Racism, mistrust worsen psychiatric conditions in minority perinatal patients; new paths needed to reduce care disparity

Deeper understanding of medical mistrust among pregnant and postpartum racial and ethnic minority women, as well as collaborative care models and community partnerships, can help to mitigate racialized healthcare disparities in this patient population, suggests a new paper in Harvard Review of Psychiatry.

Systemic racism has had a significant negative impact on the mental health of ethnically and racially diverse women during and after pregnancy. Women from these communities continue to harbor mistrust of the medical establishment, leading to underutilization of services and higher pregnancy-related psychiatric conditions and complications than white patients. To mitigate these disparities in perinatal mental healthcare, “a patient-centered, humanistic approach, involving collaborative care and transformational community partnerships is recommended,” suggests Nkechi Conteh, MD, MPH, of Massachusetts General Hospital, in an article published in the July issue of the Harvard Review of Psychiatry.

History of racial animosity in maternal and psychiatric care informs mistrust and underutilization of services

Although minority women present more severe psychiatric conditions such as depression than white women during pregnancy and postpartum, studies show they receive less and lower quality psychiatric care. Black and Hispanic women receive less follow-up treatment for mental health care, and Black women have much higher rates of hospital-based rather than outpatient care. A study of nearly 10,000 postpartum women revealed that Black and Hispanic women experiencing high pain received much less pain medication than their white counterparts.

Different rates of care utilization are significant. According to the NSDUH, white women had the highest utilization of psychiatric services at 21.5 %, followed by American Indian/Alaskan Native women (15.1%), Black women (10.3%), Hispanic women (9.2%), and Asian women (5.3%). When it comes to telemedicine, minority women are less inclined to appear on video for virtual visits, and have shown a preference for in-person care for prenatal purposes, so as to reduce mis-communication.

Lack of access and underutilization of services among minority women can be traced to mistrust of the medical community stemming from historical racial animosity and inequities. Enslaved Africans were thought of as absurdly tolerant of pain and immunity from disease, and Black, Indigenous, and Asian women were thought of as overly sexual. Enslaved Black women were forcibly bred and subject to gynecological procedures without their consent and often without anesthesia or pain medication. There are numerous reports of mass sterilization of minority groups in the 1970s.

Today, Black Americans experiencing mental distress are often placed in criminal justice centers instead of mental health facilities, Black neonates are sent to child protective services at much higher rates than white neonates if maternal drug use is detected, and studies show that minority women are more likely than white women to be recommended sterilization than contraceptives.

The authors suggest a number of holistic and structural approaches to address this mistrust, such as ensuring providers are empathetic, historically informed, and culturally sensitive; promoting minority representation among clinicians; anti-racism training; and accredited perinatal mental health certification programs.

Partnerships between providers and the communities they serve can also help. Two-way community programs such as doula programs and mentoring programs for high-risk pregnancies have proven to make an impact. Collaborative care models could also prove beneficial. A randomized controlled trial of prenatal patients under a collaborative care model in Seattle reduced depressive symptoms and increased treatment adherence. However, collaborative care studies aimed at reducing racialized health disparities do need more attention.

Federally Qualified Health Centers (FQHCs) and Community Health Centers (CHS), which serve millions of disadvantaged and underserved people throughout the United States, are ideal facilities where Conteh suggests interventions and training could be implemented to reduce medical mistrust.

Recent approved legislation, such as the 2021 Momnibus Act aimed at reducing racialized maternal health disparities, could provide an incentive for even more policy and financial solutions. Further, efforts that promote diverse participants and culturally sensitive staff should be part of any research study planning.