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. Author manuscript; available in PMC: 2025 Mar 1.
Published in final edited form as: Psychol Trauma. 2023 Oct 12;16(3):382–389. doi: 10.1037/tra0001593

Indirect Effect of Negative Evaluations of Therapy on the Association between Racial Stress and PTSD Symptoms in Pregnant Black Persons

Meghna Ravi 1, Emma C Lathan 1, Shimarith Wallace 1, Cecilia A Hinojosa 1, Dominique Jones 1, Jamie Villalobos 1, Sriya Karra 1, Abigail Powers 1,*, Vasiliki Michopoulos 1,*
PMCID: PMC10842040  NIHMSID: NIHMS1950182  PMID: 37824259

Abstract

Objective:

Black pregnant individuals are at disproportionate risk for posttraumatic stress disorder (PTSD) compared to other groups. A wealth of literature suggests racial stress contributes to this inequity, but cultural and structural mechanisms, such as perceived barriers to mental health treatment, underlying the relationship between racial stress and PTSD symptoms remain understudied. Negative evaluations of psychotherapy and stigma represent potential mechanisms, though no previous studies have examined these associations. To address this gap, we tested an indirect effect of racial stress on PTSD symptoms through perceived barriers to mental health treatment in pregnant Black individuals.

Method:

Mediation analyses were used to assess an indirect relationship between racial stress and PTSD symptoms through perceived barriers to mental health treatment.

Results:

At the bivariate level, racial stress was significantly associated with PTSD symptoms (r=.20, p=.03) and negative evaluations of therapy (r=.22, p=.02), but not with stigma (r=.140, p=.147). Negative evaluations of therapy were also associated with PTSD symptoms (r=.43, p<.001). There was an indirect effect of racial stress on PTSD symptoms through a negative evaluation of therapy (β=.08, SE=.04, CI[.01, .18]). More specifically, racial stress was associated with a more negative evaluation of therapy, which was in turn associated with more PTSD symptoms.

Conclusions:

Results highlight the need for accessible and culturally competent mental health care for pregnant Black individuals.

Keywords: PTSD, racial stress, pregnancy, negative evaluations of therapy, stigma

Introduction

Posttraumatic stress disorder (PTSD) is a debilitating and heterogenous disorder that can develop after experiencing a traumatic event (APA, 2013). According to the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition’s (DSM-5), a qualifying (i.e., Criterion A) traumatic event must involve exposure to actual or threatened death, serious injury, or sexual violence (APA, 2013). A person can be exposed to a traumatic event by directly experiencing it, witnessing it, learning the event happened to a close relative or friend, or being repeatedly exposed through their occupation (APA, 2013). In addition to exposure to a Criterion A traumatic event, PTSD is characterized by a number of psychiatric symptoms, including intrusions/re-experiencing, avoidance, negative changes in cognition and mood, and alterations in arousal and reactivity (APA, 2013). Black individuals are disproportionately affected by PTSD as compared to other racial groups; while rates of lifetime PTSD are approximately 7% in the general population (Keane et al., 2009), rates in Black communities with few economic resources are as high as 46% (Gillespie et al., 2009). Pregnant individuals in these communities are at even higher risk for PTSD (Seng et al., 2011), as evidenced by lifetime PTSD rates as high as 56% (Powers et al., 2020). Therefore, a better understanding of factors contributing to PTSD within pregnant Black persons with few economic resources is necessary to provide effective care and to reduce symptom burden.

