Black Pregnant and Postpartum Peoples’ Perspectives on Mental Health and Substance Use Disorders

Abstract

Introduction:

Mental health and substance use disorders in pregnant and postpartum people (PPP) are common, and most will not receive adequate treatment. In addition, Black PPP experience higher rates of mental health conditions and are less likely to receive treatment compared with White PPP. Yet, our understanding of the experience of Black PPP with respect to these conditions is limited. The goal of this study was to better understand these experiences with respect to mental health, substance use, and barriers to treatment.

Methods:

Semi-structured interviews were completed with 68 Black PPP who were pregnant or had been pregnant in the last 24 months to gain an understanding of mental health and substance use screening and treatment during the peripartum and postpartum period. Interview data were analyzed with qualitative software, using a qualitative content analysis method, informed by grounded theory.

Results:

Four main themes were identified: (1) personal beliefs and views about mental health and substance use, (2) family and community beliefs about mental health and substance use, (3) personal experience with mental health and substance use, and (4) comfort in talking to others about mental health and substance use. Subthemes evolved within each of the four themes. Black PPP indicated that maternal mental health and substance use disorders are common in the Black community, but negative stigma related to these conditions often prevents PPP from talking about these conditions or seeking support or treatment despite believing that support and treatment can be beneficial.

Conclusions:

Clinical practice initiatives within this population can focus on advanced training for providers to more clearly understand personal experiences and related stigma related to mental health and substance use disorders, with the goal of supporting Black PPP mental health needs.

Introduction

Over the past decade, the significant rise in maternal mortality among pregnant and postpartum people (PPP) in the United States has prompted increased attention to critical factors influencing maternal health, including mental health disorders (MHDs) (perinatal mood and/or anxiety disorders) and substance use disorders (SUDs) (including licit and illicit substances).^1

–4 The most recent data from the Centers for Disease Control and Prevention include 1,018 pregnancy-related deaths from 36 states between 2017 and 2019, demonstrating mental health conditions accounted for 23% of all maternal deaths via suicide and drug overdose, a percentage higher than any other cause of mortality.⁵ Maternal MHDs and SUDs are common, affecting 15–20% of PPP, and are leading risk factors for suicide and drug overdose.⁶ In addition to impacting maternal mortality, untreated maternal MHDs and SUDs negatively impact maternal and child health and are associated with a multitude of poor obstetric outcomes such as prematurity and low birth weight,^7,8 an increased risk of behavioral problems (externalizing behaviors), poor academic performance, and depression in children born from mothers with MHDs or SUDs.^7,9,10

Significant racial disparities exist among rates of maternal MHD and SUD detection and treatment. Some studies demonstrate that rates of suicide and drug overdose are higher among White PPP compared with Black PPP,¹¹ whereas others report higher rates of MHD and SUD among Black PPP.^12,13 It is likely that MHD and SUD in Black PPP are underdetected,¹⁴ and importantly, there are clear racial disparities in access to treatment.^15
–17 Data from national surveys demonstrate that rates of substance use in the past month among pregnant Black women are higher than national averages,^14,18 but Black PPP are less likely than their White counterparts to receive SUD treatment.¹⁹ Black PPP with postpartum depression are also more likely to experience delays in care and less likely to receive follow-up treatment, or fill prescriptions, compared with White PPP with postpartum depression.^15,16

The extant literature has noted that stigma around maternal MHD and SUD disproportionately impacts PPP of color owing to significant health inequality across races such as heightened risk of being drug tested and reported to criminal authorities for SUDs,^20,21 limited access to MHD or SUD treatment services, and more negative experiences with these services.²²

