Barriers and Opportunities in Access to Perinatal Mood and Anxiety Disorders (PMADs) Healthcare Services in Tennessee

Introduction: Mental health conditions are a leading cause of maternal mortality in the United States and Tennessee. Despite the high prevalence of Perinatal Mood and Anxiety Disorders (PMADs), persistent structural, geographic, and systemic barriers prevent equitable access to care, particularly for rural and marginalized populations. This dissertation systematically investigates these barriers to identify actionable policy opportunities to advance maternal mental health equity in Tennessee. Methods: Grounded in the Levesque Framework of Access to Healthcare, this research employed a multi-method, three-phase qualitative design. First, a national scoping review mapped systemic barriers to access. Second, a Gadamerian hermeneutic phenomenological analysis explored lived experiences using secondary focus group data from 60 Tennessee women. Third, a reflexive thematic policy analysis was conducted using key informant interviews and cross-state legislative comparisons. Results: Findings revealed a deeply fragmented maternal mental health system. Approachability and acceptability of maternal mental health care are severely hindered by pervasive educational gaps, stigma, a profound fear of child welfare involvement, and a lack of culturally congruent providers. Availability and affordability of care are constrained by chronic workforce shortages, unreliable rural broadband limiting telehealth efficacy, and restrictive TennCare administrative 5 Barriers to Maternal Mental Health Care Access 6 policies that penalize patients seeking out-of-pocket care. Furthermore, the appropriateness of care is undermined by insufficient integrated behavioral health models and a lack of sustainable funding for community-rooted support workers, such as doulas and peer specialists. Discussion: Expanding postpartum Medicaid coverage to 12 months, while necessary, is insufficient to achieve maternal mental health equity. Meaningful improvement in Tennessee could be achieved through cohesive, system-level reforms. Key recommendations include expanding rural broadband infrastructure, financially incentivizing collaborative care within obstetric settings, establishing sustainable Medicaid reimbursement for community-based perinatal workers, dismantling punitive insurance administrative barriers, and adopting mandated universal PMAD screening and provider education protocols modeled after successful regional peers.