This article considers the historical, structural, and dynamic aspects of systemic racism and how it affects both patients and providers in perinatal mental health.
An emergency psychiatry consult was called for a 30-year-old healthy Black woman who arrived at the hospital overnight, had an uncomplicated delivery of a baby girl, and now wanted to leave the hospital against medical advice. According to the obstetrical team, she would not let anyone go near her or her baby. She was refusing all postnatal care and appeared paranoid. By contrast, the nursing report was that the patient was attentive to her baby and bonding.
I (C. K.) entered the room and introduced myself. The patient was holding her baby and pacing. She did not look at me and said angrily, “I'm finished. Don't get in my business.” She then turned as if to address someone else in the room and mumbled under her breath.
I came to learn that the patient grew up in foster care, had a long history of sexual trauma and domestic violence, and was now living on the street. At age 19 years she was diagnosed with schizophrenia, subsequently hospitalized multiple times, and was repeatedly lost to follow-up. Three years ago, she delivered a child who was immediately taken into child protective services custody due to drug use. Since then, she engaged in substance abuse treatment and, per the clinic report, had been abstinent and working with a case manager to regain custody of her older child. All along, however, per clinic reports, she refused psychiatric and medical care, including prenatal care, due to a long-standing distrust of doctors.
My evaluation revealed a woman who was paranoid, internally stimulated, and mildly distressed. She had poor insight and was unable to engage in a necessary conversation about where she would go upon leaving the hospital and how she would care for her infant on the street.
This mother was actively psychotic. Her postpartum psychosis, which may be defined as an exacerbation of her untreated psychotic illness, increased her risk for suicide and infanticide in the following weeks. It was clear that this mother needed inpatient psychiatric treatment, which meant that she would have to be separated from her baby. I knew that I would have to advise the team to make a report to child protective services.
After I gave the team my recommendations, the patient's nurse pulled me aside and asked, “Are you calling child protection because she is Black?”
Until that moment I had not considered the fact that the two obstetric/gynecology residents and I were White and the patient's nurse and aid were Black. I realized that my failure to consider this was part of my privilege as a White physician. I also realized that, despite my intentions, which were motivated by compassion and empathy, there was no way I could fully understand what the patient or the nurse was feeling in this situation. Despite trusting my clinical judgment, I felt defensive and at a loss to respond to the nurse. To this day, I cringe when I think of her question and wonder what I had done, said, or implied to make her ask it. On reflection, I realize I might have responded to the nurse by asking her assessment of the patient, acknowledging that the patient and the nurse are Black and that I am White, and asking whether there were aspects of the patient's clinical situation and needs that I was missing.
Racial disparities are pervasive in health care in the United States. Socioeconomic inequities compound this. Specifically, pregnant Black women receive a lower quality of prenatal care and have worse peripartum outcomes compared to their White counterparts. It is well established that inadequate obstetrical care leads to a stark increase in morbidity and mortality in Black mothers and their infants.1–4 In addition, whether due to a lack of culturally appropriate care, fear of stigmatization, worry about provider bias, or fear of potential involvement of social services, psychiatric care may be difficult to access or intentionally avoided during pregnancy.
The mistrust of the patient and the nurses in the illustrative case are informed by a history of mistreatment of African Americans in Western medicine. Many medical advancements were developed by using African American people as test subjects explicitly against their will or without full informed consent to the research being done.
The history of modern reproductive medicine begins with the surgical developments of Marion J. Sims, known as the “Father of Gynecology.” Sims practiced his gynecologic techniques on enslaved Black women who were often unanesthetized and forced to assist Sims in restraining other people during procedures.5 In Killing the Black Body, Dorothy Roberts5 thoroughly details the history of measures to control Black women's child-bearing, whether to increase their offspring during slavery or to restrict their ability to procreate due to the belief that women were unable to control their own fertility and, therefore, the source of societal problems. Thus, it may come as no surprise that the development of involuntary sterilization, a levonorgestrel-releasing implant, and the medroxyprogesterone acetate shot were primarily tested on women of color with the intention of limiting fertility of Black women.5,6
Other strategies to control reproduction among Black women and poor women included the criminalization of substance use during pregnancy in the 1980s during the crack-cocaine epidemic as well as policies such as the “family cap law,” which limited welfare payments to women that have two or more children.5 These attempts to control Black child-bearing form the basis of racism in the medical field toward Black women and inform the skepticism and wariness of Black women interacting with the medical system.
