Women’s Experiences of Helplessness and Powerlessness During the Perinatal Period

Women’s Experiences of Helplessness and Powerlessness During the Perinatal Period | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Women’s Experiences of Helplessness and Powerlessness During the Perinatal Period Stephanie Hanson This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9595534/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Perinatal mental health disorders (PMHDs) affect approximately one in five U.S. women and are associated with significant maternal and infant morbidity. Experiences of helplessness (internal belief that action is futile) and powerlessness (externally imposed lack of control) may play distinct roles in shaping PMHD trajectories. However, these concepts are often conflated, and little is known about how they are experienced or differentiated by women during the perinatal period. Methods Using a phenomenological qualitative design, this study explored women’s lived experiences of helplessness and powerlessness in relation to PMHDs. Eighteen postpartum women, recruited from a larger survey study and stratified by combinations of PMHD status and responses to questions about helplessness and powerlessness, participated in 67–174 minute semi-structured interviews. Data were thematically analyzed using comparative analysis and analytic induction. Trustworthiness was enhanced through reflexive journaling, member checking, and intercoder reliability (Cohen’s κ = 0.82). Results Three themes emerged: (1) a cyclical relationship between helplessness and PMHD symptoms; (2) helplessness and powerlessness brought on by a lack of provider engagement in perinatal care; and (3) internal and external attributions of helplessness and powerlessness—women with PMHDs tended to internalize helplessness and externalize powerlessness, while women without PMHDs reversed these attributions. Conclusion Findings illuminate complex psychological, relational, and structural pathways linking helplessness, powerlessness, and PMHDs. Addressing PMHDs effectively requires care models that validate women’s experiences, strengthen autonomy, and disrupt cycles of learned helplessness. Attributional differences by PMHD status suggest novel intervention targets for enhancing empowerment in perinatal care. Background Perinatal mental health disorders (PMHDs), including perinatal depression, anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, bipolar disorder, and postpartum psychosis, represent a critical and growing area of concern within maternal health (Howard & Khalifeh, 2020 ). Affecting approximately one in five women in the United States, PMHDs can significantly impair women’s cognitive functioning, strain interpersonal relationships, and negatively impact both maternal and infant outcomes (CDC, 2023; Sipos et al., 2025). Despite increased awareness and clinical emphasis on mental health during the perinatal period, many individuals continue to experience distress that goes unrecognized, untreated, or unvalidated by healthcare providers (Association of American Medical Colleges, 2024 ). Helplessness and powerlessness have been conceptualized in related but different ways. Helplessness has been defined as, “the belief that there is nothing anyone can do to improve a bad situation” (Wallston, 2015 , p. 819). Powerlessness has been defined as, “lacking the ability to control outcomes” (Dow et al., 2022 , para. 4). Within empowerment theory (Zimmerman, 1995), helplessness and powerlessness are each negatively associated with empowerment. Helplessness has been conceptualized as psychological in nature, being grounded in internal circumstances, and the focus is on the belief that action is futile (Zimmerman, 1995). In contrast, powerlessness has been conceptualized as structurally or socially based, grounded in external circumstances, and the focus is on the lack of access to power or decision-making (Zimmerman, 1995). Interactions between helplessness and powerlessness are important to explore because empowerment requires decreasing feelings of both powerlessness and helplessness (Zimmerman 1995). The concept of helplessness is central to learned helplessness theory, which posits that repeated exposure to uncontrollable and negative events can lead individuals to internalize a belief that they are unable to change their circumstances (Seligman, 1972 ). A sense of learned helplessness has been linked to depression and other adverse mental health outcomes (Seligman, 1972 ) and may be particularly salient in the context of PMHDs. For instance, a woman who experiences repeated dismissal of her concerns during prenatal visits may begin to feel that her voice does not matter—potentially compounding existing symptoms of depression or anxiety. Moreover, the interplay between helplessness and/or powerlessness and PMHDs may not be one-directional or universal; rather, it may vary based on individual mental health status and symptom severity, the presence or absence of feelings of helplessness or powerlessness, and other contextual factors such as social support, race, or socioeconomic status. An example of this may be that individuals who have been immersed in impoverished settings may be so used to feeling unable to counteract their financial circumstances despite tremendous effort that if a PMHD develops following the delivery of a child, they may be less likely to see value in pursuing care for themselves to counteract the symptoms related to their PMHD. Helplessness and powerlessness have been associated with poor mental health outcomes, including depression and anxiety (Lim et al., 2020; Pryce et al., 2011). However, these concepts are often conflated or used interchangeably in both clinical and research contexts, with little exploration into how individuals experience or differentiate them. This is particularly problematic in the perinatal period, where biological, psychological, and social vulnerabilities converge and may uniquely shape perceptions of control, agency, and self-efficacy. Prior research suggests that negative interactions with healthcare providers, birth trauma, lack of social support, and other stressors may not only exacerbate PMHDs but also reinforce experiences of helplessness and powerlessness (Beck, 2004 ; Slade, 2006 ). Yet few studies have qualitatively explored how women themselves interpret and experience these feelings during and after pregnancy, or how those interpretations may vary depending on the presence or absence of PMHDs. The focus of this study was to explore two research questions: (1) How do women experience helplessness and powerlessness during the perinatal period? and (2) What is the intersection among women’s experiences of helplessness, powerlessness, and PMHDs? The goals of this study are to further the understanding of how helplessness and powerlessness present among women who have recently given birth and expand the exploration of these concepts within perinatal mental health research. Exploring how helplessness and powerlessness are experienced, differentiated, and influenced may offer valuable guidance for developing more supportive, empowering, and effective perinatal care models, and ultimately improving maternal mental health outcomes. All participants provided consent to participate in the study. Methods This research was conducted in accordance with the Declaration of Helsinki. The IRB at South Dakota State University approved this work. All participants provided consent to participate in this research by utilizing the eConsent feature in REDCap, followed by verbal consent before beginning the interviews. Clincal trial number: not applicable. Reflexivity Statement As the lead researcher and interviewer, I acknowledge that my positionality shaped the research process. My professional background in perinatal mental health and personal experience as a mother with lived experience of PMHDs informed both my approach to data collection and interpretation. While this perspective provided empathy and rapport with participants, it also introduced potential bias in coding and theme development. To mitigate these influences, I engaged in structured reflexive journaling throughout the study, documenting personal reactions and assumptions after each interview and during data analysis. Additionally, the coding team—comprising individuals with diverse disciplinary backgrounds and no direct lived experience with PMHDs—participated in team reflexive discussions to identify and address positionality-related biases. Peer debriefing and member checking were employed to ensure that interpretations reflected participants’ voices rather than researchers’ preconceptions. These strategies collectively enhanced the credibility and confirmability of the findings. Study Design A phenomenological qualitative design was selected for this study. Phenomenological studies center lived experiences to better understand specific phenomena (Urcia, 2021). This design was selected because the focus of this study was on understanding how women experience the phenomena of helplessness and powerlessness. An additional layer included understanding these experiences in the context of PMHDs. Recruitment and Sampling Procedure The sample for this study is a subsample from a larger study focused on birth trauma and PMHDs. The larger study utilized crowdsourcing through Amazon’s Mechanical Turk (MTurk) platform to recruit participants for a cross-sectional study. Survey data was collected in December 2024 via REDCap, which is a web-based, HIPAA-compliant application developed by Vanderbilt University to capture clinical research data and create databases and projects (Patridge & Bardyn, 2018). To be eligible for the study, participants needed to be: at least 18 years of age, residing in the United States, fluent in English (written and verbal), at least four weeks postpartum, less than seven months postpartum, not participating in any inpatient mental health or substance use treatment program(s), and not experiencing a current mental health crisis or emergency. If eligibility requirements were met, participants completed the eConsent process in REDCap where they reviewed the informed consent documents and provided their consent for survey participation. At the conclusion of the survey, participants indicated whether they would be interested in completing a virtual, semi-structured interview related to their experiences of empowerment, disempowerment, and/or PMHDs during the perinatal period. They also provided their email at that time. A total of 300 respondents completed the initial survey. After removal of duplicates ( n =7), data quality assurance checks ( n =35), and confirmation of timing of symptom onset ( n =9), there were 249 usable responses. This study was focused on survey participants’ experiences of helplessness, powerlessness, and PMHDs. As such, survey respondents who indicated interest in participating in an interview were sorted into three categories based on their survey responses related to measures of helplessness, powerlessness, and PMHDS. In the survey, helplessness and powerlessness were measured using one question each. PMHDS were measured using the following scales: depression scale (EPDS), anxiety scale (PASS), birth trauma (CBTS), OCD (DOCS); bipolar disorder (MDQ), and postpartum psychosis (PSC). Respondents whose total score on the