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    Women's Reproductive Mental Health

    May 5 2022

    What exactly is women's reproductive mental health? Psychiatrist Dr. Amalia Londoño and reproductive endocrinologist Dr. Eleni Jaswa join us to talk about what women's reproductive mental health entails, the disparities that exist, and policies that can help improve the care we provide to moms and their families.

    Dr. Greenwood Jaswa is a reproductive endocrinologist and fertility specialist who cares for patients seeking evaluation and treatment of infertility, planning for future conception, dealing with recurrent miscarriages, and experiencing menstrual abnormalities. Dr. Greenwood Jaswa earned her Master of Science degree in biological sciences at Stanford University and completed her medical degree at Weill Cornell Medicine. She completed a residency in obstetrics and gynecology and a fellowship in reproductive endocrinology and infertility at the University of California San Francisco.

    Dr. Amalia Londoño Tobón is a psychiatrist and researcher with expertise in perinatal, childhood, family, and cultural aspects of mental health. Dr. Londoño Tobón attended Stanford University, where she received her medical degree. She went on to complete her psychiatry residency and child psychiatry fellowship at Yale University as well as a perinatal mental health research and clinical fellowship at Brown University.

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    Transcript for Audio

    Kit Hall: Hello and welcome to Mentally Healthy Nation, a podcast from the American Psychiatric Association Foundation. I'm today's host, Kit Hall. Today, we're going to talk about women's reproductive mental health.

    Kit Hall: For this conversation, I'm honored to be joined by two esteemed guests, Dr. Eleni Jaswa and Dr. Amalia Londoño. Dr. Jaswa, who's one of our foundation board members, is a reproductive endocrinologist and fertility specialist who cares for patients seeking evaluation and treatment of infertility and patients planning for future conception.

    Kit Hall: Her research interests include mental health and wellness, recurrent pregnancy loss, fertility, preservation methods and more. Dr. Amalia Londoño is a psychiatrist and researcher with expertise in perinatal, childhood, family and cultural aspects of mental health. She has authored several publications in scientific journals, provided expert interviews and presented at national and international venues.

    Kit Hall: Thank you both so much for being here today. Can you talk about what women's reproductive mental health means, how it relates to your fields and a bit about why you chose the specialty?

    Dr. Eleni Jaswa: Hi, good morning. Thanks so much for having me, Kit, and for that very warm welcome. I'm Eleni Jaswa and I work as an assistant professor in the Department of Obstetrics, Gynecology and Reproductive sciences at the University of California, San Francisco where I specialize in reproductive endocrinology.

    Dr. Eleni Jaswa: That means I do a combination of clinical work and research, caring primarily for individuals and folks who are trying to build their families and need a little bit of assistance with that. As far as how I got into this field, I initially chose to go into medicine because as a young girl, I lost my mom to breast cancer when I was six. I thought I'd do something cancer related, but ultimately found that to be a little too close to home and too sad and was able to invert the paradigm, flip that on its head and celebrate motherhood and take care of young women and moms in a totally different way through my work in fertility and family building.

    Dr. Eleni Jaswa: And so that's been my mission, my calling, to celebrate parenthood, motherhood and take care of parents when I never was able to as a young girl. As far as women's reproductive health and how it applies to my field, as you might imagine, nobody really wants to see an infertility doctor. I think we're raised to think in Disney terms that you meet someone, fall in love, and the rest is history, that having a baby is pretty simple.

    Dr. Eleni Jaswa: But for a lot of people, it's a big challenge. Some research even suggests more distressing to deal with things like infertility than a cancer diagnosis. And so in my clinical work, as well as research interests, I do see a lot of distress, a lot of depression, a lot of anxiety and work closely with reproductive psychologists and providing holistic supportive care for individuals who are struggling to build their family.

    Dr. Eleni Jaswa: Postpartum depression absolutely is a huge component of women's reproductive health. But from where I stand in the reproductive journey, that's a lot further along more distal to the experiences I see. I see primarily individuals struggling to build family, dealing with loss of miscarriage or repeated pregnancy losses, trying to better understand how to think of even their identity, young individuals, perhaps freezing eggs, because they're not where they thought they'd be in their life and having a reckoning with thoughts about future family.

    Dr. Eleni Jaswa: To me, that's a long-winded way to say women's reproductive mental health starts a lot earlier on in the pathway from just envisioning how reproduction, how family, how identity, how legacy is part of one's narrative and sometimes encountering challenges along the way to realize those dreams and that's my privilege to help people in that element of their lives.

    Kit Hall: Thank you. Thanks for sharing that. How about you, Dr. Londoño?

    Dr. Amalia Londoño: Well, first of all, thank you so much for inviting me to be with you and I love Dr. Jaswa's very insightful way of thinking about mental health. I am a psychiatrist, so that means I went to medical school and then did psychiatry training. I did specific training in perinatal mental health and women's mental health.

