Proceedings of a Workshop—in Brief

Convened October 23, 2024

Examining Critical Issues at the Intersection Between Mental Health and Reproductive Health
Proceedings of a Workshop—in Brief

OVERVIEW

On October 23, 2024, the National Academies of Sciences, Engineering, and Medicine (the National Academies) Standing Committee on Reproductive Health, Equity, and Society held a webinar to explore intersections between mental health and reproductive health. Speakers, including researchers and clinicians, discussed the relationship between intimate partner violence and reproductive health, social and structural determinants of health affecting access to mental health treatment and outcomes, mental health implications of restrictions on access to abortion care, among other topics. Discussions also focused on identifying potential contextual and systemic solutions to root causes of mental health inequities and opportunities to improve engagement in mental health care services.

This Proceedings of a Workshop—in Brief is a high-level summary of the topics and discussions that occurred during the workshop. It should not be viewed as providing consensus conclusions or recommendations of the National Academies.

FRAMING REMARKS

Moderator Katherine L. Wisner, Children’s National Hospital and George Washington University School of Medicine and Health Sciences, opened the webinar by briefly describing the mental health care landscape for women in the United States. Wisner noted that the burden of mental health disorders in women is substantial, with several disorders, including anxiety, panic disorder, and post-traumatic stress disorder, occurring more commonly in women than men. She added that major depressive disorder is common globally—according to the World Health Organization (WHO), twice as many women are affected as men—and poses a significant public health impact. “It’s the leading cause of disability worldwide and a major contributor . . . to the global burden of disease,” Wisner said. A person’s health is affected by a “network of factors,” which can play a role in contributing to the mental health burden; this can include genetics, interpersonal relationships, living conditions, environment, and social and economic policies. Wisner discussed two challenges in thinking about this network of factors—the challenge of understanding which factors render women more susceptible to mental illness than men and the challenge of delivering health care in ways that can tackle these factors. In closing, Wisner noted that it is necessary to reconceptualize “what we do in health care . . . for people to truly have more positive health outcomes.”

GENDER BASED VIOLENCE, MENTAL HEALTH, AND REPRODUCTIVE HEALTH

Elizabeth Miller, University of Pittsburgh, discussed the role of intimate partner violence (IPV) as one of the “social drivers of health and, specifically, mental health.” Additionally, she discussed the ways IPV affects mental health outcomes among U.S. women, and evidence-based strategies for supporting survivors of IPV. Miller explained that IPV is prevalent in the United States and has a direct impact on mental health outcomes and reproductive health and autonomy.

Miller said that reproductive coercion¹ is “one mechanism that connects [IPV] with poor sexual and reproductive health outcomes.” She referred to a report by the National Domestic Violence Hotline,² discussing results of its 2023 survey which documents “ways in which partners control reproductive decision making, including through birth control sabotage, condom manipulation, forcing a partner to get an abortion or preventing them from getting one, engaging in economic abuse, withholding finances needed to purchase contraception, and participating in pregnancy coercion.” Miller said that over a third of survey respondents reported that their partner refused to use or prevented their use of birth control methods. She noted that 42 percent of those who said they had experienced reproductive coercion said they have never reached out for support.

Another mechanism related to IPV is mental health coercion,³ Miller said. According to the National Center on Domestic Violence, Trauma, and Health (NCDVTH), “89 percent of callers to the domestic violence hotline [shared] that they had experienced at least one type of mental health coercion.” The reported experiences included partners threatening to report callers as “crazy” or preventing callers from seeking help or taking prescribed medications. Miller said the NCDVTH reports on not only how people may use substances to cope with the pain of partner violence but also the prevalence of substance use coercion, which may include “being pressured or forced to use substances or made to use more than they wanted.”

Miller noted that IPV increases during public health emergencies. She served on the National Academies committee for the report Essential Health Care Services Addressing Intimate Partner Violence,⁴ which underscored “that we have to recognize the intersections of systemic and structural inequities that increase vulnerability to intimate partner violence and poor health outcomes as we plan for public health emergencies.” Miller said it is critical to “involve survivors, advocates, and practitioners and promote cross-sector collaborations” to develop solutions, and she referred to the tools developed by the University of Pittsburgh alongside the American Academy of Pediatrics and the Centers for Disease Control and Prevention to support IPV survivors and their children, which were based on lessons learned during the COVID-19 pandemic.