Materials and Methods

The goal of this qualitative study was to gather information via interviews with Black PPP and to share their experiences, perspectives, and insights into MHD and SUD during the peripartum period, with the goal of informing approaches to reduce disparities in access to MHD and SUD support and treatment. The study includes perspectives of Black PPP with and without experiences of perinatal MHDs and/or SUDs. The Medical University of South Carolina Institutional Review Board (IRB) granted a waiver of written informed consent (Pro # 00085580). Verbal consent to participate in an interview was provided by participants after reviewing a research statement with the research staff before each interview. Participants were eligible for the study if they were adult females, self-identified as Black, and were currently pregnant or had been pregnant within the past 24 months. Black PPP could participate if they reported past and/or current SUD (other than tobacco alone) and/or past and/or current MHD during pregnancy (perinatal mood and/or anxiety disorder) or within the past 24 months following pregnancy. In addition, Black PPP who did not have a past or current SUD or MHD could also be included in the study. Participants were excluded if they had a current untreated psychotic disorder, were currently experiencing suicidal or homicidal ideation, or were unable to comply with study procedures.

Participants were recruited nationally via public advertising on Facebook and social media pages of academic institutions and via TrialFacts, a specialized patient recruitment service that adheres to IRB requirements, as well as local recruitment in a women’s health clinic.

The Consolidated Criteria for Reporting Qualitative Research guided reporting of methods and results.²³ A semi-structured interview guide was created with a comprehensive set of questions to obtain information about MHD and/or SUD personal experiences during pregnancy, childbirth, and parenting among Black women in the United States. Participants were also asked about family and community perceptions of MHD and SUD and available resources and support for treatment.

Between December 1, 2020, and October 8, 2021, 84 participants met the criteria for inclusion and enrolled in the study; 68 patients (81%) who were currently pregnant or had been pregnant within the prior 24 months completed qualitative, semi-structured interviews. The remaining 16 individuals did not appear for the scheduled interview after enrolling in the study. Of the 68 participants, 53% (n = 36) were recruited via national patient recruitment databases and 47% (n = 32) were recruited in the local women’s health clinic. Interviews were conducted via Microsoft Teams with the participant and interviewers using audio and visual capabilities. Interviews were conducted by two trained, doctoral-level, female clinicians who were not involved in patient care delivery and did not know study participants. Interviews lasted between 40 minutes and 60 minutes (mean length of interviews = 46.5 minutes). Interviews were audio-recorded and transcribed verbatim, and field notes were taken during the sessions to track observation and saturation of themes. A $20 gift card was provided to all participants following the interview. In addition, if a participant attended the first scheduled interview and did not “no-show” or cancel the interview less than 24 hours prior to the scheduled date, they received an additional $20 gift card (n = 47 participants). Participants who referred a contact they believed were eligible for the study received a $20 gift card (n = 13).

Data analysis consisted of a qualitative content analysis²⁴ informed by grounded theory,²⁵ which was used to explore participants’ unique perspectives via identification of themes/patterns that naturally emerge from data and a systematic classification of these themes.²⁶ Specifically, a three-step inductive approach was used, in which each participant’s interview responses were carefully examined to develop a comprehensive codebook to capture all possible themes emerging from the data. The codebook was then used by two independent coders to code and analyze each participant’s responses to the interview questions.^24,27 Coders applied more than one code to participant responses, if applicable. The overall interrater reliability for the double-coded interviews was 95% and ranged from 91% to 99%. Inter-rater discrepancies were discussed and resolved by the two coders. Finally, themes were refined, merged, and/or subdivided into subthemes via collaborative discussion until a comprehensive codebook was developed. NVivo 12 software was used for data management and analysis.²⁸

Results

Participants were on average age 31.2 years old (standard deviation 4.3); 100% self-identified as Black and 3.5% self-identified as Hispanic or Latina. Of all the participants, 58% reported being currently married, engaged, or living together as a couple, and 42% completed college. Most participants reported having a perinatal MHD (43% [29/68]), more than one-third reported having a perinatal SUD (37% [25/68]), and 21% (14/68) of participants did not have any psychiatric history.

Results are presented with four main themes, including (1) personal beliefs and views about mental health and substance use, (2) family and community beliefs about mental health and substance use, (3) personal experience with mental health and substance use, and (4) comfort in talking to others about mental health and substance use. Subthemes within each theme are described later. The percentage of time each of the four themes was discussed is included in Table 1, with representative quotes from the themes provided in Table 2.