    Dr. Amalia Londoño: That means that I had specific training to work with individuals along the life course. In terms of reproductive psychiatry, it really encompasses thinking about in this specific instance, women through a biological, a psychological and a social lens and thinking about all the different factors that women have that are different than other individuals, than men, people that identify as other genders.

    Dr. Amalia Londoño: For example, we know that Dr. Jaswa knows more about this for sure as an obstetrician gynecologist, there are different hormonal experiences that individuals have and there's different time points throughout the life course. For example, puberty, menstrual cycle changes during pregnancy, during postpartum, during menopause and all those biological changes really impact not only the health in general, but also the mental health and wellbeing.

    Dr. Amalia Londoño: And then from this psychosocial aspect, we know that women throughout history have had to experience different challenges that also make their lives and their experiences different and affect their mental health. In terms of how I came to this space from a personal standpoint, I have had family members, friends that have experienced a range of mental health conditions and that drove me first to going to psychiatry. I also found that particularly during the perinatal period and even when I say the perinatal period, that's conception through one year, postpartum is usually what we define it, but now we're finding out that postpartum really is much more prolonged and we have studies that postpartum depression affects people up to like three years.

    Dr. Amalia Londoño: We also know from Dr. Jaswa that those experiences even preconception really impact the wellbeing of perinatal individuals at different points. It's really important to think about all the different aspects. This period, we know it's a very sensitive period biologically, and that really drives me to being in this field because we know that this period is very hard. It's also very exciting. There's a lot of wonderful things as well, but we need to support women and their families during that process so that they can feel good. They can also be able to overcome challenges and we can provide them with the best support we can.

    Kit Hall: Thank you. I know a lot of us may be tired of talking about COVID 19, but I think it's important to understand how the pandemic and the associated isolation and anxiety have contributed to perinatal and postpartum mental health, especially for those who had tougher, traumatic pregnancies and births and those with mental health diagnoses. What have you witnessed in your practices related to all this?

    Dr. Eleni Jaswa: Yeah, it's a really good question, Kit. Starting from my intersection with the patients in the preconception period, it certainly has been stressful in the sense of the increasing isolation. My patients who have already historically had a tough time, I notice, are increasingly challenged by the social isolation component where I think most people have historically blown off steam by going out with friends, talking through what they're experiencing and now with lockdowns and everything, that had became more challenging.

    Dr. Eleni Jaswa: There's also been shifts in the provision of care, of center care, for example, where patients were used to going in every month to see their OB. And now most things are done virtually through telehealth communication for many medical systems. Dr. Londoño could speak better to this, but I'm not sure that everyone feels as comfortable, perhaps sharing their deepest concerns through a two-dimensional format as they might have historically with frequent in-person touch points.

    Dr. Eleni Jaswa: Just the act of a physician of actually reaching out and touching a patient can really engender a sense of trust and a little bit more connection. What I've seen is an exacerbation of overall distress with perhaps social isolation, depression, anxiety that are ongoing in addition to the challenges of a telehealth relationship pre-dominating from the patient and provider perspective throughout pregnancy.

    Dr. Amalia Londoño: I couldn't agree more with Dr. Jaswa. I think the pandemic has really been such a huge change for individuals and that has really impacted different communities very, very differently. But in general, we know even from the beginning, we were hearing this very upsetting stories of women having to go into labor on their own, not being able to be with family members during such a big event of their lives and now, things have changed and people can go with their partners, but it's not the same.

    Dr. Amalia Londoño: There's still restrictions. Not everybody can go and have a lot of visitors. There's also these fears about, well, if I go out with support systems, what is the risk to my baby and to me and I think that continues to go on. We're still in the pandemic because the pandemic has not passed.

    Dr. Eleni Jaswa: Absolutely. From personal experience as the mom of a newborn in the heart of the pandemic in summer of 2020, I just felt the added imposition of isolation just as you mentioned, Dr. Londoño. Where having to think about introducing your newborn to their family as a potential biologic threat is just such a sad way that we've kind of changed the way we see the world, seeing each other not as part of an interconnected network, but instead, a potential health and safety threat.

    Dr. Eleni Jaswa: That was a big challenge for me and a sad kind of loss and source of anxiety for me personally. As things continue to open up and continue to be safer and now the vaccines are available and safety measures are improving, I look with great optimism at the future as we can reconnect and reframe the way that we perceive one another and our role together.

    Dr. Amalia Londoño: I also had a child during the pandemic. In that way, we potentially experience similar things. I think also very hard part was how people feel different about the safety measures and the challenges that can come up in the family system and the tensions. It's already hard. It's like the common postpartum conflicts that may arise, like do you parent this way, do you feed this way? Do you put them to sleep this way? But on top of that, it's like do we allow somebody in the house or not? Do we go somewhere or not?