One factor that could help explain the disparity in rates of PTSD between pregnant Black persons and other groups is racism. Racism is a complex and multifaceted oppressive system designed to uphold white supremacy at the expense of other racial groups (Braham et al., 1992; Corneau & Stergiopoulos, 2012). Racism occurs at the individual, cultural, institutional levels and can therefore negatively impact Black individuals in a multitude of ways (Jones, 1991). Individual racism consists of behaviors and attitudes (intentional or unintentional) where members of a marginalized race are treated differently due to their race (Jones, 2000). Individual racism can manifest in many ways, including a lack of respect, suspicion of committing crime, or hate crimes/police brutality against racially marginalized individuals (Jones, 2000). Institutional racism consists of policies and procedures that deny marginalized racial groups access to opportunities and resources, which prevents upward mobility (Jones, 2000). Finally, cultural racism refers to the widespread belief that White ideologies and values are superior to other racial groups, and where the culture and values of other racial groups are perceived negatively (Oliver, 2001; Utsey, 1999).

Because the pervasive nature of racism is inherently traumatizing, it can lead to racial stress, or psychological distress caused by racism (Plummer & Slane, 1996). Racial stress is a potential consequence of overt or covert experiences of racism at the individual, cultural, and systemic levels and can be experienced personally or vicariously (Williams et al., 2018). Racial stress can negatively impact overall mental health for Black individuals (Comas-Díaz et al., 2019; Kirkinis et al., 2021; Mekawi, Carter, et al., 2021). For example, racism is associated with reduced life satisfaction in Black adults (Broman, 1997), and with more symptoms of depression and anxiety (Williams & Mohammed, 2009). In the context of PTSD, experiencing racism is associated with a future PTSD diagnosis among Black and Latinx adults (Bird et al., 2021; Sibrava et al., 2019). Racial stress is also associated with PTSD symptoms among Black individuals with few economic resources, even while controlling for confounding factors like distress levels, crime rates, and perceived safety (Brooks Holliday et al., 2020; Mekawi, Carter, et al., 2021). Further, when Black persons also have few economic resources, the intersection of racism and classism make them vulnerable to being marginalized in additional social and cultural contexts as well as experiencing associated psychological consequences (Sarno et al., 2021).

While existing literature demonstrates that racial stress exacerbates PTSD symptoms in non-pregnant Black individuals, studies focusing on pregnant Black individuals are lacking. Importantly, pregnant Black persons are disproportionately affected by negative pregnancy outcomes like pre-term birth and preeclampsia (Purisch & Gyamfi-Bannerman, 2017; Ross et al., 2019). Psychopathology during pregnancy, including PTSD, can increase risk for these negative pregnancy outcomes (Shaw et al., 2017; Yonkers et al., 2014). Black individuals might be at particularly high risk for racial stress when they are pregnant due to increased contact with the health care system, which is steeped in racism (Hoberman, 2012; King, 1996). Pregnant Black individuals’ increased risk for both PTSD and experiences of racism highlight the need to understand the role of racial stress in their PTSD symptomology to increase clinicians’ ability to provide high quality maternal care, and thus, the likelihood of a healthy pregnancy.

Although the link between racial stress and PTSD is well-established, little is known about mechanisms underlying the association between racism and PTSD. The complex and all-encompassing nature of racism suggests multiple pathways by which racial stress might worsen PTSD outcomes. Especially in the United States, systemic racism has ensured that Black communities are more likely than other groups to have few economic resources (Beech et al., 2021) and insufficient access to adequate health care (Yearby et al., 2022), both of which can exacerbate PTSD symptoms (Nayback, 2008). However, even after accounting for socioeconomic differences, Black persons are still disproportionately impacted by PTSD (Williams et al., 2010), suggesting that economic resources and health care access do not fully explain racial disparities in PTSD.