Current State and Statistics
In the US, Black women are 3 to 4 times more likely to die from pregnancy-related causes than White women.1 This increases up to 12 times in some cities.1 Death from pregnancy is also elevated in groups of Latinx women, Indigenous women, Asian women, and Pacific Islander women.1 In New York City (NYC) from 2006 to 2010, Black women accounted for 57% of pregnancy-related deaths, whereas White women accounted for only 6.5%.2 Black women have the highest rates of morbidity in 22 of 25 of the severe morbidity indicators used to predict pregnancy outcomes.1 Most of these deaths and severe illnesses are from preventable conditions.
These racial disparities in morbidity and mortality persist when socioeconomic status, education, neighborhood poverty, pre-pregnancy obesity, and other comorbidities are controlled for, suggesting that racism is a contributing factor.1,3 In fact, Black women with at least a college degree had greater rates of life-threatening complications during pregnancy compared to all women who had not graduated from high school.1 A study among NYC hospitals found that Black and Latinx women were still at higher risk of severe morbidity even when giving birth in the same hospitals as White women.4
The gap in care for Black, Latinx, and Indigenous pregnant women extends to mental health as well, although the research is limited. Rates of depression and anxiety during pregnancy are thought to be equal across racial groups, with some data showing an increased risk among Black and Latinx women.7,8 Despite this, Black and Latinx women are less likely to be initiated on treatment for postpartum depression compared to White counterparts.9 If treatment is started, there is often a longer delay of care after delivery to diagnosis compared to White women, which is a critical time in the disease process.9 Black and Latinx women are also less likely to have follow-up or to receive continuing care.9
Racism has been found to affect reproductive clinical care on both the patient and provider level. Studies have found that Black, Latinx, and Indigenous women are more likely to experience mistreatment by a provider compared to White women.10 Mistreatment includes being shouted at, providers ignoring requests for help, violations of privacy, coercion of treatment (cesarean delivery or episiotomy), and dismissal of pain.10 These experiences during pregnancy are associated with pain and suffering, reminders of prior trauma, posttraumatic stress symptoms, sleep disturbances, poor self-rated health, fear of having another child, negative body image, and feelings of dehumanization.11–13 These encounters and outcomes can have a destructive impact on a woman's physical and mental health, resulting in consequences on the pregnancy and her family.
When we examine the structural elements that affect perinatal health care, it requires an acceptance of racism embedded within medical education in America.14 A 2018 Association of American Medical Colleges survey found that people who are Black or Latinx comprised fewer than 7% of medical faculty in the US, even though they represent nearly 30% of the US population.15 Research from that same year showed that non-White faculty were promoted at slower rates than their White counterparts.15 The choice to pursue perinatal psychiatry (a developing field of medicine) may intensify pre-existing isolation for the underrepresented doctor-in-training and deter interest in its pursuit; this limits access to perinatal psychiatrists for Black, Latinx, and Indigenous women.
Currently, there are 19 training programs in the US that offer a fellowship in perinatal psychiatry. The lag in clinical training of psychiatrists in perinatal mental health translates to a deficit in access to care and, as is seen across medicine, the greatest disparity is in marginalized groups of birthing women. It is generally accepted that personal relationships are easiest to forge between people with a shared sense of identity.16,17 Studies show that when physicians and patients share the same race or ethnicity, patient experience in systems of care and adherence to medical recommendations improves.18
The “mother-blaming narrative” is an example of the ways in which structural racism erodes the mother-baby dyad for Black and Latinx mothers. It is defined as holding pregnant women exclusively responsible for the ill health of their children.19,20 Blaming women for poor reproductive health outcomes ignores the circumstances under which a woman becomes pregnant and abdicates responsibility for providing quality care by implying that negative birth outcomes are unpreventable among Black and Latinx women. In underserved communities, in which familial support and childcare are disproportionately limited, prioritization of baby over mother dismisses the importance of the mother-baby dyad on infant well-being. Solutions to these structural barriers, in addition to insurance limitations, geographic consolidation of services, and racial and cultural discordance between patients and providers, are essential to comprehensive perinatal care.
