I don't recall noticing that I was struggling with early motherhood before the nurse at my son's first checkup flagged my mental health screening.
It's no wonder, though. After all, my introduction to motherhood had included a brief NICU stay for my son and residual birth trauma and body pain for me. Plus, my husband and I had concerns over my son's ability to latch and thrive. All of this brought on sadness and occasionally disassociation. It didn't take long before these feelings became a way of life.
Desperate to feel better, I took the doctor's recommendation to see a therapist, but he wasn't a fit. I had been assigned an older white psychotherapist who was friendly enough, but he grossly oversimplified my experience as a first-time mother and military spouse. And he didn't understand how it made me feel to rarely see another person of color. I went a couple times and then stopped.
I was growing increasingly anxious and overwhelmed. My body hurt constantly, and all I wanted was the space to cry.
In the U.S., roughly one in seven women will be diagnosed with postpartum depression after giving birth. Although underreporting, bias within the screening process and cultural differences create barriers to exact figures, research suggests that Black women experience PPD at a higher rate than white women and are less likely to receive treatment. By two weeks postpartum, 44% of Black mothers report depressive symptoms as compared to 31% of white ones.
A history of depression, lack of social support and past traumatic experiences — including during pregnancy and birth — are all risk factors for PPD. External factors, like the use of general anesthesia and physical pain postpartum, also increase one's risk. For Black women, each of these interacts with bias, systemic oppression, socioeconomic limitations and mental health stigma — creating a cocktail of vulnerability.
I recently connected with Dr. DaCarla M. Albright, an associate professor of clinical obstetrics and gynecology at the University of Pennsylvania and a member of HealthyWomen's Women's Health Advisory Council, to discuss the issue. She believes screening during the pregnancy and postpartum period, regardless of depression and anxiety history, can normalize postpartum depression and increase recognition, patient reporting and, ultimately, management.
Falling through the cracks
Albright says patients fall through the cracks when they don't report symptoms to providers. Some women, like I had, underestimate the severity of what they're experiencing; others don't have a provider they can trust.
Moreover, women who experience discrimination during care are twice as likely to miss postpartum visits, which are instrumental in catching concerns early.
“Many Black women may be hesitant to open up and discuss these concerns when the provider is not of the same race. This may impact their concerns about bias and being misunderstood, especially if the healthcare provider lacks a deeper understanding of their cultural context," Albright said.
She notes that standardized screening tools can intensify this process for Black women, as people of color don't always identify with words like “anxiety" or “depression." Also, some Black mothers are afraid that reporting their mental health issues could result in their children being removed from the household, and this fear can further increase feelings of isolation and anxiety.
Barriers to screening
When it comes to the lack of access to treatment for Black women, it's the perfect storm of barriers.
Ineffective mental health screening resources at birth, limited access to affordable and accessible counselors, and stigma are concerns for all women experiencing PPD. For Black women in particular, though, disproportionate representation in neighborhoods with limited access to mental and behavioral health resources and fear of discrimination are reflective of broader systemic issues.
These barriers are exacerbated by uniformity in diagnostic materials across races and limited access to mental health professionals who understand the nuances of black culture.
The military made accessing care easier for me than most. For many Black moms, caretaking responsibilities, employment, insurance status, and even transportation barriers can make postpartum visits another problem to solve.
But not all care is effective care. Not having access to medical or mental health providers who understood how alienated I felt as a new mom of color in an overwhelmingly white town was an additional barrier to successful treatment for me.
The U.S. Preventive Services Task Force — an independent, volunteer panel of national experts in disease prevention and evidence-based medicine — recommends counseling for everyone battling PPD, and the use of antidepressants for some. However, one study indicates that Black women are less likely to accept prescriptions and are more likely to seek spiritual guidance rather than mental health counseling to manage depression.
Albright believes we need more research on the specific ways PPD impacts Black women. She explained that societal and cultural norms mean Black women are expected to remain strong and resilient despite the consequences of battling sexism and racism — leaving them more likely to suffer in silence or use substances (such as drugs or alcohol) to manage their emotions. Albright says patients and providers should look out for feelings of isolation, detachment from one's child, and unexplained physical issues — in addition to sadness.
“The symptoms of depression may be more physical [with Black women] than emotional, with fatigue, headaches and gastrointestinal issues as notable complaints," she says.
Black women often rely on existing social networks to fill in gaps left by institutions. But online resources such as The 4th Trimester Project can also be helpful; advocacy organizations, such as Black Mamas Matter Alliance and Black Women's Health Imperative, prioritize Black women's holistic needs.
Albright said that community-based efforts have proven effective at providing personalized care. Still, providers are at the front lines and must adapt to support clients, including providing culturally tailored screening and postpartum care efforts.
“Having language and education in the healthcare setting where patients are being seen that address PPD throughout prenatal care is essential," Albright said. “Encouraging postpartum follow up with assessment at that time is also highly important."
The process of educating people and providers on the nuance of Black life is one of the most emotionally taxing/stressful aspects of the process. I'm hopeful that better-informed providers — as well as better access to them — in the near future will offer the next set of Black mothers better tools to cope.