One other mechanism through which racial stress could negatively impact PTSD symptoms is perceived barriers to mental health treatment, which could prevent recovery after experiencing a traumatic event and prolong persistence of PTSD symptoms. Indeed, a systematic review found that negative attitudes towards mental health services and stigma around mental illness prevents trauma survivors from seeking mental health care, and that these relationships are exacerbated in ethnically minoritized individuals (Kantor et al., 2017). Additionally, in a qualitative study with elderly Black adults with depression, barriers like stigma around mental illness and mistrust of the mental health care system (i.e., lack of confidence in mental health care, a mistrust of providers) prevented participants from seeking mental health care (Conner et al., 2010). Participants also felt that stigmatizing attitudes around mental illness were exacerbated for Black individuals with depression as compared to other racial groups (Conner et al., 2010). Participants with PTSD from a community sample of Black adults with few economic resources endorsed high levels of stigma around seeking mental health services (Powers et al., 2022). In regard to treatment adherence, one study found that Black veterans with PTSD maintained pharmacological treatment for PTSD based on their perception of their provider but maintained talk-based psychotherapy based on what their therapist focused on during sessions (Spoont et al., 2017). Barriers to care are also associated with worse mental health; for example, impediments to mental health treatment, including stigma and negative beliefs about mental health care, predicted more depressive and PTSD symptoms among combat veterans (Wright et al., 2014).

Importantly, experiences of racial discrimination within the health care system predict lower utilization of preventative health services (Trivedi & Ayanian, 2006), underutilization of medical services (Klassen et al., 2002), and less engagement with mental health care among Black Americans (Burgess et al., 2008). Relationships between racial stress and reduced health care engagement could be explained through increased stigma about mental illness (Krill Williston et al., 2019) or a mistrust of the health care system (Hausmann et al., 2013). While existing literature suggests that racial stress within the health care system can lead to negative beliefs and mistrust of the overall health care system, less research has been conducted on the impacts of general racial stress on stigma and perceptions of mental health care.

Given the negative effects of racial stress on mental health, it is important to understand whether stigma and perceptions of mental health care help to explain the relation between racial stress and PTSD symptoms in pregnant Black persons. Thus, to address gaps in research in this area, the current study examined associations between racial stress and PTSD symptoms and two perceived barriers to psychological treatment: negative evaluations of therapy and stigma surrounding mental illness. We conducted follow-up mediation analyses on significant associations to determine the existence of an indirect association between racial stress and PTSD symptoms through perceived barriers to psychological treatment. We hypothesized that racial stress would be associated with more negative evaluations of therapy and greater stigma, which would in turn be associated with more PTSD symptoms.

Methods

Procedure

Participants (N=109) seeking prenatal care at a publicly funded hospital (primarily serving minoritized communities with few economic resources) were recruited for involvement in an ongoing study assessing the impact of maternal trauma exposure and responses on perinatal and obstetric outcomes within an urban population. Participants were enrolled between 2018 and 2022. As part of the study, trained interns approached patients in the obstetrics clinics regarding potential participation. During COVID-19, hospital patients were invited to participate via telephone. Eligibility criteria included pregnancy, self-identified Black race, age between 18 and 40 years old, no active psychosis, and ability to provide informed consent. Age restrictions for study inclusion were based on the larger parent grant’s inclusion criteria, which consisted of individuals in the most likely period for reproductive age (Brinton et al., 2015; Gold et al., 2013). Additionally, individuals with active psychosis were excluded in attempt to ensure accuracy of self-report measures. If participants agreed to participate, they gave informed consent and underwent an interview assessing PTSD symptomatology, perceived barriers to psychological treatment, and racial stress; this interview was administered by extensively trained research assistants supervised by a licensed clinical psychologist. A description of interview content was given during the informed consent process, so participants were aware that questions regarding trauma exposure and related symptoms would be asked. Interviews were conducted in a private space to ensure participant confidentiality and comfort, and participants were given full autonomy to not answer any questions or to stop the interview at any time. Interviewers underwent a thorough 1–2 month training process that included didactics in trauma and PTSD, research interviewing, human subjects, cultural humility and competence, and crisis management; practice interviews; and observation of taped interviews and live participant interactions before official clearance. During each interview, a licensed psychologist was available to ensure participant well-being and provide assistance if a participant was distressed. Additionally, interviewers engaged in a de-brief with participants following the interview and offered a list of resources to all participants following the interview. Participants were compensated $40 for their time in the study, and all procedures were approved by the Emory University Institutional Review Board and Grady Research Oversight Committee. Only participants who had experienced at least one criterion A traumatic event as defined by the DSM-5 were included in the current analyses.