An Alternative Experience
A Black woman in her early twenties presented to me, a Black woman psychiatrist (C. D.), with depressive symptoms in her 26th week of pregnancy. The patient had a long history of trauma, early abandonment and foster care, major depressive disorder, and substance use disorders that had been alternately untreated and undertreated, resulting in multiple hospitalizations for suicidality and agitation. She was carefully adherent to prenatal appointments, but her obstetrician had not screened for depression. With weekly supportive psychotherapy and psychoeducation, initiation and upward titration of a selective serotonin reuptake inhibitor, and coordination with the patient's obstetrician, her depressive symptoms remitted and she remained sober and euthymic in the postpartum period despite significant housing challenges.
I was able to provide this care in a drop-in center for homeless youth and young adults that also provides case management and medical and psychiatric care in addition to basic needs like food and access to showers and shelter. The center has adopted clear but responsive policies informed by a harm-reduction approach for all members including pregnant members and parents of young children. The center's professional team is composed of a group of highly skilled leaders, case managers, social workers, peer educators, and support staff, nearly all of whom are Black, Latinx, or identify as LGBTQ+ (lesbian/gay/bisexual/transgender/queer or questioning), reflecting the identities of the youth who use their services. I was struck by my patient's resilience and generosity when she began to let the pregnant women in her orbit know that this care was available.
Before long, I had a busy practice of people seeking peripartum psychiatric care. These were women who were working against every disadvantage—racism, poverty, housing insecurity, limited access to education and health care, and histories of having been traumatized by the mental health system; yet they sought treatment for themselves where it was offered. They weathered what they knew of the history of psychiatry and poor Black and Latinx people, inconvenient hours, and the long distances they had to travel for care. Nonetheless, these women secured the treatment they needed and served others by spreading the word that care was available.
It is reasonable to expect that reducing barriers to entry into medicine and subspecialty training for underrepresented minorities in medicine (URiM), students and trainees, and working to ensure equitable pay, promotion, and work environments for URiM faculty in academic centers is likely to improve outcomes for Black, Latinx, and Indigenous women in the peripartum period as it does for other health outcomes. As peripartum psychiatric services are most readily available in academic medical centers, retention of URiM psychiatrists in academia is particularly important. Similarly, we suggest that institutions seek to increase the number of reproductive psychiatry training positions, situate those training programs in underserved areas, and prioritize recruiting URiM trainees into those spots.
We support Medicaid reimbursement for doula services, as doulas have been shown to help women navigate the health care system, address gaps in health literacy, and provide social and community support during the birth and postpartum process.21
We also recommend that providers who care for women in the peripartum period (ie, obstetricians/gynecologists, midwives, doulas, reproductive and general psychiatrists, and pediatricians) seek to identify and address quality issues that stratify by race in their individual practice areas and engage in the scholarly practice of sharing successes and failures. It is also important to adopt flexible, parent-centered policies around allowing babies and children to accompany their mothers to perinatal mental health visits, which is a practice that is less common in clinic settings.
The patient described in the illustrative case at the start of this article did not have access to what we know is essential to the care of women with serious mental illness in the perinatal period. It has been detailed here the extent to which structural racism affects Black, Latinx, and Indigenous women in the peripartum period. Psychiatrists must commit to working against these disparities to ensure equitable care for Black, Latinx, and Indigenous women.
- New York City Department of Health and Mental Hygiene. Severe maternal morbidity in New York City, 2008–2012. Accessed October 7, 2020. https://www1.nyc.gov/assets/doh/downloads/pdf/data/maternal-morbidity-report-08-12.pdf
- New York City Department of Health and Mental Hygiene. Bureau of Maternal and Child Health. Pregnancy associated mortality, New York City, 2006–2010. Accessed October 7, 2020. https://www1.nyc.gov/assets/doh/downloads/pdf/ms/pregnancy-associated-mortality-report.pdf
- Rosenthal L, Lobel M. Explaining racial disparities in adverse birth outcomes: unique sources of stress for Black American women. Soc Sci Med. 2011;72(6):977–983. doi:10.1016/j.socscimed.2011.01.013 [CrossRef] PMID:21345565
- Howell EA, Egorova NN, Janevic T, et al. Race and ethnicity, medical insurance, and within-hospital severe maternal morbidity disparities. Obstet Gynecol. 2020;135(2):285–293. doi:10.1097/AOG.0000000000003667 [CrossRef] PMID:31923076
- Roberts DE. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. Vintage Books; 1999.