IPV must be addressed to reduce maternal mortality, Miller added. “Nearly half of all female and one-tenth of male homicide victims are killed by intimate partners.” Miller added that, “Homicide during pregnancy, or within two months of giving birth, exceeds all the leading causes of maternal mortality by more than twofold.” She emphasized that this problem disproportionately affects Black women and girls.

Miller emphasized a universal education approach as an important strategy in reducing IPV, referring to universal education is an opportunity for patients to make the connection between violence, health problems, and risk behaviors. She said there are many reasons patients may not disclose abuse during a routine health screening, such as fear of law enforcement or feelings of shame among others. Miller described working with Futures Without Violence to develop an evidence base around a universal education intervention.⁵ In closing, Miller

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emphasized the importance of “building and sustaining effective partnerships to promote bidirectional referrals between the health system and advocates who work in our victim service agencies.”

BARRIERS TO ACCESS AND ENGAGEMENT IN MENTAL HEALTH TREATMENT

Inger Burnett-Zeigler, Northwestern University Feinberg School of Medicine, presented on the challenges Black women face in accessing mental health treatment. To better understand these issues, she emphasized the need to consider intersectionality or how multiple forms of inequality or disadvantages related to one’s identity compound themselves, and those aspects of identity may include one’s race, class, ethnicity, gender, sexuality, or other aspects.

Burnett-Zeigler highlighted the ways in which social and structural determinants of health affect how a person engages with mental health treatment, noting that this context may include their immediate family, their neighborhoods, the larger social environment, and institutions or policies, all of which have an impact on access to care. She noted that several factors, such as lower than average income, limited access to care providers, limited access to abortion, and more exposure to violence, racism, and discrimination, are associated with “an increased risk for mental illness.” These social and structural determinants are particularly salient in the lives of Black women, Burnett-Zeigler said. She added that in states where there are higher rates of Black poverty, “There’s more restrictive abortion access, increasing the risk for mental illness among Black women.” In addition, Black women experience greater exposure to racism, discrimination, intimate partner violence among other risk factors, which are a “driving force of health inequities and inequitable access to the healthcare system.” She noted that several epidemiological studies indicate that Black women have low rates of mental health conditions, these studies controlled for various social and economic factors like education and employment. However, several other studies show that Black women face a lifetime prevalence of major depressive disorder at 14 percent, generalized anxiety disorder at 6 percent, and post-traumatic stress disorder at 12 percent (McKnight-Eily et al., 2009; Lacey et al., 2015; Jones et al., 2020).

Despite their risk of developing a number of mental health conditions, Burnett-Zeigler explained that Black women are estimated to be 50 percent less likely to receive mental health treatment than White women. Burnett-Zeigler noted that facets of the health care system can act as barriers, including lack of diversity among care providers, lack of culturally tailored intervention options, medical mistrust, and limited access to providers in low-income communities. She added that cultural norms may be barriers or facilitators to accessing treatment. Burnett-Zeigler described how these factors can intersect by referring to “the prototype of the strong Black woman whereby Black women may be less inclined to . . . [expose] their suffering, particularly to race-discordant providers.” She also presented research illustrating that “Black women who experienced more adverse childhood experiences and felt a stronger obligation to present an image of strength” were more likely to mask symptoms of depression, anxiety, and other disorders and were less likely to engage in mental health treatment.

Social and structural determinants of health provide a framework for understanding who is more at risk for developing a mental health condition and who is at greatest risk for having unmet mental health needs, Burnett-Zeigler said. “We can also use this framework for understanding opportunities for intervention.” She described her work on health care quality in partnership with federally qualified health centers in Chicago. Efforts have focused on evidence-based strategies like diversifying the pool of mental health care providers, ensuring the cultural relevance of interventions, and “taking into consideration the existing attitudes and beliefs about mental health treatment within particular communities.”

Looking ahead, Burnett-Zeigler emphasized that examining mental health equity requires reexamining our health care policies, particularly policies around reimbursements for mental health services that are delivered in community. She noted that addressing social and structural determinants of health is key and explained that the work done within the health care system represents a segment of a larger picture and, to improve outcomes, must be accompanied by addressing inequities in education and employment among other areas.

