, 523, 524, 525, 526, 527, 528, 529, 982, 983
Inpatient 100, 1000, 1001, 1002, 1003, 1004, 1005, 101, 110, 111, 112, 113, 114, 116, 117, 118, 119, 120, 121, 122, 123, 124, 126, 127, 128, 129, 130, 131, 132, 133, 134, 136, 137, 138, 139, 140, 141, 142, 143, 144, 146, 147, 148, 149, 150, 151, 152, 153, 154, 156, 157, 158, 159, 160, 164, 167, 169, 170, 171, 172, 173, 174, 179, 190, 191, 192, 193, 194, 199, 200, 201, 202, 203, 204, 206, 207, 208, 209, 210, 211, 212, 213, 214, 219, 22, 24, 524, 525, 550, 551, 552, 559, 660, 661, 662, 663, 669, 720, 721, 722, 723, 724, 729, 987180, 181, 182, 183, 184, 185, 187, 188, 210, 211, 212, 213, 214, 215, 217, 218, 220, 221, 222, 223, 224, 225, 227, 228, 280, 281, 282, 283, 284, 285, 287, 288, 289, 650, 652, 653, 654, 655, 657, 658, 660, 662, 663, 664, 665, 667, 668, 860, 862, 863, 864, 865, 867, 868, 018F, 018G,018H, 018I, 018J, 018K, 018M, 018O, 018X, 018Y, 018Z, 021F, 021G, 021H, 021I, 021J, 021K, 021M, 021O, 021X, 021Y, 021Z, 022F, 022G, 022H, 022I, 022J, 022K, 022M, 022O, 022X, 022Y, 022Z, 028F, 028G, 028H, 028I, 028J, 028K, 028M, 028O, 028X, 028Y, 028Z, 065F, 065G, 065H, 065I, 065J, 065K, 065M, 065O, 065X, 065Y, 065Z, 066F, 066G, 066H, 066I, 066J, 066K, 066M, 066O, 066X, 066Y, 066Z, 086F, 086G, 086H, 086I, 086J, 086K, 086M, 086O, 086X, 086Y, 086Z
Emergency Department and/or observation 99281, 99282, 99283, 99284, 99285, G0380, G0381, G0382, G0383, G0384
EDsurgprocPOS23 if place of service = 23 AND CPT between 10050–69979
ObsProc if CPT codes: 99217, 99218, 99219, 99220, G0378, G0379
ObsRev if revenue code 0762
045, 0981
Psychotherapy 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90820, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90832, 90833, 90834, 90836, 90837, 90838, 90839, 90840, 90841, 90842, 90843, 90844, 90846, 90847, 90849, 90853, 90855
Substance Use Disorder Related291.xx, 357.xx, 425.xx, 535.xx, 571.xx, 980.xx, 303.xx, 305.xx, 760.xx, F10.xx, G62.xx, I42.xx, K29.xx, K70.xx, O99.xx, 304.xx, F12.xx, F14.xx, 292.xx, 779.xx, 648.xx, 655.xx, 965.xx, F55.xx, O35.xx, F16.xx, F18.xxP04.xx, P96.xx, Q86.xx, F11.xx, F15.xx, F19.xx, F13.xx, T36.xx, T37.xx, T38.xx, T39.xx, T40.xx, T41.xx, T42.xx, T43.xx, T44.xx, T45.xx, T46.xx, T47.xx, T48.xx, T49.xx, T50.xx, T51.xx, T52.xx, T53.xx, T54xx, T55.xx, T56.xx, T57.xx, T58.xx, T59.xx, T60.xx, T61.xx, T62.xx, T63.xx, T64.xx, T65.xx, T71.xx, V65.xx, F17.xx9462, 9461, 9463, 946, 9446, 9469, 9468, 9467, 9465, 9464, 9466G0397, G0396, H0048, H2034, H0014, H0027, H0029, H0007, H0016, H0026, H0028, H0003, H0009, H0005, H0015, H001, H0012, H0011, H0013, H0020, H0008, T1006, H0050, H0022, H0006, H0021, H0047, H2036, H2035, H0001, H0049, T102, T1007, T1011, S9475, G0442, H0039, H0040, H0004, H2012, H0030, H0023, H0025, H0017, H0024, H0002, H0019, H018, G0443, T1009, H2015, H2016, H2011, T1008, T1010, H2025, H2026, H0033, H2001, H0038, H2014, H2019, H2020, H2ZZZZ, HZ63ZZZ, HZ33ZZZ, GZ3ZZZZ, HZ82ZZZ, HZ83ZZZ, HZ87ZZZ, HZ86ZZZ, HZ81ZZZ, HZ85ZZZ, HZ84ZZZ, HZ80ZZZ, HZ89ZZZ, HZ88ZZZ, HZ93ZZZ, HZ97ZZZ, HZ96ZZZ, HZ92ZZZ, HZ95ZZZ, HZ94ZZZ, HZ98ZZZ, HZ91ZZZ, HZ90ZZZ, HZ99ZZ