helplessness measure was one standard deviation or greater above the mean were categorized as experiencing helplessness. This same process was used to determine the presence or absence of powerlessness. If a participant was assessed as experiencing increased feelings of helplessness, powerlessness, or helplessness and powerlessness, they were characterized as having a positive response to concepts negatively associated with empowerment (+CNAE). Participants who scored 1 SD below the mean for helplessness or powerlessness were characterized as having a negative response to concepts negatively associated with empowerment (-CNAE). Participants were also assessed for PMHDs based on the screening tool indicators for each disorder. If a participant screened positive for any PMHD, they were considered to be positive for a PMHD. The resulting three categories included: (1) experienced helplessness or powerlessness CNAE AND experienced any PMHDs (+CNAE/+PMHD), (2) did not experience helplessness or powerlessness AND experienced any PMHDs (-CNAE/+PMHD), and (3) experienced helplessness or powerlessness AND did not experience any PMHDs (+CNAE/-PMHD). A total of 198 of the 249 participants who completed the survey, and who fell into one of the three categories for this study, indicated they would be open to participating in an interview. An invitation to complete the interview was sent to a random subset of 60 participants of the 198 survey participants who indicated they would be interested in completing an interview in January 2025 who fit into one of these three categories. Seven individuals responded and confirmed their interest in an interview. Outreach was sent to an additional 75 individuals of the 198 survey participants who indicated they would be interested in completing an interview in February 2025 inviting them to complete the interview, and 5 responded to confirm their interest. Finally, in March 2025, the remaining survey participants ( n =63) who indicated they would be open to an interview were sent an invitation to participate in an interview. An additional six respondents verified their willingness to participate in an interview, leading to a total of 18 people who completed an interview for this study. Sample Six participants in each of the three categories completed interviews. Descriptive sociodemographic data was collected as part of the original survey and is presented in Table 1. Table 2 provides further information about birthing experiences and mental health of the study participants. The sample included 18 individuals with an age range from 23-52 years old. Overall, 94.4% ( n =17) of the sample identified as White. Within the study sample, 27.8% ( n =5) had a household income of $0-$49,999, 22.2% ( n =4) had between $50,000-$99,999, 22.2% ( n =4) had between $100,000-$149,999, 16.7% ( n =3) had between $150,000-$199,999, and 11.1% ( n =2) had $200,000+. Nearly all participants held a Bachelor’s degree or higher ( n =17, 94.4%). Most of the births occurred in a hospital setting ( n =15, 83.3%), and were vaginal deliveries ( n =11, 61.1%). All study participants had at least one previous live birth. Slightly more than half of participants screened positive for experiencing birth trauma ( n =10, 55.6%). All participants who screened positive for birth trauma screened positive for at least one PMHD. Data Collection Participants who agreed to complete an interview were sent consent forms to review prior to conducting the interview and instructions for how to sign up for an interview with the study investigator. They also selected whether they wanted to participate in a 1.5-hour interview or a 2.5-hour interview. The longer interview time allowed for additional interview questions that were related to topics not relevant to the current research questions. All interviews were conducted by the first author and recorded virtually using Zoom Health. At their scheduled interview time, participants logged on and were introduced to the interviewer. The interviewer asked what questions they had about the study, and then each participant was asked to sign the consent form and submit a copy to the interviewer. Before audio from each interview was recorded, participants were also asked to provide verbal consent to record the interview. During the semi-structured interview, participants were asked questions related to the phenomena of helplessness and powerlessness. Some sample questions from the interview guide include, “How do you feel the word ‘helpless’ relates to your perinatal experience?”, “How do you feel the word ‘powerlessness’ relates to your perinatal experience?”, and ” “How do you think helplessness and powerlessness are different?”. Toward the end of the interview, participants were asked if there was any information that they wanted to share that was not asked about during the interview. At the conclusion of the interview, each participant was provided with a list of resources for support and services that they could access if they desired. Participants were compensated $70 for booking and completing a 1.5-hour interview or $100 for booking and completing a 2.5-hour interview via eGift card, for their time and willingness to share their experiences. This study was approved by the Institutional Review Board at South Dakota State University (IRB-2024-192) and approved for secondary data analysis by the Institutional Review Board at the University of Minnesota-Twin Cities. Data Analysis Interviews ranged from 67 to 174 minutes, with an average duration of 82 minutes. The audio recordings were available through Zoom Health and were transcribed verbatim using TranscriptionWing.com. Interview transcripts were uploaded to a project file in NVIVO 14 for data analysis. Once uploaded, open coding was independently conducted by three members of the coding team to inductively identify codes within individual transcripts (Coates et al., 2021). The interviewer and lead member of the coding team is the author of this paper. Her research agenda is focused on perinatal mental health and she is a mother with lived experience with PMHDs. The second member of the coding team is a white male with doctoral training in social welfare and research methodologies. His positionality is influenced by theories regarding resilience, stress, coping, and the influence of systems on mental health. The final member of the coding team is a white female with doctoral training in biology and in-depth training in qualitative data analysis. She is trained as a medical lab scientist, and her analysis was informed by previous research about the impact of healthcare on mental health. All three members of the coding team independently coded the same three transcripts and then met to develop an initial codebook. Consensus was achieved through a series of three meetings by discussing discrepancies in coding and agreeing upon final codes that were to remain in the initial codebook. All transcripts were coded using thematic analysis by a minimum of two people on the coding team (Naeem et al., 2023). The constant comparative analysis method was utilized by each member of the coding team to compare qualitative findings between their two assigned groups (Glaser, 1965). Each member of the coding team was randomly assigned two participant groups to code and analyze and they were blinded to the groups they were assigned. Analytic induction was utilized by all members of the coding team to expand the codebook during the coding process (Patton, 2015). Analytic induction involved beginning thematic analysis with the initial codebook and applying the codes within that codebook to transcripts. If the codes included in the codebook accurately captured the meaning of the data in the transcripts, the codebook remained the same. As more transcripts were analyzed and deviant or negative cases were encountered that could not be explained by the existing codebook, codes were either split into subcodes, collapsed into more general codes, or new codes were added to capture the meaning of the data. This iterative process occurred until the codebook accurately explained all existing transcripts included in the data set. This process helped to inform a richer understanding of experiences of helplessness, powerlessness, and perinatal mental health disorders for individuals who completed the interviews. Four random transcripts (22%) were coded by all three members of the coding team to ensure intercoder reliability, which was assessed in NVIVO by calculating Cohen’s Kappa. Cohen’s Kappa was calculated in NVIVO 14 to be 0.82 for this study. After the coding of all transcripts was completed, a series of three meetings were held for the coding team to discuss major codes and overall themes identified within the transcripts. Trustworthiness Techniques to ensure trustworthiness were utilized to enhance rigor. To address credibility, all members of the coding team addressed reflexivity by participating in a structured team-reflexive discussion (Olmos-Vega et al., 2022). The structured team-reflexive discussion was completed after members of the coding team were provided with a list of personal reflexive questions to consider and respond to. Some example questions included in this process included, “In what way might my experience shape my participation in the project?”, and “What theories do I tend to favor while analyzing data?” (Barry et al., 1999). During the team-reflexive discussion, all members of the coding team were asked to share their responses and the team collectively brainstormed ways for each coder to mitigate the potential impact of their own positionality during the coding process. One outcome of the discussion was that all members of the coding team agreed to utilize reflexive journaling to document personal reactions, responses, and instances where there was either alignment with the views of the participants or misalignments (Thorpe, 2004). Team members were asked to share insights from the reflexive journaling process with the whole coding team at weekly meetings that were held throughout the entire data analysis process. Transferability was addressed through the utilization of thick descriptions during the interview process. While each participant was being interviewed, one member of the research team conducted the interview and a second member of the research team was tasked with taking notes about tone of voice, body language, and contextual factors such as socioeconomic status that came up during the interview that may influence both the perception of the participant and the interviewer. The use of a co-moderator to document this information is a common technique that is used when conducting focus groups or in-depth interviews that was adopted for use in this study (Krueger & Casey, 2014). Convenience sampling was utilized for recruitment (Moser & Korstjens, 2018); however, there was a clear process for classifying participants into categories for analysis, leading to a clearly defined sampling strategy. This clearly defined sampling strategy was also utilized to address transferability (Padgett, 2016). The coding team utilized thorough methodological documentation and detailed audit trails to address dependability. All methodological decisions were documented in an Excel spreadsheet for tracking purposes. During codebook development, all decisions about included codes, including when codes