Racial and ethnic inequities in perinatal mental health care in the US: The impact of medical mistrust and residential segregation

Postpartum depressive symptoms (PDS) affect one in eight people in the US, with racially minoritized individuals experiencing higher rates of PDS than White Americans, yet lower access to screening and care. Healthcare gaps likely result from discriminatory practices and policies, but little research has explicitly examined this using measures of interpersonal and structural racism. Using population-based, longitudinal data from seven US jurisdictions in the Postpartum Assessment of Health Survey (2020) this dissertation examines racial and ethnic inequities in postpartum depressive symptoms and care and potential mechanisms behind these patterns. First, I examined patterns of self-reported PDS, perinatal mood and anxiety disorder (PMAD) diagnosis, and receipt of postpartum mental health care by racial and ethnic identity. Of 4,542 people who delivered live births, 11.8% reported PDS. Among them, 25% received a PMAD diagnosis and 50% received mental health care. Diagnosis did not differ by race and ethnicity, but racially minoritized individuals – particularly Asian, Native Hawaiian, or Pacific Islander, Southwest Asian, Middle Eastern, or North African; Black; and Hispanic respondents were significantly less likely to receive mental health care than their White counterparts. I next assessed patterns of medical mistrust and its relation to gaps in PMAD diagnosis and mental health care. Among 454 individuals with PDS, the highest medical mistrust based on identity (MMBI) was observed among individuals who were single, Black, Hispanic, had less than a college degree, and had public insurance. However, MMBI was not significantly associated with diagnosis or care. To explore structural mechanisms behind inequities in postpartum mental health care, I examined whether the racial residential segregation of one’s county was related to receipt of PMAD diagnosis and mental health care and explored the role of health professional shortages. Among 560 individuals with PDS, those living in counties with higher concentrations of racially minoritized populations were less likely to receive postpartum mental health care than those in counties with a greater concentration of White individuals, though healthcare provider shortages were not related. Findings highlight stark racial and ethnic inequities in postpartum depression management in the US that may largely stem from structural causes like residential segregation.