Maternal mental health conditions are the leading cause of death for women in the first year postpartum with suicide and addiction overdose deaths accounting for the majority of postpartum deaths. Non-Hispanic Black women are twice as likely as White women to experience perinatal depression. Black women and other women of color report higher rates of feeling mistreated and post-traumatic stress postpartum. Non-Hispanic Black and native women are at higher risk for intimate partner violence and death from homicide. A community-based and culturally appropriate and diverse mental health workforce is important to implementing intervention strategies to mitigate adverse mental health outcome.
Key points
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Prevalence and Impact: Mental health conditions affect 1 in 5 mothers during pregnancy and postpartum, with depression and anxiety being the most common. These conditions are the leading cause of maternal death in the first year postpartum, primarily due to suicide and addiction.
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Racial Disparities: Black women experience maternal mental health conditions at rates 2 to 4 times higher than White women, yet they are less likely to receive adequate care. Non-Hispanic Black individuals are particularly at risk for perinatal depression and anxiety.
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Influence of Trauma and Violence: Higher rates of mistreatment during childbirth and exposure to intimate partner violence significantly increase the risk of maternal mental health disorders, especially among Black women.
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Need for Culturally Competent Care: Addressing these disparities requires a diverse mental health workforce and community-based interventions that are culturally sensitive, as well as systemic changes to improve access to care and destigmatize mental health issues.
Introduction
Mental health conditions are the most often encountered complication of pregnancy, childbirth, and the postpartum period affecting 1 in 5 mothers and over 800,000 women and their families annually. , Maternal mental health conditions are the leading cause of death for women in the first year postpartum with suicide and addiction overdose deaths accounting for most of those postpartum deaths.
Conditions that make up maternal mental health (MMH) disorders include depression, anxiety disorders, obsessive–compulsive disorder, post-traumatic stress disorder, bipolar illness, psychosis, and substance use disorder (SUD). Depression and anxiety during the perinatal period impact 10% to 16% of pregnant individuals and 10% to 15% postpartum people have depression, and 20% have an anxiety disorder. The prevalence of perinatal depression increases to 25% to 50% when minor bouts of depression or anxiety are considered.
Racial and ethnic differences in maternal mental health conditions
It is well established that Black women are disproportionally impacted by maternal death with rates 2 to 4 times higher than rates for White women.
When it comes to perinatal depression and anxiety disorder, investigation of racial and ethnic differences has been mixed over the last decade. , In particular, one study suggests that non-Hispanic Blacks have a higher anxiety score. Sujan examined racial differences in anxiety and depression diagnosis in the year before, during, and after pregnancy in (n = 116,449) individuals and depression severity in the year during (n = 72,475) and the year afterward (n = 71,243). The study documented racial and ethnic disparities in depression, anxiety, and comorbid depression/anxiety before, during, and after pregnancy. In comparison to White individuals, Non-Hispanic Black individuals had a higher risk of perinatal depression, comorbid depression/anxiety, and moderate/severe and severe depression; depression diagnoses during pregnancy (RR = 1.35; 95% CI:1.26–1.44). Hispanic individuals had lower risk of depression during pregnancy and perinatal anxiety; depression during pregnancy (RR = 0.86, 95% CI:0.82–0.90), but Hispanic individuals had a higher risk of postpartum depression (RR = 1.14, 95% CI:1.09–1.20) and moderate/severe and severe depression during and after pregnancy; severe depression during pregnancy (RR = 1.59, 95% CI:145–1.75). Asian individuals had a lower risk of perinatal depression and anxiety; depression during pregnancy (RR = 0.35, 95% CI: 0.33–0.38) and postpartum moderate/severe depression (RR = 0.63, 95% CI: 0.60–0.67) and severe (RR = 0.66, 95%CI: 0.61–0.67). However, Asian women had a higher risk of moderate/severe depression during pregnancy (RR = 1.18, 95% CI:1.26–1.44).
Black women are twice as likely as White women to experience MMH conditions and half as likely to receive care. In fact, up to 40% of Black mothers will experience a mental health condition and single Black mothers are 6 times more likely than the general population to experience depressive symptoms. Existing research suggests that pregnant and parenting adolescents are at greater risk for experiencing depressive symptoms than pregnant and postpartum adult women. Depression in the perinatal period is also a risk factor for substance and alcohol abuse and a harsher parenting style in adolescents. Pregnant adolescents like all adolescents are at a significantly increased risk for injury and accidental death due to increased risk-taking behavior. As such, when mental health conditions occur during these physiologic changes of adolescence, it can provoke an even greater risk for behavior that can lead to harmful consequences.
Black women and other women of color report higher rates of feeling mistreated as defined by loss of autonomy; being shouted at, scolded, or threatened; being ignored, refused, or receiving no response to requests for help during hospital birthing process. , Studies have noted higher rates of post-traumatic stress (PTSD) from childbirth for Black women. The peak traumatic exposure occurred between 16 and 20 years of age, which is the approximate age at which many Black women experience pregnancy, especially adolescents who already have a higher risk for MMH disorder due to age. This study also found that socioeconomic status did not have a significant role in determining PTSD risk in Black women but rather the traumatic effect being the greatest predictor for risk. Higher rates of trauma exposure over a lifetime as well as Black women being 3 to 4 times more likely to experience a birth complication increases the risk of MMH conditions, birth trauma, and post-traumatic stress disorder.
Homicide, suicide, and drug overdose are leading pregnancy-associated causes for maternal death in the United States. Black women are also more likely to be exposed to intimate partner violence (IPV) as are other underserved populations. Mothers exposed to community violence are at risk for both poor physical and mental health including depression, aggressive behaviors, and negative parenting practices. Women in the United States are more likely to be murdered during or after childbirth than to die from the obstetric-related causes of hemorrhage and hypertension.