- Washington HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present. Knopf Doubleday Publishing Group; 2008.
- Ponting C, Mahrer NE, Zelcer H, Dunkel Schetter C, Chavira DA. Psychological interventions for depression and anxiety in pregnant Latina and Black women in the United States: a systematic review. Clin Psychol Psychother. 2020;27(2):249–265. doi:10.1002/cpp.2424 [CrossRef] PMID:31960525
- Rich-Edwards JW, Kleinman K, Abrams A, et al. Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. J Epidemiol Community Health. 2006;60(3):221–227. doi:10.1136/jech.2005.039370 [CrossRef] PMID:16476752
- Kozhimannil KB, Trinacty CM, Busch AB, Huskamp HA, Adams AS. Racial and ethnic disparities in postpartum depression care among low-income women. Psychiatr Serv. 2011;62(6):619–625. doi:10.1176/ps.62.6.pss6206_0619 [CrossRef] PMID:21632730
- Vedam S, Stoll K, Taiwo TK, et al. GVtM-US Steering Council. The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States. Reprod Health. 2019;16(1):77. doi:10.1186/s12978-019-0729-2 [CrossRef] PMID:31182118
- Reed R, Sharman R, Inglis C. Women's descriptions of childbirth trauma relating to care provider actions and interactions. BMC Pregnancy Childbirth. 2017;17(1):21. doi:10.1186/s12884-016-1197-0 [CrossRef] PMID:28068932
- Swahnberg K, Schei B, Hilden M, et al. Patients' experiences of abuse in health care: a Nordic study on prevalence and associated factors in gynecological patients. Acta Obstet Gynecol Scand. 2007;86(3):349–356. doi:10.1080/00016340601185368 [CrossRef] PMID:17364312
- Schroll A-M, Kjærgaard H, Midtgaard J. Encountering abuse in health care; lifetime experiences in postnatal women - a qualitative study. BMC Pregnancy Childbirth. 2013;13(1):74. doi:10.1186/1471-2393-13-74 [CrossRef] PMID:23521853
- Hardeman RR, Medina EM, Kozhimannil KB. Structural racism and supporting black lives—the role of health professionals. N Engl J Med. 2016;375(22):2113–2115. doi:10.1056/NEJMp1609535 [CrossRef] PMID:27732126
- Association of American Medical Colleges. Diversity in medicine: facts and figures 2019. Accessed October 7, 2020. https://www.aamc.org/data-reports/workforce/interactive-data/fostering-diversity-and-inclusion
- Hardeman RR, Karbeah J, Kozhimannil KB. Applying a critical race lens to relationship-centered care in pregnancy and childbirth: an antidote to structural racism. Birth. 2020;47(1):3–7. doi:10.1111/birt.12462 [CrossRef] PMID:31630454
- Gaertner SL, Dovidio JF, Guerra R, Hehman E, Saguy T. A common ingroup identity: categorization, identity, and intergroup relations. Handbook of prejudice, stereotyping, and discrimination. Psychology Press; 2009:433–454.
- Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived quality and use of health care. Arch Intern Med.1999;159(9):997–1004. doi:10.1001/archinte.159.9.997 [CrossRef] PMID:10326942
- Scott KA, Britton L, McLemore MR. The ethics of perinatal care for black women: dismantling the structural racism in “mother blame” narratives. J Perinat Neonatal Nurs. 2019;33(2):108–115. doi:10.1097/JPN.0000000000000394 [CrossRef] PMID:31021935
- Richardson SS, Daniels CR, Gillman MW, et al. Society: don't blame the mothers. Nature.2014;512(7513):131–132. doi:10.1038/512131a [CrossRef] PMID:25119222
- Kozhimannil KB, Vogelsang CA, Hardeman RR, Prasad S. Disrupting the pathways of social determinants of health: doula support during pregnancy and childbirth. J Am Board Fam Med.2016;29(3):308–317. doi:10.3122/jabfm.2016.03.150300 [CrossRef] PMID:27170788