    Dr. Amalia Londoño: That can cause a lot of conflict in families which add so much stress. I've seen it in the patients that I care for and that has been very hard. They may already have traumatic experiences and that event really exacerbates their traumatic symptoms, their depression, their anxiety or their psychosis, whatever symptoms they're dealing with. When we are under more stress, we know that is going to exacerbate how we're feeling and our conditions.

    Dr. Amalia Londoño: It's not only psychiatric conditions. We know that under stress, diabetes can also worsen. Under stress, hypertension also worsens. And also, does the stressors that new families have to endure, right? Do I take my child to daycare or do I not? Do I have somebody in the house to help me or do I not? And some people don't even have the privilege of asking those questions, they just have to go to work. They've had to work throughout the pandemic to make ends meet. And so this is a very, very big change for families, for people.

    Dr. Amalia Londoño: This is a particularly sensitive period. Biologically, we know it affects families in a different way than other periods. We know it changes the brain of moms, the brain of dads, children's brains are growing rapidly. This is the period to invest and make policies and have policies that really invest in families.

    Kit Hall: A question for both of you, what disparities exist for those seeking reproductive mental healthcare, for example, for minority and underserved populations or BIPOC, low income and transgender individuals.

    Dr. Amalia Londoño: I love this question because this is an area that I really specialize in and I work in. As a Latina immigrant, Colombian American, I'm very sensitive to these issues and I also work with a lot of medically underserved populations and that's the area where I focus my research. I think there are so many disparities and inequities across healthcare. We know beginning from people being screened to people being evaluated, to people accessing treatment and quality treatment, there's so many disparities there.

    Dr. Amalia Londoño: We know in the United States in particular that certain groups due to stress burden, that they face discrimination to racism, they have to face more obstacles to receiving care. That's a long-winded way again, of saying that a lot of individuals do experience lack of access to care or decrease access to care. We also need to think about it not across the healthcare spectrum, but we know that those things are influenced as well by all the societal components that really influence care such as access to insurance, access to parental leave, access to services. So all of those are really influencing mental health, but overall health and I'll let Dr. Jaswa speak to access in terms of obstetric care and even preconception care, which I know there's a lot of disparities there as well.

    Dr. Eleni Jaswa: Yeah. I couldn't agree more with Dr. Londoño who's really an expert in this field. But absolutely from where I stand in my setting as a reproductive health specialist, we see so many dimensions of disparities. The first and most obvious as was mentioned by Dr. Londoño is really that socioeconomic disparity. So many people can't even get in the door to see a reproductive health specialist because it's generally not covered by insurance in most states.

    Dr. Eleni Jaswa: We're making progress on that from a legislative perspective, but still it's out of reach socioeconomically for most individuals struggling, for example, with infertility. And so if you can't even get in the door, you can't even access the support, some people can be seen by a physician and then have mental health challenges and need the support. But once you try to find an expert in reproductive psychiatry or psychology to support you on the continuous journey, that is the path to building families, riddled with challenges, disappointments and ultimately hopefully success, but a roller coaster for most individuals and families.

    Dr. Eleni Jaswa: There's a shortage, I think, of providers with expertise in the specific type of psychosocial support that's needed for a lot of the patients that I see. With a shortage of providers and many of whom do not take new patients and certainly not insurance, the socioeconomic barriers are huge. But that's just really the tip of the iceberg. I think another thing mentioned was just coming from different backgrounds. So whether it's different races, a different mindset with regard to religion and faith, being a same sex couple rather than heterosexual couple. There are disparities in the provision of care when the providers have a different worldview and perhaps can't meet patients where they're coming from.

    Dr. Eleni Jaswa: Something as simple as a lesbian couple filling out forms about their male partner's urologic history, which don't apply to them. These small kind of things are issues and challenges that suggest opportunities for improvement in adequately providing care that is culturally competent, specific to the individual, meets them where they're coming from and really engenders a relationship of trust.

    Dr. Eleni Jaswa: I think between provider and patient, which is so important to a good therapeutic relationship. And so many dimensions, whether they're socioeconomic, sexual orientation-based, faith-based, culturally sensitive care-based, that there's a lot of obstacles and a lot of opportunity for improving disparities, I would say.

    Kit Hall: What role can providers like you play in addressing these disparities?

    Dr. Eleni Jaswa: I think a huge part is, well, education. I think of it as like an individual level and then expanding to team-based and beyond at a systems level. At the individual level, I think the onus is on us to educate ourselves. How do people use pronouns and why does that matter in the instance of transgender care, for example? How can I provide culturally sensitive care? How do people with different religions see the world differently and what might trigger them in a way that I wouldn't have thought of from just a purely medical perspective?

    Dr. Eleni Jaswa: A lot of that is just doing the work to better understand. I'm shocked that it's 2022 and I live in San Francisco, one of the most progressive places on earth and still patients encounter insensitivities with regards to sexual orientation, gender expression and otherwise.

