SELF | Patia Braithwaite
When Kira S.* discovered she was pregnant in 2012, she was optimistic at first. Kira, now 43, had great insurance coverage, a committed partner, and a long, trusting relationship with her ob/gyn. But there were difficulties, too, that weighed on her mental health. There was her previous miscarriage, which left her fearful. There was her high blood pressure, which developed into preeclampsia. There was her placental abruption, a rare condition where part of the placenta separates from the abdominal wall, which led to bed rest. And there was a sinking feeling in her gut as she realized her partner wasn't who she thought he was, so she needed to leave.
Still, Kira was fortunate in that she had a level of prenatal care that often isn’t reserved for black women. Her ob/gyn, also a black woman, was “invested,” Kira tells SELF. “My ob/gyn sent me to a million other doctors” like a pregnancy cardiologist for a better chance at comprehensive care, Kira says. Even with the attention and care she received, Kira, like far too many other black women, went into preterm labor.
Kira gave birth to a beautiful baby boy via an emergency cesarean section when she was seven months pregnant. From there, her worries only grew. In the months that followed, her relationship dissolved. She was left alone to recover from her C-section while caring for her premature son. Without any trace of doubt in her voice, Kira says that she spent much of her pregnancy and postpartum period feeling mentally unstable.
“If my doctor had referred me to a therapist, I would’ve gone,” Kira says. “Maybe I would’ve felt like my feelings were validated.” But Kira never told her doctor—or anyone else—about her postpartum suicidal thoughts and feelings of despair.
As SELF continues to explore black maternal mortality—black women are three to four times more likely to die from pregnancy-related complications, according to the Centers for Disease Control and Prevention (CDC)—it is important that we look at the structures in place to support maternal mental health. Of course, general therapy can be helpful when people have the financial and logistical resources they need to make it work. But when it comes to the intersection of parenthood and mental health, reproductive psychiatry and psychology are especially vital to this conversation. They both aim to focus on the mental wellbeing of pregnant and postpartum people, along with anyone dealing with reproductive issues like infertility.
There aren’t currently industry-wide training requirements that outline exactly what a doctor or mental health expert needs to do in order to describe themselves as a reproductive psychiatrist or psychologist. The field is still pretty young and only really began to gain momentum in the mid-90s as more people became aware that hormonal fluctuations could increase the chances of psychiatric disorders from before a person’s first period through menopause and beyond, according to a 2015 paper in the American Journal of Psychiatry.
As a baseline, a reproductive psychiatrist does need to have an M.D. or D.O. degree, as does any other type of psychiatrist. Reproductive psychiatrists may have gotten their expertise through specialty training during their residencies (like in women’s mental health, which usually encompasses reproductive health), post-residency fellowship programs, “on the job” training, research, or a mix of these avenues, per a 2017 Academy Psychiatry paper. (The paper identified 12 women’s mental health fellowships nationwide.) But since reproductive psychiatry isn’t recognized as a subspecialty by the American Board of Psychiatry and Neurology, as a 2017 paper in Archives of Women’s Mental Health explains, no standardized curricula exist across training programs.
Similarly, reproductive psychology doesn’t have a concrete training trajectory. As with psychiatrists, psychologists may take a special interest in reproductive mental health during their training and self-identify as reproductive psychologists for that reason. In addition, organizations like the American Society for Reproductive Medicine offer certificate training, mentorship, and continuing education instruction on issues like infertility to mental health providers.
With all of this in mind, how can reproductive psychiatry and psychology address the unique concerns and challenges that impact black people during pregnancy and parenthood? What is necessary for moving the field forward? What is holding it back? How can black pregnant people and new parents remain empowered, given the circumstances? We talked to five reproductive mental health experts for answers to these questions and more. Keep reading for their insights.
1. Reproductive therapists need to validate black women’s feelings.
“Historically, reproductive psychiatry has stepped in to answer the questions that general psychiatry has not been able to answer for patients, like the safety of treating mental illness with medication during pregnancy. The field has since expanded to discuss issues like fertility, postpartum depression, and traumatic birth. But there’s a lot more that reproductive mental health professionals need to do.
Cultural competence is an area where the mental health fields need to put forth time and attention. It’s been neglected. Yes, we have to study the brain and brain chemistry. We have to study the mind and human relationships. But we also have to look at culture. Just like the food we eat impacts our cardiac health, issues around stress as they relate to prejudice and discrimination impact people’s emotional health.
I’m not an expert on how marginalization impacts mental health, but when treating patients of color, I try to listen to their experiences and where they’re struggling. I try to be with them emotionally and help them to trust that their feelings are valid. When dealing with things that often seem ‘invisible' to people who aren't of color, it’s very important to validate that if you’re feeling it, it is real. That validation is one of the most powerful things therapy can provide.” —Alexandra Sacks, M.D., reproductive psychiatrist and host of the Motherhood Sessions podcast
2. We need more psychiatric research to adequately address black pregnant people.
“I know that there are a lot of black people who have anticipatory anxiety around childbirth, but we want to make sure we don't overemphasize death during childbirth. Most people do not die during birth. Still, as the stigma around mental health in the black community is changing, we need for reproductive psychiatry to look at what is different about the ways black pregnant people experience perinatal depression, perinatal anxiety, and other mental health illnesses.