were split apart, condensed, or added, were documented using a pre-determined color-coding scheme to develop an audit trail specifically for the codebook. Coders did not code from the marked up version, but instead coded from a clean version that was updated and maintained by the primary study investigator in NVIVO. All other research process decisions and notes were also maintained in the Excel spreadsheet to maintain documentation of the audit trail (Carcary, 2020). To address confirmability, several techniques were utilized. First, peer debriefing was utilized after every interview (McMahon & Winch, 2018). Both members of the research team that were present at each interview met for at least 30 minutes following the completion of an interview. Initial impressions were discussed and documented, as well as major takeaways from the interview. Emotional reactions were specifically documented given the heavy content of some of the interviews. Another method that was used to address confirmability was member checking. Participants whose quotes were selected for final inclusion in this paper were asked to review the identified themes, their individual transcript, and their selected quotes to ensure that themes and quotes aligned and quotations were not misrepresented in the findings (McKim, 2023). The data collected as part of reflexive journaling practices was also utilized to address transferability (Thorpe, 2004). Results Themes Table 3 is a qualitative matrix comparing participant responses across the three study groups. The Cyclical Relationship between Helplessness and PMHDs Regardless of their experiences with helplessness and powerlessness, most participants who screened positive for PMHDs described a cyclical and mutually-reinforcing relationship between feelings of helplessness and their mental health struggles. This relationship was not only pervasive, but it was deeply embedded into their personal narratives about their experiences during the perinatal period. Several participants described how the emotional and psychological aftermath of childbirth, particularly when accompanied by distress or trauma, often initiated or intensified mental health symptoms. One +CNAE/+PMHD participant described how her feelings of helplessness began during labor and were compounded by the challenges of managing her mental health postpartum. She stated, Probably the hardest thing for me has been feeling helpless during my birth, then being diagnosed with depression and anxiety, nothing working to treat that depression and anxiety, and feeling helpless in my ability to change my mental health or even wanting to change it. All part of this thing where I keep feeling helpless over and over again. Adding to the recursive loop of helplessness and worsening mental health symptoms, several participants described being aware that there was a misalignment between their perceptions and feelings, and what they knew to be true and rational. This was evident in both the +CNAE and -CNAE groups. One participant (-CNAE/+PMHD) illustrated this feedback loop in the context of postpartum anxiety and described, Um, I mean, in the postpartum, definitely, like, again, with anxiety, like, knowing - like, knowing what I’m feeling is irrational. Like, I know it is not being able to change how I feel. I mean, that’s like - that’s extreme helplessness. I mean, I feel like that - like, that’s anxiety to me is feeling helpless regardless of the - what you know to be true or not. In addition to these emotional experiences, PMHDs often eroded participants’ sense of competency and self-worth, furthering their feelings and experiences of helplessness. Several women spoke of how their symptoms made them question their fitness as mothers and fed into perceptions of failure or inadequacy, reinforcing feelings of CNAE. One woman (+CNAE/+PMHD) expressed, My mental health convinced me that I was not capable of taking care of my babies. I was helpless. When my milk didn’t come in right away, to me, this was further proof that I was an unfit mom. With my mental health being as bad as it was, my family didn’t even trust me to take care of them, and I didn’t blame them. This theme was often accompanied by reflections on the experience of helplessness itself, suggesting that for many women, helplessness was not only a symptom of PMHDs but a defining feature of their entire postpartum experience. Many participants discussed how the concept of helplessness resonated with them and their experiences. One participant (-CNAE/+PMHD) stated, Helplessness completely describes my experience with my mental health during the postpartum period. There is not a more fitting word to describe the hell that I have experienced dealing with postpartum depression and postpartum anxiety and all that goes with those. Together, these narratives suggest that PMHDs and helplessness exist in a dynamic interplay where one amplifies the other, ultimately shaping participants’ experiences of early motherhood in profoundly destabilizing ways. Helplessness or Powerlessness Brought on by Lack of Provider Engagement in Patient Concerns Among the women who experienced CNAE, a recurrent and significant source of distress was the perception that their healthcare providers were disengaged, dismissive, or unresponsive to their needs—especially during moments of acute vulnerability. This perceived disregard served as a powerful initiator for feelings of helplessness and powerlessness. Many participants described how attempts to advocate for themselves were often met with indifference or minimization, leading to a sense of invisibility or futility. One participant (+CNAE/+PMHD) whose elevated blood pressure readings were repeatedly ignored, recounted, My blood pressures were like through the roof crazy. Every time I would call OB triage, they would tell me to come in because of my blood pressure, so then I would go in, and they would do nothing…. And then they were just all like super rude and dismissive and I told my husband, I said, ‘Unless this child is coming out of me, I’m never going back to triage.’ This all made me feel so powerless. Even in cases of severe psychiatric distress, participants reported being inadequately assessed or dismissed altogether, leading to dangerous delays in care. For one participant (+CNAE/+PMHD), this was exactly her experience. She shared, During those weeks of psychosis, I actually did go to the hospital several times. I went to the emergency room several times, um, and they would prescribe me. I would tell them what - what is wrong and like what I’m thinking that I’m like not in reality. I’m telling them all these things, and they would prescribe me a sleep medicine, um, and that didn’t work actually at all. I was powerless. Several participants also spoke about situations where the healthcare environment itself failed to accommodate or acknowledge their emotional needs during traumatic events, such as stillbirth. One participant (+CNAE/+PMHD) described being kept in the same hospital room that she experienced a stillbirth in throughout the duration of her hospitalization. In the room, she could hear other crying infants and visiting families, which negatively contributed to her mental health symptoms. She recalled, I felt helpless. I mean, there was never a discussion of, like, if we were gonna stay in the same room we originally got in from the get-go, and they thought nothing was wrong, and I was being an overreactive mom. For many participants, these experiences contributed to a loss of agency and an erosion of trust in the healthcare system. Several described a withdrawal from care or the perception of an inability to advocate for themselves as a direct consequence of feeling ignored by providers. One participant (+CNAE/+PMHD) shared that she felt that self-advocacy and getting second opinions were not options for her, despite her intuition that something was wrong. She said, “Um, I really just like basic self-advocacy and like reaching out and getting second opinions, um, when I knew something was wrong and that I wasn’t being listened to. I felt helpless.” These women’s accounts underscore how failures in provider engagement can catalyze and compound emotional distress, especially for those already navigating PMHDs, reinforcing a dangerous cycle of marginalization and psychological vulnerability. Internal and External Attribution of Helplessness and Powerlessness Participants across the sample articulated nuanced understandings of the concepts of helplessness and powerlessness. All participants described the two concepts as being related, yet distinct. Notably, however, their attributions of these states—whether perceived as internally or externally driven—varied systematically by PMHD status. Among participants who screened positive for at least one PMHD, helplessness was consistently articulated as being an internal experience—originating from diminished self-efficacy, confidence, or perceived psychological failure—whereas powerlessness was attributed to external forces, such as provider behavior or systemic inadequacies. One mother (+CNAE/+PMHD) described, I felt helpless when I believed I couldn’t advocate for myself; my self-confidence was at its lowest point. This was completely different from when I was powerless. I felt powerless when I didn’t believe I had the ability to even say what my needs were. The people in the room with me had taken that right away from me. Similar reflections were offered by several other participants, where helplessness was attributed to being an internal feeling, and powerlessness was an external attribution. One woman (+CNAE/+PMHD) summed this up as, “Helplessness is internal, personal; and powerlessness is something someone took away from you.” In particular, powerlessness was consistently described as being a process where something was taken away from the participant. One participant (-CNAE/+PMHD) stated, “Powerlessness I feel like is something that like was just taken away from me.” In contrast, most participants who screened positive for CNAE but negative for PMHDs described these concepts in reverse. Among this group, helplessness was more often associated with external conditions or interpersonal interactions, while powerlessness reflected a perceived lack of internal capacity to effect change. One woman (+CNAE/-PMHD) illustrated this as, “... powerlessness maybe being a little bit more like internal, um, like there’s nothing in your own personal power that you can really do to make the situation better.” Women in this group consistently described interpersonal interactions as being a catalyst for feelings of helplessness, and feelings of powerlessness as being rooted within their own circle of influence. One woman (+CNAE/-PMHD) described, Helpless, I feel like, is more based on the people around you. You’re screaming in the room like, “‘Help me. Help me. Help me.” and they’re just, you know, kind of ignoring you, but powerless is more like within yourself. These attributional differences may reflect different psychological frameworks or coping mechanisms adopted by women depending on the presence or absence of PMHDs. While women who experience PMHDs may internalize distress more deeply—interpreting failures or challenges as personal shortcomings—women without PMHDs may be more likely to externalize distress, placing responsibility on external systems or