Reproductive Justice: A Framework for Improving Maternal Mental Health

According to Winnicott, “the foundations of health are laid down by the ordinary mother in her ordinary loving care of her own baby” (1973, p. 17). Tragically, the maternal mortality rate in the United States is currently 2-3 times greater than in similar high-income countries and has been on the rise since 2000 (Gunja, et al., 2024). Recent national efforts to change and address this preventable crisis include the Black Maternal Momnibus Act of 2021 and the U.S. Health and Human Services Call to Action to Improve Maternal Health. Recent data suggests an improvement, with a decrease in maternal mortality in 2022 (817 deaths) when compared to 2021 (1,205 deaths) (Hoyert, 2024). Nonetheless, much work remains. Mental health conditions are the most frequent underlying cause of pregnancy-related deaths in the U.S. (Trost et al., 2024). Consequently, maternal mental health is receiving more recognition as a pivotal factor for reducing adverse maternal-infant outcomes and promoting women’s health.

Nurses must develop competency in reproductive and maternal health care through education and training focusing on integrating mental health care into all healthcare. This is especially true for perinatal mental health conditions and care for pregnant and postpartum people with substance use disorders. Unfortunately, most nurses receive limited (or no) education in maternal mental health care (Posmontier et al., 2022). Nurses’ limited knowledge, skills, and abilities in maternal mental health care is unexpected, given the fact that the majority of mental health patients are women, over 80% of all women will experience at least one pregnancy, and nearly all will have menstrual cycles and go through menopause (CDC, 2022). The Reproductive Justice movement presents a framework emphasizing access to comprehensive healthcare, especially reproductive health care, as a right for all people (Ross & Solinger, 2017). The purpose of this article is to review the current maternal mental health crisis through the lens of Reproductive Justice. By utilizing the three Reproductive Justice principles as a framework, this article will identify action steps that nurses can take today to help create a culture of health for mothers and babies.

Maternal Mortality in the U.S.
Approximately 3.6 million women give birth in the U.S. each year (Hamilton et al., 2024). Childbirth is one of the most common reasons for hospital admission among non-elderly people, and cesarean delivery is the most common surgical procedure in our nation. Despite improved access to advanced medical care, severe maternal morbidity and mortality rates in the U.S. increased by over 200% between 1993 and 2014 (CDC, 2022). In 2021, there were 1,205 maternal deaths in the U.S., representing a maternal mortality rate of 32.9 per 100,00 live births, compared with 861 deaths in 2020 and 754 deaths in 2019 (Hoyert, 2024). U.S. maternal mortality rates continue to rise and are over three times the rates of other high-income countries (Gunja et al., 2024).

For non-Hispanic Black mothers, the mortality rate is exceptionally high (2.6%) when compared to non-Hispanic White birthing persons (Gunja et al., 2024). Although not necessarily a new or unknown problem to healthcare community members (Johnson et al., 2006; Lu et al., 2010), this important issue has been widely publicized through the award-winning journalism of Nina Martin that first appeared in 2017. This investigative journalist was featured in the recently released documentary “American Delivery” (Frank & Jones, 2024), which explores the maternal health crisis and nurses’ role in listening to women and offering birth choices.

Maternal Mental Health
Improving maternal mental health in the U.S. starts with increasing access to treatment and recovery support systems that are safe, reliable, and provide quality community-based care. Data suggests that women develop mental health problems at significantly higher rates than men, with prevalence rates for any mental illness higher for women (22.3%) than men (15.1%) (Taiwo et al., 2024). Women are twice as likely as men to develop major depressive disorder, with 10%-15% of women experiencing depression during the perinatal period. In fact, during pregnancy and postpartum, one in five women is diagnosed with a mental health condition of some kind (Taiwo et al., 2024). Perinatal Mood and Anxiety Disorders (PMAD), such as Improving maternal mental health in the U.S. starts with increasing access to treatment and recovery support systems that are safe, reliable, and provide quality community-based care. depression, are the most common and most unrecognized complications during the perinatal period. Moreover, mental health complications have been identified by the Centers for Disease Control and Prevention (CDC) as the leading cause of pregnancy-related death in the United States (Trost et al., 2024). Recognition of mental health challenges complicated by pregnancy have led to a renewed focus on high-quality reproductive and maternal mental health care to be safely delivered to all individuals of reproductive potential.