We as a field don't know a lot, but there is an emerging interest among reproductive psychologists and psychiatrists as we see more publicity around black maternal mortality. Research is far behind and catching up when it comes to adequately exploring what is driving the disparity.
I’m actually working on publishing a comprehensive literature review with my team to get a sense of what we know about black maternal mortality and mental health. We'll review all the available literature and prior research on the onset of mental illness in postpartum African-American women with the aim of determining whether it is more likely that African-American women are more at risk than their white counterparts. If this appears to be true, we aim to determine whether there is data to inform what increases this risk. Are African-American women more likely to have mental health complications due to a genetic predisposition or other inherent risk factors? Or are African-American women more at risk due to factors such as disproportionately lower socioeconomic status and battling systemic issues of limited access to mental health care?
We really need studies that compare black pregnant people to other groups. We need to look at things like whether or not they come in for treatment with more somatic complaints; do the same medications work for them; and what therapeutic techniques are better for them so that we can tailor treatment more effectively for black pregnant people.” —Crystal T. Clark, M.D., M.Sc., assistant professor of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology at Feinberg School of Medicine at Northwestern University
3. Clinicians need to better screen for postpartum mental health issues in black people.
“If someone is a little anxious about the possibility of traumatic birth, that’s one thing. But if you have symptoms that are impacting your functioning—you're waking up in the middle of the night and not being able to sleep, or if you have suicidal thoughts—you should see your doctor for an evaluation.
But providers also really need to be screening everybody for symptoms appropriately. It's not being effectively communicated that it is as important to treat mental health as it is to treat, for instance, diabetes during pregnancy. Depending on the population, black women are less likely to be identified as depressed even when they are. In inner-city Baltimore, for instance, African-Americans have a really high rate of stressful life situations, and doctors subject to unconscious biases can interpret those depressive symptoms as being due to stressful circumstances instead of as an illness.” —Jennifer L. Payne, M.D., director of the Women’s Mood Disorders Center at Johns Hopkins Medicine
4. Telehealth services may make it easier for black mothers to get culturally competent mental health care.
“Many of my black clients have shared their concern that if medical staff did not take Serena Williams’ symptoms seriously, then providers definitely will not listen to them. I also encounter a lot of black women who don’t necessarily trust providers from a different racial or ethnic background because they’re worried that they won’t receive the same quality of treatment. Therefore, they have the burden of either finding a provider of the same background (of which there are fewer) or vetting non-black providers for their cultural sensitivity. This can feel like an added burden because they’re already dealing with challenges related to fertility and reproductive health.
If someone is in need of a reproductive mental health provider but they don’t have immediate access, I’d encourage them to find one who is licensed and willing to provide telehealth services. This can also help widen the pool of black mental health providers. There is a national directory of black therapists on Therapy for Black Girls that allows you to search specifically for providers who offer virtual therapy services. I’d also encourage someone in that situation to seek culturally sensitive support groups in their area or through online resources. Fertility for Colored Girls is focused on supporting women of color specifically, for instance.” —Andreka Peat, Psy.D., M.P.H., clinical psychologist at Women’s Wellness Atlanta
5. The medical system should bear the burden of solving black maternal mortality.
“Black maternal mortality is a problem that cannot be remedied with do-it-yourself stress reduction techniques. I know that can sound a little hopeless, but it is really important not to take this on as something black pregnant people can ‘yoga through.’ The medical system is neglecting a large percentage of the people it is charged with caring for.
People of color and black women, in particular, are stressed disproportionately and often aren’t offered the benefits of progress that's been made in medical care over the years. Not in preventive care that helps us maintain our health and not in advanced care that might be needed to treat a particular illness. Care that is affirming of black women's experiences is very rare.
The psychological toll that these statistics and birth experiences take is insidious. The poor care we might receive sends the message that our lives are not treated with the same care as other people's lives. That realization can be extremely destructive to one's self-esteem, and for someone who's about to become a parent, self-esteem is incredibly important.
It’s clear that black women do need to be demanding because our needs aren't being met by the medical system, but there's always this undercurrent of, ‘How demanding can we be as black women?’ I tell patients that it's worth fighting through that self-consciousness because this really is a life-or-death issue.
Still, I’m optimistic. Based on the idea that we all have biases and we have to learn how to calibrate around them, there is a great deal of focus now in medical education around knowing your biases and implicit assumptions. I think that will be helpful.” —Christin Drake, M.D., assistant attending psychiatrist at NYU Langone Medical Center
Quotes have been edited for length and clarity.
*Name has been changed upon request.