Table 1.

Rates of Themes and Subthemes

Theme	Percentage of time discussed (%)
Personal beliefs and views about mental health and substance use	9.7
Family and community beliefs about mental health and substance use	23.8
Personal experience with mental health and substance use	41.4
Comfort in talking to others about mental health and substance use	25.1

Table 2.

Black Peripartum Participants’ Assessment of Perinatal Mental Health Disorders and Substance Use Disorders

Theme	Definition	Reflective quotes
Theme 1: Personal beliefs and views about mental health and substance use
Link between peripartum period and MHD and SUD	Degree that mental health is related to substance use and description of any relationships	“It can be someone dealing with a mental illness they may or may not know that they have, and substance abuse is something that they use to cope.” “I feel like they go hand in hand.”
Perceptions that MHD and SUD are not prevalent	Perceptions of Black PPP that MHD and SUD are not prevalent and cannot be acknowledged; include a lack of awareness of these disorders and the detrimental effects	“I definitely know that Black people will be quick to say, ‘We don’t suffer from that,’ or they won’t acknowledge that they feel like they are because they won’t acknowledge mental illness.” “With mental health, I think about the taboo. With postpartum depression, people speak about their feelings.But I think it was scary what came to mind when I think about postpartum because you definitely don’t want to be one of those…victims.”
Differences in MHD and SUD from pregnancy to postpartum	MHD and SUD effects from pregnancy to postpartum and notable differences	“When you’re pregnant, you have support—some women have support of their families, doctors...once you have the baby, it’s harder as you don’t have those frequent doctor visits anymore. The baby relies on you…you still have the support of family, but not so much.” “Substance use isn’t good anyway…wouldn’t do that when pregnant, but then after you have the baby…I’m free of this.”
Theme 2: Family and community beliefs about mental health and substance use
MHD and SUD are not understood or discussed	Ongoing lack of understanding of MHD and SUD in minority populations; MHD and SUD are typically not discussed in some populations with a belief that they can resolve over time	“A lot of people downplay it as if it’s not something serious…it’s not depression or it’s not really that bad. You’ll get over it, it’s a phase.” “People tend to think of psychiatry as kind of witchcraft or something...so people tend to shut off from talking about mental health.” “I did not discuss it even with my immediate family. Even if you know it’s there, it’s not—people go to church and don’t really talk about it too much. They keep quiet. We kind of turn a blind eye…like, maybe it’ll work out.”
Negative feelings about MHD and SUD	Some minority populations have negative stigma related to MHD and SUD	“Honestly, it [mental health] is shunned. I come from a Caribbean background, but I have friends who are also African American, and it is something that is shunned. You don’t talk about it. Someone will think less of them because they have a mental health disorder.” “When you speak about mental health in my community, or to my family, it can come off as if, something really is wrong versus just maybe needing an outlet to speak with someone, or you are having a hard time adjusting to a newborn child.” “Substance use is criticized. Especially when a woman is pregnant, even postpartum.”
Opinions about MHD and SUD are generational	Older generations of Black families typically do not discuss MHD and SUD; however, newer generations are more open to discussions	“The older generation says, ‘We went through it, we didn’t need help, so why do you?’” “I feel like in the community, in 2021, my generation, is talking more open about [MHD]...people on social media talk about it and they have friends that are open to talk about it. However, that was not the way I was raised. I was raised that we do not talk about any of those issues, and it was uncomfortable being in that conversation.”
Distrust in the health care system	Some women are fearful of losing their children; they have distrust in health care systems, so they lack transparency about health issues	“As Black women, we think, ‘the system always gets in our business and tries to take our children away.’ Therefore, we’re not going to express those issues.” “I think a lot of women are afraid of being honest and transparent with our health care providers out of fear that something happening as far as a custody situation…I don’t want to lose my child.” “I think a lot of women are afraid of being honest and transparent with our health care providers out of fear.”
Theme 3: Personal experience with mental health and substance use
Experience with MHD or SUD	Personal experiences with MHD or SUD	“I was in therapy while in the hospital, there was some traumatic things that happened…after I got home, I was noticing a few things. Anxiety really bad, would cry a lot for no reason. I didn’t sleep for a while.” “I didn’t want to get out of bed at all…to even take a shower. When my 12-year-old come and needed help, I was like, ‘Ask somebody else.’ That’s when I knew something’s not right.” “I suffer from depression and anxiety, so a lot of times when I do use substances, it’s to subside the feelings I am having. Most of the time I just try to self-medicate. Most of the time I just resort to my substance use to calm my nerves and just to get by with my day.” “Knowing I was pregnant became so stressful for me that I began…drugs…I took it as shame. After becoming pregnant, I kept it from my friends. I would not tell them I’m using drugs…It was so hard for me to open up to them.”
