One of every five mothers and birthing people in California experiences prenatal or postpartum anxiety or depression. At a time that can be joyful, many new parents experience anxiety or depression that makes it difficult to adjust to a new baby.
While perinatal mental health conditions are common, some communities are more affected than others. Among all racial and ethnic groups, Black mothers and birthing people report the highest rates of perinatal anxiety and depression. There is an economic disparity as well. Compared to women and birthing people in private insurance plans, Medi-Cal enrollees experience prenatal and postpartum depressive symptoms at significantly higher levels (PDF).
The good news is that people experiencing maternal mental health conditions will get better with the right support, and early detection and prevention can make a significant, positive impact. Because 40% of California births are covered by Medi-Cal, the state has a huge opportunity to use the program to support the mental health of pregnant and postpartum individuals. This is a goal of the comprehensive Birthing Care Pathway being developed by the California Department of Health Care Services to cover Medi-Cal enrollees from conception through the newborn’s first birthday. The care model encompasses physical health, behavioral health, and health-related social needs, with a goal of reducing maternal morbidity and mortality and addressing significant racial and ethnic disparities in maternal health outcomes.
Recently I spoke about maternal mental health with Anna King, PhD, LCSW, who is deputy executive director at Diversity Uplifts, program manager for the Maternal Health Network of San Bernardino County, and a certified perinatal mental health specialist who provides psychotherapy services. At the time of our interview, she was serving as director of training at Maternal Mental Health NOW, where she taught providers about perinatal mood and anxiety disorders. We discussed the relationship between maternal mental health and birth equity, how she prioritizes her own mental health, and more. Our conversation has been edited for length and clarity.
Q: What inspired you to work in maternal mental health?
A: I was always interested in mental health and studied psychology in undergrad. I went on to get my master of social work degree after I worked in a halfway house for women recovering from substance use issues. I would interview people who were in jail and negotiate with drug court, their probation officers, and attorneys to allow them to finish their time at the halfway house. I really grew to love it.
My work is inspired by my ancestors. My great-grandmother was a traditional healer in her hometown and community. She was like a spiritual birth and death doula. I see my work as a direct way to honor my ancestors’ sacrifices, to continue making sure that nobody else has to suffer in any of the ways that people currently do or any of our ancestors did.
Q: Burnout is common for people who provide mental health and other support services. How do you create healthy mental space and boundaries in your work?
A: Many of the people who work in mental health are highly empathetic and caring, and they need more proactive care to sustain their work. I have always been sensitive to my own needs, but when I had my baby, I started to realize, “OK, taking care of myself is not a luxury. It’s a necessity. Otherwise, I’m not going to last very long doing any of this.”
To me, being able to sustain the work means cultivating a relationship with my body and with my evolving needs. It also means being able to set healthy and strong boundaries. I think people tend to associate boundaries with the idea that “I’m checking out” or “I can’t engage with you.” But to me, a healthy boundary says, “This is the capacity that I have, and these are the limitations and parameters around which you have access to me.” It has been a journey for me to sustain and protect my well-being by continuing to peel off the layers of conditioning and accept that I need rest, joy, and connection.
Q: The Listening to Mothers in California survey found the highest rates of anxiety and depression among Black mothers and birthing people. Numerous studies have shown positive mental health outcomes occur when patients are racially matched with a mental health care provider. What prescriptions do you have for expanding the workforce of Black maternal mental health professionals?
A: In mental health work, especially as providers of color, we experience and bear witness to trauma. We literally see it happen in front of us, and then we are expected to go about our lives as if it’s no big deal. Because I operate from a mental health and holistic wellness perspective, I see a massive opportunity to provide just the basic, bare minimum of what people need so that they can continue to show up. The system wasn’t built to sustain this kind of work long-term or full-time — especially without a living wage or the ability to take time off to restore and care for oneself.
An example of a basic need for the maternal mental health workforce is affordable education. My student loans just went back into repayment, and I’m thinking about how much of a burden that places on your ability to just take care of yourself.