POTENTIAL IMPLICATIONS OF DOBBS⁶ DECISION ON PSYCHOLOGICAL WELLBEING DURING PREGNANCY

M. Antonia Biggs, University of California, San Francisco, discussed the mental health implications of restrictions on access to abortion care. She said 21 states have enacted total or near total bans on abortion access, placing significant constraints on individuals’ pregnancy decisions. Although states with total bans have exceptions under some conditions, many people are unable to get in-person abortion care in their state of residence, Biggs explained, because the exceptions are poorly defined, and clinicians can face significant penalties for providing abortion care. She added that even in states without bans, laws mandating waiting periods or in-person counseling also impose burdens on patients. She said these laws are often rooted in a claim that abortion itself is unsafe and associated with physical or mental health risks, which is “not supported by the scientific literature, and . . . ignores the risks of pregnancy and having to overcome obstacles to care on pregnant people’s mental health.” Biggs referred to a recent case in which a federal judge in Texas issued a “preliminary ruling aimed at invalidating the [Food and Drug Administration’s] approval of mifepristone,” which is one of the drugs used in medication abortions. The ruling falsely suggested that women face mental health risks from abortion, Biggs said.

Biggs discussed findings from The Turnaway Study, a longitudinal study examining whether abortion is associated with mental health harm. The study compared mental health outcomes among nearly 1,000 women who had abortions compared to those who were denied abortions and carried their pregnancies to term.⁷ The study collected data on six different measures of mental health and well-being: depression, anxiety, suicidal ideation, post-traumatic stress, self-esteem, and life satisfaction over a 5-year period and found no evidence of mental health harm resulting from abortion. Biggs noted that the study found that individuals who were denied access to abortion had worse mental health outcomes compared to those who received abortions. In fact, the study found that women who were denied abortions “exhibited more symptoms of anxiety and lower self-esteem” for the first six months following denial. Also, individuals in abusive relationships who were able to access abortion care were less likely to continue in those relationships as compared to the individuals who were denied care, Biggs said, but for those who carried pregnancies to term, respondents were “tethered to that abusive, violent relationship.” In addition to abortion denial, the study found other factors associated with adverse mental health outcomes for individuals post-abortion seeking, including a history of mental health diagnoses, history of abuse or neglect, and perceived abortion stigma, meaning “the people close to them, or people in the community would look down on them, were more likely to experience subsequent psychological distress.”

Biggs presented findings from a study conducted prior to the Dobbs decision illustrating the impact of delays in abortion care on mental health outcomes. The 2019 study included 784 respondents from four clinics in California, Illinois, and New Mexico. The data showed that “most people in these protected access states experience some kind of delay-causing obstacle,” such as travel, cost, or access to abortion care facilities. “We found that people who experienced such delay-causing obstacles were at significantly greater risk of depression and anxiety,” Biggs said.

In closing, Biggs emphasized that “denying people an abortion is more harmful, at least in the short term, than allowing people to get the abortion that they want,” and obstacles to accessing care can contribute to mental health harm. Biggs said policies that suggest abortion causes adverse mental health outcomes are “not evidence-based” and likely have a negative effect on patients’ psychological well-being.

EQUITY AND DETERMINANTS OF MENTAL HEALTH OUTCOMES

Ruth Shim, University of California, Davis, began by highlighting that the terms ‘health inequities’ versus ‘health disparities’ to describe differences across populations offer a fuller picture of root causes. The WHO defines health inequities as disparities in health that are the result of systemic, avoidable, and unjust social and economic policies and practices that create barriers to opportunity, and Shim added that it is important to name

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these systemic causes when thinking about the challenges at hand. For example, women experience higher rates of depression than men, and examining this challenge as the result of a “fundamental difference between men and women” does not account for “the fact that we live in a deeply patriarchal society . . . in which women are more subjected to violence” and have less power over their reproductive health.

Shim shared a diagram conceptualizing the root causes of adverse mental health outcomes and inequities (Shim and Compton, 2020). She stated that social determinants of health create risk factors for adverse mental health outcomes, and those determinants are ultimately underpinned by unfair and unjust distribution of opportunity based on the interaction between social norms and public policies.

As an example of this interaction, Shim referred to the crack-cocaine epidemic of the 1980s. She said the media presented a picture of Black women—“a highly gendered, highly racialized picture that Black women were really putting the needs of themselves and their interest in crack-cocaine above the care for their children,” and “Those social norms led to public policies.” One such policy, Shim said, was the Anti-Drug Abuse Act of 1986, which created a “sentencing disparity between crack-cocaine and powder-cocaine . . . that meant that, if you were arrested with one gram of crack-cocaine in your possession, you would get the same jail sentence as somebody who was arrested with 100 grams of powder-cocaine.” This policy led to a number of social determinants of health being activated, including poverty, difficulty accessing employment, and adverse childhood experiences. She explained that this is just one example of a policy that has “led to unfair and unjust distribution of opportunity, activating the social determinants of mental health” which can lead to poor health outcomes.

