Instructor in Psychiatry Ammon-Pinizzotto Center for Women’s Mental Health Department of Psychiatry Massachusetts General Hospital Harvard Medical School Boston, Massachusetts
Colin Smith, MD
Chief Resident, Internal Medicine- Psychiatry, PGY-6 Department of Psychiatry and Behavioral Sciences Department of Medicine Duke University Hospital Durham, North Carolina
Cole Davis
BSc Candidate in Chemistry Trinity College of Arts and Sciences Duke University Durham, North Carolina
Marla Wald, MD
Associate Professor Department of Psychiatry and Behavioral Sciences Duke University Hospital Duke University School of Medicine Durham, North Carolina
Jane Gagliardi, MD, MHS
Associate Professor Department of Psychiatry and Behavioral Sciences Department of Medicine Duke University Hospital Duke University School of Medicine Durham, North Carolina
Disclosures
The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products. The opinions expressed in this article are those of the authors and not of Duke University, Massachusetts General Hospital, or the US Government.
Black women are more likely to present in crisis and, hence, to acute care settings, which is likely related to disparities in screening and early detection.16,17 In a recent study investigating racial and ethnic differences in postpartum depression care, Chan et al16 found that Black women experience higher rates of hospital-based care compared with other racial groups. This study highlights the unavailability or inaccessibility of primary preventive measures to women in racial minority groups, which supports earlier studies that reported a correlation between access to care and severity of illness.16 Women in crisis may experience magnified disparities in access to high-quality care as they encounter institutional racism, potential loss of parental rights, and barriers due to insurance status.17,18 Furthermore, access to care for patients who are members of racial minority groups is limited in settings where culturally competent practices are absent or diminished, or discriminatory procedures are implicitly accepted and prevalent.12,19-22 The adverse impact of language constraints on accessibility of care is also well-documented, with recommendations such as ready access to interpreters to mitigate against miscommunications.23
Black and Hispanic women also experience significant delays between the time of delivery and treatment initiation.4 Studies of postpartum depression detection and treatment in specialty and primary care clinics show that, even when they desire treatment, women of color are less likely than White women to be offered treatment for postpartum depression.24 In terms of treatment options, research suggests women of color prefer psychotherapy over medication management.25,26 However, studies show that White women are more likely to be referred to psychotherapy.27 Research also reveals that Black and Hispanic women who are receptive to psychotropic medications have reduced rates of medication refills,4 which suggests that in these patients, counseling and monitoring adverse effects is suboptimal. In terms of treatment for substance use disorders (SUDs), after adjusting for maternal characteristics, Black and Hispanic women are significantly less likely to receive medication-assisted treatment (MAT) in pregnancy,28 and MAT is significantly less likely to be available in neighborhoods more densely populated by individuals of color.29,30
Several studies have explored possible explanations for discrepancies in treatment, including cultural expectations, differences in socioeconomic class, and racism. The stigma associated with psychiatric illness, misinformation about psychiatric treatments, and financial limitations have a substantial bearing on a patient’s willingness or ability to engage in psychiatric care.25 Regarding SUDs, a fear of legal reprisal is likely to deter women of color from seeking care.31 Such fears are not unfounded; research has demonstrated that interactions with Child Protective Services are increased among women of color compared to White women in similar situations.32
Furthermore, there is evidence that women of color receive less practical support, such as childcare, breastfeeding support, and transportation, during the postpartum period. Despite the preponderance of literature demonstrating the psychological benefits of breastfeeding,33,34 structural and psychosocial barriers appear to disproportionately affect breastfeeding rates in Hispanic, Black, American Indian, and Native women, with Black women experiencing the lowest rates of breastfeeding overall.35 Women in minority groups additionally experience disproportionate uncertainty about employment-based breastfeeding regulations.35,36 Specifically, many low-income jobs are not covered under the Family and Medical Leave Act, and compared to White women, Black women return to work on average 2 weeks earlier to jobs that are less welcoming to breastfeeding.35 In addition, insufficient education and support from health care settings and counselors play significant roles in disincentivizing women in minority groups from engaging in recommended breastfeeding and childcare practices.37,38
Continue to: COVID-19’s influence on these disparities...