    Dr. Eleni Jaswa: So I think there's the individual level, but then at the systems level, like changing our paperwork. Not everybody is a woman with a man partner. I see plenty of single women, plenty of same sex couples being inclusive from the moment you hit the paperwork, let alone the front door and figuring out how to best support people in a really individual way of meeting them where they're coming from.

    Dr. Eleni Jaswa: But I think at large, the systems issues are educating and training a workforce that is diverse and looks like the people we are serving, alongside advocating for access from the legislative perspective so folks who traditionally are excluded or can't access care may perhaps have more opportunities to access it.

    Dr. Eleni Jaswa: I think telehealth has made a big change in the mental health space, as far as the geographic reach that a therapist or psychiatrist perhaps. I'd love to hear Dr. Londoño's thoughts on this, but being able to reach a greater sphere with specific expertise is great, but there's still challenges like we are licensed in California. So I can't provide care for somebody next door in Nevada, for example. There's still work to be done.

    Dr. Amalia Londoño: Yeah. I think those are great points. Telehealth has, in some ways, been a boon and has been very helpful for some people. But we do know that psychiatric care through telehealth is different and it doesn't work for everyone. I think it is a silver lining of the pandemic, I have to say, because it really has increased access in ways that we didn't see before and we have to think about how to leverage what we learn about telehealth during the pandemic to be able to provide flexible care that meets the needs of patients as we move hopefully past the pandemic and really onto the new normal.

    Dr. Amalia Londoño: I think the other thing that we need to kind of take a step back and think in terms of disparities is like that there are disparities for everyone. In general, for mental health in particular, we know that women in general are not getting appropriate mental healthcare or resources, period. All women.

    Dr. Amalia Londoño: We know that for example, in obstetrics, clinic screening for postpartum depression or even depression during pregnancy, we know that ranges from 20% to 80% in some clinics and not all obstetricians feel comfortable treating mental health. Across the board, there is this disparity and we know that certain groups, again, as Dr. Jaswa said from religious beliefs, gender identity, and race/ethnicity, different groups are experiencing added disparities.

    Dr. Amalia Londoño: We also have to think about intersectionality as well when it comes to disparities. By that, I mean like multiple intersections. So you may identify as a woman, Black and then also Hispanic and then all these things add up. And then that also affects the care that you will get or the access to care. With regards as to what we can do, I love how Dr. Jaswa started really thinking about starting with ourselves.

    Dr. Amalia Londoño: I think with regards to mental health in particular and how can we decrease disparities in mental health, there are some really neat programs that are being developed, evidence-based. For example, the Massachusetts Child Psychiatry Access Program for moms, MCPAP for moms. And this is a model, this access program model allows for the few psychiatrists that exist that focus on reproductive perinatal psychiatry to really provide support to obstetricians as they do the care because they're the ones that see most individuals and actually care for mental health of individuals, because there's just not enough mental health providers.

    Dr. Amalia Londoño: There's not enough psychiatrists, there's not enough social workers, therapists. There's just not enough psychologists to be able to meet the needs. We know that one in five individuals struggles with a mental health condition during this period. That's 20%. That's a lot of individuals and there's just not enough providers.

    Dr. Amalia Londoño: So these programs then provide consultation, to obstetricians, to pediatricians to other primary care providers that are the ones that are seeing women in the clinic and their families and screening them and then they need to support them in the clinic, in their medical home, what we call them medical home. I think that is one model that we can leverage to be able to increase access to perinatal mental health support.

    Dr. Amalia Londoño: We also need to think beyond our traditional medical models to think about peer support systems. Because women with lived experience are a great support system for each other. We know about how important it becomes for individuals during this period to have support with each other and how much we can learn from each other during this period from conception, preconception to postpartum.

    Dr. Amalia Londoño: Those networks of peer supports are really crucial. We also have other ally professions. We know that doulas reach certain communities in a way that is different from obstetricians. We also have nurse midwives, social workers, case managers, all these different professions that make up the healthcare system during this period and we really need to work together and leverage all these resources to be able to meet individuals where they're at and to be able to decrease these disparities.

    Dr. Eleni Jaswa: I think that's such a beautiful way of thinking about it, Dr. Londoño and such a just creative outside the box change the way that the provision of care looks. I think as a relatively new mom myself, new mom in a pandemic, I only began to appreciate how isolating motherhood can be in the beginning, how isolating the experience can be for variety of factors, but also as a relatively recent invention of modern society, that in most situations, a woman is at home with a baby rather than having a community of both friends and family, but also multidisciplinary support like you suggested.

    Dr. Eleni Jaswa: Kind of going back in time when generations lived together and there was more of a sense of integrated community, I think that is one thing that's lacking and can be challenging from a perinatal mental health perspective now, but being able as the physician, there's a certain role we play, but also to leverage those resources in an understaffed context while increasing the pipeline of providers is a great way to leverage our resources and enhance access and support for people in need.

