In July, I had the privilege of speaking to over 100 survivors of PPD and other perinatal mood and anxiety disorders at the first Warrior Mom™ Conference about expanding outreach to underserved communities. When those of us who are survivors expand our advocacy efforts to support other struggling moms, we can benefit from reflecting on our own experience and understanding how the experience of perinatal emotional complications differs across different groups.
First, what do we mean by “underserved”? While women from ALL different places and backgrounds struggle with perinatal mood and anxiety disorders during pregnancy and postpartum, they face different challenges based on their identities, privilege, and life circumstances. A large body of research indicates that rates of maternal mental health disorders are higher among women who are disenfranchised. Women of color and low-income women experience PPD and related illnesses at nearly twice the rates of middle class white women; in fact, one study indicates that 40-60% of women living in poverty experience postpartum depression.   Moms who struggle with domestic violence, have a history of previous trauma, are recovering from substance abuse, and become a mother during the teenage years experience higher rates of depression and anxiety.  Women of color are also more likely to experience poverty and pregnancy complications, which can lead to and exacerbate emotional complications. Lack of support, social isolation, and lack of access to physical and mental health services also contribute to and worsen depression and anxiety. Plus, not only do women of color and economically disenfranchised women experience higher rates of mood and anxiety disorders, their rates of treatment are significantly lower.
Examining privilege, intersectionality, and the lens of diversity
As survivors, we may have ideas of how to help other moms who are struggling, based on our own experiences with PPD and related illnesses and what we found to be helpful. Before we can think about how we can support others, though, it is important to look at our own privilege. Privilege refers to any unearned benefit or advantage we receive in society because of an aspect of our identity, such as race, religion, gender identity, sexual orientation, class/wealth, ability, etc. When we say, “we warrior moms,” we may be making many assumptions about who “we” is, and, despite our best intentions, we may fail at being inclusive and/or representing folks outside our demographic. Reflecting on our privilege helps us think about how we can work with folks who share our privilege– as well as those who don’t– to create changes that benefit everyone.
Looking at perinatal mood and anxiety disorders through a “lens of diversity” can help us see how different aspects of our identities—and our privilege—affect our experiences with PPD, including whom we felt we could tell, the treatment we sought, our barriers to care, and the professionals who helped us. This process can illuminate why what was helpful for us may not necessarily be helpful to other moms. Here are some questions to consider:
What does postpartum depression mean for different communities? Here’s the thing: being able to SAY that you are experiencing postpartum depression, anxiety, or another perinatal emotional complication (let alone have the ability to seek treatment for it) is a privilege. For many moms, the challenges of unstable housing, poverty, homophobia, unsafe neighborhoods, and racism may exceed the need for treatment. Different moms have a different hierarchy of needs, and addressing their own mood and mental state may be seen as overly indulgent when there are bigger fish to fry.
Moreover, these same challenges may BE the actual source of stress for some moms. For example, one study found that 30% of low-income families can’t afford adequate diapers for their baby, and that this specific need was linked to depression and anxiety. Research has clearly demonstrated the link between extenuating life circumstances (such as poverty, trauma, isolation, etc) and maternal mental illness, so, for some moms, it can be difficult—and not really relevant– to parse out the difference between a mental health issue and an expected reaction to incredible challenges.
Also, along these lines, some communities may view postpartum depression and related illnesses as unacceptable—or as something that happens to other people. A qualitative study of African American women provides some keen insight into the different conceptualizations and experiences of mental health issues. According to one participant in the study, “There is no postpartum depression. Only white people go through it.” Another participant stated that a neighbor had told her that, “depression is something young mothers do to get out of needing to take care of their kids”.
Who seeks and receives treatment and why? Treatment (such as talk therapy or medication) may be appealing and possible for some women and not others. One study found that Black and Latina women receive treatment at nearly half the rates of white women, and, considering that rates of depression and anxiety are higher among women of color, this statistic is particularly troubling. In some communities, mental/behavioral health issues are heavily stigmatized; moreover, women may not have the ability to see a mental health provider who looks like her or represents her community. Just like many women may want to see a female Ob-Gyn, women of color may want to see a clinician of her racial/ethnic group—and may not be able to do so.