Resources for MHD and SUD	Personal knowledge of resources available for MHD and SUD	“I talked to my family and friends.” “Getting out of the house and walking. We walk and maybe go grocery shopping. Just getting out of the house.” “With postpartum depression—it was lots of prayer. And then I had to seek counseling. Counseling and medication.” “I started looking at parenting groups to see if I could join and see if I could fit in...that helped. Joining groups on Facebook was good. That helped…alleviate everything so I didn’t feel as lonely, but it still was tough finding the right folks to…understand where I’m coming from.”
Referral process	Personal experiences with the referral process to receive mental health and substance use counseling	“When I went to the website, nobody reached out to me. It told me to contact my primary care doctor…process was a headache.” “It was easy to get connected, but to get an appointment, it was hard. I had to wait for…three weeks to a month. Maybe four weeks.” “I told my doctor and nothing came from it. They had me call a mental health lady…said she was going to have a screener call. They never called…I got a letter, ‘Nobody’s been able to get in contact, We’re worried.’ Haven’t gotten one voicemail. My number hasn’t changed.” “Instead of referring me to somebody who could help with my anxiety, it was, ‘Oh I’m sorry you feel that way, let’s get your weight.’”
Barriers to receiving counseling	Reported barriers to receiving counseling after getting a referral	“Only thing I know is that when you see somebody, you actually get comfortable with them. It’s like you can’t keep them. You got to see somebody else. That’s the only thing I don’t like.” “They were kind of giving me the run-around because of my insurance. I had Medicaid…this department doesn’t handle that with Medicaid, so we don’t know who you would have to deal with…okay. Guess I’m not going to get care at this time.”
Experience receiving counseling	Personal experiences with the counseling process	“Talking about your problems to the counselor, how to cope with it and deal with it, stuff like that was very helpful. I wish more people would do that.” “I felt more comfortable…in group therapy there was a lot more African American men and women that were leading the group so it was a lot easier to relate and talk about the things I had gone through. ‘Okay, they do look like me. They understand where I’m coming from.’”
Theme 4: Comfort in talking to others about mental health and substance use
Perceived support	Description of different types of support systems that were helpful to women with MHD and SUD; supportive and nonjudgmental caregivers improved participant comfort	“[My family] would always encourage me. ‘You’re doing a good job...a great mom.’ And then they would help with my son so I would get one-on-one time with my daughter, and vice versa. My mom and sister stayed overnight...thankfully they were there to help me through.” “You know, it’s okay. There’s nothing wrong with having mental health issues. There’s nothing wrong with suffering from postpartum depression or depression. It’s normal…after talking to her and seeing my doctor, I felt a lot better because I have someone I can go to, that I can talk to that won’t judge me or make me feel like there’s something wrong with me like, I’m broken or damaged really badly.” “She mentioned [postpartum depression] to me and my husband as something that we should keep an eye out for…happens to a lot of women, and it’s nothing to be ashamed of, and to get help if I needed it.” “I knew it was a safe space for me to voice my concerns, and not have anyone label me or think badly of me. When it feels like they’re just checking a box, you don’t have a safe space to open up and say anything.” “Basically, nobody could’ve talked to me. I just wanted to be alone with it.”
Trust in provider	Varied levels of trust that participants experienced with providers	“I think part of it will stem from the health care providers during pregnancy being open and compassionate with patients and making them feel safe…my health care provider really did make me feel safe. She made me feel more like she’s listening to me and she heard my concerns…these providers really paying attention to their patients and not just trying to get them in and out.” “That’s one thing that’s really common in the Black community. Nothing stays between the person you said something to. But I feel like if I call my doctor, ‘Hey, I’m feeling like this today,’ I feel like it’s confidential between me and her.” “I think if I’m assured the information wouldn’t be shared with anyone else and if all was assured that my details won’t appear anywhere.” “But when we got that connection slowly—it took months. But once we got that connection, we just flowed. I felt like she was my diary. Like I could tell her everything.” “After I got comfortable with my doctor and we start having conversations, I start telling her the truth.”
Shared common experiences	Perception of common experiences improved the comfort levels of participants	“Seeing actual people talking about postpartum depression or just depression/anxiety…made me want to come out and share my story in public…Black women speak up about their mental health because when we see that…does push people to actually talk more.” “I speak to my best friends because they go through the same thing that I’m going through…I can speak to them because they completely understand.”

