Reproductive Justice is a Mental Health Imperative
In the Spring of 2012, Bei Bei Shuai was released from jail over a year after the State of Indiana had charged her with attempted murder. Bei Bei had attempted suicide, which itself was not a crime in Indiana, but she had been pregnant at the time and her infant had died several days after a premature delivery following her attempt. Bei Bei’s case is troubling, but not unique. There are countless examples of people struggling with mental health or substance use whose pregnancies have been criminalized by restrictive reproductive legislation and unsympathetic societal treatment. This has left them to navigate these issues not within the framework of compassionate care, but instead against the punitive and traumatic landscape of the carceral system.
It is impossible to disentangle mental health advocacy from the ongoing struggle for reproductive justice. Mental health is not merely an aspect of this struggle, rather reproductive justice itself is a mental health imperative. The idea of reproductive sovereignty extends well beyond access to safe and legal abortion, encompassing the rights of all birthing people to feel safe and supported in all their decisions about childbearing and parenthood, including and beyond whether or not to become parents in the first place.
Historically, medicine had relegated mood changes in the perinatal period, the weeks immediately before and after birth, to the domain of psychology. Until the early 1970s, Sigmund Freud’s popular psychodynamic approach to the mind, which itself was imbued with misogyny, held that the low mood experienced by many women around the birth of their children was a symptom of deep-rooted antipathy toward the concept of motherhood and a rejection of the caregiver role. The therapeutic approach to perinatal mental health management that grew from this mindset was often simply to send the new mother away, separated from her child, or to heavily sedate her.
“Mental health is not merely an aspect of this struggle, rather reproductive justice itself is a mental health imperative.”
In 1858, roughly a century prior to Freud’s ill-informed efforts, a young physician named Louis-Victor Marcé published a meticulous and thoughtful catalog of some of the mood disturbances experienced by new mothers. The first published scholarly work of its kind dedicated solely to the unique mental health concerns of women during and after pregnancy, it was remarkable in its acknowledgment of the physiological connection between reproduction and the brain and the attendant effects on the mind and mood. In his interviews and observations, Marcé noted not only an increased prevalence of depression and anxiety associated with birthing but also stressed the sensitivity of patients with pre-existing mental illness to the mood-altering effects of pregnancy. While his ideas provided invaluable insights into perinatal mental health, Marcé died when he was only 37, before his reports could be widely published or translated, so they languished in relative obscurity for over 150 years.
For women who are already struggling with conditions such as major depression, bipolar disorder, or schizophrenia, the emotional rifts brought on by pregnancy and childbirth can be seismic. Both pregnancy and childbirth put patients at a slightly higher risk for experiencing an episode of severe mood disturbance. In those with a pre-existing diagnosis of bipolar disorder, this slight elevation leaps to up to a 50 percent increased risk for a rare but devastating perinatal mood disorder called postpartum psychosis. Often described as a heightened state of agitated mania, new parents in the throes of postpartum psychosis are more likely to require hospitalization, commit suicide, or act on intense intrusive thoughts of harming their children. While extreme examples and case studies allow neuroscience to dissect the neurochemical agents of perinatal mental illness, the reality is that a majority of those who have just given birth experience a period of low or unstable mood, commonly reduced to the so-called “baby blues.”
For many, systemic racial and economic inequities in healthcare quality and access, lack of adequate social support, and any number of physical or mental health concerns add layers of trauma and complexity to an already challenging transition. And for any new parents, the transition to the new role of caregiver may engender a period of mourning for other aspects of their identities that have suddenly been redefined.
Reproductive justice focuses on supporting pregnant people and those who have the potential to become pregnant in making authentic choices around all aspects of their reproductive health and providing them with material resources to do so. This might take the form of free or low-cost birth control, or it might mean doula support, community-based childcare, or meal deliveries for recent parents adjusting to a new routine. It also means ensuring access for all to safe abortions. In their text, “Reproductive Justice: An Introduction,” Loretta J. Ross and Rickie Solinger emphasize that this movement grounds the discourse on reproductive rights in its historical context of racist, ableist, gendered policies that disproportionately harm women of color and jeopardize and politicize their reproductive agency. Any discussion of mental health before, during, and after pregnancy must, therefore, proceed from this intersectional perspective.
The political debate at the boundaries of physical and mental health captures the deeper dilemma faced by clinicians as they approach mental illness: the tension between the social and environmental forces that weigh on a person’s psyche and open the door to depression and anxiety and the more subtle chemical and physiological agents of neuropsychiatric pathology, like psychosis and schizophrenia. Pregnancy is accompanied by tidal shifts in levels of hormones, such as estradiol and progesterone, and these shifts help facilitate fetal development. To establish a nurturing environment for the fetus, the developing placenta secretes a complex cocktail of steroid hormones, immune factors, and neuropeptides that act as molecular guideposts through pregnancy and lactation. As these factors work together to reimagine the physiology of the body, these newly introduced hormonal forces also powerfully influence a pregnant person’s moods, behaviors, and thoughts.
