What a Post-Roe v. Wade World Means for Maternal Mental Health

According to the Center for Disease Control’s Maternal Mortality Review Committees, more than 80% of pregnancy-related deaths are preventable [1]. Despite that, about 700 women die each year from pregnancy-related causes [2]. Preeclampsia, hemorrhages, and infections are common underlying causes of maternal mortality or the deaths of women during pregnancy and up to a year postpartum. Racism is also a leading factor contributing to disparities in maternal mortality, in which Black women and Indigenous American women are most vulnerable [3]. Policymakers and health organizations have implemented strategies to combat these disparities, such as implicit bias or racial equity training. However, racial disparities and high maternal death rates persist in the US. With the overturning of Roe v. Wade this past summer, the US must face an emerging issue that may worsen these mortality rates: an increase in suicide due to struggles with maternal mental health.

Maternal mental health is a pressing issue, as pregnancy-related suicide is in fact the leading cause of maternal death. Mental health conditions (including deaths to suicide and overdose/poisoning related to substance use disorder) accounts for 23% of maternal death in the US, while hemorrhages account for only 14% of maternal death, cardiac-related causes account for only 13% of maternal death, and infections account for only 9% of maternal death [1].

While the prevalence of maternal suicide is already high, there is still evidence that maternal suicide rates are underreported. Using pregnancy mortality surveillance data from 2005 to 2010, a study done by researchers affiliated with Columbia University and the University of Colorado estimated that 30% of US pregnancy-related suicides had no recorded pregnancy status. Many suicides that were in fact pregnancy-related were likely unreported as maternal death because the victim's pregnancy status was unknown, which implies that the current number of maternal suicides is likely lower than the true value [4].

Reports and proper treatment of maternal mental health issues and suicide heavily depend on intrapartum and postpartum mental health screening. Most women are not screened for suicidality or depression at postpartum health appointments [5]. Furthermore, Black women are 36% less likely than white women to be screened for postpartum depression, and Indigenous American women are 56% less likely [6]. This is especially concerning as Black women and women of color have approximately 50% elevated depressive symptoms during pregnancy compared to white women [7]. In other words, the people who are most at risk for maternal suicide are receiving the least postpartum care. However, while racial disparities exist in postpartum mental health screening, they do not seem to appear in perinatal screening when mothers interact with health providers the most [6]. Thus, while the racial bias of health providers is a contributing factor, it is not the sole reason for the racial disparities in postpartum mental health care.

Systemic poverty also has a major impact on who can receive postpartum care. In a study by researchers affiliated with California State University and University of California, San Francisco, women with low socioeconomic status experienced an increase in depressive symptoms postpartum [8]. Low socioeconomic status was often associated with low access to medical care, transportation, and partner or spousal support, which limited access to postpartum care. Race and socioeconomic status intersect; women of color are more likely to be of lower socioeconomic status, preventing them from seeking postpartum mental health care [9].

Women of low socioeconomic status are also more likely to experience unwanted pregnancies. Unwanted pregnancy is one of the most common risk factors for maternal suicide [5]. This fact is especially relevant now with the overturning of Roe v. Wade, as more women will now be forced to undergo pregnancy and childbirth. In addition, access to abortion is crucial to combatting racial disparities in maternal health. Black women in states that support abortions experience lower maternal mortality rates than Black women in states unsupportive of abortion [10]. States unsupportive of abortion care normally have low-quality maternal care, so women may not have access to a maternal health provider for depression screening. Another leading cause of maternal suicides is high parental stress, which would also be higher for those who had to experience an unwanted pregnancy and were financially unprepared for parenthood [5].

More needs to be done to support mothers and reduce maternal suicide. Advanced and frequent assessments of intrapartum and postpartum health are essential. Additionally, public health professionals must do more to address social determinants of health, such as racism and poverty. The potential implications of the overturning of Roe v. Wade are disheartening, making reproductive justice essential to addressing maternal health issues in policy and public health discussions.

References

1. CDC Newsroom. (2016, January 1). CDC. https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html

2. Preventing Pregnancy-Related Deaths | CDC. (2022, June 8). https://www.cdc.gov/reproductivehealth/maternal-mortality/preventing-pregnancy-related-deaths.html

3. Villavicencio, J. C., McHugh, K. W., & Edmonds, B. T. (2020). Overview of US Maternal Mortality Policy. Clinical Therapeutics, 42(3), 408–418. https://doi.org/10.1016/j.clinthera.2020.01.015

4. Mangla, K., Hoffman, M. C., Trumpff, C., O’Grady, S., & Monk, C. (2019). Maternal self-harm deaths: An unrecognized and preventable outcome. American Journal of Obstetrics and Gynecology, 221(4), 295–303. https://doi.org/10.1016/j.ajog.2019.02.056

5. Orsolini, L., Valchera, A., Vecchiotti, R., Tomasetti, C., Iasevoli, F., Fornaro, M., De Berardis, D., Perna, G., Pompili, M., & Bellantuono, C. (2016). Suicide during Perinatal Period: Epidemiology, Risk Factors, and Clinical Correlates. Frontiers in Psychiatry, 7. https://www.frontiersin.org/articles/10.3389/fpsyt.2016.00138

6. Sidebottom, A., Vacquier, M., LaRusso, E., Erickson, D., & Hardeman, R. (2020). Perinatal depression screening practices in a large health system: Identifying current state and assessing opportunities to provide more equitable care. Archives of Women's Mental Health, 24(1), 133-144. https://doi.org/10.1007/s00737-020-01035-x

7. Orr, S. T., Blazer, D. G., & James, S. A. (2006). Racial disparities in elevated prenatal depressive symptoms among black and white women in eastern North Carolina. Annals of Epidemiology, 16(6), 463-468. https://doi.org/10.1016/j.annepidem.2005.08.004

8. Goyal, D., Gay, C., & Lee, K. A. (2010). How much does low socioeconomic status increase the risk of prenatal and postpartum depressive symptoms in first-time mothers? Women's Health Issues, 20(2), 96-104. https://doi.org/10.1016/j.whi.2009.11.003

9. White, R. (2020). Multidimensional poverty in America: The incidence and intensity of deprivation, 2008-2018. Springer Nature.

10. Patterson, E. J., Becker, A., & Baluran, D. A. (2022). Gendered Racism on the Body: An Intersectional Approach to Maternal Mortality in the United States. Population Research and Policy Review, 41(3), 1261–1294. https://doi.org/10.1007/s11113-021-09691-2