What barriers do women face when speaking honestly about emotional complications and/or seeking treatment? Women of color and/or women who are economically disenfranchised may face numerous barriers to seeking and receiving care, including cultural stigma, lack of mental health providers who accept Medicaid, lack of culturally or linguistically appropriate services, lack of childcare, lack of transportation, and fear of children being taken away. Also, although women of color are at a higher risk for perinatal mood and anxiety disorders, they are less likely to disclose symptoms to a healthcare provider.
What are common images of women who suffer from perinatal emotional complications? What do they look like? Do they look like US? Like everyone? One participant from Sampson’s qualitative study “criticized current TV commercials for antidepressants, saying,
“Based on what you see on TV and their commercials and the ones holdin’ the dog by the window, that is so completely garbage. When asked how a commercial that accurately portrays PPD would look, one participant gave this vivid example: She movin’ around. She droppin’ the kids, you tired, you overworked. She doin’ the most, she cookin’, she cleanin’, she washin’ dishes. Doin’ everything at one time….Baby hollerin’, hand doin’ this here, I mean it’s just no time to stop, no time to stop.…Everything has to be done. Nobody else is gonna do it.”
Common media representations of mental health issues did not reflect the experiences of these women. What does that say about how we represent mental health issues?
What do we usually say to women who are struggling with perinatal emotional complications? We as survivors and advocates may be quick to say things like, “It’s OK, it’s not your fault, many women struggle like this, please don’t be ashamed, there is help, you can heal and be well”, etc. While many women will gain comfort from these statements, not all will. In some communities, postpartum depression is seen as something that affects weaker mothers and that “strong” mothers don’t “catch” depression. This blame, along with stigma, lack of diversity among mental health professionals, copious barriers to accessing care, and the stark reality that no amount of therapy will erase poverty and racism, illustrate how what we say will resonate differently with women in different life circumstances. In other words, the statement “there is help for you” doesn’t mean much if the logistical and cultural barriers to accessing help feel insurmountable.
So, when we look at maternal mental health disorders through this lens of diversity, we can see that we as advocates cannot talk about the importance of getting treatment without understanding the context of women’s lives: life circumstances; privilege, and lack thereof; and the barriers faced by so many women—transportation, childcare, lack of insurance, language, cultural stigma, lack of mental health providers of color.
So, how can we, as survivors, be better advocates for all moms who are struggling with PPD and related illnesses? We’ll discuss that, along with some tangible places to start making a difference, this Friday in Part Two!
 Chaudron LH et al. Accuracy of Depression Screening Tools for Identifying Postpartum Depression Among Urban Mothers. Pediatrics. 2010. doi: 10.1542/peds.2008-3261
 Satcher D. Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. U.S. Department of Health and Human Services, Washington, DC; 2001
 Isaacs MR (2006). Maternal depression: The silent epidemic in poor communities. Baltimore, MD, Annie E. Casey Foundation.
 Troutman BR & Cutrona CE Nonpsychotic postpartum depression among adolescent mothers. Journal of Abnormal Psychology. 1990; 99(1) :69-78.
 Ross L & Dennis CL (2009). The prevalence of postpartum depression among women with substance use, an abuse history, or chronic illness: A systematic review. Journal of Women’s Health, 18 (4), 475-486.
 Templeton L. Velleman R, Persaud A., Milner P. The experiences of postnatal depression in women from black and minority ethnic communities in Wiltshire, UK. Ethn Health. 2003;8(3):207-221.
 Sampson M et al. A disease you just caught: Low-income African-American mothers’ cultural beliefs about postpartum depression. Women’s Healthcare. 2014 Nov:44-50.
 Kozhimannil, K. B., Trinacty, C. M., Busch, A. B., Huskamp, H. A., & Adams, A. S. (2011). Racial and Ethnic Disparities in Postpartum Depression Care Among Low-Income Women. Psychiatric Services(Washington, D.C.), 62(6), 619–625. doi:10.1176/appi.ps.62.6.619.
Divya Kumar, Sc.M., CLC, PPD Divya Kumar has a Masters in public health and is certified as a postpartum doula and lactation counselor. In 2013, she helped create a state-funded perinatal support pilot program in four community health centers in Massachusetts. She currently provides perinatal support for women and families at Southern Jamaica Plain Health Center, one of the four pilot sites. In addition, she facilitates support groups for new parents and conducts workshops about the transition to parenthood. Divya tells it like it is and brings honesty, compassion, camaraderie, and humor to her work with new families. She is also the mother of two children and a survivor of perinatal emotional complications.
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