The enormous potential for harm to mental health inherent in threats to reproductive rights is often overlooked. Roe v. Wade is in many respects synonymous with the legal fight for reproductive rights, but the original Roe v. Wade ruling occurred alongside the case of Doe v. Bolton. This case challenged laws that only permitted abortion if certain criteria were met and medically vetted by a group of physicians. “Bolton specifically stated that ‘health’ risk includes mental health and well-being,” explains Robin Marty, an author who reports on reproductive rights issues and formerly served as the Director of Communications at the Yellowhammer Fund, a reproductive justice organization based in Alabama. Sandra Bensing (née Cano) filed the lawsuit alongside a group of medical professionals and social workers under the name Mary Doe. She had applied for an abortion at a public hospital on the basis of ongoing mental health issues that had at one point required hospitalization and had led to the loss of custody of two of her children. The courts eventually ruled in her favor, setting an important precedent for the reproductive rights of pregnant people struggling with mental illness.
Opponents of pro-choice initiatives and legislation argue that the primary outcome of cases such as Bensing’s will be unfettered, on-demand access to abortion. But these arguments are predicated on the idea that abortion is synonymous with reproductive rights rather than representing a single facet of a much larger issue. For some, terminating a pregnancy may be the option they consider to be the least harmful and most supportive of their mental and physical health. Reproductive sovereignty extends through pregnancy and beyond, and for many, concerns for their safety throughout pregnancy, their mental health, and their ability to care for their children are all amplified by the threat of punitive legislation that fluidly redefines the legal status of a fetus.
“Reproductive sovereignty extends through pregnancy and beyond, and for many, concerns for their safety throughout pregnancy, their mental health, and their ability to care for their children are all amplified by the threat of punitive legislation that fluidly redefines the legal status of a fetus.”
These are the issues that community support structures and mutual aid organizations like the Yellowhammer fund seek to redress. Echoing the sentiments of Marcé 150 years ago, the reproductive justice movement acknowledges the emotional toll of pregnancy and childbirth for all birthing people and the necessity for social support. Yellowhammer works to provide financial aid and support for safe access to legal abortion and assists single parents of young children through their Family Justice program. According to deputy director Lindsay Rice and Executive Director Laurie Bertram Roberts, the mutual aid provided includes weekly food baskets, monthly stipends for expenses such as childcare and rent, assistance with job training, and referrals to counseling services.
Marcé’s work has seen renewed interest in the biomedical research community in the last few decades, coalescing around the formation of the International Marcé Society in 1980. Dr. Crystal Clark is an Associate Professor of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology at Northwestern University’s Feinberg School of Medicine and serves as the president of the North American branch of the Marcé Society. As Clark explains, the society works to unite a consortium of researchers around the world to address perinatal mental health in a scientifically rigorous way. This allows otherwise isolated research groups and clinicians to engage with each other’s work in a way that will meaningfully impact patient care.
In her own work, Clark has sought to provide support to bipolar patients with mental health resources at every step of their pregnancies, from planning to birth and beyond. She says that in addition to adjusting medications and assessing whether psychotherapy alone might be effective in certain cases, there is other support for people with a diagnosis of bipolar disorder during the pregnancy and through lactation. Stress and sleep are both major factors in regulating mood in this disorder, so Clark works with her patients to assess their stress levels and the personal resources available to them.
“If they’re stressed about something,” Clark explains, “how can we deal with that through psychotherapy to mitigate that stress so it’s not a trigger.” She has seen positive outcomes when she worked with patients to bring in doulas, night nannies, and family support to maintain the quality of their sleep. “That’s been able to actually help them begin their families or expand their families while staying well, and that’s been very exciting.”
Pregnancy and childbirth can be an enormous source of joy for new parents, who may embrace their new roles as caregivers with excitement. Others may approach pregnancy and parenthood with trepidation. For people who already struggle with mental illness, navigating the challenges of managing medication and keeping up healthy daily routines during this time can be overwhelming without the right support systems. Punitive anti-choice legislation has the power to restrict more than a person’s access to safe abortion, as countless court cases that have criminalized the pregnancies of people managing mental illness or substance use disorders have made clear. The community-minded approaches of the reproductive justice movement and the work of Marcé and those who followed his lead also shed light on the more fundamental problem of pathologizing the mental health concerns associated with pregnancy and parenthood rather than acknowledging the breadth of emotional responses that may naturally arise during such a major life transition. While the original Roe v. Wade ruling placed physical health at the center of many modern-day reproductive rights debates, mental health is just as essential in the fight for reproductive justice.