Shim went on to say that “we have different ideas about people, and therefore different policies that then lead to differences in health outcomes.” One example is postpartum depression screening. Shim said, Black, Asian, Native American, Hawaiian, Alaskan Native, and multiracial women are less likely to be screened for postpartum depression compared to White women, as are women with Medicaid compared to women with private insurance.

Shim ended her remarks by discussing high level solutions. She said that solutions must focus on equity rather than equality, meaning “We customize the tools to identify and address the inequality so we focus on giving the particular population what [it] needs to be successful.” She noted that equity work must be coupled with justice: in other words, “fix[ing] the system to offer equal access to both tools and opportunities.”

DISCUSSION

To close the webinar, speakers responded to questions posed by audience members.

Speakers were asked to discuss how restrictions on access to reproductive health care affect exposure to IPV. Miller emphasized that “limiting women’s access to health care, including mental health care and access to abortion, increases vulnerability for . . . continued experiences of abuse.” She explained that it’s critical to address ways in which “policies and institutional decisions really impact and increase vulnerability for those who are experiencing marginalization and oppression.” Biggs echoed that access is critical and highlighted that telehealth abortion care can provide more accessible options for certain individuals, particularly those who want to keep the decision private, such as those in violent relationships.

Speakers also shared insights on interventions to reduce the high rate of maternal mortality in the United States, which is particularly high among Black women. Burnett-Zeigler noted that while the Black maternal health crisis has received attention, any interventions must also consider the “role of trauma and the disproportionate burden of stress in the lives of Black women” and the ways in which these processes affect maternal health outcomes. Burnett-Zeigler hopes to see implementation of stress management and “trauma support intervention . . . available for all Black women in pregnancy.” Shim said, “Whenever we are talking about the negative health consequences of oppression,” it is also crucial to think beyond medical interventions and consider opportunities to promote economic and reproductive justice. Miller added that addressing firearm violence should be part of discussions about reducing maternal mortality and intimate partner violence.

REFERENCES

DISCLAIMER This Proceedings of a Workshop—in Brief has been prepared by Jamie Durana as a factual summary of what occurred at the meeting. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

COMMITTEE MEMBERS Claire Brindis (Chair), University of California, San Francisco; Wanda Barfield (Ex Officio Member), Centers for Disease Control and Prevention; Alison N. Cernich (Ex Officio Member), Eunice Kennedy Shriver National Institute of Child Health and Human Development; Andreia Alexander, Indiana University; Elizabeth Ananat, Columbia University and National Bureau of Economic Research; Bruce N. Calonge, University of Colorado; Judy Chang, University of Pittsburgh; Ellen Wright Clayton, Vanderbilt University; Cat Dymond, Atlanta Birth Center; Michelle Bratcher Goodwin, Georgetown University; Barbara J. Grosz, Harvard University; Vincent Guilamo-Ramos, Johns Hopkins University; Lisa Harris, University of Michigan; Justin R. Lappen, Cleveland Clinic and Case Western Reserve University; Monica McLemore, University of Washington; Rebecca R. Richards-Kortum, Rice University; Sara Rosenbaum, George Washington University; Yvette Roubideaux, University of Colorado; Alina Salganicoff, KFF; Susan C. Scrimshaw, University of Illinois at Chicago; LeKara Simmons, AMAZE; Melissa Simon, Northwestern University; Lisa Simpson, University of South Florida and George Washington University; Tracy A. Weitz, American University and Center for American Progress; Katherine L. Wisner, Children’s National Hospital and George Washington University.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Zewditu Demissie, US Public Health Service Commissioned Corps and Reid Mergler, University of Pennsylvania. Leslie Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS This workshop was partially supported by the Standing Committee on Reproductive Health, Equity, and Society.

STAFF Julie Pavlin, Senior Board Director; Ashley Bear, Board Director; Natacha Blain, Senior Board Director; Priyanka Nalamada, Program Officer; Laura DeStefano, Director of Strategic Communications & Engagement; Melissa Laitner, Senior Program Officer, Special Assistant to the President; Adaeze Okoroajuzie, Senior Program Assistant; and Kavita Arora Shah, Consultant.

For additional information regarding the workshop, visit http://www.nationalacademies.org/our-work/standing-committee-on-reproductive-health-equity-and-society.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2025. Examining critical issues at the intersection between mental health and reproductive health: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/29053.

Health and Medicine Division Division of Behavioral and Social Sciences and Education National Academy of Medicine Policy and Global Affairs Copyright 2025 by the National Academy of Sciences. All rights reserved.