Racial & ethnic disparities in the United States
Racial and ethnic disparities in health status, health care access and quality of care have been well-documented in the United States. Black women are about three times more likely than white women to die from pregnancy-related causes even after accounting for socioeconomic status and educational attainment. The preterm delivery and infant mortality rates for black mothers are also much higher than for white mothers. Racial health inequalities are not only unjust but costly, accounting for approximately $230 billion in direct medical expenditures. Nevertheless, the research on racial and ethnic disparities in perinatal mental health (and mental health in general) is lacking, and the majority of research in this area focuses on postpartum depression.
Postpartum depression (PPD), which is defined as “intense feelings of sadness, anxiety, or despair that prevent [new mothers] from being able to do their daily tasks,” is one of the most common childbirth-related complications, affecting about one in seven pregnant women in the United States; however, many women are not diagnosed and even fewer are appropriately treated. Depression or anxiety before or during pregnancy, recent stressful life events and poor social support are strong risk factors for PPD, and some research has also found low subjective socioeconomic status to be a predictor.
The evidence is inconclusive on whether women of certain races or ethnicities are at a higher risk of developing perinatal mental health issues, but some research has shown racial disparities in treatment. One study found that black and Latina women were less likely than white women to initiate mental health care after delivery for PPD, and among those who did seek care, black and Latina women tended to initiate treatment later and were significantly less likely to receive follow-up care. There are a number of potential explanations for this disparity, including health system barriers such as challenges receiving referrals for mental health services and sociocultural factors such as fear of stigma for seeking treatment for PPD. The quality of care a woman receives when she is screened or initially treated for perinatal mental disorders may also affect the likelihood that she continues to seek care.
In order to address racial and ethnic disparities in the diagnosis and treatment of perinatal mental health, we need to identify women at risk of developing not just PPD but other perinatal mental health issues.
Neglected populations in low- and middle-income countries
Perinatal mental health issues are common in non-U.S. global settings as well. A systematic review of evidence from low- and middle-income countries (LMICs) found an average prevalence of 16% and 20% of perinatal mental illness among pregnant and postnatal women respectively. Risk factors included socioeconomic disadvantage, unintended pregnancy, being young and/or unmarried and lacking support from intimate partners and family. Women who belonged to an ethnic majority and who had higher educational attainment, a steady job and a supportive intimate partner were less likely to develop these conditions. Another systematic review found that one in three migrant women from LMICs suffered from perinatal mental health issues. However, these results are based on research from a subset of countries; most LMICs around the world are not represented in global estimations of prevalence, which limits the ability to measure the scope of the problem and associated risk factors.
Given the high prevalence of perinatal mental health issues in the U.S. and around the world, additional research focused on inequalities and neglected populations is warranted. Evidence suggests that certain women are at a disproportionately high risk of suffering from perinatal mental disorders, but the current body of research is insufficient for accurately identifying the most vulnerable women. Sound measurement and research is a necessary first step for identifying high-risk populations and designing evidence-based interventions to address inequalities in perinatal mental health.
Read the MHTF blog series on maternal mental health.
Read the MHTF blog series on inequities in maternal mortality in the U.S.
Learn more about racial and ethnic disparities in U.S. health care from The Commonwealth Fund, the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation.
Check out the perinatal mental health series in The Lancet.