The World Health Organization (WHO) defines reproductive health as “a state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes” (WHO 2024). According to the Reproductive Justice framework, all fertile persons require a safe and dignified context for fertility management, childbirth, and parenting (Ross & Solinger, 2017). The preconception and perinatal period offers an ideal timeframe for nurses to help identify maternal mental health conditions and intervene. The three principles of the Reproductive Justice movement offer a framework to assist nurses and other interprofessional partners with improving maternal and infant health outcomes.

Reproductive Justice Overview

The Reproductive Justice movement started with a small group of 12 concerned pro-choice Black female conference attendees at an event in 1994 (Ross & Solinger, 2017). While these pioneers recognized the importance of abortion as a healthcare option, they also identified the need for parents to have access to safe and dignified contexts for the experiences of childbirth and motherhood, including access to healthcare, education, financial stability, and childcare. These leaders saw a gap in care and wanted to make a difference. Empowering people to make their own choices about having and caring for children, the Reproductive Justice movement has grown over the decades and continues to galvanize organizations and advocates to promote reproductive health (Ross & Solinger, 2017).

Loretta Ross, one of the founders of this movement, defined reproductive justice in the following terms: “Reproductive justice is a contemporary framework for activism and for thinking about the experience of reproduction. It is also a political movement that slices reproductive rights with social justice to achieve reproductive justice” (Ross & Solinger, 2017, p. 9). Building upon this definition are the three primary principles of reproductive health: 1) the right not to have a child; 2) the right to have a child; and 3) the right to parent in safe and healthy environments (Ross & Solinger, 2017). In other words, reproductive justice concerns fertility management, childbirth, and parenting. Using these three principles of reproductive justice, I will now outline specific action steps that nurses can take to promote reproductive mental health (see Table 1).

Table 1. (option 1)

Table 1. (option 2)

Reproductive Justice Principle 1: The Right Not to Have a Child

Access to Abortion
Since the 2022 Dobbs v. Jackson Women’s Health Organization U.S. Supreme Court decision to overturn Roe v. Wade, accessibility to abortion has drastically changed and varies by geographical location. For this reason, nurses need to know the current laws within their state(s) and associated healthcare organization policies where they practice locally. With these changes to abortion care, the importance of preconception health care and accessibility to contraception has become a renewed focus (NAM, 2024).

Preconception Health Care
Nurses need to be competent and proficient in preconception health teaching and promotion. Preconception health involves person-centered care for individuals and couples before they become parents. Preconception care focuses on 1) promoting women’s health and reducing adverse maternal-infant outcomes; 2) increasing the likelihood of conception when pregnancy is desired; and 3) providing contraceptive education and promotion to help prevent unintended pregnancies (AAFP, 2015; Harper et al., 2023). Topics for preconception health teaching, promotion, and associated recommended interventions include chronic disease management, nutritional status and healthy body weight, family and genetic history, importance of folic acid, updated immunization status, screening for intimate partner violence, social and behavioral history, substance use assessment, screening for infectious disease Nurses are uniquely positioned throughout our healthcare systems to collaborate interprofessionally and promote preconception care.and STIs, and contraception and reproductive planning (AAFP, 2015; Close et al., 2023). Preconception health teaching and promotion is closely aligned with the Healthy People 2030 goal for Family Planning: “Improve pregnancy planning and prevent unintended pregnancy” (Healthy People 2030).

Nurses are uniquely positioned throughout our healthcare systems to collaborate interprofessionally and promote preconception care. Some of the goals for nurses engaged in preconception care include providing education to individuals and couples, assessing for risks, and connecting individuals and couples to appropriate evidence-based care to help decrease the likelihood of poor pregnancy-related outcomes.

Contraception
As is true with most health care, prevention is critical. Preventative care is at the heart of preconception health teaching and promotion. Of particular importance for nurses following Reproductive Justice Principle 1 (i.e., the right not to have a child) is effective contraception. Approximately 50% of all pregnancies in the U.S. are unintended and are disproportionately experienced by low-income populations (Taiwo et al., 2024). Unintended pregnancies have been associated with adverse outcomes for both women and infants (Harper et al., 2023).