I also think about the importance of mentorship and peer support. When I first started working in mental health, there was not a lot of Black representation, and I had to figure it out as I went. It’s important to create an environment of support and create multiple opportunities for people to explore the careers that are out there and what resonates for them. We also need to do a better job of connecting existing workforce diversification efforts so that, instead of doing a lot of exploratory work, we can instead make substantial investments together in the diversification interventions that work and are not exploitive or inequitable.
Q: Maternal mental health is directly connected with birth equity. So what does birth equity look like in practice?
A: I didn’t just one day decide, “I’m going to work in the birthing space. I’m going to work in birth equity.” I worked on following what lit me up while holding in mind what I was taught growing up around Black empowerment, Black liberation, and always living and embodying my values. It’s difficult for me to tolerate a space for long that doesn’t align with that or where there are overt, covert, explicit, or implicit injustices and inequities.
When we center the needs of those who are most marginalized, everybody benefits. I see birth equity in practice as centering the needs of communities that are chronically overlooked, such as Black, queer, trans, or disabled birthing people, and involving them in everything that’s done. Rather than making assumptions about the needs of a community, it’s important to develop a trusting relationship so that the resources we funnel into a community are not wasted on flawed and misaligned ideas.
We need to remember that needs change during the perinatal period. You need different things during pregnancy than when you have the baby, and you need different things when you’re raising older children.
Q: How can diversifying maternity care teams help us achieve birth equity?
A: Having diverse perinatal care teams is important because each team member’s specialization serves as a piece of a puzzle to make sure we don’t overlook any important needs in a birthing person’s care.
If we rely only on ob/gyns to provide care, we’re missing many opportunities to address care holistically. With different types of providers contributing to a birthing person’s care, we can create a collaborative and integrative approach to address all of their needs. You can’t separate the mental from the physical from the spiritual, so you have to look at the whole person. To generate long-term birth equity solutions, you need diverse perspectives.
Q: What’s the main barrier facing birthing families who need mental health services?
A: Access. For various reasons, more than 50% of therapists don’t accept any insurance, and they’re often charging $150 to $200 an hour. Most people can’t access that, including myself. There are also long wait lists for more affordable forms of therapy. And due to stigma, many families don’t feel comfortable accessing this form of support at all.
Q: What improvements do you hope to see in the near future to improve maternal and infant health outcomes for Black birthing families?
A: It would be wonderful if we could follow the systems that some other countries have modeled around meeting the basic needs of birthing families in order to proactively set them up for success. This might include paid time off and job security when you have a baby, access to free, healthy food, connection to community and childcare, and other basic things that families need to survive. Then our efforts can focus on helping people thrive. It’s protecting and helping future generations. The way I see it, this work is intergenerational. It’s futuristic. It’s time travel.
Authors & Contributors
Amber Bolden
Amber Bolden, MPP, is a freelance communications consultant and member of the Los Angeles Chapter of the National Association of Black Journalists. She works as a consultant facilitator for the Village Fund, the community grantmaking program for the African American Infant and Maternal Mortality (AAIMM) prevention initiative. She has worked on several community development initiatives and served as a founding member of the Sankofa Birthworkers Collective in the Inland Empire.
Amber is a board member of Tru Evolution, a direct service health equity nonprofit organization that prioritizes the LGBTQ+ community by providing HIV, health, housing and community services.
Ringo Chiu
Ringo Chiu is a Los Angeles–based photojournalist whose work has been published in newspapers across the globe. He won a 2021 Pulitzer Prize in breaking news photography and was a 2019 Pulitzer finalist in that category. Chiu was born in China and raised in Hong Kong before coming to the US.
Chiu works as a freelance photographer for the Associated Press, Los Angeles Times, Agence France-Presse, Reuters, European Pressphoto Agency, Getty Images, Xinhua, and Zuma Press. He also works as a chief editorial photographer for the Los Angeles Business Journal.
