Racial disparities in perinatal mental health care during COVID-19
The pandemic has exacerbated barriers to screening, diagnosis, and treatment of women of color
COVID-19’s influence on these disparities
The COVID-19 pandemic has disproportionately impacted individuals of color. Black communities have experienced a higher rate of COVID-19 infection and a higher rate of death attributed to COVID-19, even after adjusting for age, poverty, medical comorbidities, and epidemic duration.39 The reasons for the disproportionate effects of the pandemic are complex and deeply ingrained in society.39 Emerging data indicate that COVID-19 might also lead to increased levels of psychological distress, anxiety, and depression in pregnant women33,40,41 and in Black women in particular.42 A survey of 913 pregnant women in Philadelphia conducted in May 2020 found significantly higher rates of anxiety and depression among Black women compared with White women, even after controlling for maternal age, gestational age, socioeconomic status, and marital status.42 A cross-sectional study of 163 women found that during the perinatal period, women of color were more likely than their White counterparts to experience negative changes in their mental health.43 These differences are concerning because pregnant women who experience high levels of stress during the pandemic are at high risk for preterm delivery and perinatal complications.44
Women of color may be disproportionately excluded by models of care that have become commonplace during the pandemic. Remote obstetric care became more common during the COVID-19 pandemic45; however, Black and Hispanic patients have been less likely than White patients to use telehealth services.46 Whether the differences are related to a lower likelihood of having a usual source of care, less access to digital resources, decreased awareness of the availability of telehealth, or less familiarity with digital technology, the common factor in all of the hypothesized reasons is structural racism.46 This is despite the fact that pregnant Black women report higher rates of concern than their White peers regarding the quality of their prenatal care during the pandemic.42 In a small study that surveyed 100 women about their preference for obstetric care, a significantly higher proportion of White women preferred virtual visits, with non-White women preferring in-person visits.47 Reasons cited for preferring virtual visits included convenience, safety with respect to viral transmission, compatibility with working from home, and less time waiting for the clinician; reasons cited for preferring in-person visits included a feeling of missing out on important parts of care, receiving less clinician attention, and having less of a connection with their clinician during virtual visits.47 Women of color have lower rates of perinatal depression screening than their White counterparts,9 and less frequent telehealth visits might lead to a further reduction in the detection and treatment of depression and other mental health conditions in this population.
Along with increasing telehealth services during the pandemic, many hospitals implemented stricter visitation policies for patients, including women giving birth, with the potential for greater detrimental impact on women of color. Before the pandemic, a survey of >2,500 women found that up to 10% of Black women reported experiencing racism during hospitalization for obstetrics-related care.48 These women also reported barriers to open and supportive communication with their clinicians.48 A recent study by Gur et al42 found that pregnant Black women reported more worries about the birthing experience during the pandemic than White women. In a setting with restricted visitors, all women are at risk for having a lonelier birth experience, but women of color who are already concerned about barriers to communication and racist care practices also must contend with their lived experience of systemic inequity, barriers to communication, and concerns about frank racism, without the support and potential advocacy they may usually rely upon to get them through medical experiences. Furthermore, pregnant women with mental illness are at greater risk for pregnancy complications. Together, these data suggest that women in minority groups who are pregnant and have mental illness are particularly vulnerable and are at greater risk without social support and advocacy during hospitalization.
The postpartum period is accompanied by unique concerns in terms of breastfeeding and social support for women of color. Women in minority groups had lower breastfeeding rates before the pandemic. Several studies looked at the impact of COVID-19 and associated restrictions on breastfeeding. In the United Kingdom, women in minority groups were more likely to stop breastfeeding due to the challenges of COVID-19–related restrictions.49 Compared with White women, these women were also more likely to report less practical support for breastfeeding during the pandemic.49 Other factors associated with low breastfeeding rates include lower levels of education and stressful living conditions.49 Though these factors were present before COVID-19, the pandemic has exacerbated these differences. Taken together, the evidence points to a role of long-standing structural and systemic inequity and racism in the health and wellbeing of women in minority groups.
A look towards solutions
Although perinatal mental health racial disparities predate the COVID-19 pandemic, differences in access to screening, identification, and treatment for mental health disorders place pregnant women of color and their children at heightened risk for poor health outcomes compared to their White counterparts during and after the pandemic. Despite the advent and progression of telehealth, existing race-based differences appear to have been maintained or exacerbated. The reasons for disparities are multifactorial and interrelated, and some of the outcomes perpetuate certain drivers of racism, which in turn drive continued inequity. Given the symptoms of depression, it is especially worrisome that clinicians may expect vulnerable women with illness-induced amotivation, anhedonia, and apathy to advocate for their own care.
Overall, the evidence confirms an imperative need—before, during, and after the COVID-19 pandemic—to provide education in mental health and cultural competency to clinicians such as obstetricians and pediatricians, who are more likely to have the first contact with women with perinatal depression. Health systems and government agencies also bear a responsibility to provide avenues for perinatal care clinicians to receive training and to increase access to culturally appropriate treatments through policy and structural changes.
Bottom Line
Racial disparities in perinatal mental health care persist despite widespread incorporation of telehealth into psychiatric services. Until causal factors are appropriately addressed through education, implementation, and structural changes, the benefits that have accompanied expanded psychiatric services via telehealth may only serve to exacerbate these differences.