Measures

Perceived Barriers to Psychological Treatment Scale (Mohr et al., 2010)

The PBPT scale is a 27-item questionnaire that determines potential barriers to mental health treatment. Each item asks about a potential problem that might prevent someone from seeking therapy. Participants are asked to answer on a scale of 1 (not difficult at all) to 5 (impossible) in determining how much each problem would prevent them from seeking therapy. Items are scored for a total score as well as subscales that comprise specific types of barriers to treatment. For this study, we focused on two subscales: negative evaluations of therapy and stigma. The PBPT had good psychometric properties in a racially diverse sample of adults seeking primary care (Mohr et al., 2010). In the current study, the Cronbach’s α for negative evaluations of therapy was .76, and the Cronbach’s α for stigma was .80.

Index for Race-Related Stress (Brief) (Utsey, 1999)

The IRRS is a 22-item scale that assesses racial stress across various domains. For each question, participants are asked to answer on a Likert scale ranging from 0 (this event never happened to me) to 4 (this event happened to me, and I was extremely bothered by it). The scale has three subscales, each respectively measuring individual racial stress, institutional racial stress, and cultural racial stress. Total racial stress was determined by taking the mean score of all the items on the scale to ensure each subscale had equal weight for the total racial stress score. The IRRS was developed and validated in a Black sample and shows good psychometric properties (Utsey, 1999). The Cronbach’s α for the sample was .94.

PTSD Checklist for DSM-5 (PCL-5) (Blevins et al., 2015)

The PCL-5 is a well-validated, 20-item scale assessing PTSD symptoms across four symptoms clusters as defined by the DSM-5: intrusions/re-experiencing symptoms, avoidance, and negative changes in cognitions and mood, and alterations in arousal and reactivity. For each item, participants respond on a Likert scale from 0 (not at all) to 4 (extremely). Overall PTSD symptoms were defined as the total sum across symptom clusters. The psychometric properties of PCL-5 have been validated in a Black community sample (Mekawi et al., 2022), and the Cronbach’s α for the sample was .936.

Traumatic Events Inventory (TEI) (Gillespie et al., 2009)

Lifetime trauma history was assessed using the TEI, which determines exposure to different types of traumatic events. This measure was developed in a demographically similar population (Gillespie et al., 2009) and shows construct validity with trauma-related psychological symptoms in primarily Black individuals with few economic resources (Mekawi, Kuzyk, et al., 2021).

Data Analytic Plan

We first checked the distribution of each measure and found that the IRRS and PCL-5 fell within normal range. The two perceived barriers to psychological treatment (negative evaluations of therapy and stigma) were positively skewed, so the data were transformed by taking the natural log of the raw values to normalize the distribution. All subsequent analyses were conducted using the transformed values for negative evaluations of therapy and stigma. We initially ran bivariate correlation analyses between negative evaluations of therapy, stigma, total racial stress, and PTSD symptoms. We conducted follow-up tests on significant correlations (p < .05) using simple mediation analyses with PROCESS macro in SPSS Version 28 (Hayes et al., 2017). Through the mediation analyses, we examined whether racial stress (X) impacted PTSD symptoms (Y) through each perceived barrier to therapy (M). In the mediation analysis, the a path represented the effect of racial stress on a perceived barrier to therapy, and the b path represented the effect of the perceived barrier on PTSD symptoms. The indirect effect (calculated by multiplying the a and b coefficients together; ab) represents racial stress’ relation to PTSD symptoms through a perceived barrier to therapy. Five-thousand bootstrapped samples were generated to determine a 95% confidence interval for the indirect effect. The indirect effect was considered significant if the bootstrapped confidence interval did not contain zero.

