My unconscious bias was revealed to me many years ago while working as a registered nurse (RN) at a family planning clinic. A young woman came requesting a pregnancy test. I admit to feeling relief when the test was negative and was genuinely surprised when her reaction was grief. As we discussed the result, she revealed that she had been attempting to achieve pregnancy and had the full support of her partner and family. Where did my reaction come from? Why had I assumed that she was trying to avoid conception rather than trying to achieve it? Had my assumptions caused distress for the patient?
A rights-based approach to reproductive health means that everyone has the right to decide if, when and how often they have children. However, our unconscious bias – our inherent preferences that we’re not knowingly aware of – may impact the mental wellness of patients in our care.
As healthcare providers, we know that the mental wellness of our patients is impacted by many things, including gender, ability, relationships, socio-economic status, education, social support and access to services. But, do we consider the role of how our own comfort and bias impacts people during the significant life events associated with reproductive health care?
Even most of the research on reproductive health and mental wellness has focused on the experience of cisgender women in higher income countries. It’s a fact that the world of reproductive health is hyper-gendered and synonymous with women’s health. Have we unconsciously excluded transgender people, people with non-binary or gender non-conforming identities or men from research and supports that related to reproductive health and wellness? What is the experience of same-sex couples trying to access reproductive health care? Do we have enough information about the intersections of diversity and the impact on mental wellness?
Reproductive health across the lifespan is fraught with transition; consider the list: puberty, trying to prevent pregnancy, trying to get pregnant, infertility, pregnancy, parenting, adoption, abortion, miscarriage, and andropause/menopause. Is that it? I’m not sure, there is probably more. It’s a fact people can have increased risk to their mental wellness during these times of reproductive health transition. We need to be careful not to make assumptions about what the experience means for them, but also be aware of specific risks during these transitions, including:
- Early puberty may be associated with impacts to self-esteem, body image and early sexualization.
- Recent studies suggest that depression or feelings of decreased well-being may be possible side-effects of birth control pills. While research is still being conducted, counselling and support around the possibility is needed for patients.
- Infertility is a stressful experience for all people, which impacts relationships, self-esteem, body-image and can be associated with experiences of anxiety, grief and depression.
- People with a history of depression have a 20x higher risk of postpartum depression (PPD). Having gestational diabetes also increases the risk for PPD.
- Risk factors for mental wellness during pregnancy and postpartum include smoking, use of alcohol, use of non-prescription drugs and a history of physical and/or sexual abuse.
- Rates of mental health problems for women with an unintended pregnancy are the same whether they have had an abortion or have given birth; however, those with underlying mental health concerns may require additional supports.
- Menopause may impact wellness for people who experience negative effects, including low mood, anxiety, body image, impact to self-esteem over loss of reproductive potential, reduced libido, difficulties with sexual functioning, etc.
- Andropause may impact wellness for people who experience negative effects, including low mood, reduced libido, fatigue, body image/weight gain and difficulties with sexual function.
There are gaps. We don’t know, what we don’t know. But this is what I know to be true: as health care providers, we have an opportunity to work with vulnerable people during times of transition. For some people, this can be extremely stressful.
- We need to avoid assumptions about the meaning of the experience and ask them, “How are you doing today?”
- Avoid assumptions about how they might be impacted; what choices they might make or even whether they are aware of all their choices.
- Be inclusive when talking about reproductive health and open the conversation to extend past “women’s health.”
- Use inclusive language and avoid heteronormative assumptions using partner/spouse rather than husband/wife.
- Know your resources, whether it’s for a person experiencing infertility and looking for assisted reproductive health technologies, a person looking for pregnancy options support, transgender youth during puberty or someone experiencing significant symptoms of perimenopause.
Ultimately, we all need the same thing. Access to timely, inclusive, non-judgmental, non-stigmatizing services. After all, reproductive rights are human rights, for all people.