actors. These patterns offer important insights into how mental health symptoms can shape the cognitive and emotional processing of adversity and, by extension, affect help-seeking and recovery for PMHDs. Discussion The learned helplessness hypothesis contends that because of repeated exposures to negative events or situations, individuals internalize the belief that they have no influence on the outcomes they experience and they are subject to the influence of the situations and environment around them no matter how negative or unpleasant they are (Seligman, 1972). Learned helplessness has been widely studied in the context of other factors that can influence mental health conditions, including health literacy, social support, child poverty, and cumulative risk exposure (Evans & Cassells, 2014; Hao et al., 2022; Xie et al., 2023). The learned helplessness hypothesis was originally written in the context of depression (Seligman, 1972), but the commonality of experience expressed by women in this study and the themes that emerged from the data suggests the hypothesis extends to other PMHDs. Women in this study who screened positive for at least one PMHD often described experiencing feelings of helplessness during pregnancy and/or childbirth, and they also described how their mental health reinforced those feelings. For participants who did not experience feelings of helplessness prenatally or during childbirth but screened positive for at least one PMHD, these feelings still resonated with them as being part of their journey with PMHDs. In these cases, women would experience symptoms of PMHDs and then experience feelings of helplessness. These feelings would feed back into worsened symptoms of PMHDs, creating a cyclical relationship. It was common for participants to describe feeling trapped within the cycle of helplessness and PMHDs, feeling helpless in their situation and having no will to change the outcomes they faced because they felt helpless. The second theme is related to findings from other scholars where women were often unsatisfied with the care that they received during the perinatal period (Creech, 2024). When women are dissatisfied with the care they receive during pregnancy, it has been linked with poorer physical and mental health outcomes and lower attendance at prenatal visits (Britton, 2012; Creech, 2024). Unfortunately, these kinds of experiences were common amongst study participants and their experiences resulted in feelings beyond the level of dissatisfaction. The stories told by study participants during the interviews included instances of repeated presentation to providers of concerns related to pregnancy or postpartum, and a stillbirth where a woman was kept in a labor and delivery room and exposed to the sounds of crying infants and happy families arriving to visit. All these experiences exacerbated feelings associated with disempowerment, according to study participants. Scholars have cited several reasons for diminished provider engagement across all specialties of medicine, including obstetrics, that include limited time and resources, communication barriers, burnout, and inadequate training (Fleming et al., 2017). However, no amount of work constraints should lead to women feeling helpless and powerless during their pregnancy and birthing experiences. It is imperative that women’s experiences with their healthcare providers during the perinatal period prioritize dignity and reinforce women’s sense of autonomy and self-efficacy. Within the psychology literature, helplessness is defined as, “the belief that there is nothing anyone can do to improve a bad situation” (Wallston, 2015, p. 819). In comparison, powerlessness is defined as, “lacking the ability to control outcomes” (Dow et al., 2022, para. 4). For the third theme, women who screened positive for at least one PMHD articulated an internal attribution for helplessness, while powerlessness was given an external attribution. This was the reverse for women who did not screen positive for at least one PMHD, as they attributed helplessness to being external and powerlessness to being internal. Based on some definitions for helplessness and powerlessness, this is neither an alignment or misalignment with the definitions of these concepts; however, the contradiction between the two groups of women warrants more inquiry. It is interesting to consider the layers that could be contributing to the flipped attribution that was observed in the third theme when examining the additional context that can be added when taking into account other concepts, such as shame and guilt. Extant literature shows that individuals who experience high levels of PMHDs experience high levels of shame and guilt (Biggs et al., 2023; Staneva et al., 2017). Shame and guilt are attributed to internal feelings (Eisenberg, 2000). Scholars have also linked feelings of shame and guilt to feelings of helplessness (Tilghman-Osborne et al., 2008). It is possible that associations between shame, guilt, and helplessness, may be applicable in the context of PMHDs and the added exploration of shame and guilt in future research might lend itself to more refined definitions of helplessness and powerlessness among women who experience PMHDs and women who do not. The three themes identified in this paper create a multifaceted picture of the complexity surrounding feelings of helplessness and powerlessness in both the presence and absence of PMHDs. The findings demonstrate how individual psychological processes, systemic provider behaviors, and broader emotional experiences—such as shame and guilt—interact in ways that may shape women’s mental health trajectories during the perinatal period. The cyclical nature of helplessness, its reinforcement through inadequate care, and its association with internalized emotions such as shame and guilt suggest that interventions to improve perinatal mental health must extend beyond clinical symptom management to address relational, structural, and emotional contributors. Furthermore, the inversion of helplessness and powerlessness attributions between those with and without PMHDs represents a novel area of inquiry and highlights the need for deeper exploration of attributional processes in this population. Taken together, these findings underscore the importance of holistic, empathetic, and patient-centered care models that not only validate women’s concerns but actively work to disrupt cycles of learned helplessness and disempowerment. Limitations As with all studies, this study faced some limitations. The first limitation relates to sampling and the study sample. Despite nearly two-thirds ( n =198) of the participants in the larger study indicating they were interested in participating in an interview, the majority of invitations for an interview went unacknowledged. Despite efforts to group women into three categories based on their reports of disempowerment and PMHDs, it is possible that women in the study only represent a portion of possible experiences surrounding helplessness and powerlessness during the perinatal period. Additionally, given the limited racial diversity in the study sample, experiences of women who identify with a race or ethnicity other than White are largely missing from the data. Scholars have found that Black, Hispanic, and Asian women are more likely to experience mistreatment during pregnancy or birth (Vedam et al., 2019); experience lower levels of respect, have less say in decision-making, and feel more pressure to accept interventions (Vedam et al., 2018); and experience “obstetric racism” (Davis, 2019) than their White counterparts. These kinds of experiences would add significant and nuanced depth to the data that was not present given the racial and ethnic similarities in this study population. Finally, it was presupposed that helplessness and powerlessness were conceptually different and distinguishable to study participants; this may have introduced bias as well. Implications The findings from this study illuminate the complex, cyclical relationship between helplessness and PMHDs, revealing these experiences as mutually reinforcing processes shaped by personal attributions, systemic interactions, and broader sociocultural dynamics. The data suggest that helplessness is not an incidental byproduct of PMHDs, but is a potential driver of their persistence and severity—one that is deeply embedded in women’s lived experiences of pregnancy, childbirth, and the postpartum period. This underscores the need for public health and clinical strategies that move beyond symptom management to address the cognitive, relational, and structural factors that sustain this cycle. From a public health perspective these results reinforce the necessity of incorporating assessments of helplessness and powerlessness into standard perinatal care. Screening protocols should be expanded to include experiential and cognitive markers, not solely symptom checklists, particularly in populations at heightened risk due to trauma histories, structural inequities, or prior experiences of medical dismissal. The downstream effects of PMHDs on maternal functioning, infant development, and family stability make early detection and disruption of helplessness cycles a pressing public health priority. Community-based programs, peer support networks, and culturally responsive outreach may be particularly valuable in identifying and engaging those who internalize distress and may otherwise be reluctant to seek care. Clinically, the narratives presented in this study expose a persistent gap in provider engagement during critical moments of vulnerability. Reports of dismissal, minimization, or procedural insensitivity—such as failing to relocate bereaved mothers away from the sounds of crying infants—were not isolated incidents, but emblematic of systemic shortcomings in perinatal care. Such lapses are not only failures of interpersonal care but breaches in patient safety, trust, and dignity. Addressing this requires structural reforms: embedding trauma-informed and empowerment-based approaches into clinical training, ensuring mental health professionals are integrated into perinatal teams, and institutionalizing practices that actively solicit and validate maternal concerns. Environmental and relational contexts must be recognized as core determinants of psychological outcomes, not peripheral considerations. The results of this study highlight the critical need for interprofessional collaboration in perinatal care to address the complex interplay between psychological, relational, and structural factors influencing maternal mental health. Women’s experiences of helplessness and powerlessness were often exacerbated by fragmented care and inadequate provider engagement, underscoring the importance of integrated teams that include obstetric, nursing, and mental health professionals. Collaborative practice models can ensure that mental health screening and intervention occur alongside routine obstetric care, reducing delays in treatment and improving continuity of support. Interprofessional education should be prioritized to foster shared understanding of empowerment principles, trauma-informed care, and communication strategies that validate patient concerns. By embedding mental health specialists within perinatal care teams and promoting joint decision-making, healthcare systems can create a more