Overcoming Bias: Addressing Postpartum Depression (PPD) in Minority and Low-Income Women

Overcoming Bias: Addressing Postpartum Depression (PPD) in Minority and Low-Income Women

November 19, 2024

Editorially reviewed by Nicole Cirino, MD, IF, CST, PMH-C

Are anti-bias training and education the keys to reaching more women struggling with PPD?

Woman with her doctor

Introduction
    Mental health has been at the forefront of public health in recent years, and for good reason. According to the Centers for Disease Control and Prevention, approximately 1 in 4 Americans live with mental illness.1 Globally, mental health disorders are the leading cause of disability and present an increased risk for premature death.2,3 Postpartum depression (PPD) is one of these mental illnesses, with approximately 10% of pregnant women and 13% of postnatal women suffering from depression internationally.4 However, PPD presents a unique set of treatment barriers like stigma and the hesitation some women feel about disclosing their symptoms, leading to 50% of cases remaining undiagnosed.5  

   More specifically, low-income women and women from minority backgrounds, such as Hispanic and African-American women, can be more reluctant to seek help for symptoms of PPD due to mistrust of healthcare professionals (HCPs),6 and the feeling that their concerns or symptoms may be dismissed.7 According to one systematic review that evaluated perceived discrimination and medical mistrust, there is mounting evidence of pro-White/anti-minority (Black, Hispanic, American Indian, etc.) bias in HCPs toward patients.8 Therefore, there is a need for anti-bias education in the healthcare system. Perhaps this education could be the key to more women feeling secure enough to seek help for their PPD symptoms.
 

Socioeconomic Status  
    Socioeconomic status plays a major role in whether women seek help and receive treatment for PPD. Based on several studies, PPD occurs at a significantly higher rate in women of low socioeconomic status compared to women of middle to upper socioeconomic status. Furthermore, lower socioeconomic status is one of the major predictors of PPD.9-15  Even though women of low socioeconomic status have a greater risk of developing PPD, they may be more hesitant to seek help due to stigma. Furthermore, women of low socioeconomic status often have to overcome financial barriers such as lack of transportation or insurance, and even when an HCP can see them, they may not feel comfortable enough to disclose their symptoms. Some women with low socioeconomic status feel as though HCPs are dismissive of their symptoms or talk down to them. Additionally, even when screened, some women may feel their issues were not explained in a way they could comprehend.7
 

Race and Ethnicity
    Similar to women of low socioeconomic status, women from minority backgrounds are at a greater risk of developing PPD. However, White women were more likely than Black or Latina women to receive a diagnosis of and treatment for PPD.7 Specifically for Latina women, there are added barriers of language, inadequate health knowledge, and a lack of social and emotional support.16 There is also a pervasive feeling of medical mistrust among racial and ethnic minorities linked to prior feelings of discrimination. This mistrust can lead to reduced communication between HCPs and patients and poorer health outcomes.6

    As mentioned earlier, according to one systematic review that evaluated perceived discrimination and medical mistrust, 84% of studies included showed evidence of pro-White/anti-minority (Black, Hispanic, American Indian, etc.) bias in HCPs toward patients.8 Within this systematic review, six studies identified an association between implicit bias in HCPs toward patients and gaps in treatment recommendations, management of pain, and empathy. Furthermore, one study determined that some HCPs thought of Black patients as less educated, agreeable, and friendly and saw them as more likely to partake in risky and non-compliant behaviors as opposed to their White patients. It was also noted that HCPs who demonstrate implicit racial and ethnic biases tend to have poorer communication with patients from minority backgrounds, which can make medical encounters uncomfortable for these patients.8 So, how can HCPs work to overcome stigma and reach women who are the most at risk for developing PPD?
 

Combating Bias
  Recently, a training program called ‘Responding to Experienced and Anticipated Discrimination’ (READ) was established to help train medical students on anti-bias interventions. The goal of the project was to develop future doctors who can identify and address mental health-based discrimination and serve as “change agents” in the anti-bias movement.17 The program was implemented in 15 medical schools across 12 low-, middle-, and high-income countries. The results were studied in an international, non-randomized, pre- vs post-controlled study. According to the findings, READ was associated with positive changes in knowledge, attitudes, skills, and patient-perceived empathy amongst the medical students who participated in the training program.17 Perhaps the widespread implementation of such anti-bias training for HCPs who treat and evaluate pregnant women and mothers can help overcome the stigma and treatment barriers associated with PPD.

Conclusion
  The prevalence and impact of PPD highlight a significant public health challenge, particularly for low-income women and women from minority backgrounds. The continued presence of barriers to seeking and receiving appropriate care, such as socioeconomic status, race, and ethnicity, demonstrates the need for more empathetic health care. The evidence of implicit bias toward patients of minority backgrounds further exacerbates the issue, highlighting the need for anti-bias education and training within the healthcare system. Initiatives such as the READ program can serve as a promising step toward addressing these disparities, aiming to support a new generation of HCPs trained to provide empathetic and unbiased care. Continued development and support of these programs are needed to ensure that all women, regardless of their background or socioeconomic status, have access to the support and care they need to navigate the challenges of PPD.

References:

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