Portrait of an expectant mother. Source: DC Studio / Shutterstock.com
Faced with successive hurricanes, including Matthew, Florence, Michael, and Dorian, more expectant mothers on Medicaid showed up at North Carolina emergency departments seeking treatment for mental health crises. Yet one vulnerable group was missing: pregnant women from predominantly Black communities.
Climate change is contributing to the increased prevalence of extreme weather, straining the already fragile last-resort systems meant to catch and support mothers. At the same time, pre-disaster laws and policies may prevent already marginalized groups from accessing the resources they need during disaster recovery. A new approach is needed to understand the layered barriers that influence Black women’s experiences at the intersection of gender, motherhood, mental health, structural racism, and disasters.
Which Women Are Missing Out on Mental Healthcare?
Hurricanes can inflict significant mental health consequences on affected people and communities, with severe storm damage linked to major depressive disorders, post-traumatic stress disorders, and anxiety. Pregnant women are particularly vulnerable, facing unique challenges related to reproductive health, such as unplanned cesarean births and heightened stress for both the child and the mother. While there is evidence on the various mental health impacts of individual hurricanes, there is limited research on how back-to-back storms affect pregnant populations.
My colleagues and I sought to analyze the impact of single and consecutive hurricanes on emergency department visits for mental health crises among Medicaid-eligible pregnant women in North Carolina. Our work focused on the impacts of four major storms that affected the region—Matthew in 2016, Florence and Michael in 2018, and Dorian in 2019—and accounted for factors such as rurality, maternal age, race and ethnicity, economic segregation, and access to maternal care. Findings revealed that overall, pregnant women from areas affected by repeated storms sought emergency mental health care more than those in areas hit by just one storm. Specifically, multiple storm exposures were associated with increased risks for maternal mental disorders during pregnancy, including perinatal mood or anxiety disorders, as indicated by visits to emergency departments.
However, this trend did not hold for expectant mothers from majority Black communities. Even in places hit by back-to-back storms, we found that Black expectant women visited emergency departments for psychiatric illnesses less frequently, as compared to communities with no storm exposure.
Recurrent disaster exposures may increase trauma for Black mothers, yet low engagement with behavioral health treatment among this population may mean missed opportunities for screening of maternal mental disorders. While Black mothers may very well be feeling the mental health effects of these storms, social and economic barriers to care can also prevent them from seeking adequate treatment.
The Unique Challenges Black Expectant Women Face
Black communities are more likely to be located in the path of storms and have less access to recovery resources compared to White communities. Yet even before disasters occur, Black women must navigate a complex risk landscape. Pregnant Black women in low-income areas experience higher trauma exposure and greater risk for trauma-related mental health disorders compared to their White counterparts. Nevertheless, they are less likely to use behavioral health services due to financial constraints, time constraints, institutional biases, and other factors.
Moreover, interactions with state and local safety-net agencies often prove challenging and may deter families from seeking help due to the risk of family separation. For instance, Black children are overrepresented within the foster care system, with documented bias among medical professionals in reporting to child welfare systems. As a result, seeking assistance through safety net systems like healthcare has the potential to trigger the enduring trauma of family separation. Calling attention to the demographic vulnerabilities and inequitable institutional policies and responses at play before disasters is key. It helps us understand the unique response and recovery challenges that mothers in these communities may face.
A Legal Framework for Uncovering Hidden Risks
There’s an urgent need to examine the structural inequalities that perpetuate these disparities in access to mental health care in the context of repeated disasters. Legal epidemiology, the study of how policies and laws shape health outcomes, can be a powerful framework in this context. Leveraging this approach may allow researchers and practitioners to reveal and, crucially, interrogate the social roots of disaster risk.
Recent policy studies demonstrate the growing application of legal epidemiology in disaster work. For instance, my previous research examined laws that could enable or limit healthcare volunteers' ability to respond during disasters. In other instances, researchers have examined the policies that shaped state and local authority to respond to public health emergencies like the COVID-19 pandemic. Such studies highlight barriers and opportunities for improving disaster response. Legal epidemiology also has the potential to reimagine our disaster risk frameworks by deepening our understanding of how upstream determinants influence mental health and healthcare infrastructure.
With the promise of more powerful storms ahead, there’s an urgent need for more reparative and restorative pre-disaster policies. Resilience through this lens centers the holistic well-being of expectant women. Critically evaluating how our pre-existing policies shape disaster impacts and recovery is imperative, not only for women but for the future of families and communities in places at risk to disasters.
Natasha Malmin is a tenure-track assistant professor of environmental health at Georgia State University. A scholar at the intersection of public policy, health equity, and disaster resilience, Malmin holds a joint PhD in public policy from the Georgia Institute of Technology and Georgia State University, complemented by a Master of public health in Global Environmental Health from Emory University. Malmin's research examines how bureaucratic processes in federal disaster recovery programs create administrative burdens that disproportionately affect marginalized communities, with particular attention to their cascading effects on social and health equity.