holistic, patient-centered approach that mitigates feelings of disempowerment and enhances maternal autonomy and well-being. The inversion of attributional patterns for helplessness and powerlessness between women with and without PMHDs represents novel findings with direct implications for intervention design. For women with PMHDs, helplessness was often internalized, aligning with the learned helplessness hypothesis and reflecting entrenched self-blame, shame, and guilt—emotions that can impede recovery and engagement with care. For women without PMHDs, helplessness was more often externalized, associated with situational or systemic factors, while powerlessness reflected a lack of internal capacity to effect change. This suggests that interventions must be tailor to cognitive and emotional orientations: attribution retraining, self-compassion practices, and shame reduction may benefit those with internalized helplessness, while advocacy skill-building and systems navigation support may be more relevant for those who externalize helplessness. Framing these results within the learned helplessness hypothesis expands its application in the perinatal context, extending beyond depression to encompass a broader range of PMHDs. The findings also affirm empowerment theory as a complementary framework, offering a pathway for disrupting helplessness cycles through the restoration of agency, self-efficacy, and control. The alignment between these conceptual frameworks and the lived experiences of participants strengthens the case for interventions that operate simultaneously at the intrapersonal, interpersonal, and systemic levels. The findings of this study underscore the need for systemic changes in both educational preparation and policy frameworks to address experiences of helplessness and powerlessness during the perinatal period. From an educational perspective, curricula for nursing, midwifery, and obstetric training should integrate empowerment theory as a foundational concept to help providers recognize and mitigate disempowering experiences. In addition, trauma-informed care and mental health competency training must be expanded beyond symptom checklists to include experiential markers such as helplessness and powerlessness, which were shown to be deeply intertwined with PMHD trajectories. Communication skills training should emphasize active listening, validation, and shared decision-making to prevent provider disengagement—a recurrent theme in participants’ narratives. Interprofessional education that brings together obstetric and mental health professionals can foster collaborative care models, while embedding reflexivity and cultural humility within training programs can help providers critically examine biases and systemic factors influencing patient experiences. Policy implications are equally significant. Routine perinatal assessments should incorporate screening for helplessness and powerlessness alongside standard mental health evaluations to identify women and heightened risk for PMHDs. Policies that mandate documentation of patient concerns and provider responses can enhance accountability and reduce dismissive practices that contribute to disempowerment. Structural reforms should prioritize embedding mental health specialists within perinatal care teams to ensure timely intervention and integrated support. Accreditation standards must also include patient-centered care requirements that safeguard autonomy and dignity, such as environmental accommodations for bereaved mothers. Finally, public health campaigns should aim to raise awareness about helplessness and powerlessness as risk factors for PMHDs, promoting early help-seeking and community engagement in maternal mental health. Conclusion This research calls for a shift in perinatal mental health care—from a narrow biomedical focus on symptom reduction to a holistic approach that acknowledges and addresses the psychological, relational, and structural determinants of distress. Breaking the cycle of learned helplessness requires coordinated, multi-level strategies: validating women’s concerns in real time; equipping providers with resources, skills, and accountability to engage meaningfully; embedding empowerment principles into all aspects of care delivery; and fostering environments where maternal autonomy and dignity are safeguarded as fundamental rights. By reframing helplessness and powerlessness not merely as consequences, but as active drivers of PMHDs, public health and clinical systems can more effectively prevent, mitigate, and resolve these conditions—ensuring that the perinatal experience is defined not by constraint and despair, but by agency, connection, and resilience. Declarations Funding - Funding for this project was provided by the Health Resources and Services Administration. Author Contributions - SH: Conceptualization, Methodology, Analysis, Investigation, Original Draft, Review & Editing Data availability - Data is available upon request to the author. The author has no conflicts of interest to disclose. This study was approved by the IRB at South Dakota State University. All participants provided consent for participation. This study was approved by the South Dakota State University IRB. Acknowledgement I would like to acknowledge the guidance and mentorship provided by Lynette Renner, Ph.D., Mini Choy-Brown Ph.D., Joseph Merighi, Ph.D., and Susan Marshall Mason, Ph.D. References Association of American Medical Colleges. (2024). Maternal Mental Health. Retrieved June 30 from https://www.aamc.org/about-us/mission-areas/health-care/maternal-mental-health#:~:text=Mental%20health%20conditions%20are%20the%20most%20common,conditions%2C%2075%25%20are%20left%20untreated%20and%20undiagnosed Beck, C. T. (2004). Post‐traumatic stress disorder due to childbirth: The aftermath. Nursing Research, 53 (4), 216–224. https://doi.org/10.1097/00006199-200407000-00004 Britton, J. R. (2012). The assessment of satisfaction with care in the perinatal period. Journal of Psychosomatic Obstetrics & Gynecology, 33(2), 37-44. https://doi.org/10.3109/0167482X.2012.658464 Carcary, M. (2020). The Research Audit Trail: Methodological Guidance for Application in Practice. Electronic Journal of Business Research Methods, 23(2). https://doi.org/10.34190/JBRM.18.2.008 Centers for Disease Control and Prevention (CDC). (2023). Depression among women . Symptoms of Depression Among Women | Reproductive Health | CDC Dow, B. J., Menon, T., Wang, C. S., & Whitson, J. A. (2022). Sense of control and conspiracy perceptions: Generative directions on a well-worn path. Current Opinion in Psychology, 47(October 2022). https://doi.org/10.1016/j.copsyc.2022.101389 Eisenberg N. (2000). Emotion, regulation, and moral development. Annual review of psychology , 51 , 665–697. https://doi.org/10.1146/annurev.psych.51.1.665 Evans, G. W., & Cassells, R. C. (2014). Childhood Poverty, Cumulative Risk Exposure, and Mental Health in Emerging Adults. Clinical psychological science : a journal of the Association for Psychological Science , 2 (3), 287–296. https://doi.org/10.1177/2167702613501496 Glaser, B. G. (1965). The Constant Comparative Method of Qualitative Analysis. Social Problems , 12 (4), 436–445. https://doi.org/10.2307/798843 Hao, Y., De France, K., & Evans, G. W. (2022). Persistence on challenging tasks mediates the relationship between childhood poverty and mental health problems. International journal of behavioral development , 46 (6), 562–567. https://doi.org/10.1177/01650254221116870 Howard, L. M., & Khalifeh, H. (2020). Perinatal mental health: a review of progress and challenges. World Psychiatry, 19(3), 313-327. https://doi.org/10.1002/wps.20769 Krueger, R. A., & Casey, M. A. (2014). Focus Groups: A Practical Guide for Applied Research (5th ed.). McKim, C. (2023). Meaningful Member-Checking: A Structured Approach to Member-Checking. American Journal of Qualitative Research, 7(2), 41-52. https://doi.org/10.29333/ajqr/12973 Moser, A., & Korstjens, I. (2018). Series: Practical guidance to qualitative research. Part 3: Sampling, data collection and analysis. The European journal of general practice , 24 (1), 9–18. https://doi.org/10.1080/13814788.2017.1375091 Naeem, M., Ozuem, W., Howell, K., & Ranfagni, S. (2023). A Step-by-Step Process of Thematic Analysis to Develop a Conceptual Model in Qualitative Research. International Journal of Qualitative Methods , 22 . https://doi.org/10.1177/16094069231205789 Olmos-Vega, F. M., Stalmeijer, R. E., Varpio, L., & Kahlke, R. (2022). A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Med Teach, 1-11. https://doi.org/10.1080/0142159X.2022.2057287 Padgett, D. K. (2016). Qualitative methods in social work research (3rd ed.). SAGE Publications, Inc. Patton, M. Q. (2015). Qualitative research & evaluation methods (4th ed.). Thousand Oaks, CA: Sage. Seligman M. E. (1972). Learned helplessness. Annual review of medicine , 23 , 407–412. https://doi.org/10.1146/annurev.me.23.020172.002203 Şipoş, R., Calugar, I., & Predescu, E. (2025). Neurodevelopmental Impact of Maternal Postnatal Depression: A Systematic Review of EEG Biomarkers in Infants. Children , 12 (4), 396. https://doi.org/10.3390/children12040396 Slade, P. (2006). Towards a conceptual framework for understanding post‐traumatic stress symptoms following childbirth and implications for further research. Journal of Psychosomatic Obstetrics & Gynecology, 27 (2), 99–105. https://doi.org/10.1080/01674820600714582 Thorpe, K. (2004). Reflective learning journals: From concept to practice. Reflective Practice , 5 (3), 327–343. https://doi.org/10.1080/1462394042000270655 Wallston, K. A. (2015). Control Beliefs: Health Perspectives. In J. D. Wright (Ed.), International Encyclopedia of the Social & Behavioral Sciences (Second Edition) (pp. 819-821). Elsevier. https://doi.org/10.1016/B978-0-08-097086-8.14070-X Tables Table 1. Participant Demographics (N=18) n % Age 23-28 29-34 35-40 45-52 5 7 4 2 27.8 38.9 22.2 11.1 Race White Native American 16 2 88.9 11.1 Ethnicity Hispanic/Latino Non-Hispanic/Latino 1 17 5.6 94.4 Income $0-49,999 $50,000-99,999 $100,000-149,999 $150,000-199,999 $200,000 or more 5 4 4 3 2 27.8 22.2 22.2 16.7 11.1 Insurance Medicaid Indian Health Service Private 8 1 9 44.4 5.6 50.0 Education Associate’s Degree Bachelor’s Degree Master’s Degree Doctoral/Professional 1 9 7 1 5.6 50.0 38.8 5.6 Table 2. Birthing Experience and Mental Health (N=18) n % Birth Location Hospital Birthing Center Home 15 1 2 83.3 5.6 11.1 Birth Modality Vaginal Cesarean Section (C-Section) 11 7 61.1 38.9 Number of Previous Live Births 1 18 100 Self-Reported Experiencing Birth Trauma 10 55.6 Experienced Birth Trauma and Screened Positive for at Least One Perinatal Mental Health Disorder 12 66.7 Prevalence of Perinatal Mental Health Disorders Depression Anxiety Obsessive Compulsive Disorder Bipolar Disorder Psychosis 12 12 8 2 1 66.7 66.7 44.4 11.1 5.6 Prevalence of Helplessness 12 66.7 Prevalence of Powerlessness 12 66.7 Table 3. Qualitative Matrix Comparing Themes by Groups with Exemplar Quotes Theme Group 1: +CNAE / +PMHD Group 2: -CNAE / +PMHD Group 3: +CNAE / -PMHD Cyclical Relationship Between Helplessness and PMHDs Probably the hardest thing for me has been feeling helpless during my birth, then being diagnosed with depression and anxiety, nothing working to treat that depression and anxiety, and feeling helpless in my ability to change