Severe Maternal Morbidity Codes
VariableICD Diagnosis CodeICD Procedure Code
Acute Myocardial Infarction410.xx, I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I21.9, I21.A1 and I21.A9, I22.0, I22.1, I22.2, I22.8, I22.9
Aneurysm441.xx, I71.00–I71.03, I71.1, I71.2, I71.3, I71.4, I71.5, I71.6, I71.8, I71.9, I79.0
Acute Renal Failure584.5, 584.6, 584.7, 584.8, 584.9, 669.3x, N17.0, N17.1, N17.2, N17.8, N17.9, O90.4
Adult Respiratory Distress Syndrome518.5x, 518.81 518.82 518.84, 799.1, J80, J95.1, J95.2, J95.3, J95.821, J95.822, J96.00, J96.01, J96.02, J96.20, J96.21, J96.22, R09.2
Amniotic Fluid Embolism673.1x, O88.11x *, O88.12, O88.13
* x = 1st, 2nd, and 3rd trimester
Cardiac Arrest/Ventricular Fibrillation427.41, 427.42, 427.5, I46.2, I46.8, I46.9, I49.01, I49.02
Conversion of Cardiac Rhythm 99.6x, 5A2204Z, 5A12012
Disseminated Intravascular Coagulation286.6, 286.9, 666.3x, D65, D68.8, D68.9, O72.3
Eclampsia642.6x, O15.00, O15.02, O15.03, O15.1, O15.2, O15.9, O14.22, O14
Heart Failure/Arrest during Surgery or Procedure997.1, I97.120, I97.121, I97.130, I97.131, I97.710, I97.711
Puerperal Cerebrovascular Disorders430.xx, 431.xx, 432.xx, 433.xx, 434.xx, 436xx, 437.xx, 671.5x, 674.0x, 997.02, I60.0x, I60.1x, I60.2, I60.3x, I60.4, I60.5x, I60.6, I60.7, I60.8, I60.9; I61.1, I61.2, I61.3, I61.4, I61.5, I61.6, I61.8, I61.9; I62.0x, I62.1, I62.9; I63.0xx, I63.1xx, I63.2xx, I63.3xx, I63.4xx, I63.5xx, I63.6, I63.8, I63.9; I65.0x, I65.1, I65.2x, I65.8, I65.9; I66.0x, I66.1x, I66.2x, I66.3, I66.8, I66.9; I67.0, I67.1, I67.2, I67.3, I67.4, I67.5, I67.6, I67.7, I67.8xx, I67.9; I68.0, I68.2, I68.8; O22.51, O22.52, O22.53, I97.810, I97.811, I97.820, I97.821, O87.3, 674.0x
Pulmonary edema/Acute Heart Failure518.4, 428.1, 428.0, 428.21, 428.23, 428.31, 428.33, 428.41, 428.43, J81.0, I50.1, I50.20, I50.21, I50.23, I50.30, I50.31, I50.33, I50.40, I50.41, I50.43, I50.9
Severe Anesthesia Complications668.0x, 668.1x, 668.2x, O74.0, O74.1, O74.2, O74.3, O89.01, O89.09, O89.1, O89.2
Sepsis038.xx, 995.91, 995.92, 670.2x (after October 1, 2009); O85, O86.04, T80.211A, T81.4XXA, T81.44, T81.44XA, T81.44XD, T81.44XS, R65.20 or A40.0, A40.1, A40.3, A40.8, A40.9, A41.01, A41.02, A41.1, A41.2, A41.3, A41.4, A41.50, A41.51, A41.52, A41.53, A41.59, A41.81, A41.89, A41.9, A32.7
Shock669.1x, 785.5x, 995.0, 995.4, 998.0x, O75.1, R57.0, R57.1, R57.8, R57.9, R65.21, T78.2XXA, T88.2XXA, T88.6XXA, T81.10XA, T81.11XA, T81.19XA
Sickle Cell Disease with Crisis282.42, 282.62, 282.64, 282.69, D57.00, D57.01, D57.02, D57.211, D57.212, D57.219, D57.411, D57.412, D57.419, D57.811, D57.812, D57.819
(5th digit: unspecified, acute chest syndrome or splenic sequestration)