    Dr. Amalia Londoño: Yeah, absolutely. I think also the fact that in our systems, there's this inequity in mental health and this kind of dichotomy of mental health and health, when really they are the same, they're one. Thinking about mental health is really integral to general health.

    Dr. Amalia Londoño: And sometimes, to really address mental health needs, we may need a therapist. But maybe to really address the mental health need of a mom, maybe we need to support her with lactation, or help her in the process of deciding whether or not it makes sense for her and for family or they and their family to chest feed or to formula feed or feed their baby in whatever way makes the most sense.

    Dr. Amalia Londoño: In order to address these disparities. In general, we just need to integrate these two systems that are so separate. Particularly during this period, they're so intertwined. All these things are so intertwined and we really need to work more together and really listen to families, listen to what their needs are, not prescribe to them what we think they need. Yes, sure. We have some knowledge and we can provide them with resources, but also listen to what they need and be able to provide them that as a way to reaching mental health and wellbeing.

    Kit Hall: You've both touched on this a bit. I know, although this episode is about women's reproductive mental health, this is obviously an issue that affects the whole family as you both noted. Can you weigh in on how these issues extend beyond the individual experiencing them and what cultural aspects need to be considered?

    Dr. Amalia Londoño: I can try to take that one. I love this question because besides kind of my role as a perinatal psychiatrist and again, this is the dichotomies that are in the healthcare system. I also trained in child & adolescent psychiatry and in that training as well, we think a lot about family systems. I think it's very important to focus on women and the issues that they struggle with. But women are not on their own during this period. It's not like, oh, a woman is just on their own and that's it and we're just treating this person or we're helping and supporting this person in their journey.

    Dr. Amalia Londoño: No, they have families. In whatever configuration that looks like, however you define family. That system really affects the woman. It affects the perinatal individual. So if they're not okay, if the perinatal individual's not okay or the woman's not okay, then that affects the whole family system, that affects the partner, that affects the infant, that affects the friend, the community.

    Dr. Amalia Londoño: And then same if like the father or the partner is not feeling well, then that also affects the woman and that also affects the child. So it is all really intertwined. The same thing for infants. Infants also may have their own health problems and that really affects the family system. There's some families that have to deal with having their baby being in the NICU. And how stressful that is for the family. How stressful and how much that impacts the woman's mental health. Going back to fathers and men and partners, we have research now that shows that partners, that men do develop perinatal depression. They also develop perinatal anxiety. These conditions are not unique to women, and we really need to think about them and really support them in their journey because this is a family unit. If we're not supporting the whole family unit, our interventions on our support will only go a certain way. It really is very important to think about the family system when we're caring for people during this period.

    Kit Hall: Thank you. Since you're both passionate about research, I'm curious to hear what gaps do you think exist in reproductive mental health research and what are the potential implications of those?

    Dr. Eleni Jaswa: I guess in my realm, in more of the preconception world, the gaps are immense. You can think of, again, systems-level structural gaps, how do we improve access? How do we integrate care to provide a holistic, positive empowering experience in a healthcare setting, which is often riddled with disappointment like infertility treatment, IVF. Even in some of my own research, just looking at women, for example, primarily single women freezing eggs to offset the risk of future age-related infertility, we started to ask women how they cataloged that experience when they had frozen eggs a couple of years prior and unearthed a prevalence of decision regret around the decision to freeze eggs. That was surprising.

    Dr. Eleni Jaswa: Until you ask the patient what their experience is and how it fits into the narrative of their life, you don't really know what treatment means beyond that bio part of the biopsychosocial model. And so even just beginning to shift the focus a bit on patient-centered outcomes beyond how many eggs did we get, how many embryos were created, how many pregnancies were generated, how many babies were born and actually asking what the human experience and some of the human costs along the way was.

    Dr. Eleni Jaswa: First, we have to identify kind of the issues in the provision of treatment and the psychosocial implications and mental health implications for folks pursuing fertility treatment specifically and then we can kind of begin to address it. I think one of the things is just turning the focus from a purely biomedical focus to actually a more holistic patient-centered human research program where we learn more about the patient experience and potential mental health repercussions that can endure for years after they leave our office.

    Dr. Eleni Jaswa: That will allow us to be able to better provide a multidisciplinary support system and care and address some of those problems. But other research, I think Dr. Londoño had a good point. Like men are often an afterthought whenever we're thinking through some of the psychosocial or mental health challenges.Certainly as reproductive endocrinologists, we're guilty of focusing much more on the women. And so it's the women who experience PTSD-like symptoms after a diagnosis of recurrent miscarriages. It's the women who have the depression and anxiety when IVF fails, but we're only beginning to really understand and appreciate how men experience that and what the implications are for them as individuals, as a couple, what that means as a family, what that means. And so starting to also open our ears to their narratives, their story, I think people, all individuals express things in different ways, but certainly until we ask, we don't really know.