Results

Participants

On average, participants were 28.17 years old (SD=5.49) and experienced 5.56 types of traumatic events in their lifetime (SD= 3.28). Almost half of the participants reported being currently unemployed (49.1%), and most were experiencing significant economic disadvantage (i.e., a monthly household income of less than $2,000; 57.3%). Sample demographics can be found in Table 1.

Table 1.

Sample Demographics

Demographic M SD %
Age (years) 28.17 5.49
Total types of trauma (witnessed or experienced) 5.56 3.28
Monthly household income
 $0-$249 6.7
 $250-$499 5.6
 $500-$999 12.4
 $1000-$1999 32.6
 $2000 or more 42.7
Education
 Less than 12th grade 9.3
 12th grade/high school graduate 37
 GED 3.7
 Some college or technical school 29.6
 Technical school graduate 4.6
 College graduate 15.7
Employment
 Currently unemployed 49.1
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Correlational Analyses

Zero-order correlations can be seen in Table 2. Racial stress was associated with PTSD symptoms (r=.185, p=.041) and negative evaluations of therapy (r=.239, p=.013), but not stigma (r=.135, p=.165). Negative evaluations of therapy and stigma were each significantly associated with PTSD symptoms (r= .425, p<.001 and r=.569, p<.001, respectively).

Table 2.

Means, Standard Deviations, and Correlations Among Variables of Interest

Variable M SD 1 2 3 4
1. Average racial stress 2.538 .926 - .199* .217* .140
2. PTSD Symptoms 24.527 18.348 - .425** .569**
3. Negative Evaluations of Therapy 5.343 2.442 - .635**
4. Stigma 10.750 4.456 -
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*

p<.05,

**

p<.001

Mediation Model

Based on significant results in the correlation analyses, we conducted one mediation analysis to test the indirect association between racial stress and PTSD symptoms through negative evaluations of therapy. Results revealed that more racial stress was associated with a more negative evaluation of therapy (path a, β= .217, p=.024), which was in turn associated with more PTSD symptoms (path b, β=.349, p<.001). A confidence interval using 5,000 samples was generated to determine the indirect effect of racial stress on PTSD symptoms through negative evaluations of therapy. Altogether, we found a significant indirect effect of racial stress on PTSD symptoms through negative evaluations of therapy (β=.076, SE=.042, CI: [.010–.176) (Figure 1).

Figure 1:

Figure 1:

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Indirect relationship of racial stress on PTSD symptoms through negative evaluations of therapy.

Discussion

In the current study, we aimed to determine potential pathways linking racial stress and PTSD symptoms in a sample of Black pregnant persons. We found an indirect effect of racial stress on PTSD symptoms through a negative evaluation of therapy; in other words, experiencing more racial stress predicted a more negative evaluation of therapy, which in turn predicted higher PTSD symptoms. Our findings support previous work demonstrating a link between racial stress and negative perceptions of the health care system (Alang, 2019), and literature showing that mistrust of the health care system mediates a relationship between racial stress and reduced health care engagement (Hausmann et al., 2013). Overall, the current study results add to the literature on the impact of racism on PTSD symptoms and provide additional information on mechanisms underlying this relationship, namely negative evaluations of therapy. Importantly, the current study focused on Black and pregnant individuals with few economic resources, who are at disproportionate risk for PTSD (Powers et al., 2020; Seng et al., 2011) and negative pregnancy outcomes (Purisch & Gyamfi-Bannerman, 2017; Ross et al., 2019).

