Politics and development as drivers of women's reproductive mental health

Howard et al1 provide an excellent and nuanced overview of women's mental health in relation to life-course and common reproductive events, with careful consideration of complicated bi-directional influences (e.g., mental health in relation to sexual violence and contraception access and choice). Their summary includes some attention to social-political contextual factors as moderators of different reproductive experiences and mental health outcomes, including exposures in low- and middle- vs. high-income countries, gender unequal compared to more equal societies, as well as variables functioning at the group and individual level such as race and sexual orientation. From an historical perspective, the authors’ emphasis on sex-based experiences as fundamental to understanding and treating women's mental health is radical, yet essential for progress in basic and translational research. However, two drivers of women's reproductive mental health deserve amplification: a) the political determinants of health2, defined as government action (or inaction) and policy, which create the social determinants of health mentioned multiple times in the paper; and b) the role of childhood experiences, particularly adverse ones, as a risk factor for compromised reproductive events and mental health. In her insightful book Unwell Women: Misdiagnosis and Myth in a Man-Made World3, E. Cleghorn dissects modern scientific medicine as part and product of the culture from which it emanated, with strict gender divisions, ascribing power and dominance to men, and heralding the superiority of the male body. She notes that, as early as Aristotle, the female body was described as inverse of the male's, with genitalia “turn'd outside in”. Women were marked as different and thus inferior, except for their reproductive capacities, which were used to define them, and limit them. Women's different bodies and biology were regarded as the foundation of their nervous constitution, unsteady judgement, and susceptibility to emotional storms. The “mythical” uterus was viewed as influencing all disorders and dysfunctions of women's mind and body. Medicine constructed the ideology that a woman was her biology, that she was ruled by it, governed by it, at the mercy of it, and her diseases were linked to the “secrets” and “curiosities” of her reproductive organs, which made her unwell a part of every month, and thus overall unfit for activities outside of domestic ones and those related to childcare. Throughout history, medicine's focus on female biology, as the defining factor of being a woman, worked against the understanding of illness and disease. Indeed, as penned by Scotland's first licensed woman physician, S. Jex-Blake, near the turn of the 19th century, women needed to be viewed as “human first” to receive unbiased and good medical treatment. Over 150 years later, the US National Institutes of Health – the largest public funder of biomedical research in the world – began to require the consideration of sex as a biological variable in its funded studies on vertebrate animals and humans. This policy aimed to correct the historic focus on male research and the under-reporting of sex and gender in preclinical studies, which had reflected both ongoing male dominance and the subsuming of women under men, an extreme distortion of a “human first” approach. The centuries-long fight for women's social, political and economic equality necessitated a “human first” rationale. Today, even in the context of ongoing health inequities and disparities related to identities and demographics, sex-based biology and biologically-based reproductive events can be examined in relation to women's mental health to foster the most rigorous and clinically-relevant research. Howard et al's life-course approach to women's reproductive mental health provides an opportunity to amplify its implicit developmental perspective. They note that “trauma is a shared mechanism mediating and/or moderating many of the relationships between reproductive life events and mental health” and refer to “early life trauma” as a risk factor for sexual dysfunction as well as attachment difficulties, which in turn is a risk factor for compulsive sexual behavior. In several recent reports, associations have been identified between: a) childhood adversity (abuse, neglect, low socio-economic status, violence, bullying) and earlier age for reproductive events4; b) sexual abuse or parental separation and reduced odds of contraception use5; c) total childhood adverse events and repeat induced abortion6; d) childhood adversity (abuse, neglect, household challenges) and worse verbal memory in peri-menopausal women, with higher inflammation as a mediator7. Each of these outcomes is a potential contributor to experiencing a mental health condition. Mental health conditions should be viewed as emerging from individuals’ adaptations to their environments over time rather than as something a person “has”. Recent research demonstrates that exposure to stressors and other psychosocial experiences “gets under the skin” to influence subcellular processes such as immune and endocrine regulation, with consequences for somatic and brain functioning across the life course8. Mitochondria appear to play a critical role in the biological embedding of stress, affecting physical and mental well-being8. A biologically informed, developmental perspective applied to women's reproductive mental health underscores the urgency to implement systems focused on early intervention as well as to devise innovative early preventive therapies and approaches. Throughout the paper, the authors appropriately highlight the social determinants of health as key drivers of women's reproductive mental health outcomes. And yet, as D. Dawes powerfully argues in his book The Political Determinants of Health2, social factors such as access to resources including good education, quality health care, safe environments, and healthy food, are proximal conditions influencing health status. To affect change in population health, it is imperative to look upstream to the drivers of these social factors, to the politics and policies that then trickle down in the form of implemented systems to shape the quality of lives and the associated health outcomes. The recent US Supreme Court decision that rescinds the constitutional right to complete reproductive health care including abortion services underscores the role of politics in driving women's reproductive health. The ruling returned to state legislatures the power to regulate abortion access. Following the Supreme Court ruling, one recent study found a small but significant increase in depression and anxiety scores in states with immediate bans on abortion versus those without9. To address health inequities in resources related to women's reproductive mental health, and the social-economic factors contributing to disparities in well-being, we must actively engage with the political drivers of health.