UCSF

Mental health conditions are a leading cause of pregnancy-related death in the United States (U.S.) and they are referred to as the most common complication of childbirth. Pregnancy is a social experience that unfolds differently across cultures and populations, and the perinatal period is emotionally and physically complex and relationally transformative. Yet, the predominant obstetric model of perinatal healthcare in the U.S. does not reflect the multidimensionality of pregnancy and postpartum health, leaving considerable gaps in care. As perinatal health outcomes in the U.S. worsen (e.g., birth and medical trauma; high depression/anxiety, suicide, and drug overdose rates), scholars and advocates have highlighted the intersectional impact of racism and misogyny on pregnancy-related death and injury, including harmful mental health outcomes, most significantly impacting Black and Indigenous women. Creating solutions to improve perinatal health outcomes and equity for all birthing people in the U.S. is urgent and must be responsive to mental health needs and the social, structural, emotional, spiritual, and cultural aspects of perinatal health and healthcare. This dissertation takes a sociological approach to understanding the dynamics of mental health integration in perinatal healthcare in three key ways, including (1) tracing the implementation of standardized mental health screening and co-location of mental health professionals in obstetric settings, (2) exploring perinatal healthcare clinicians’ efforts to attend to their pregnant patients’ multifaceted needs, and (3) investigating pregnant and postpartum people’s experiences of their perinatal mental healthcare. Using constructivist grounded theory, I conducted 75 hours of ethnographic observation with one behavioral health team embedded in an obstetric setting and 82 in-depth interviews with pregnant and postpartum people and interprofessional perinatal healthcare clinicians between June 2019 and December 2021. This study reveals the possibilities and consequences of standardized mental health screening and behavioral health team integration in perinatal healthcare, primarily in obstetric settings. I describe how a combination of structural constraints impede obstetric clinicians’ ability to address patients’ mental health. I illustrate two strategies mental health clinicians use in obstetric settings to navigate high patient volume and the challenges imposed by medical authority and interprofessional hierarchy. These strategies include knowledge brokering to normalize mental health issues in pregnancy and improve their colleagues’ competencies and leaning on standardized care logics in the medical model to enforce professional boundaries around their scope of practice. I next show how midwives and obstetricians strive to implement perinatal healthcare that encompasses the mental well-being of pregnant and postpartum people. I describe how this resembles a whole person health framework that is structurally facilitated or impeded in different practice settings. Finally, I demonstrate the consequences of the social construction of risk in obstetric care, arguing that the institution of obstetrics routinely takes up some aspects of health as a cause for concern while diminishing the clinical significance of others. I show how obstetrics’ current form of surveillance medicine directly harms pregnant and postpartum people’s mental health. Despite it being a well-intended intervention for perinatal health, I found that integrating mental healthcare in biomedically-structured perinatal care leads to challenging interprofessional negotiations and creates a new field of risk for surveillance medicine to address. In full, this project expands on sociological literatures to analyze perinatal healthcare in the U.S. with a focus on integration of mental health into obstetric settings. I elucidate the consequences of integration, which include enforcement of the mind-body binary, the biomedicalization of pregnancy and childbirth, and the persistent marginalization of midwives and mental health clinicians in the organization of healthcare. This research contributes to our understanding of the misalignment between universal needs and lived experience and the culturally and structurally biomedicalized approach to pregnancy, childbirth, and postpartum in the U.S. It points to the need for policy change and comprehensive care that is better sensitized to mental health as a predominant health-related concern in the perinatal period.