Experiencing racism at any level can lead to negative evaluations of and a mistrust of the health care system, including the mental health care system (Alang, 2019). In terms of racism experienced at the individual level, more negative experiences with police (a form of racism) is associated with medical mistrust (Alang et al., 2020), and both major and everyday discrimination (i.e. disrespect in everyday settings) outside of the health care system are associated with reduced engagement with the mental health care system (Burgess et al., 2008). In addition to individual racism, a legacy of historically racist practices has harmed Black communities, leading to mistrust of mainstream systems that are intended to be helpful (Alsan & Wanamaker, 2018; Williamson & Bigman, 2018). This mistrust of systems also translates to the mental health care system (Castro-Ramirez et al., 2021), which has caused harm to Black communities. For example, 53% of racially minoritized individuals report racist microaggressions from their therapist (Owen et al., 2014), and Black persons are also disproportionately diagnosed with psychotic disorders (Schwartz & Blankenship, 2014). The mental health care system also often criminalizes the behavior of Black individuals, sometimes leading to involuntary hospitalization or involvement of law enforcement when unnecessary, all of which leads to further mistrust of mental health care (Alang, 2019).

The mistrust of the mental health care system is especially problematic in pregnant Black persons, who are at increased risk for mental illness compared to other groups (Seng et al., 2010). Pregnant Black persons often face structural barriers, such as a lack of economic resources (Beech et al., 2021) and inadequate access to quality health care (Yearby et al., 2022), which can exacerbate and prolong mental illnesses (Nayback, 2008). Pregnant Black persons with few economic resources are particularly vulnerable to mental health concerns given their increased likelihood of simultaneously experiencing racism, classism, and pregnancy (Cole, 2009). Specifically, pregnant Black persons with few economic resources experience a unique type of racism due to their intersecting identities (Branch, 2007; Monnat, 2008), and often face racism and mistreatment at prenatal care appointments that they might not experience when not pregnant (Hoberman, 2012; King, 1996). In addition to the social context of being a Black pregnant person, pregnancy is associated with profound biological and social changes that might negatively impact mental health (Ravi et al., 2022; Smith, 1999). Mental illness during pregnancy not only impacts the pregnant person’s well-being, but is also associated with negative pregnancy outcomes like pre-term birth (Cappelletti et al., 2016; Shapiro et al., 2013) and can impact offspring development (Cao-Lei et al., 2016). It is therefore critical to understand how racial stress impacts PTSD symptoms in Black pregnant persons specifically, since Black pregnant individuals are disproportionately impacted by negative pregnancy outcomes. Importantly, previous work from our group has found that PTSD is underdiagnosed in pregnant Black persons (Powers et al., 2020), highlighting an opportunity for intervention for many individuals. Addressing mental illness and other stressors during pregnancy may help address health inequities in pregnancy outcomes, and so it is important to provide adequate, culturally-informed mental health care for Black pregnant individuals. Importantly, pregnant Black persons, regardless of socioeconomic status, face racist mistreatment at the hands of prenatal care providers, resulting in disproportionately high rates of negative pregnancy outcomes, like maternal mortality (Davis, 2019; Lathan et al., 2023; Sayyad et al., 2023). Thus, Black persons may be particularly mistrustful of health care providers during pregnancy. This mistrust of health care providers might transfer to a mistrust of mental health care providers as well, potentially leading to a persistence of mental health concerns.

