Prenatal Mental Health – The Missing Part of the Conversation on Global Maternal Health

In the recent years, the topic of maternal and infant mortality has become one of dire importance. Living in the United States, which is erroneously thought of globally as a leader in health (among other things), it is very real to me that women do not fare well in their overall reproductive health. In a report from NoCeilings.org, it states that though we have had some improvements in terms of reducing maternal mortality and expanding reproductive health services, specifically family planning, the progress is uneven for poor, rural and marginalized women. What the report fails to mention is that the effects of poverty and oppression, particularly racism for me, creates a mental health crisis for childbearing women that dictates their overall health and that of their children.

There has been a lot of attention given to postpartum depression by female celebrities such as Christy Turlington sharing their experiences and coverage in the media. While these efforts have raised awareness and opened up dialogue, the link between preexisting mental health issues prenatally and postpartum depression is largely overlooked. Prenatal depression must come to the forefront as the number one cause of postpartum depression. Low-income African American and Latina women are the most vulnerable to maternal depressive disorders. It must be recognized, addressed and viable solutions created to lower a host of risks to mother and child. This is my everyday reality and work living in the South Bronx.

Mental health is an integral part of overall health, particularly during the perinatal and postpartum period. 10 to 20 percent of women experience depression during pregnancy or postpartum. This number only reflects reported cases; in reality the numbers are much higher. There are many risks for the mother and child with untreated depression. Many women do not receive treatment out of negligence by healthcare providers not screening women, fear of talking about their troubles, the mental health stigma that exists in society and lack of education, among other things. For example, African American women are often raised to emulate the image of the “strong Black woman”, which exacerbates the stigma around mental health. It discourages them from showing vulnerability and instead pushes them to mask their emotions, thus being denied support for depressive moods. This is further compounded by the denial of African American and other ethnic groups that mental health affects their communities at all, further silencing the voice of those suffering from depressive disorders (Okeke 2013).

Rates of maternal health issues are at about 35% for African American women while Latina women have uniformly high rates. Outside of race, low-income women are at an increased risk. The impact of maternal depression on the mother and child have profound effects.  Mothers experiencing prenatal depression are more likely to engage in risk-taking behaviors. This includes substance abuse, reckless sexual behavior and dangerous driving. Additionally, a mother to be struggling with depression may not comply with their prenatal care. This means they will be likely to skip prenatal appointments, important assessments/tests, be at risk for having a poor diet and ignore danger signs for serious conditions. Prenatal depression increases rates of maternal suicide. This neglect to her health becomes a risk for complications and poor birth outcomes. Mothers with prenatal depression are more likely to deliver preterm and low birth weight infants.

Furthermore, the long-term issues for the children also include the development of impaired immune systems that leave them susceptible to disease later in life.  The infant is vulnerable to the mother’s depression and stress and can be predisposed to high stress reactivity and mental health issues as well. While nine months is not enough time to reverse a lifetime of stress, intervening in pregnancy can begin the healing.

Though the odds seem stark, the increasing awareness of maternal depression has motivated change at different levels. From the work I do as a midwife and doula, I see how support prenatally can improve these outcomes. Solutions that focus on expanding a support network for pregnant women that is both preventative and healing must be explored. One suggestion would be to increase access and the quality of care for all women but in particular low-income African American and Latina women. The emphasis on vulnerable groups of women to have more access is because systematically they are exposed to healthcare providers who are not be sympathetic and have biases towards this population.

Another solution to increasing quality of care prenatally would be making midwives more accessible to women. Because midwifery care is woman-centered, having women who are especially predisposed to being triggered into prenatal depression be seen by midwives can drastically improve outcomes.  As opposed to the often rushed and shorter visits with obstetricians and gynecologists, midwives tend to spend anywhere from 60 to 90 minutes with their clients. In these visits, they are not only assessing vital signs for mother and fetus but also building trust, answering questions and have the opportunity to notice mental health changes.

Another idea is incorporating more doula care in the birth and postpartum process. Doulas are often trained in screening mothers for prenatal and perinatal depression. Two examples of organizations that have their doulas trained in identifying and supporting mothers both prenatally and postpartum are Ancient Song Doula Services and Northern Manhattan Perinatal Partnership. Birth doulas have the unique ability to give mental, emotional and spiritual support to pregnant and laboring women.  Postpartum doulas encourage the initiation and maintain of breastfeeding, which promotes recovery from childbirth, reduces risk of diseases such as cardiovascular disease, ovarian and breast cancer, as well as diabetes. The promotion of breastfeeding is also important in developing healthy bonding between mother and infants, which can help prevent postpartum depression. Aside from the benefits of breastfeeding for the mental health of the mother, benefits for the infant include stronger immune systems and optimal cognitive development. Postpartum doulas are able to help women transition into parenthood, and can also help identify any mental health issues that may arise. They are in a position to link new mothers to outside resources and referrals (Choices In Childbirth 2014).

Community education is another important aspect to promoting more community support and encouraging women to speak up. Because there is such a stigma around mental health not just in society but increasingly so in disenfranchised populations, it may prove to be beneficial to find ways to spread information about maternal depression. Included in this education would be the prevalence, signs and symptoms, as well as the risks to mother and child. It would be ideal if the outcome for the mother and child were tied to the future and well-being of the community at large.

In conclusion, prenatal depression is an important part of prenatal care. It should be understood as both a continuum of lifelong determinants in a woman’s life and a state of being triggered by pregnancy. More awareness of prenatal depression must be made to prevent postpartum depression. Specifically, low-income African American and Latina women must be considered as they keep falling through the cracks. The solutions exist. They must be implemented and understood to produce better outcomes for women and their families.

Sources:

Okeke, Alexandria. “A Culture of Stigma: Black Women and Mental Health.” Georgia State University Library. Undergraduate Research Awards. 2013.

Strauss, Nan, JD ; Giessler, Katie, MPH; Elan McAllister. Doula Care In New York City: Advancing the Goals of the Affordable Care Act. Choices in Childbirth 2014.