    Dr. Eleni Jaswa: So I think that's another opportunity from a more couple-based/family-based approach to understand the different experiences two people looking at the exact same outcome may have in their own narrative, how that affects their relationship and their future family too.

    Kit Hall: Thank you. Dr. Londoño.

    Dr. Amalia Londoño: Yeah, I love what Dr. Jaswa said. I did have in my training as well, the opportunity to work in a reproductive and endocrinology and fertility and it's really remarkable how sometimes we lose sight of all the human experience and we focus so much on the medical outcomes and miss all these other aspects that are going along with infertility and reproductive endocrinology treatments.

    Dr. Amalia Londoño: Yes, we have so much work to do there in research and develop treatment modality support that are evidence-based and really testing them and seeing if these are helpful in people's journeys as they think about having a family. Beyond that, some individuals are able to use that route, but there's different ways of configuring a family. Sometimes people have adoption. We don't really understand that as well as other aspects of mental health. How does that affect people's journey?

    Dr. Amalia Londoño: How can we support them? What are the issues that they're struggling with? What are some of the strengths of individuals as well? I think a lot of times in medicine, we focus on what the problems are, what the challenges are. But we also need to harness the human potential, harness all the human strengths of all these individuals that go through all these challenging experiences.

    Dr. Amalia Londoño: It's remarkable, individuals that go through IVF treatments, all the strengths that they have. My area in research is more focused on the perinatal period. Once there is conception and once there's a pregnancy, but there's so much work to be done there. We have evidence-based treatments, which is wonderful. We had pharmacologic and we also have talk therapies and other treatments to really support individuals and their families during this period. We have to work a little bit more on the family system and on partners definitely for sure.

    Dr. Amalia Londoño: But what really interests me is these disparities that we have been talking about and how do we get these treatments to individuals? Because we know that they're out there, we're know they're in the literature and we have evidence for them, but they're not reaching our communities. They're not reaching the families. They're not reaching the women and that's problematic because then we have all these individuals that develop sometimes psychiatric conditions, but sometimes not, they're just struggling and they're not having access to those treatments.

    Dr. Amalia Londoño: Think about all the possible positive outcomes and help that we could be giving individuals if we were able to figure out solutions, innovative solutions and test them out to be able to get these treatments to families. That's, I think, an area that we really need to focus on and an area that I'm particularly interested in.

    Kit Hall: That's a great segue to my next question, which is what are some individual, community, organizational, and/or policy-level actions that could help prevent negative reproductive mental health outcomes?

    Dr. Amalia Londoño: I think we touched on some of them, but I think they're interrelated. These barriers are what we really need to think about advocating for in terms of access to care. We know that insurance and how the system works, there's a lot of issues with access to care, with cost of care and we really need to focus on that system-level problem. And we really need to identify solutions for it, whether that be right now there's extensions of Medicaid, but it is not happening everywhere. There's also a lot of problems with that.

    Dr. Amalia Londoño: There's also access to parental leave. Not everybody has access to parental leave. Not the same quality of parental leave in terms of work in the workplace, not everybody has access to a support to be able to go to medical appointments, to be able to go to postpartum appointments, to be able to take care of their kids.

    Dr. Amalia Londoño: There's challenges that come with having a child and we are not supporting families. We are just not. In the workplace, we are not. We really need to focus on policies that really support families. And it's not only the women. Again, it's the family and being able to go through this big change in their lives. And in order to do that, we really need to think about these system-level issues.

    Dr. Amalia Londoño: The other thing in medicine, goodness. Talk about again, how our system is so siloed, so broken. Sometimes we know that obstetric care, usually... You have a lot of obstetric visits during your pregnancy and postpartum. You have one, maybe two depends on your pregnancy and your postpartum, how it went. But usually you have a six week postpartum visit and then people have to go access care in other ways.

    Dr. Amalia Londoño: And that fragmentation of care, having to go somewhere else for treatment, that mental health is not integrated into general health. That then you have to go to the pediatrician, but the pediatrician is treating the child. Yet they're screening sometimes for a postpartum depression, but then, okay, they have postpartum depression. Sometimes they don't know where to refer individuals. They don't have the ability to support people when they screen them for postpartum depression and other mental health conditions. We really need to work in the healthcare system to bridge this fragmentation of care, really rethink healthcare and really center it on families, center it on the needs of families, not on what we think from this medical perspective, what should be. We really need to think about the families if we're truly invested in serving them.

    Dr. Eleni Jaswa: I agree, absolutely with what Dr. Londoño said and would just add that even proximal to the access issues, even upstream of that are issues that remain around stigma with mental health and I think as an example, one of the missions that the American Psychiatric Association Foundation is so committed to is destigmatizing mental health care, mental health issues altogether so that it doesn't matter if you have all the access in the world if the individual is too embarrassed or ashamed or doesn't want to be perceived as abnormal for the true medical illness of depression or anxiety or postpartum, psychotic thoughts, things like that people may not even feel empowered to access care in the first place.