Limitations and Future Directions

The current study helps address a gap in understanding how racial stress in everyday life is associated with perceptions of the mental health care system, and how this in turn impacts PTSD symptoms in a high-risk, understudied group. Despite this strength, there are also limitations that must be considered. First, the study was cross-sectional in design, which makes it difficult to assess causality among racial stress, negative evaluations of therapy, and PTSD symptoms. Future studies could focus on how perceived barriers to therapy change with racial stress exposure over time to better understand relationships between racial stress, perceived barriers to psychological treatment, and PTSD symptoms. Second, our study design did not assess the effects of other oppressive systems that participants may also be experiencing, such as sexism, homophobia, or classism. Future studies should aim to understand how the intersection of multiple marginalized identities are related to perceived barriers to psychological treatment and PTSD symptoms. Third, in the current study we used a self-report scale for PTSD and assessed symptom severity, as opposed to PTSD diagnosis. Despite this limitation, the PCL-5 has been well-validated with the gold-standard, clinician administered PTSD scale (Blevins et al., 2015). Fourth, the PCL-5 is based on PTSD symptoms as defined by the DSM-5; only participants who had experienced a Criterion A traumatic event as per the DSM-5 were included in the current study. The DSM-5 does not acknowledge racial trauma as a traumatic event unless it falls under the specific criteria listed in Criterion A (APA, 2013), even though racial trauma can result in PTSD-like symptoms in the absence of Criterion A traumatic events (Williams et al., 2018; Williams et al., 2021). Future studies could assess relations between negative evaluations of therapy and symptoms specifically related to racial trauma to ensure findings are generalizable to Black persons who have not experienced a DSM-5 Criterion A traumatic event. Fifth, the current study only included pregnant individuals up to the age of 40, and so we could not determine the relations between racial stress, negative evaluations of therapy, and PTSD symptoms in Black pregnant persons aged 40 and over. Because Black pregnant persons over the age of 40 still experience racism that might contribute to a negative evaluation of therapy, future studies should include pregnant persons aged 40 and above as well. Furthermore, the current study did not include individuals experiencing active psychosis in an attempt to ensure accuracy of self-report measures. Black pregnant persons with active psychosis are especially likely to receive poorer care from clinicians (McGuire & Miranda, 2008) and to hold negative beliefs about the mental health care system due to this mistreatment (Maura & Weisman de Mamani, 2017), and so the relations between racial stress, negative evaluations of therapy, and PTSD symptoms may be particularly meaningful in those experiencing psychosis. Thus, future studies should include pregnant persons with active psychosis after considering ways to overcome challenges with self-report measures. Finally, the current study included a sample of Black pregnant individuals, primarily with few economic resources, which could limit generalizability to other groups. Nevertheless, Black pregnant persons have historically been excluded from psychiatric research despite disproportionate risk for PTSD, so the current study is well warranted as it addresses needs for a group that experiences greater health inequities.

Conclusions

Mental health care providers need to be actively anti-racist and address implicit racial biases (Greenwald & Krieger, 2006; Naz et al., 2019), since microaggressions at the hand of therapists and institutionally racist practices can lead to mistrust of the mental health care system (Alang, 2019; Owen et al., 2014; Trivedi & Ayanian, 2006). Clinicians must also actively engage clients in determining the best treatment course, as clients who feel pressured into treatments that they may not trust hold more negative beliefs about mental health care (Conner et al., 2010). Training programs for mental health care providers must also remove barriers and make it easier for Black individuals to become clinicians, as some clients may find it easier to build rapport with a therapist with a firsthand understanding of the negative effects of racism (Chang & Yoon, 2011; Conner et al., 2010). Finally, due to systemic racism, the US health care system’s design and organization reduces the likelihood that Black individuals with few economic resources receive appropriate mental health care (Yearby et al., 2022). Policies should be created and implemented to ensure that everyone, and especially Black pregnant persons with few economic resources, have social, financial, and proximal access to high quality mental health care and to therapists dedicated to providing anti-racist and trauma informed care. Overall, active efforts to provide accessible, culturally competent care are required to reduce PTSD symptom burden in Black pregnant individuals.

Clinical Impact Statement:

Experiencing more racial stress was associated with greater PTSD symptoms via a more negative evaluation of therapyin a sample of Black pregnant persons with few economic resources. Accessible, culturally informed therapy options for Black and pregnant individuals are needed.

Acknowledgements.

This work was supported by the National Institute of Mental Health (MH071537; MH100122; MH102890), the National Institute of Child Health and Human Development (HD071982), and the National Center for Complementary & Integrative Health (K23AT009713). We acknowledge the entire Grady Trauma Project team for their contributions to data collection and management and are particularly grateful to our participants for their willingness to be a part of this project.

Footnotes

Conflicts of Interest. We have no known conflicts of interest to disclose.

Positionality Statement: All of the authors of this manuscript identify as women, and six of the authors also identify as BIPOC.

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