Nurses following Reproductive Justice Principle 1 (i.e., the right not to have a child) need to be aware of state and local laws related to abortion access and be competent and proficient in contraceptive health teaching and promotion. Nurses are uniquely positioned to promote: 1) reproductive control and autonomy; 2) the benefits of a planned pregnancy; 3) exploration of ambivalence surrounding contraception use; and 4) promotion of congruent contraceptive behaviors that match preconception intention and planning for individuals and couples (Borrero et al., 2015). When pregnancy is not desired (Stulberg et al., 2020), nurses can promote safe sex and evidence-based contraception (Britton et al., 2020).

Reproductive Psychiatric Advance Directive
Promoting preconception care and reproductive autonomy is especially important for the vulnerable population of women of reproductive potential with serious mental illness. An innovative tool that deserves closer evaluation is the Reproductive Psychiatric Advance Directive (Reproductive PAD) (Dossett et al., 2023). A psychiatric advance directive (PAD) is a Promoting preconception care and reproductive autonomy is especially important for the vulnerable population of women of reproductive potential with serious mental illness. written document, completed during times of stability, that enables individuals with serious mental illness to articulate and pre-plan their medical and psychiatric care choices, including reproduction and pregnancy (Dossett et al., 2023). A Reproductive PAD is a person-centered tool that promotes reproductive autonomy that nurses and interprofessional care teams may consider with clients. It empowers individuals to make choices about having and caring for children in the event they experience a mental health crisis, impacting their decision-making capabilities.

Reproductive Justice Principle 2: The Right to Have a Child

Perinatal Mood and Anxiety Disorder (PMAD)
The second principle of Reproductive Justice, the right to have a child, and the third principle, the right to parent in safe and healthy environments, are closely related. The preconception and perinatal period (i.e., pregnancy and first year postpartum) provides nurses with an ideal window of time to screen for unmet mental health and social needs. As noted above, pregnant women are at an increased risk of developing mental health condition such as depression and anxiety. One in five pregnant and postpartum individuals experience a Perinatal Mood and Anxiety Disorder (PMAD) (Taiwo et al., 2024). PMADs are the most common complication during and after pregnancy. Sadly, PMADS are conditions that often go undiagnosed and untreated (Morain et al., 2023). PMADs are associated with maternal hypertension, diabetes, preeclampsia, preterm birth, low birth weight, cessation of breastfeeding, neurodevelopmental delay, behavioral problems, attachment disorders, and other preventable risks to mother and child (Taiwo et al., 2024). As noted above, mental health complications have been identified by the CDC as the leading cause of pregnancy-related death in the United States (Trost et al., 2024).

Screening, Brief Intervention, and Referral for Treatment (SBIRT) Model
To improve and provide care to individuals with a perinatal mental health condition, we must improve screening and early detection of depression, anxiety, bipolar disorder, suicidality, substance use, and postpartum psychosis (ACOG, 2023). Nurses are uniquely positioned throughout the health care system to help screen for these perinatal mental health conditions. A Screening, Brief Intervention, and Referral for Treatment Model (SBIRT) model for the nurse and interprofessional team has proven its value (Hargraves et al., 2017). Substance Abuse and Mental Health Services Administration (SAMHSA) defines the three components of SBIRT as follows: 1) Screening quickly assesses the severity and identifies the appropriate level of treatment; 2) Brief Intervention focuses on increasing insight and awareness and motivation toward behavioral change; 3) Referral to Treatment provides those identified as needing more extensive treatment with access to specialty care (SAMHSA, 2017).

Use of the SBIRT model of care continues to expand due to easily accessible, validated screening tools that interprofessional team members may implement across various health care settings. Recommended screening tools for perinatal mental health screening and substance use include the Edinburg Postnatal Depression Scale (EPDS), Patient Health Questionnaire -9 (PHQ-9), Generalized Anxiety Scale-7 (GAD-7), Mood Disorder Questionnaire (MDQ), Primary Care PTSD Screen for DSM-5, and the 5Ps Prenatal Substance Abuse Screen for Alcohol and Drugs (ACOG, 2023). This SBIRT model of care promotes the importance of care coordination and interprofessional partnerships through screening, provision of treatment options, and appropriate referral for follow-up perinatal mental health services.