Air and Thrombotic Embolism415.1x, 673.0x, 673.2x
673.3x, 673.8x, I26.01, I26.02, I26.09, I26.90, I26.92, I26.99, O88.011-O88.019, 088.02, O88.03, O88.211-O88.219, O88.22, O88.23, O88.311-O88.319, O88.32, O88.33, O88.81, O88.82, O88.83
Blood Products Transfusion 99.0x, 30233H1, 30233L1, 30233K1, 30233M1, 30233N1, 30233P1, 30233R1, 30233T1, 30233H0, 30233L0, 30233K0, 30233M0, 0233N0, 30233P0, 30233R0, 30233T0, 30230H1, 30230L1, 30230K1, 30230M1, 30230N1, 30230P1, 30230R1, 30230T1, 30230H0, 30230L0, 30230K0, 30230M0, 30230N0, 30230P0, 30230R0, 30230T0, 30240H1, 30240L1, 30240K1, 30240M1, 30240N1, 30240P1, 30240R1, 30240T1, 30240H0, 30240L0, 30240K0, 30240M0, 30240N0, 30240P0, 30240R0, 30240T0, 30243H1, 30243L1, 30243K1, 30243M1, 30243N1, 30243P1, 30243R1, 30243T1, 30243H0, 30243L0, 30243K0, 30243M0, 30243N0, 30243P0, 30243R0, 30243T0, 30250H1, 30250L1, 30250K1, 30250M1, 30250N1, 30250P1, 30250R1, 30250T1, 30250H0, 30250L0, 30250K0, 30250M0, 30250N0, 30250P0, 30250R0, 30250T0, 30253H1, 30253L1, 30253K1, 30253M1, 30253N1, 30253P1, 30253R1, 30253T1, 30253H0, 30253L0, 30253K0, 30253M0, 30253N0, 30253P0, 30253R0, 30253T0, 30260H1, 30260L1, 30260K1, 30260M1, 30260N1, 30260P1, 30260R1, 30260T1, 30260H0, 30260L0, 30260K0, 30260M0, 30260N0, 30260P0, 30260R0, 30260T0, 30263H1, 30263L1, 30263K1, 30263M1, 30263N1, 30263P1, 30263R1, 30263T1, 30263H0, 30263L0, 30263K0, 30263M0, 30263N0, 30263P0, 30263R0, 30263T0
Hysterectomy 68.3x-68.9x, 0UT90ZZ, 0UT94ZZ, 0UT97ZZ, 0UT98ZZ, 0UT9FZZ
Temporary Tracheostomy 31.1, 0B110Z4, 0B110F4, 0B113Z4, 0B113F4, 0B114Z4, 0B114F4
Ventilation 93.90, 96.01, 96.02, 96.03, 96.05, 5A1935Z, 5A1945Z, 5A1955Z
Bateman Obstetric Comorbidity Index
VariableICD Diagnosis Code
Comorbidity Index
291, 303, 3050, 493, 394, 395, 396, 397, 424, 42822, 42823, 42832, 42833, 42842, 42843, 412, 413, 414, 581, 582, 583, 585, 587, 588, 6462, 7450, 7451, 7452, 7453, 7454, 7455, 7456, 7457, 7458, 7459, 7460, 7461, 7462, 7463, 7464, 7465, 7466, 7467, 7468, 7469, 7470, 7471, 7472, 7473, 7474, 6485, 304, 3052, 3053, 3054, 3055, 3056, 3057, 3058, 3059, 6483, 6423, 042, V08, 6424, 6427, 651, V272, V273, V274, V275, V276, V277, V278, 6410, 6411, 250, 6480, 401, 402, 403, 404, 405, 6420, 6421, 6422, 6427, 6542, 4160, 4168, 4169, 6425, 6466, 2824, 2826, 7100, F10, J44, J45, I05, I06, I07, I08, I09, I34, I35, I36, I37, I38, I39, I500, I20, I25, N022, N03, N04, N05, N08, N171, N172, N18, N25, O268, Q20, Q21, Q22, Q23, Q24, Q25, Q26, O994, F11, F12, F13, F14, F15, F16, F18, F19, O13, O16, B20, B24, O987, Z21, O11, O14, O30, O31, Z372, Z373, Z374, Z375, Z376, Z377, Z3790, O44, E10, E11, O245, O246, O247, I10, I11, I12, I13, I15, O10, O11, O3420, I270, I272, I278, I279, O14, O15, D56, D57, M32


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Figure 1. Cohort selection and attrition (unit of analysis: delivery).
Figure 1. Cohort selection and attrition (unit of analysis: delivery).
