ORIGINAL ARTICLE Mental Health Care Among Low-Income Pregnant Women with Depressive Symptoms: Facilitators and Barriers to Care Access and the Effectiveness of Financial Incentives for Increasing Care Rebecca M. Sacks • Jessica Greene • Ryan Burke • Erin C. Owen Ó Springer Science+Business Media New York 2014 Abstract Access to mental health care is suboptimal for low-income pregnant women. Using in-depth interviews, we examined barriers and facilitators to accessing care among 42 low income pregnant women with depressive symptoms. To pilot whether financial incentives would increase utilization during pregnancy, half the women were randomized to receive $10 gift cards after mental health visits. Women reported external and internal barriers to accessing mental health care, and internal and interpersonal facilitators. Financial incentives did not impact how often the women visited mental health providers, suggesting that small incentives are not sufficient to catalyze mental health care use for this population. Keywords Perinatal depression Á Financial incentives Á Mental health care access Á Medicaid Background Nearly one-quarter of all women experience a major depressive episode in their lifetimes, and between 7 and 20 % of pregnant women experience depression during pregnancy (Kessler et al. 1993; Lee et al. 2007). While research on reproductive health and mental care has often focused on postnatal depression, studies have shown that episodes of postnatal depression are usually preceded by antenatal depression (Austin et al. 2008; Feinberg et al. 2006). A systematic review commissioned by the Agency for Healthcare Research and Quality and the Safe Moth- erhood Group found that approximately 15 % of women experience a new depressive episode during pregnancy (Gavin et al. 2005). Despite the relatively high incidence of depressive symptoms during pregnancy, the symptoms are often not treated (Flynn et al. 2006; Goodman and Tyer-Viola 2010). One study found that while 20 % of pregnant women screened positive for depressive symp- toms, only 14 % of those who screened positive received any treatment for their depression (Marcus et al. 2003). The study also found that unemployment and lower educational attainment were associated with a substan- tially higher incidence of depressive symptoms during pregnancy. In addition to the negative impacts of untreated depressive symptoms on pregnant women, untreated pre- natal depressive symptoms are associated with negative outcomes in newborns. A meta-analysis found that mater- nal depressive symptoms were associated with an increased risk of both preterm birth and low birth weight (Grote et al. 2010). The study also found that socioeconomically dis- advantaged women with depressive symptoms had nearly double the risk of low birth weight and preterm birth than their non-disadvantaged counterparts. Additionally, new- borns of low socioeconomic status depressed mothers were less responsive to both animate and inanimate stimuli than newborns of low SES mothers who did not have depressive symptoms (Field et al. 2011). Electronic supplementary material The online version of this article (doi:10.1007/s10488-014-0562-4) contains supplementary material, which is available to authorized users. R. M. Sacks (&) Á J. Greene School of Nursing, George Washington University, 6915 SE Mall St, Portland, OR 97206, USA e-mail: rsacks@email.gwu.edu R. Burke Health Policy Research Northwest, Eugene, OR, USA E. C. Owen Slocum Research & Education Foundation, Eugene, OR, USA 123 Adm Policy Ment Health DOI 10.1007/s10488-014-0562-4