As the coronavirus pandemic has unfolded, the uncertainty of this crisis has stoked heightened awareness and precaution in each aspect of our lives. We have incorporated personal protective equipment into our human interactions, and we are compulsively practicing sanitation rituals. Our social connections have been tethered at a distance for months on end. As a society, we are experiencing collective grief. Grieving hundreds of thousands of lives lost and the ambiguous losses in this altered way of life for the foreseeable future. As physicians, it is important we address the psychological effects of these times, which impact our patients, as much as the physical effects. Further, we must acknowledge the disproportionate morbidity and mortality among Black communities in the U.S.
In psychiatry, our primary focus is our patients’ mental and emotional health and wellbeing. Psychiatric care — delivered in the hospital setting and in community clinics — helps provide tools and coping strategies for the inevitable uncertainties in life. The scope of psychiatric care includes social determinants of mental health and wellbeing, including the effects of discrimination and racial bias. Systemic racism is the effect of policies and practices that reinforce racial inequalities. Studies have shown systematic racism to be a determinant of poorer health outcomes for people of color. Patients’ worries about potentially substandard medical care based on unequal treatment by providers may cause race-based traumatic stress. This is a reality in the lives of many Black women in the perinatal period. Reproductive psychiatry, or maternal mental health, involves specialized care for the mental health needs of women during pregnancy and in the postpartum period.
Nationally, Black women delivering babies are twice as likely as their white counterparts to have their newborns die before their first birthday. Poverty is not the only reason. In fact, infants born to Black mothers who are well-educated and middle class are still more likely to die than infants born to impoverished white mothers who have less than a high school education. These statistics are staggering for Black women, both those who are pregnant and those who are not yet — with the hopeful and exciting months of pregnancy suffused with a looming fear of what to expect during delivery or after giving birth. State and local health department task forces, hospital committees, and non-profit organizations have led efforts to eradicate disparities in maternal and infant mortality, but much work remains to be done. Our hope is to bring awareness to the added burden of fears about the experience of childbirth that have a direct impact on the internalized stress for mom — which in turn affects the baby.
As the pandemic has evolved, delivery of care on maternity wards has changed as well. Inevitably, infection control and safety precautions have led to changes in hospital visitor policies, which have impacted expectant families. Extended family and other supports have limited access to mom and baby after delivery, and hospital lengths of stay have been shortened for some mothers. New Black mothers go through childbirth with the fear of acquiring COVID, a particular concern for poor health outcomes, as well as now having minimal visitors to provide support.
In this new era of social distancing, after discharge from the hospital, many mothers risk having limited emotional support. Yet maternal mental health is critical for the healthy development of newborns. In the postpartum period, mothers are at risk for developing postpartum depression. We recognize some moms are at higher risk depending on prior personal or family history, histories of trauma, or other psychosocial determinants of mental health. Studies have demonstrated that rates of postpartum depression are higher among low-income women, and we know that, due to the effects of systemic racism, Black and Latina women are disproportionately affected by poverty in this country. Once diagnosed, adequate access to psychiatric care in the postpartum is a barrier for many low-income women, more often Black and Latina women than white. In attempts to prevent postpartum depression, we stress the importance of being able to get enough sleep and having social support. Understandably, there are unique barriers to getting help from families and friends during these times. We foresee additional child-care costs leading to financial strain, and the daily worries of the pandemic — let alone of life and death — increasing the risk and rates of postpartum depression.
The coronavirus crisis has underscored the importance of community and social connection. It is important to recognize that regulations, hospital policies, and public health practices — which are critical measures for infection control — may have a disproportionate psychological impact on the mental health of expecting mothers, especially Black women. The psychological impact of this moment in time requires attention, acknowledgment, and patient advocacy on the part of physicians.
Brennin Brown is a psychiatry resident. Susan Hatters Friedman is a reproductive and forensic psychiatrist.
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