A reproductive justice framework recognizes that social determinants impact women’s reproductive health and the context of giving birth (i.e., Reproductive Justice Principle 2) and parenting (i.e., Reproductive Justice Principle 3). With the addition of a newborn into a family, perinatal mental health conditions can challenge the system’s ability to adapt and function (Wisner, 2024).

Reproductive Justice Principle 3 - The Right to Parent Children in Safe and Healthy Environments

Social Determinants of Health (SDOH)
Perinatal mental health conditions frequently co-occur with other social and contextual challenges related to Reproductive Justice Principle 3: the right to parent children in safe and healthy environments. The World Health Organization defines the social determinants of health (SDOH) as the conditions in which people are born, live, learn, work, and age (WHO, 2024). Healthy People 2030 organized the SDOH into five domains, which include: 1) economic stability; 2) education access and quality; 3) neighborhood and built environment; 4) Perinatal mental health conditions frequently co-occur with other social and contextual challenges related to Reproductive Justice... health care access and quality; and 5) social/community context (Healthy People 2030). SDOH are believed to account for 40% of an individual’s health status and are essential contributors to health disparities and inequalities that impact maternal and child health outcomes (Jones et al., 2009). 

Social Support
Social support from family and friends has been recognized as an important contributor to SDOH that influences mental and physical health (Bedaso et al., 2021). From a health promotion perspective, social support is defined as functional support that leads the receiver of the support to feel cared for and valued, along with a sense of belonging to a larger social network (De Sousa Machado et al., 2020). Low social support is associated with significant risks for perinatal and/or postpartum mental health conditions and impaired maternal-infant bonding. Conversely, strong social support has been shown to have protective properties against postpartum depression and can promote general health and well-being (Bedaso et al., 2021).

Nurses are uniquely positioned throughout our nation’s healthcare systems to discuss with pregnant women the level and source of perceived social support they receive. Strong social support has been identified as a significant buffer against PMAD. Nurses and interprofessional partners can implement social support assessment tools, such as the Multidimensional Scale of Perceived Social Support (MSPSS) (Dahlem et al., 1991) or the Maternity Social Support Scale (MSSS) (Webster et al., 2000).

Social Prescribing
Medical treatments typically do not work for societal problems such as low social support. Nurses, however, can still leverage the determinants of health when seeking to improve maternal and infant outcomes. There is growing evidence for the value of social prescribing (Zisman-Ilani et al., 2023). Social prescription is a person-centered care plan based on the preferences, goals, and perinatal needs of the mother and/or couple. Closely related to care coordination, social prescribing provides a means through which the nurse and other interprofessional partners can address the social needs of the perinatal individual and/or couple by connecting them to opportunities and services available in the community that improve health and well-being. Social prescribing prioritizes what matters to the individual, increases a sense of belonging, and can improve emotional regulation (Zisman-Ilani et al., 2023). Examples of social prescribing are numerous (i.e., volunteering, hobby groups, etc.) and based on what is important to the individual or couple. Specific examples could include reconnecting with a faith community or attending a breastfeeding support group.

Nurses can seek ways to develop and expand community resources and support networks, such as peer support groups and community outreach programs (Girardi et al., 2023). A critical resource for social support that nurses need to be aware of is Postpartum Support International (PSI). PSI offers over 50 free and virtual support groups weekly, a 24/7 free and confidential National Maternal Mental Health Hotline for pregnant and new moms, and a free resource app for families and caregivers (PSI, 2024).

Violence & Safety
Pregnant and postpartum individuals are twice as likely to die by homicide than other pregnancy-related causes (i.e., hemorrhage or sepsis) (Wallace et al., 2021). Most of these deaths involve firearm violence. In addition to assessing for social support, nurses need to routinely assess for intimate partner violence (IPV) and engage in routine assessment for intimate partner violence (USPSFT, 2018; ENA, 2019) and firearm access and safe storage (Wallace et al., 2021; Tudhope, 2023).

The Missing Half in Reproductive Health
The male partner is often missing in conversations related to reproductive and preconception health. The presence of supportive fathers has been recognized to improve pregnancy and infant health outcomes (Alio et al., 2011). When appropriate, nurses can help promote paternal involvement during the perinatal period.