Theme 1: Personal beliefs and views about mental health and substance use

Link between peripartum period and MHD and SUD

The theme related to personal beliefs and views about MHD and SUD included the impact of a stressful environment during the peripartum period on mental health symptoms and substance use during this time (Table 2). Multiple participants described that during this time period, mental health and substance use can be worsened by significant changes and stressors specific to pregnancy and postpartum periods. One participant described, “With a lot of mothers going through postpartum and dealing with…mental issues…just to get something to relax…[drugs] are the easiest thing to get because they can’t afford a doctor.”

Perceptions that MHD and SUD are not prevalent

Stress experienced during this time period can be further compounded by not recognizing or acknowledging MHD or SUD and barriers to seeking treatment, including stigma and care access. According to participants, although some individuals within Black communities are familiar with postpartum depression, others will not acknowledge MHD or are not aware of the negative effects. One participant stated, “You’d be surprised by how many African American women…are not even aware of what mental illness is or how it affects their brains.” In addition, there is a type of “taboo” regarding mental health illness and falling “victim” to this type of condition, which can prevent PPP from seeking treatment.

Differences in MHD and SUD from pregnancy to postpartum

It was reported that support is more readily available during pregnancy because after a person has a baby, they do not have frequent doctor appointments and contact with health care providers and, thus, they feel avenues for resources lessen dramatically. A reduced support system with the added stress of having a newborn baby can worsen mental health symptoms and increase substance use.

Theme 2: Family and community beliefs about mental health and substance use

MHD and SUD are not understood or discussed

Participants discussed family and community beliefs about MHD and SUD, which were similar to personal beliefs and views (Table 2). Participants stated that the Black community downplays mental illness and believes mental health challenges to be “a phase,” describing that one can pray for mental health problems. One participant explained, “Mostly with the Black community…we have been taught to give all our problems to God. Which I pray, but sometimes people need extra help. But you’re considered crazy, so you don’t talk about it.”

In addition, MHD and SUD are typically considered “secretive” and not discussed in the Black community, even among close family members. A participant shared, “In my family anything related to [substance use] was always very secretive…you didn’t discuss that person and you didn’t interact with people who had [substance use] issues, and those issues were not openly discussed.”

Negative feelings about MHD and SUD

Black PPP feel that Black communities are judgmental of MHD and SUD, as these diagnoses are publicly “shunned and criticized” in these communities. Because of these negative community perceptions, many Black individuals will not seek treatment or support for these conditions. As one participant stated, “In the Black community you are considered crazy if you try to get help for mental illness…a lot of people don’t seek help because they don’t want to be considered crazy…but mental health isn’t crazy.”