    Dr. Eleni Jaswa: Working as a society to talk more about miscarriage, loss, grief, depression, anxiety, things that riddle many people that most women don't really want to talk about, but are there and are real and should be talked about more and should be de-stigmatized to empower the approach to access in the first place.

    Dr. Amalia Londoño: I love that. I just have to say, that's my comment. I love that. Instagram is filled with pictures of happy pregnancy and postpartum or happy IVF journey. When in reality, there are so many ups and downs and that's part of the human experience and we really need to see all sides and that all sides are part of this journey. And there's nothing wrong with having thoughts about sometimes I'm so frustrated. I feel like I want to throw my baby out the window and oops, yes, no, I'm not going to throw the baby away. But sometimes I have those thoughts because I'm so exhausted and I haven't slept in a couple of days.

    Dr. Amalia Londoño: We really need to begin talking about those things. From the side point, from the side of systems, gosh, can we stop scaring people from being able to express those feelings?

    Dr. Amalia Londoño: I know a lot of women and a lot of people are scared of sharing those thoughts with their providers. Like, "Maybe they're going to think that I'm a bad parent." Or, "Maybe they're going to refer me to protective services if I say something like that." So we really need to create systems that are supporting families and in the journey rather than telling them, "No, no. What you're doing is wrong." Or, "No, those thoughts are wrong." We need to just acknowledge that this is part of the experience and sometimes they're problematic and we're going to support you through the journey.

    Kit Hall: When you hear about the APA Foundation and our work, at some point, you're likely to hear the terms, notice, talk and act. This is the framework that we reference across almost all of our programs to guide people in how they can express care and concern, develop a relationship, and support those who may be experiencing mental health issues or really anything that's preventing them from living to their fullest potential and most productive lives.

    Kit Hall: So keeping this Notice. Talk. Act. framework in mind and for those listening who may be a partner or loved one of someone who's experiencing a reproductive-related mental health issue, can either of you provide guidance as to how to be most supportive, what behavior changes we should notice, some helpful things to say, or perhaps not say and appropriate ways to connect individuals in need to support services?

    Dr. Amalia Londoño: I'm sure you've heard this, also Dr. Jaswa, but a common thing that I hear from friends and family that have been in the perinatal period, they're like, "I didn't know that I had postpartum depression. I just felt this way and I thought maybe it's normal or maybe..." It's so hard to know what's what.

    Dr. Amalia Londoño: And so family members play this incredibly important role in seeing how women are during postpartum or even during pregnancy. And the most important thing is to number one, educate yourself. If you have someone or a loved one and you feel like there's a change, really we're looking for changes. Some changes are part of the process, but if it starts interfering with the person's ability to care for themselves, the person's ability to enjoy the things that they used to enjoy, it's affecting the way their ability to work, their ability to relate to other ones.

    Dr. Amalia Londoño: If that's happening and there's that change, it's really important to pay attention and educate yourself on these different conditions and there's great resources including... The APA has great resources on what to look for when somebody's depressed, when somebody's anxious, when somebody maybe has psychotic symptoms, when somebody may have thoughts about harming themselves or even thoughts about harming the baby.

    Dr. Amalia Londoño: That happens. And so arm yourself with knowledge. Know that you are not alone and that you can seek out support from healthcare providers. There's also great lines like the postpartum support international that is not only for postpartum, but if you want to get some knowledge about things, you can also reach out to them. There's lines, peer specialists. There's also NAMI, which is the organization for families that supports families of individuals with different mental health conditions.

    Dr. Amalia Londoño: Those are resources to arm yourself. You're not alone. Then the other thing is once you're armed with that knowledge and you reach out for help, letting the person know, your loved one know that they're not alone, that you are there and being empathetic and caring and letting them know that you are not angry at them, that you're not...

    Dr. Amalia Londoño: Even though you may feel sometimes like take a step back and be like, "You're dealing with something that is... It looks like it's out of their control at this time. So let me take a step back and let me be supportive of them and be empathetic towards their experience."

    Dr. Amalia Londoño: Let them know that you want to help them, let them know about resources that you researched or the ones I mentioned or other ones that you find through your healthcare provider. And frame it always in the way that there is support, and we can figure this out together. That's what I tell the families that I work with.

    Kit Hall: Looking ahead and into the future, what would you like the field of reproductive mental health to look like in the next 10 years? Do you think there are reasons to be hopeful?

    Dr. Eleni Jaswa: I think there's a lot of reason for hope. I think even if you think about how far we've come in the past 50 years as a society with advances in medicine and psychiatry and mental health care and therapeutic options and understanding cognitive behavioral therapy and other treatment options.