Specifically missing in conversations related to reproductive and preconception health is any discussion of men and their role and responsibility in fertility management and the use of contraceptives. Contraceptive use is typically taught and discussed as a “women’s issue.” A recent voice that invites men into this important reproductive justice conversation can be found in the author/blogger Gabrielle Blair’s (2022) book titled “Ejaculate Responsibly: A Whole New Way to Think About Abortion.” In this short book, the non-healthcare professional author reminds the reader of essential and often overlooked principles of reproductive health that can directly impact maternal mental health. She begins by making the following bold claim: “An unwanted pregnancy only happens if a man ejaculates irresponsibly—if he deposits sperm into a vagina when he and his partner are not trying to conceive. It’s not asking a lot for men to avoid this” (p. 2). The rest of this short and well-articulated argument compares and contrasts key features of reproductive health and invites men to participate in fertility management.

Education and Training
Nurses need to develop proficiency in reproductive and maternal mental health care through improved education and training in alignment with the American Nurses Association (ANA) Scope and Standards of Practice (ANA, 2024) and Code of Ethics (ANA, 2015). Since the release of the AACN Essentials by the American Association of Colleges of Nurses in 2021, there has been an intentional shift to competency-based education within nursing (AACN, 2021). The AACN Essentials identify 10 domains (i.e., areas of competence) essential for nursing practice. While all 10 domains are important to nursing practice and, more specifically, the promotion of reproductive health, Domain 2: Person-Centered Care, Domain 3: Population Health, and Domain 7: Systems-Based Care are particularly important.

The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) released the 9^th Edition of AWHONNN’s Standards for Professional Nursing Practice in the Care of Women, Newborns, and People Across the Life Span (AWHONN, 2023). These standards are based upon the American Nurses Association (ANA) Scope and Standards of Practice, Fourth Edition. According to this important document, these standards “apply to registered nurses who provide preceonception, interconception, antepartum, intrapartum, postpartum, and newborn care in high- and low-risk settings; sexual and reproductive health care; and care across the patient’s life span” (p. 11).

Multiple approaches and resources can help improve competency-based nursing education and training in reproductive and maternal mental health care. This author has enhanced the competency-based curriculum for a post-graduate Integrative Community Psychiatry Nurse Practitioner Fellowship Program. Recently, Psychiatric Mental Health Nurse Practitioner (PMHNP) Fellows, learners in our 12-month accredited fellowship program, completed the PSI 3-day training that prepares them for Certification in Perinatal Mental Health (PSI, 2024). These four PMHNP Fellows also participate in weekly virtual rounds at the Center for Women’s Mental Health at Massachusetts General Hospital. Over the next four years, our program will prepare 16 new PMHNPs with proficiency in reproductive mental health. Nursing Educators and Nursing Professional Development specialists must identify similar opportunities and resources to ensure competency and strengthen expertise in reproductive and maternal mental health training.

Conclusions

The United States has the highest rate of maternal deaths compared to any high-income country, with the highest rate for Black women. Mental health conditions such as Perinatal Mood and Anxiety Disorders (PMAD) are the most common complication during the perinatal period, and the leading cause of pregnancy-related deaths in the U.S. Nurses following a Reproductive Justice framework can improve perinatal mental health and support a culture of health for mother and baby.

Author

James K. Tudhope, DNP, APRN, PMHNP-BC, NPD-BC
Email: jtudhope@kent.edu
ORCID ID: 0000-0002-2910-6410

James K. Tudhope, DNP, APRN, PMHNP-BC, NPD-BC has been a registered nurse since 2001, a licensed professional counselor since 2008, and a Psychiatric Mental Health Nurse Practitioner since 2013. He is an Assistant Professor at the College of Nursing, Kent State University, where he coordinates the Psychiatric Mental Health NP Concentration. Additionally, he is the Medication Clinic Coordinator and Program Director for the Integrated Community Psychiatry Nurse Practitioner Fellowship Program at Portage Path Behavioral Health in Akron, Ohio. Dr. Tudhope’s practice-based research focuses on professional development for nurses and the design and development of advanced practice registered nurse (APRN) post-graduate education programs.