Opinions about MHD and SUD are generational

Several participants described that negative perceptions regarding MHD and SUD in the Black community are generational. Older generations still shy away from conversations regarding mental illness, whereas newer generations are more open to discussions about mental health and credit the widespread use of social media and broad opinion sharing in helping reduce the stigma of these conditions. This shift in acceptability of MHD and SUD was explained by two participants. One individual stated, “Older Black families are taught you don’t talk about family business…and what goes on in the family,” whereas another individual explained a benefit of social media: “I guess with social media and things like that now…[MHD are] definitely talked about more and recognized.”

Distrust in the health care system

Finally, distrust in health care systems and providers is pervasive. Participants reported that many Black women often do not reveal problems with MHD or SUD to health care providers because they fear negative repercussions, such as fear that their children may be taken away.

Theme 3: Personal experience with mental health and substance use

Experience with MHD and SUD

Participants described personal experiences with MHD or SUD (Table 2). Personal experiences included a prior diagnosis of depression that was exacerbated during pregnancy and the postpartum period, in addition to new mental health symptoms including anxiety and feelings of helplessness and the experience of loneliness and isolation. Some participants reported they would use substances to alleviate mental health symptoms. One participant reported the benefits of cannabis use to reduce nausea and improve her appetite, thus allowing her to gain needed weight during pregnancy. Many participants reported feelings of “shame” or “guilt” related to their substance use and did not discuss their substance use with others.

Resources for MHD and SUD

When discussing personal experiences with MHD and SUD, participants also described helpful means of coping with mental health symptoms. Specifically, participants described that talking to friends and family, finding support groups, praying, listening to music, engaging in wellness activities, and professional counseling and medication were beneficial when experiencing MHD and SUD. Learning information about MHD and SUD was also beneficial as it allowed participants to understand these conditions and know how and when to seek professional help. The benefits of knowledge were demonstrated: “…just knowing information…knowing what is depression, knowing what is anxiety, knowing when you need help. It’s just knowing those things, and that’s what made it easier and made it okay.”

Referral process

Participants also shared challenges, frustration, and negative experiences of receiving referrals to counseling services for MHD and SUD. Participants reported it was difficult to obtain information on counseling services, obtain a referral, and make an appointment. When a patient was able to reach someone to make a counseling appointment, the first available time was often weeks in the future.

Barriers to receiving counseling

Reported barriers to counseling included transportation, lack of counselor availability, inability to see a consistent counselor, lack of trust in counselors, cost, and lack of adequate health insurance. One participant stated that online counseling (telemedicine) would be beneficial so that she could attend from home while her baby was sleeping.

Experience receiving counseling

Conversely, participants who reported being able to receive counseling were pleased with these experiences and reported that counseling was advantageous to their recovery. One participant stated, “…talking about your problems…was very helpful.” Importantly, one participant stated that she appreciated having Black health care providers leading a group counseling session because she was able to relate to them and felt a sense of belonging since they had a strong understanding of cultural experiences.

Theme 4: Comfort in talking to others about mental health and substance use

Perceived support

Participants reported different types of support systems that were beneficial to women with MHD and SUD, including health care providers, family members, and friends (Table 2). They felt more comfortable discussing MHD and SUD with individuals who were nonjudgmental and encouraging and those who created a “safe place” to share feelings and experiences. Alternatively, a few participants reported they did not feel comfortable discussing these challenges with anyone because of a lack of trust, fear of repercussion, and desire to handle challenges independently.

Trust in provider

Participants benefited from providers who offered positive attention and expressed concern for them and/or their baby. It was helpful for participants to hear candid information from providers on MHD and SUD to help void any associated stigma, so patients felt more comfortable and could have a “safe space” to share their feelings. One participant described, “[My provider] took time…had the hard conversation but [said]…‘It’s okay.’ It felt like a safe space. She genuinely was concerned and cared…that plays a part. When you feel like someone cares and they’re genuinely concerned, not only with your baby but you, it helps.” When providers offered a safe place for patients to share experiences, women were able to slowly gain more trust in them and appreciated the confidentiality and opportunity to speak through challenges.

