It had been six weeks since Danielle Lerner delivered her second child via cesarean section in April 2019, and her emotions were all over the place. She struggled to breastfeed, pumping up to 12 times a day as she recovered from surgery while still caring for a toddler.

What she had chalked up to the baby blues just weeks prior had ballooned into intrusive thoughts of self-harm and full-blown panic attacks. She didn’t want to hold her newborn. She debated running away.

As a local news anchor, Lerner also grappled with the stigma associated with her feelings: What would her coworkers and viewers think if they found out she wasn’t basking in maternal bliss like the perfect moms she saw all over social media?

“I’m such a burden. I’m so sorry that you have to deal with me. You guys deserve better; you don’t need me,” she remembers texting her husband at the time.

Lerner was diagnosed with postpartum depression, a medical condition some women experience following childbirth that involves intense sadness, anxiety and fatigue. She began taking medication and attending therapy — interventions she acknowledges were aided by her health insurance and a supportive family environment.

Though the mental health challenges she faced are not an anomaly, not everyone has the resources Lerner did.

Nationwide as well as in Arizona, severe outcomes for women during and after pregnancy are becoming increasingly common. The number of maternal deaths in the U.S. more than doubled from 1999 to 2019, according to a July 2023 study from the Institute for Health Metrics and Evaluation, which looked at the total number and rate of maternal deaths per 100,000 live births.

In Arizona, that rate nearly tripled — from 10.3 deaths in 1999 to 29.3 in 2019 — with the most dramatic increases among the state’s minority populations. Native American mothers died at more than triple the rate of their White counterparts in 2019, for example, while Black maternal deaths occurred at a rate almost five times that of White mothers.

“Maternal mortality is a primary public health indicator for any community,” said Frida Espinosa, a doctoral candidate focused on birth justice in the Global Health program at Arizona State University. An increase in maternal deaths, specifically in communities of color, “demonstrates that our health systems … have failed.”

The U.S. Department of Health and Human Services identified maternal health as a top priority in 2020 when it announced its vision to make the U.S. one of the safest countries to give birth. Since then, the federal agency has invested $105 million in community-based maternal and infant health organizations across the country, adopted a national strategy to improve maternal mental health care and established a 24/7 hotline for pregnant and new moms.

Arizona, for its part, has secured a considerable portion of federal funding aimed at reducing maternal deaths, including a $10.5 million State Maternal Health Innovation grant, a $4 million grant to fund rural care in Nogales from the Health Resources and Services Administration, and a $2.25 million ERASE Maternal Mortality grant from the U.S. Centers for Disease Control and Prevention. The state prioritized maternal mortality under former Gov. Doug Ducey, creating an action plan for fiscal years 2020-2025.

In addition to hosting an annual maternal and infant mortality summit, the Arizona Department of Health Services has a maternal mortality review program that meets monthly to examine pregnancy-associated deaths and make recommendations to improve maternal health outcomes.

Some of those recommendations — such as a phone line to help medical providers care for pregnant and postpartum patients with mental health and substance use disorders and a public health campaign about postpartum warning signs — have been carried out. Others, like increasing access to high quality mental and behavioral health services, adopting universal health care and establishing paid sick and family leave would require fundamental policy shifts.

Recommendations are intended to be implemented by a mix of state agencies, health care providers and community partners, according to ADHS. But despite repeated inquiries from AZCIR, state health officials could not articulate who was responsible for carrying out several specific recommendations and did not seem to be keeping track of overall progress.

The CDC has estimated 80% of maternal deaths are preventable, highlighting the need for comprehensive prenatal and postpartum care. But availability of such care varies widely.

In at least three of Arizona’s 15 counties — La Paz, Graham and Cochise — residents have limited access to OB-GYNs and hospitals offering obstetric services, according to a March of Dimes report. A fourth, Greenlee County, is considered a maternity care desert, meaning it has no obstetric care at all.

“The farther a woman travels to receive maternity care, the greater the risk of maternal morbidity and adverse infant outcomes, such as stillbirth and NICU admission,” the report says.

Women with limited education and those facing economic instability and chronic stress are also more susceptible to experiencing complications during and after childbirth. From 2018 to 2019, about half of live births in Arizona were insured by Medicaid, the state’s program for low-income individuals and children. The same group, however, accounted for 72% of pregnancy-associated deaths.

