To Build a Pro-Natal Culture, Don’t Overlook Maternal Mental Health 

It was early spring in the Midwest, that season when the weather alternates haphazardly between snow and rain, and frosty nights give way to reluctant morning sun. Yet on this day, the sun dominated, and I was feeling exuberant. I was out walking with my seven-month-old daughter snuggled in the Baby Bjorn when I noticed a silver-haired woman with a slight limp padding along ahead of us. We said hello and fell in step—she seemed to need a friend, and I was happy for the adult conversation. 

As we talked and walked, the subject turned—as it inevitably does when you are a young mother in conversation with strangers—to family planning decisions. (I can’t count how many times a stranger in the grocery store has smiled at me and my five kids and then asked, “Are you done now?”) 

The silver-haired woman, who didn’t realize that the baby on my chest was one of five, warned me, “Don’t have another one.” She told me about her ex-husband and warned that men would just try to get you pregnant to trap you. She also shared about her two estranged daughters. Her bitterness made my heart bleed. 

It also made me think about the pro-natalist movement, and the kinds of messages about fertility that we transmit to one another, neighbor-to-neighbor.

In a piece earlier this spring at National Review, Lyman Stone wrote about the mixed results of Hungary’s family policy, and in a response to a letter to the editor, he astutely concluded, 

the recipe for successful pro-natalism involves both getting the policy right and creating a cultural movement that is supportive of fertility. This latter effort is if anything the bigger lift. It is not entirely clear which ideas, attitudes, and values are most influential for fertility…. Figuring out what kind of pro-natal cultural norms can be advanced in American society to support higher birth rates remains a daunting task – and in a pluralist society, most likely a set of overlapping but separate tasks.

One way to approach this question about the cultural mores that influence fertility is to ask, “How can we support women as they become mothers?” A conversation about fertility is at base a conversation about mothers—who becomes one, when, and why? And how does she fare when she does?

Surveys on why young adults are forgoing or delaying children reveal a flurry of factors: medical, financial, difficulty finding the right partner, lifestyle or career conflict, infertility, concerns about the state of the world and environment, or just not wanting kids. Notably, in a recent Pew survey 27% of women cited medical reasons as their reason for not having another child—which is unsurprising given that up to a third of American moms report that their birth experiences were traumatic, and some of those women develop postnatal PTSD. 

Yet I find that too often pro-natalist conversations about fertility remain at the level of abstraction, despite the earthy concreteness of the subject at hand—pregnancy, the process of birth, and care for children. From this vantage point, factors like maternal morbidity and mental health are underdiscussed, though they are an important part of the “overlapping but separate tasks” necessary to support birth rates. 

In the U.S. today, one in five new mothers are affected by maternal mental health conditions, like anxiety and perinatal depression, and it is estimated that 75% go untreated. The U.S. maternal mortality rate is rising even as it declines in other high-income nations, and suicide is the leading cause of maternal death one year postpartum (accounting for 9% of the maternal mortality rate). Risk factors include lack of support, particularly from the child’s father. 

In response to these trends, the U.S. Department of Health and Human Services launched a new maternal mental health hotline on Mother’s Day of this year. Though these conditions are not the majority experience, neither are they uncommon. 

That same week that I walked with the silver-haired woman, which is now over a year ago, I had a kind of maternal breakdown. It was my “there but by the grace of God go I” moment—in which I could see how the stresses and pressures of parenthood could be enough to break an avatar of me with fewer resources and fewer strong supportive relationships.

A conversation about fertility is at base a conversation about mothers—who becomes one, when, and why? And how does she fare when she does?

Motherhood is at once exquisitely meaningful, delicate like a paper crane, yet hard and unchanging as a diamond, and at times crushing as stone. It is a relationship of need that is inescapable; indeed, it is defined by that inescapability. The relationship between mother and child looms large even when a child is abandoned, something evident in Elena Ferrante’s novel and its movie adaptation, The Lost Daughter.

Over a century ago, in the wake of the Industrial Revolution, educator and reformer Charlotte Mason reflected the unique way that motherhood is “a constant drawing out of the very depths of her nature” and noted “the ‘break-downs’ of mothers, which they tell us are growing more frequent every day.” Her description is not all that different from what you might hear a mother vent on the “The Primal Scream Line”: “We feel as if what was best in us got gradually frittered away, little by little,” Mason writes. It’s astounding that women have come so far yet not far enough, in an age when maternal mental health statistics are increasingly troubling. 

All of this points to the need for more and better support both culturally and politically. This is especially crucial in the perinatal period (during pregnancy and the first year after birth), a period of staggering physiological and psychosocial change for new mothers. 

Recent op-eds by Patrick Brown and by Brad Wilcox and Wells King outline a place to start, including with an expanded child tax credit, paid family leave, and extending Medicaid and Children’s Health Insurance Program coverage to mothers for up to one year postpartum—common-sense steps for a GOP seeking to realign itself as the pro-worker, pro-family party. Research by Dr. Lindsay Admon and her team at the University of Michigan suggests this is especially important as a high proportion of pregnancy-related deaths occur more than 60 days postpartum (the typical cut-off for coverage of Medicaid for postpartum mothers). 

New moms would also benefit from increased access to quality mental healthcare, especially evidence-based interventions like cognitive behavioral therapy. Proposals like Andrew Yang’s to subsidize marriage counseling could also include counseling for pregnant and postpartum moms. And there’s some serious work to be done in creating better birthing practices in hospitals and reducing the unintended consequences of overmedicalized birth. One part of this solution is increasing access to doula support by including their services in insurance coverage. 

But as pro-natalists are right to point out, none of these supports will be easily formed and sustained in a culture that does not see fertility as a social good. To achieve the will for change, we must achieve a consensus that having children is more than a lifestyle choice. Rather, it is a true social good with implications not only for the family that welcomes the child, but for the well-being and longevity of society itself. Fertility thus calls forth both parental and societal responsibility. 

Recently, I was on another walk, this time with my daughter who is now old enough to toddle beside me, when we took a detour off the sidewalk and into a neighbor’s yard in pursuit of one of the many stray cats that she attempts to befriend.  This particular neighbor, a kind and sensitive middle-aged woman who never had children of her own, watched us and then asked: “What’s it like to see the world through the eyes of a child?” 

Her question caught me off guard. It framed my experience as a gift, something precious to ponder with wide wonder. I thought about it later, in moments of parental stress, mulled over its meaning, held it close. Here I held a pearl for which I’d traded much else—that torturous, wondrous love of mother and child—and someone else had seen a glimmer of its power and worth.  

Amber Lapp is a Research Fellow at the Institute for Family Studies and co-investigator of the Love and Marriage in Middle America Project, a qualitative research inquiry into how white, working-class young adults form families and think about marriage.