Shared common experiences

Participants disclosed that shared common experiences were beneficial in helping them feel more comfortable in sharing their own experiences related to MHD and SUD. By experiencing or hearing about similar challenges related to MHD or SUD from other Black women, they were encouraged to share their own personal stories with others either privately in small groups or publicly. One participant shared, “Seeing actual people talking about postpartum depression or just depression/anxiety made me want to come out and share my story in public.”

Discussion

Perinatal MHD and SUD are common, and these conditions are often unrecognized and untreated because of myriad barriers.⁶ Black PPP are disproportionately impacted by these conditions and experience additional barriers to the identification of and treatment for MHD and SUD.^14,22,29 It is vital to understand these racial disparities from the perspective of Black PPP so that they can inform and drive superior approaches to perinatal MHD and SUD recognition and treatment.

As evidenced in Theme 2, family and community beliefs, Black PPP report experiencing significant amounts of stigma and fear of punitive consequences associated with MHD and SUD, making it challenging to seek support and/or treatment. Furthermore, participants discussed that members of their community did not support them as they lacked knowledge regarding MHD and SUD in pregnancy and the postpartum period. These findings are consistent with the literature demonstrating that although Black individuals often have higher rates of mental health concerns than White counterparts, Black individuals are less likely to seek mental health treatment and return for follow-up after initial visits.^30,31 Research has identified primary factors for lack of treatment among Black individuals, and specifically Black women, to be stigma, shame, and embarrassment.^32,33 Furthermore, literature demonstrates that Black mothers are significantly more concerned about their children being removed from their care from child welfare than other racial groups.^34,35 This is important given that heightened stigma is associated with a lack of knowledge of MHD and SUD, especially among Black women,²² and providing Black women with information regarding MHD and SUD may help decrease personal stigma and provide helpful education.

Participants reported that providers who understand Black PPP perspectives on MHD and SUD are helpful in overcoming the negative stigma associated with these conditions and can help them seek support and treatment that may be beneficial. Specifically, participants in the current study described discomfort in discussing MHD and SUD with providers, yet providers who offered a safe place for patients to share their experiences garnered the trust of patients and were often the only people whom participants felt they could disclose problems with mental health and/or substance use.

To address these important findings, it is critical that health care providers seek ways to understand Black PPP’s beliefs and attitudes about treatment and use interventions to address stigma among this group.^33,36 Specifically, the literature has demonstrated that incorporating psychoeducation about stigma based on feedback and experience of Black individuals specifically decreased stigma and increased engagement in treatment.³⁷ A review of interventions to promote mental health and reduce stigma in Black communities found the most effective components to the development of interventions for reducing stigma to include community feedback and engagement.³⁶ Thus, future work is needed to embed psychoeducation and interventions to address Black women’s beliefs and attitudes about treatment into service systems and other points of access for Black PPP. Specifically, interventions can directly address concerns raised by Black women regarding beliefs and attitudes about treatment at all access points from assessment to treatment.

Another method may include examining the role of peer support specialists, individuals with lived SUD experience, in health care settings where Black PPP seek care. Based on our study results, Black PPP shared that hearing common experiences made them feel more comfortable in sharing their challenges related to MHD and SUD, and the use of peer support specialists has been effective in reducing stigma and increasing access to care among a variety of SUD treatment settings.^38,39 Further research is necessary to determine the best ways to implement psychoeducation, peer support specialists, and additional interventions directly targeting stigma and negative consequences among Black PPP into the existing infrastructure and to train professionals in the delivery of these components.