    Dr. Eleni Jaswa: I'm an optimist. I'm very bullish on the future for healthcare. And I'm hopeful that this becomes something that I think Dr. Londoño alluded to in the Massachusetts initiative, where really we change medicine from this fractured, fragmented, isolated, pure biomedical, myopic, silo system to a medical home, where we acknowledge that a human is more than a disease. A human is not an island. They're part of a network of a family, of a community with a narrative and a lived experience. And we're able to provide multidisciplinary care that involves not only a doctor, we're just part of it, but also social services, social support, whether that be really in the form of diapers and classes and education, but also doulas and lactation consultants and family therapists and just having a holistic, patient-centered, accessible home that helps with the whole journey from preconception throughout the crazy wild ride of pregnancy.

    Dr. Eleni Jaswa: And then the hormonal crash for many people of the postpartum experience when as many of my friends have described, you become this object of affection during your pregnancy, this glowing pregnant woman to like a discarded carcass as all attention focuses on the baby and you just try to survive. Really integrating our systems in an accessible way to support the full human, the full family. That is going to involve system-level changes. That's going to involve supportive federal policy for parental leave, like many of the Scandinavian countries have. And so there's a lot of movement and change that will be required. But my dream for the future of reproductive mental health includes kind of the medical home model that Dr. Londoño had aforementioned.

    Dr. Amalia Londoño: No additions to that, that was so beautifully said. I think we can do it. We all need to work together and continue to advocate and each voice, all of you that are listening, any social media posts that you put out there in support of this, all these little things, advocacy things really go a long way. And we have to work together towards improving these systems and improving the way we care for ourselves and for women and their families during this period and beyond.

    Kit Hall: Wonderful. My one last question was going to be is there something from this conversation or perhaps something that we haven't yet discussed that you'd like listeners to remember or take away with them?

    Dr. Eleni Jaswa: I think the fact that we're all connected and that it's our responsibility to care for one another now more than ever. I think Notice. Talk. Act. is a nice, quick, easy catchphrase to remember that and remember the interdependence of ourselves and our families.

    Dr. Eleni Jaswa: As an OB-GYN and a woman who's been pregnant, I know that pregnancy can be a time of immense change where individuals don't know really what's normal. Is being tired and sick all the time normal? All the way to the extreme of is not enjoying the things I used to enjoy and having thoughts that I sometimes think are shameful or crazy normal. Being able to express that, communicate with one another, ask for help, offer help, notice when your loved ones need help or even if you have any concerns and not being afraid because of it feeling confrontational or judgemental, being able just to openly express and enduring support and love for each other will take us as a society a long way.

    Dr. Amalia Londoño: I think going along with that using the month of May, that has significance in terms of there's mother's day, there's international women's mental health day, there's all these important dates and using those to really take a moment to step back, think about ourselves, each other. I love that interconnectedness and how can we all put just a little bit of effort, just a little bit of thought in our everyday interaction so that we can make mental health part of our day to day, something that we are proud of rather than ashamed of that we take care of because if we don't take care of our mental health, we're not taking care of our health and our society. Really leveraging these days to think about that and motivating ourselves to be able to do that throughout the year.

    Dr. Eleni Jaswa: Feeling empowered to work on mental health. That's not something people should be ashamed of. Anything worth it in life requires hard work, raising kids, achieving success and relationships, professionally. We should be proud to consciously exert effort to support our mental health and that of others and of that and self-care, awesome. Whatever that means, that should be celebrated pursuit in our lives and the lives of our loved ones and our society.

    Kit Hall: Fabulous. Thank you both so much for joining us today and for your time and expertise, Dr. Eleni Jaswa and Dr. Amalia Londoño.

    Kit Hall: Dr. Jaswa earned her Master of Science degree in Biological Sciences at Stanford University and completed her medical degree at Weill Cornell Medicine. She also completed a residency in obstetrics and gynecology and a fellowship in reproductive endocrinology and infertility at the University of California, San Francisco. Dr. Londoño also attended Stanford University where she received her medical degree. She went on to complete her psychiatry residency in child psychiatry fellowship at Yale University, as well as perinatal mental health research and clinical fellowship at Brown University.

    Kit Hall: She's currently a post-doctoral fellow at the National Institute on Minority Health and Health Disparities. For more information about the APA foundation and its programmatic work, you can visit apafdn.org.

    Kit Hall: If you enjoyed what you heard today and want to make more things like this possible, please share this episode with a friend, family member or colleague and please consider donating to the APA Foundation online at apafdn.org or via mobile phone by texting APAF-2022 to number 44321. Thanks for joining us. I'm Kit Hall, take care.

    Speaker 4: The views and opinions expressed in this podcast are those of the individual speakers in their personal capacity only and do not necessarily represent the views of the American Psychiatric Association foundation or the views, official policy or position of the institutions and organizations with which the speakers are affiliated. The content of this podcast is provided for general information purposes only and does not offer medical or any other type of professional advice. If you are having a medical emergency, please contact your local emergency response number.