Healthcare 11 02921 g001
Table 1. Demographic and clinical characteristics of deliveries with and without DAP diagnoses in Michigan Medicaid, 2012–2021.
Table 1. Demographic and clinical characteristics of deliveries with and without DAP diagnoses in Michigan Medicaid, 2012–2021.
(N = 29,665)
(N = 189,225)
(N = 218,890)
Age at delivery
Age at delivery, mean (SD)27.605.6226.785.5226.905.54
American Indian/Alaskan Native/
Native Hawaiian/Pacific Islander/Asian
None of the above5441.837349.003.887893.003.61
Federal poverty level
>0% to ≤50%355511.9821,53511.3825,09011.46
Delivery-related outcomes
Cesarean delivery10,52535.4859,46831.4369,99331.98
Preterm delivery493316.6326,76014.1431,69314.48
30-day readmission after delivery7932.6739502.0947432.17
SMM within 42 days11633.9261043.2372673.32
Clinical characteristics
Bateman OBCMI score, mean (SD)
Behavioral health diagnoses
Any diagnosis 14,69949.5518,1739.6032,87215.02
Serious mental illness377312.7236251.9273983.38
Substance use disorder626521.1283464.4114,6116.68
Other behavioral health diagnosis987733.3093394.9419,2168.78
Prescription medication use
Any psychotropic medication21,26671.6923,60312.4744,86920.50
Mood stabilizers1820.611730.093550.16
Opioid analgesics16,50755.6486,77945.86103,28647.19
Medication for opioid use disorder19606.6118760.9938361.75
Coded based on delivery hospitalization; Excluding depression and anxiety. Abbreviations: depression and/or anxiety during pregnancy (DAP), standard deviation (SD), obstetric comorbidity index (OBCMI). Other behavioral health diagnosis includes adjustment disorders, attention-deficit, conduct, and disruptive behavior disorders, bipolar disorder, miscellaneous mental health disorders, personality disorders, post-traumatic stress disorder (PTSD), other mood disorders, other psychotic disorders, schizophrenia, suicide and intentional self-inflicted injury, suicidal ideation.
Table 2. Unadjusted and adjusted odds ratios of delivery-related outcomes and utilization of health services among deliveries with and without DAP in Michigan Medicaid, 2012–2021.
Table 2. Unadjusted and adjusted odds ratios of delivery-related outcomes and utilization of health services among deliveries with and without DAP in Michigan Medicaid, 2012–2021.
UnadjustedAdjusted *
Delivery-related outcomes OR95% CIOR95% CI
Caesarean delivery1.15(1.12, 1.18)1.02(1.00, 1.05)
Preterm delivery1.21(1.16, 1.25)1.15(1.11, 1.19)
30-day readmission after delivery1.21(1.14, 1.29)1.14(1.07, 1.22)
SMM within 42 days1.29(1.19, 1.39)1.27(1.18, 1.38)
Utilization of health services
Ambulatory care visits8.32(7.26, 9.53)7.75(6.75, 8.88)
Inpatient visits1.12(1.10, 1.14)1.13(1.11, 1.15)
ED/observation visits1.72(1.67, 1.77)1.86(1.80, 1.92)
Psychotherapy visits180.85(168.14, 194.51)172.83(160.10, 186.58)
SUD visits7.17(6.89, 7.46)5.61(5.37, 5.85)
* Adjusted for delivery age, race/ethnicity, urbanicity, federal poverty level, obstetric comorbidities. Abbreviations: Depression and/or anxiety during pregnancy (DAP), odds ratio (OR), confidence interval (CI).
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Zivin, K.; Zhang, X.; Tilea, A.; Clark, S.J.; Hall, S.V. Relationship between Depression and Anxiety during Pregnancy, Delivery-Related Outcomes, and Healthcare Utilization in Michigan Medicaid, 2012–2021. Healthcare 2023, 11, 2921.

AMA Style

Zivin K, Zhang X, Tilea A, Clark SJ, Hall SV. Relationship between Depression and Anxiety during Pregnancy, Delivery-Related Outcomes, and Healthcare Utilization in Michigan Medicaid, 2012–2021. Healthcare. 2023; 11(22):2921.

Chicago/Turabian Style

Zivin, Kara, Xiaosong Zhang, Anca Tilea, Sarah J. Clark, and Stephanie V. Hall. 2023. "Relationship between Depression and Anxiety during Pregnancy, Delivery-Related Outcomes, and Healthcare Utilization in Michigan Medicaid, 2012–2021" Healthcare 11, no. 22: 2921.

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