Women of color are also generally overrepresented in Arizona’s maternal mortality rates. They may encounter a lack of culturally sensitive health care that honors their beliefs, values and traditions, research shows, and often face institutional biases grounded in racist cultural beliefs.

The state’s health care system performed the best for White populations and the worst for Indigenous and Black populations, leading to outcomes like poor quality of care and lower life expectancy, according to an analysis of health care outcomes by The Commonwealth Fund.

“That trust factor is not there,” said Elizabeth Wood, chair of Postpartum Support International’s Arizona chapter, citing the lasting effects of traumatic health care experiences on minority populations.

“There are unintentional racial biases and other factors that are present in our culture and have been for decades, if not centuries, which lead to (interventions that come) too little too late, or too much too soon,” she said.

Further complicating efforts to limit maternal mortality in Arizona are the state’s prohibitive abortion measures. In early May, the Legislature repealed a Civil War-era abortion law following widespread public outcry. A 15-week ban signed into law by former Gov. Ducey will take its place.

Such restrictions — and the legal skirmishes that surround them — can make it more difficult for pregnant people to access what is often life-saving health care when experiencing fetal abnormalities, miscarriages and other conditions.

“There are so many different complications that can happen not just in a pregnancy, but in the reproductive space,” state Sen. Anna Hernandez, D-Phoenix, told AZCIR. “I think that in order to save lives, people need to have access to the care they need. And that means also having access to abortion.”

A study examining the implications of abortion restrictions following the reversal of Roe v. Wade found that “forcing pregnant individuals to carry unwanted pregnancies worsens health outcomes and mortality risk for both the perinatal individual and the offspring.” Beyond physical complications, carrying a forced pregnancy leads to an increased risk of mental illness, researchers said, compounding the existing maternal mental health crisis.

Mental health conditions caused about a third of pregnancy-related deaths in Arizona from 2018 to 2019. The rest of the country follows a similar pattern, where mental health and substance abuse are the leading causes of maternal deaths, followed by excessive bleeding, and cardiac and coronary conditions.

About one in seven women will experience a mood and anxiety disorder following childbirth, adoption or pregnancy loss. Factors like a family history of depression, little social support, pregnancy with multiples and birth complications increase the risk of developing conditions like postpartum depression, anxiety, bipolar disorder, post-traumatic stress disorder and psychosis.

Lerner had experienced bouts of anxiety and depression in the past, though never serious enough to warrant medication. But after her second baby, she said the depression became almost paralyzing.

“There was one moment I remember sitting on the floor, I was covered in spit-up. But I felt like I couldn’t go change my shirt because, what if one of the kids needs me? And so I was literally just sitting there on the floor for like an hour, because I couldn’t bring myself to do anything,” Lerner recalled.

To address perinatal mood disorders like the one Lerner faced, experts recommend enhancing the accessibility of mental health care for populations facing significant disparities and establishing effective practices for those insured by Medicaid. In 2023, Arizona extended its postpartum Medicaid coverage through the Arizona Health Care Cost Containment System from 60 days to one year.

Wood, who serves as a maternal mortality review committee member in addition to her role with Postpartum Support International, also recommends perinatal mental health certification for maternal and obstetric care providers. Postpartum Support International prioritizes training providers of color, those who practice in rural regions and those who accept Medicaid to improve maternal health outcomes.

“We’re not just helping the parent in this case. We’re helping the parent and the child,” Wood said. “When birthing individuals are left undiagnosed and untreated with a perinatal mood disorder, that becomes the child’s first adverse childhood experience, which then sets them up for more challenges in their development, more challenges for their own mental health over the timeframe.

“This is a multigenerational issue,” she said.

When Lerner emerged from the fog of her depression and stopped comparing herself to other moms, she decided to use her platform as a TV anchor to help other women realize they are not alone. Now a mother of three young girls, she featured Wood as part of a series on postpartum depression for ABC15.

“Embrace help. Ask for help. That took me a while to be OK doing without feeling tremendous guilt,” Lerner said. “But I’ve learned over time that asking for help is better for everybody, (rather) than trying to muscle through when things are hard.”