Approximately 42.4 million (35.6%) women in the United States experience rape, physical violence, and/or stalking by an intimate partner at some point in their lifetime. According to the 2010 National Intimate Partner and Sexual Violence Survey, non-Hispanic Black and Native American/Alaska Native women reported higher prevalence rates of lifetime IPV (43.7% and 46%, respectively) compared to non-Hispanic White women (34.6%); the rate for Hispanic women was slightly higher (37.1%). Indigenous mothers/birthing parents experience disproportionate levels of mental health illness in the perinatal period compared to the general population.
IPV is significant risk factor for MMH disorders in Black women. IPV during pregnancy is a significant contributor to homicide pregnancy-associated death and Black women are at higher risk of being killed by a partner in the perinatal period than White or Hispanic women. Previous reports indicate African American women were at approximately 7 times greater risk for homicide as White women and women age 19 or younger are at higher risk than those aged 30 and older, with almost 55% of deaths caused by guns. Male violence against women and gun violence is an urgent public health crisis for safety and mental health of reproductive women and in the United States.
Most IPV involves firearms. In a study, these were used in 68% of women killed by partners around pregnancy between 2008 and 2019. In the Centers for Disease Control (CDC) report, 1,018 pregnancy-related deaths, 82 (8.4%) were determined to be suicide and 29 (2.9%) were from a homicide. Patients who have a current mental health issue, SUD, and/or IPV are at increased risk of pregnancy-associated suicide and homicide.
A review by Mangla recognized depression, IPV, and SUD as 3 of the most common risk factors for pregnancy-associated suicide. Other reports from the CDC confirm the strong link between IPV and suicide. Depression during pregnancy is significantly associated with an increased risk of antenatal suicidal ideation in multiple logistic regression modeling; for women with IPV experiences, the odds were 9 times greater. Pregnancy-associated suicide deaths are more likely to occur in older and non-Hispanic, White women. The 2022 CDC report revealed mental health conditions made up of suicide and accidental overdose/poisoning deaths as the leading underlying cause of pregnancy-related deaths among Hispanic and non-Hispanic White women.
Maternal mental health conditions are also associated with an increased risk of adverse mental health effects for children later in life. Maternal depression results in higher risk for preterm births and low birth weight infants which is related to chronic stress and stressors.
Weathering
The theory of weathering, first described by public health researcher Arline Geronimus, ScD, has been studied in pregnancy as a hypothesis to explain outcome disparities between Black and White individuals. This theory describes a process of accelerated premature aging for Black women up to 10 years from biological age compared to White counterparts presumably because of allostatic load. The cycle of persistent intergenerational stress impacts physical and mental health.
The physical and mental process leads to an earlier onset of pathophysiologic health conditions such as diabetes, hypertension, and kidney failure because of chronic exposure to social and economic disparities over the life course. The physiologic response to stress causes activation of the “fight-or-flight” neurohormonal response. Allostatic load is the cumulative physiologic effects of chronic stress. , The resultant effects of physiologic and biological cumulative sympathetic stimulation and peripheral vasoconstriction in response to repeated and prolonged adaptation to stressors point to accelerated aging as a potential explanation for heart disease causing nearly half of pregnancy-related deaths among Black women.
Weathering and accumulating allostatic load through exposure to chronic stress and conscious and unconscious biases are factors in disparity in MMH conditions, treatment delays, and higher morbidity and mortality for mental health conditions.
This is further explained by understanding the impacts of social determinants of health which are the conditions in the environments where people live and work. People of color have greater stresses resulting from food and housing insecurity, poor health care access, fewer green spaces, and lower socioeconomic status. Compounding these burdens are the racial and cultural stigmas pertaining to mental health. Thus, persons of color are less likely than their White counterparts to seek mental health care which then results in under-diagnosis and under-treatment of these serious conditions.
Intervention
For indigenous women, culturally adapted approaches advocate for indigenous workers who are familiar with the native language and customs, promoting a culturally competent workforce. The role of family is identified as an important approach to perinatal mental health. Perinatal interventions that strengthen social support are therefore recommended for both preventing and treating mental health distress focusing on behavioral and coping skills.
While Black women have been identified as having higher rates of MMH conditions, the mental health workforce is not reflective of need. A 2020 American Psychological Association Center for Workforce Studies report found that 84% of the psychology workforce identified as White and only 4% identified as Black.
Black women may not be detected through standard depression screening tools such as the Patient Health Questionnaire 8 and Edinburgh Postnatal Depression Scale as these tools may not be as valid or sensitive to the cultural and social factors encapsulated in the mental health status of non-White women. ,
Identifying community-based behavioral health services and implemented health care interventions in predominantly trusted and spiritual Black church settings is important to addressing the needs of Black women in addressing perinatal mental health.
Summary
There is significant racial and ethnic disparity in MMH conditions during the perinatal period and postpartum. For Black individuals, the factors for increased risk may be more grounded in social determinants. For Asian and Hispanic individuals and for women of all races and ethnicities, it is important to destigmatize mental health disorders so that individuals seek counseling and treatment in a timely manner. Systemic screening not only needs to occur during the perinatal period but also at the annual well woman’s visit. A community-based and culturally appropriate and diverse mental health workforce is important to implementing intervention strategies to mitigate adverse mental health outcomes ( Box 1 ). Acknowledgment that postpartum depression (and other mental health conditions) may manifest or worsen in the weeks following delivery, adds importance to the extension of Medicaid up to 12 months postpartum, which can then provide a better opportunity to screen for demographically and geographically marginalized populations ( Box 2 ).