Another important finding in the current study was that participants found when other Black PPP or Black community members shared their experiences about MHD and/or SUD, it was easier for participants to feel more comfortable talking with others about these conditions. Black participants’ perspectives in this study were similar to those in previous studies, stating that mental health and substance use are “private family business” and not to be discussed with others.⁴⁰ Because of negative perceptions of these disorders, Black PPP often have difficulty discussing MHD and SUD with even close family members or friends, especially during the peripartum and postpartum periods. Discussions of MHD and SUD being “taboo” among Black participants in the current study are also congruent with previous literature demonstrating that Black women in general were not likely to discuss mental health symptoms, owing to these symptoms being inconsistent with the image of a “strong Black woman”;^33,41 women with these symptoms often withdraw from others, are less likely to seek social support, and often feel more isolated and alone.^41,42 To address these important findings, it is imperative to identify ways for Black PPPs to disclose and receive support from other Black PPPs in the community, outside of health care providers. This could include incorporating psychoeducation programming for family members into community programs and raising awareness in Black communities about the importance of discussing and supporting MHD and SUD concerns, without stigma. Future work should focus on the development of these models and examination of feasibility and effectiveness among Black PPP.

Finally, findings from this study demonstrated that therapy, counseling, and medication for MHD and SUD were found to be beneficial, but a lack of available or accessible treatment was a barrier. These findings are consistent with studies indicating that access to treatment for MHD and SUD is limited, and myriad barriers preclude individuals to access needed services, which is exacerbated for Black individuals seeking help for MHDs or SUDs.⁴³ Barriers to access among this population include mental health and substance use stigma, cost of care, transportation, and childcare.⁴⁴ To address this gap, integrative care models have been implemented throughout Black communities to provide support and incentives for providers that integrate primary care with services for MHD and SUDs.⁴⁴ Future work should continue to embed integrative care into Black and other communities that experience disparities in access to treatment for MHDs and SUDs, as well as research to determine the feasibility, effectiveness, and cost benefit of these models.

Limitations

There are strengths and several study limitations. The sample includes many peripartum Black women, including participants who identify as Hispanic. Semi-structured interviews were conducted with a sample of pregnant and postpartum women recruited nationally. Given that women self-selected into the study, bias may have been present, in that participants who opted into the study may have had strong opinions regarding MHD and/or SUD or had positive or negative experiences compared with others who did not choose to participate. There is variability in state reporting laws of substance use and maternal mental health conditions and may have impacted participants’ experiences, and thus, results may not be applicable to specific populations. Future research should examine factors across the United States where there may be cultural differences in Black communities. Results reflect the views of Black pregnant and postpartum women and not providers; further studies are needed to assess provider perspectives, specifically related to service delivery. Finally, although the double-coding technique²⁴ was used to ensure the reliability of qualitative analysis, qualitative coding could include the coder’s unique perceptions and biases, which may have influenced specific themes extracted from the data.

Conclusions

Results from this study highlight the need for understanding and addressing personal, family, and community views and experiences related to MHD and SUD among Black pregnant and postpartum women, to better understand experiences, challenges, and stigma and to increase comfort in Black PPP disclosing MHD and SUD to health care providers. Clinical practice initiatives can include advanced training in cultural competency for health care providers and health care systems that address stigma and create a health care system that Black communities can begin to trust. Strategies can be focused on the improvement of service delivery to overcome treatment barriers related to access, cost, and transportation, with goals to increase community-based initiatives to expand the reach of services and thus decrease disparities related to MHD and SUD in Black PPP.

Footnotes

Acknowledgments

We would like to acknowledge the participants taking part in this study for sharing their time, insights, and expertise. Without them, this work would not be possible.

Authors’ Contributions

E.J.: Project conceptualization, data analysis, article composition, and editing; A.M.: Project conceptualization, data collection, data analysis, article composition, and editing; C.K.: Project conceptualization, data collection, article composition, and editing; C.G.: Project conceptualization, data collection, article composition, and editing.

Author Disclosure Statement

There are no conflicts of interest to disclose.

Funding Information

The efforts of C.G. and E.J. are funded by Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services as part of the National Telehealth Center of Excellence Award (U66 RH31458). In addition, the effort of C.G. is funded by the National Institute on Drug Abuse (NIDA) (R34 DA046730). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by NIDA, HRSA, or the U.S. government. All funding sources did not have a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the article; and the decision to submit the article for publication. E.J., A.M., and C.G. had full access to all the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis.

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