my mental health or even wanting to change it. Knowing what I’m feeling is irrational… not being able to change how I feel. I mean, that’s extreme helplessness. I mean, I feel like that—that’s anxiety to me. Not strongly represented; most narratives in this group focused on situational helplessness rather than cyclical mental health patterns. Helplessness or Powerlessness Due to Lack of Provider Engagement My blood pressures were like through the roof crazy… Every time I would call OB triage, they would tell me to come in… and they would do nothing… This all made me feel so powerless. During those weeks of psychosis… I went to the emergency room several times… I’m telling them all these things, and they would prescribe me a sleep medicine… I was powerless. Um, I really just like basic self-advocacy and like reaching out and getting second opinions… when I knew something was wrong and that I wasn’t being listened to. I felt helpless. Helpless, I feel like, is more based on the people around you. You’re screaming in the room like, ‘Help me. Help me. Help me.’ and they’re just, you know, kind of ignoring you. Internal vs. External Attribution of Helplessness and Powerlessness I felt helpless when I believed I couldn’t advocate for myself; my self-confidence was at its lowest point. This was completely different from when I was powerless. I felt powerless when… the people in the room with me had taken that right away from me. Helplessness is internal, personal; and powerlessness is something someone took away from you. Powerlessness I feel like is something that like was just taken away from me. …powerlessness maybe being a little bit more like internal, um, like there’s nothing in your own personal power that you can really do to make the situation better. Additional Declarations No competing interests reported. Supplementary Files InterviewGuide.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9595534","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":634779847,"identity":"f5c980c7-896d-4790-84f5-0bcab28ce4d3","order_by":0,"name":"Stephanie Hanson","email":"data:image/png;base64,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","orcid":"","institution":"South Dakota State University","correspondingAuthor":true,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Hanson","suffix":""}],"badges":[],"createdAt":"2026-05-02 17:24:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9595534/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9595534/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108805874,"identity":"f8814655-4057-480e-a8f5-5574a59d3ea0","added_by":"auto","created_at":"2026-05-08 15:27:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":345795,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9595534/v1/92ec6e08-a2c5-475a-a9ad-efae3ed08ce6.pdf"},{"id":108639718,"identity":"e4b780cc-639a-4e13-85cc-7adac44b58c7","added_by":"auto","created_at":"2026-05-06 19:13:46","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2107721,"visible":true,"origin":"","legend":"","description":"","filename":"InterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-9595534/v1/9d356dcd11f7f7404024f5b2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Women’s Experiences of Helplessness and Powerlessness During the Perinatal Period","fulltext":[{"header":"Background","content":"\u003cp\u003ePerinatal mental health disorders (PMHDs), including perinatal depression, anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, bipolar disorder, and postpartum psychosis, represent a critical and growing area of concern within maternal health (Howard \u0026amp; Khalifeh, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Affecting approximately one in five women in the United States, PMHDs can significantly impair women\u0026rsquo;s cognitive functioning, strain interpersonal relationships, and negatively impact both maternal and infant outcomes (CDC, 2023; Sipos et al., 2025). Despite increased awareness and clinical emphasis on mental health during the perinatal period, many individuals continue to experience distress that goes unrecognized, untreated, or unvalidated by healthcare providers (Association of American Medical Colleges, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHelplessness and powerlessness have been conceptualized in related but different ways. Helplessness has been defined as, \u0026ldquo;the belief that there is nothing anyone can do to improve a bad situation\u0026rdquo; (Wallston, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2015\u003c/span\u003e, p. 819). Powerlessness has been defined as, \u0026ldquo;lacking the ability to control outcomes\u0026rdquo; (Dow et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2022\u003c/span\u003e, para. 4). Within empowerment theory (Zimmerman, 1995), helplessness and powerlessness are each negatively associated with empowerment. Helplessness has been conceptualized as psychological in nature, being grounded in internal circumstances, and the focus is on the belief that action is futile (Zimmerman, 1995). In contrast, powerlessness has been conceptualized as structurally or socially based, grounded in external circumstances, and the focus is on the lack of access to power or decision-making (Zimmerman, 1995). Interactions between helplessness and powerlessness are important to explore because empowerment requires decreasing feelings of both powerlessness and helplessness (Zimmerman 1995).\u003c/p\u003e \u003cp\u003eThe concept of helplessness is central to learned helplessness theory, which posits that repeated exposure to uncontrollable and negative events can lead individuals to internalize a belief that they are unable to change their circumstances (Seligman, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e1972\u003c/span\u003e). A sense of learned helplessness has been linked to depression and other adverse mental health outcomes (Seligman, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e1972\u003c/span\u003e) and may be particularly salient in the context of PMHDs. For instance, a woman who experiences repeated dismissal of her concerns during prenatal visits may begin to feel that her voice does not matter\u0026mdash;potentially compounding existing symptoms of depression or anxiety. Moreover, the interplay between helplessness and/or powerlessness and PMHDs may not be one-directional or universal; rather, it may vary based on individual mental health status and symptom severity, the presence or absence of feelings of helplessness or powerlessness, and other contextual factors such as social support, race, or socioeconomic status. An example of this may be that individuals who have been immersed in impoverished settings may be so used to feeling unable to counteract their financial circumstances despite tremendous effort that if a PMHD develops following the delivery of a child, they may be less likely to see value in pursuing care for themselves to counteract the symptoms related to their PMHD.\u003c/p\u003e \u003cp\u003eHelplessness and powerlessness have been associated with poor mental health outcomes, including depression and anxiety (Lim et al., 2020; Pryce et al., 2011). However, these concepts are often conflated or used interchangeably in both clinical and research contexts, with little exploration into how individuals experience or differentiate them. This is particularly problematic in the perinatal period, where biological, psychological, and social vulnerabilities converge and may uniquely shape perceptions of control, agency, and self-efficacy. Prior research suggests that negative interactions with healthcare providers, birth trauma, lack of social support, and other stressors may not only exacerbate PMHDs but also reinforce experiences of helplessness and powerlessness (Beck, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Slade, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Yet few studies have qualitatively explored how women themselves interpret and experience these feelings during and after pregnancy, or how those interpretations may vary depending on the presence or absence of PMHDs.\u003c/p\u003e \u003cp\u003eThe focus of this study was to explore two research questions: (1) How do women experience helplessness and powerlessness during the perinatal period? and (2) What is the intersection among women\u0026rsquo;s experiences of helplessness, powerlessness, and PMHDs? The goals of this study are to further the understanding of how helplessness and powerlessness present among women who have recently given birth and expand the exploration of these concepts within perinatal mental health research. Exploring how helplessness and powerlessness are experienced, differentiated, and influenced may offer valuable guidance for developing more supportive, empowering, and effective perinatal care models, and ultimately improving maternal mental health outcomes. All participants provided consent to participate in the study.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis research was conducted in accordance with the Declaration of Helsinki. The IRB at South Dakota State University approved this work. All participants provided consent to participate in this research by utilizing the eConsent feature in REDCap, followed by verbal consent before beginning the interviews. Clincal trial number: not applicable. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReflexivity Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs the lead researcher and interviewer, I acknowledge that my positionality shaped the research process. My professional background in perinatal mental health and personal experience as a mother with lived experience of PMHDs informed both my approach to data collection and interpretation. While this perspective provided empathy and rapport with participants, it also introduced potential bias in coding and theme development. To mitigate these influences, I engaged in structured reflexive journaling throughout the study, documenting personal reactions and assumptions after each interview and during data analysis. Additionally, the coding team\u0026mdash;comprising individuals with diverse disciplinary backgrounds and no direct lived experience with PMHDs\u0026mdash;participated in team reflexive discussions to identify and address positionality-related biases. Peer debriefing and member checking were employed to ensure that interpretations reflected participants\u0026rsquo; voices rather than researchers\u0026rsquo; preconceptions. These strategies collectively enhanced the credibility and confirmability of the findings. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA phenomenological qualitative design was selected for this study. Phenomenological studies center lived experiences to better understand specific phenomena (Urcia, 2021). This design was selected because the focus of this study was on understanding how women experience the phenomena of helplessness and powerlessness. An additional layer included understanding these experiences in the context of PMHDs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment and Sampling Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample for this study is a subsample from a larger study focused on birth trauma and PMHDs. The larger study utilized crowdsourcing through Amazon\u0026rsquo;s Mechanical Turk (MTurk) platform to recruit participants for a cross-sectional study. Survey data was collected in December 2024 via REDCap, which is a web-based, HIPAA-compliant application developed by Vanderbilt University to capture clinical research data and create databases and projects (Patridge \u0026amp; Bardyn, 2018). To be eligible for the study, participants needed to be: at least 18 years of age, residing in the United States, fluent in English (written and verbal), at least four weeks postpartum, less than seven months postpartum, not participating in any inpatient mental health or substance use treatment program(s), and not experiencing a current mental health crisis or emergency. If eligibility requirements were met, participants completed the eConsent process in REDCap where they reviewed the informed consent documents and provided their consent for survey participation. At the conclusion of the survey, participants indicated whether they would be interested in completing a virtual, semi-structured interview related to their experiences of empowerment, disempowerment, and/or PMHDs during the perinatal period. They also provided their email at that time. A total of 300 respondents completed the initial survey. After removal of duplicates (\u003cem\u003en\u003c/em\u003e=7), data quality assurance checks (\u003cem\u003en\u003c/em\u003e=35), and confirmation of timing of symptom onset (\u003cem\u003en\u003c/em\u003e=9), there were 249 usable responses. \u003c/p\u003e\n\u003cp\u003eThis study was focused on survey participants\u0026rsquo; experiences of helplessness, powerlessness, and PMHDs. As such, survey respondents who indicated interest in participating in an interview were sorted into three categories based on their survey responses related to measures of helplessness, powerlessness, and PMHDS. In the survey, helplessness and powerlessness were measured using one question each. PMHDS were measured using the following scales: depression scale (EPDS), anxiety scale (PASS), birth trauma (CBTS), OCD (DOCS); bipolar disorder (MDQ), and postpartum psychosis (PSC). \u003c/p\u003e\n\u003cp\u003eRespondents whose total score on the helplessness measure was one standard deviation or greater above the mean were categorized as experiencing helplessness. This same process was used to determine the presence or absence of powerlessness. If a participant was assessed as experiencing increased feelings of helplessness, powerlessness, or helplessness and powerlessness, they were characterized as having a positive response to concepts negatively associated with empowerment (+CNAE). Participants who scored 1 SD below the mean for helplessness or powerlessness were characterized as having a negative response to concepts negatively associated with empowerment (-CNAE). Participants were also assessed for PMHDs based on the screening tool indicators for each disorder. If a participant screened positive for any PMHD, they were considered to be positive for a PMHD. The resulting three categories included: (1) experienced helplessness or powerlessness CNAE AND experienced any PMHDs (+CNAE/+PMHD), (2) did not experience helplessness or powerlessness AND experienced any PMHDs (-CNAE/+PMHD), and (3) experienced helplessness or powerlessness AND did not experience any PMHDs (+CNAE/-PMHD). \u003c/p\u003e\n\u003cp\u003eA total of 198 of the 249 participants who completed the survey, and who fell into one of the three categories for this study, indicated they would be open to participating in an interview. An invitation to complete the interview was sent to a random subset of 60 participants of the 198 survey participants who indicated they would be interested in completing an interview in January 2025 who fit into one of these three categories. Seven individuals responded and confirmed their interest in an interview. Outreach was sent to an additional 75 individuals of the 198 survey participants who indicated they would be interested in completing an interview in February 2025 inviting them to complete the interview, and 5 responded to confirm their interest. Finally, in March 2025, the remaining survey participants (\u003cem\u003en\u003c/em\u003e=63) who indicated they would be open to an interview were sent an invitation to participate in an interview. An additional six respondents verified their willingness to participate in an interview, leading to a total of 18 people who completed an interview for this study. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSix participants in each of the three categories completed interviews. Descriptive sociodemographic data was collected as part of the original survey and is presented in Table 1. Table 2 provides further information about birthing experiences and mental health of the study participants. The sample included 18 individuals with an age range from 23-52 years old. Overall, 94.4% (\u003cem\u003en\u003c/em\u003e=17) of the sample identified as White. Within the study sample, 27.8% (\u003cem\u003en\u003c/em\u003e=5) had a household income of $0-$49,999, 22.2% (\u003cem\u003en\u003c/em\u003e=4) had between $50,000-$99,999, 22.2% (\u003cem\u003en\u003c/em\u003e=4) had between $100,000-$149,999, 16.7% (\u003cem\u003en\u003c/em\u003e=3) had between $150,000-$199,999, and 11.1% (\u003cem\u003en\u003c/em\u003e=2) had $200,000+. Nearly all participants held a Bachelor\u0026rsquo;s degree or higher (\u003cem\u003en\u003c/em\u003e=17, 94.4%). Most of the births occurred in a hospital setting (\u003cem\u003en\u003c/em\u003e=15, 83.3%), and were vaginal deliveries (\u003cem\u003en\u003c/em\u003e=11, 61.1%). All study participants had at least one previous live birth. Slightly more than half of participants screened positive for experiencing birth trauma (\u003cem\u003en\u003c/em\u003e=10, 55.6%). All participants who screened positive for birth trauma screened positive for at least one PMHD. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants who agreed to complete an interview were sent consent forms to review prior to conducting the interview and instructions for how to sign up for an interview with the study investigator. They also selected whether they wanted to participate in a 1.5-hour interview or a 2.5-hour interview. The longer interview time allowed for additional interview questions that were related to topics not relevant to the current research questions.\u003c/p\u003e\n\u003cp\u003eAll interviews were conducted by the first author and recorded virtually using Zoom Health. At their scheduled interview time, participants logged on and were introduced to the interviewer. The interviewer asked what questions they had about the study, and then each participant was asked to sign the consent form and submit a copy to the interviewer. Before audio from each interview was recorded, participants were also asked to provide verbal consent to record the interview. \u003c/p\u003e\n\u003cp\u003eDuring the semi-structured interview, participants were asked questions related to the phenomena of helplessness and powerlessness. Some sample questions from the interview guide include, \u0026ldquo;How do you feel the word \u0026lsquo;helpless\u0026rsquo; relates to your perinatal experience?\u0026rdquo;, \u0026ldquo;How do you feel the word \u0026lsquo;powerlessness\u0026rsquo; relates to your perinatal experience?\u0026rdquo;, and \u0026rdquo; \u0026ldquo;How do you think helplessness and powerlessness are different?\u0026rdquo;. Toward the end of the interview, participants were asked if there was any information that they wanted to share that was not asked about during the interview. At the conclusion of the interview, each participant was provided with a list of resources for support and services that they could access if they desired. \u003c/p\u003e\n\u003cp\u003eParticipants were compensated $70 for booking and completing a 1.5-hour interview or $100 for booking and completing a 2.5-hour interview via eGift card, for their time and willingness to share their experiences. This study was approved by the Institutional Review Board at South Dakota State University (IRB-2024-192) and approved for secondary data analysis by the Institutional Review Board at the University of Minnesota-Twin Cities. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterviews ranged from 67 to 174 minutes, with an average duration of 82 minutes. The audio recordings were available through Zoom Health and were transcribed verbatim using TranscriptionWing.com. Interview transcripts were uploaded to a project file in NVIVO 14 for data analysis. Once uploaded, open coding was independently conducted by three members of the coding team to inductively identify codes within individual transcripts (Coates et al., 2021). The interviewer and lead member of the coding team is the author of this paper. Her research agenda is focused on perinatal mental health and she is a mother with lived experience with PMHDs. The second member of the coding team is a white male with doctoral training in social welfare and research methodologies. His positionality is influenced by theories regarding resilience, stress, coping, and the influence of systems on mental health. The final member of the coding team is a white female with doctoral training in biology and in-depth training in qualitative data analysis. She is trained as a medical lab scientist, and her analysis was informed by previous research about the impact of healthcare on mental health.\u003c/p\u003e\n\u003cp\u003eAll three members of the coding team independently coded the same three transcripts and then met to develop an initial codebook. Consensus was achieved through a series of three meetings by discussing discrepancies in coding and agreeing upon final codes that were to remain in the initial codebook. All transcripts were coded using thematic analysis by a minimum of two people on the coding team (Naeem et al., 2023). The constant comparative analysis method was utilized by each member of the coding team to compare qualitative findings between their two assigned groups (Glaser, 1965). Each member of the coding team was randomly assigned two participant groups to code and analyze and they were blinded to the groups they were assigned. \u003c/p\u003e\n\u003cp\u003eAnalytic induction was utilized by all members of the coding team to expand the codebook during the coding process (Patton, 2015). Analytic induction involved beginning thematic analysis with the initial codebook and applying the codes within that codebook to transcripts. If the codes included in the codebook accurately captured the meaning of the data in the transcripts, the codebook remained the same. As more transcripts were analyzed and deviant or negative cases were encountered that could not be explained by the existing codebook, codes were either split into subcodes, collapsed into more general codes, or new codes were added to capture the meaning of the data. This iterative process occurred until the codebook accurately explained all existing transcripts included in the data set. This process helped to inform a richer understanding of experiences of helplessness, powerlessness, and perinatal mental health disorders for individuals who completed the interviews. Four random transcripts (22%) were coded by all three members of the coding team to ensure intercoder reliability, which was assessed in NVIVO by calculating Cohen\u0026rsquo;s Kappa. Cohen\u0026rsquo;s Kappa was calculated in NVIVO 14 to be 0.82 for this study. After the coding of all transcripts was completed, a series of three meetings were held for the coding team to discuss major codes and overall themes identified within the transcripts. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTrustworthiness\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTechniques to ensure trustworthiness were utilized to enhance rigor. To address credibility, all members of the coding team addressed reflexivity by participating in a structured team-reflexive discussion (Olmos-Vega et al., 2022). The structured team-reflexive discussion was completed after members of the coding team were provided with a list of personal reflexive questions to consider and respond to. Some example questions included in this process included, \u0026ldquo;In what way might my experience shape my participation in the project?\u0026rdquo;, and \u0026ldquo;What theories do I tend to favor while analyzing data?\u0026rdquo; (Barry et al., 1999). During the team-reflexive discussion, all members of the coding team were asked to share their responses and the team collectively brainstormed ways for each coder to mitigate the potential impact of their own positionality during the coding process. One outcome of the discussion was that all members of the coding team agreed to utilize reflexive journaling to document personal reactions, responses, and instances where there was either alignment with the views of the participants or misalignments (Thorpe, 2004). Team members were asked to share insights from the reflexive journaling process with the whole coding team at weekly meetings that were held throughout the entire data analysis process. \u003c/p\u003e\n\u003cp\u003eTransferability was addressed through the utilization of thick descriptions during the interview process. While each participant was being interviewed, one member of the research team conducted the interview and a second member of the research team was tasked with taking notes about tone of voice, body language, and contextual factors such as socioeconomic status that came up during the interview that may influence both the perception of the participant and the interviewer. The use of a co-moderator to document this information is a common technique that is used when conducting focus groups or in-depth interviews that was adopted for use in this study (Krueger \u0026amp; Casey, 2014). Convenience sampling was utilized for recruitment (Moser \u0026amp; Korstjens, 2018); however, there was a clear process for classifying participants into categories for analysis, leading to a clearly defined sampling strategy. This clearly defined sampling strategy was also utilized to address transferability (Padgett, 2016). \u003c/p\u003e\n\u003cp\u003eThe coding team utilized thorough methodological documentation and detailed audit trails to address dependability. All methodological decisions were documented in an Excel spreadsheet for tracking purposes. During codebook development, all decisions about included codes, including when codes were split apart, condensed, or added, were documented using a pre-determined color-coding scheme to develop an audit trail specifically for the codebook. Coders did not code from the marked up version, but instead coded from a clean version that was updated and maintained by the primary study investigator in NVIVO. All other research process decisions and notes were also maintained in the Excel spreadsheet to maintain documentation of the audit trail (Carcary, 2020). \u003c/p\u003e\n\u003cp\u003eTo address confirmability, several techniques were utilized. First, peer debriefing was utilized after every interview (McMahon \u0026amp; Winch, 2018). Both members of the research team that were present at each interview met for at least 30 minutes following the completion of an interview. Initial impressions were discussed and documented, as well as major takeaways from the interview. Emotional reactions were specifically documented given the heavy content of some of the interviews. Another method that was used to address confirmability was member checking. Participants whose quotes were selected for final inclusion in this paper were asked to review the identified themes, their individual transcript, and their selected quotes to ensure that themes and quotes aligned and quotations were not misrepresented in the findings (McKim, 2023). The data collected as part of reflexive journaling practices was also utilized to address transferability (Thorpe, 2004). \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 3 is a qualitative matrix comparing participant responses across the three study groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe Cyclical Relationship between Helplessness and PMHDs\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegardless of their experiences with helplessness and powerlessness, most participants who screened positive for PMHDs described a cyclical and mutually-reinforcing relationship between feelings of helplessness and their mental health struggles. This relationship was not only pervasive, but it was deeply embedded into their personal narratives about their experiences during the perinatal period. Several participants described how the emotional and psychological aftermath of childbirth, particularly when accompanied by distress or trauma, often initiated or intensified mental health symptoms. One +CNAE/+PMHD participant described how her feelings of helplessness began during labor and were compounded by the challenges of managing her mental health postpartum. She stated, \u003c/p\u003e\n\u003cp\u003eProbably the hardest thing for me has been feeling helpless during my birth, then being diagnosed with depression and anxiety, nothing working to treat that depression and anxiety, and feeling helpless in my ability to change my mental health or even wanting to change it. All part of this thing where I keep feeling helpless over and over again.\u003c/p\u003e\n\u003cp\u003eAdding to the recursive loop of helplessness and worsening mental health symptoms, several participants described being aware that there was a misalignment between their perceptions and feelings, and what they knew to be true and rational. This was evident in both the +CNAE and -CNAE groups. One participant (-CNAE/+PMHD) illustrated this feedback loop in the context of postpartum anxiety and described, \u003c/p\u003e\n\u003cp\u003eUm, I mean, in the postpartum, definitely, like, again, with anxiety, like, knowing - like, knowing what I\u0026rsquo;m feeling is irrational. Like, I know it is not being able to change how I feel. I mean, that\u0026rsquo;s like - that\u0026rsquo;s extreme helplessness. I mean, I feel like that - like, that\u0026rsquo;s anxiety to me is feeling helpless regardless of the - what you know to be true or not.\u003c/p\u003e\n\u003cp\u003eIn addition to these emotional experiences, PMHDs often eroded participants\u0026rsquo; sense of competency and self-worth, furthering their feelings and experiences of helplessness. Several women spoke of how their symptoms made them question their fitness as mothers and fed into perceptions of failure or inadequacy, reinforcing feelings of CNAE. One woman (+CNAE/+PMHD) expressed, \u003c/p\u003e\n\u003cp\u003eMy mental health convinced me that I was not capable of taking care of my babies. I was helpless. When my milk didn\u0026rsquo;t come in right away, to me, this was further proof that I was an unfit mom. With my mental health being as bad as it was, my family didn\u0026rsquo;t even trust me to take care of them, and I didn\u0026rsquo;t blame them. \u003c/p\u003e\n\u003cp\u003eThis theme was often accompanied by reflections on the experience of helplessness itself, suggesting that for many women, helplessness was not only a symptom of PMHDs but a defining feature of their entire postpartum experience. Many participants discussed how the concept of helplessness resonated with them and their experiences. One participant (-CNAE/+PMHD) stated, \u003c/p\u003e\n\u003cp\u003eHelplessness completely describes my experience with my mental health during the postpartum period. There is not a more fitting word to describe the hell that I have experienced dealing with postpartum depression and postpartum anxiety and all that goes with those.\u003c/p\u003e\n\u003cp\u003eTogether, these narratives suggest that PMHDs and helplessness exist in a dynamic interplay where one amplifies the other, ultimately shaping participants\u0026rsquo; experiences of early motherhood in profoundly destabilizing ways. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHelplessness or Powerlessness Brought on by\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e \u003cstrong\u003eLack of Provider Engagement in Patient Concerns\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong the women who experienced CNAE, a recurrent and significant source of distress was the perception that their healthcare providers were disengaged, dismissive, or unresponsive to their needs\u0026mdash;especially during moments of acute vulnerability. This perceived disregard served as a powerful initiator for feelings of helplessness and powerlessness. Many participants described how attempts to advocate for themselves were often met with indifference or minimization, leading to a sense of invisibility or futility. One participant (+CNAE/+PMHD) whose elevated blood pressure readings were repeatedly ignored, recounted,\u003c/p\u003e\n\u003cp\u003eMy blood pressures were like through the roof crazy. Every time I would call OB triage, they would tell me to come in because of my blood pressure, so then I would go in, and they would do nothing\u0026hellip;. And then they were just all like super rude and dismissive and I told my husband, I said, \u0026lsquo;Unless this child is coming out of me, I\u0026rsquo;m never going back to triage.\u0026rsquo; This all made me feel so powerless. \u003c/p\u003e\n\u003cp\u003eEven in cases of severe psychiatric distress, participants reported being inadequately assessed or dismissed altogether, leading to dangerous delays in care. For one participant (+CNAE/+PMHD), this was exactly her experience. She shared,\u003c/p\u003e\n\u003cp\u003eDuring those weeks of psychosis, I actually did go to the hospital several times. I went to the emergency room several times, um, and they would prescribe me. I would tell them what - what is wrong and like what I\u0026rsquo;m thinking that I\u0026rsquo;m like not in reality. I\u0026rsquo;m telling them all these things, and they would prescribe me a sleep medicine, um, and that didn\u0026rsquo;t work actually at all. I was powerless. \u003c/p\u003e\n\u003cp\u003eSeveral participants also spoke about situations where the healthcare environment itself failed to accommodate or acknowledge their emotional needs during traumatic events, such as stillbirth. One participant (+CNAE/+PMHD) described being kept in the same hospital room that she experienced a stillbirth in throughout the duration of her hospitalization. In the room, she could hear other crying infants and visiting families, which negatively contributed to her mental health symptoms. She recalled, \u003c/p\u003e\n\u003cp\u003eI felt helpless. I mean, there was never a discussion of, like, if we were gonna stay in the same room we originally got in from the get-go, and they thought nothing was wrong, and I was being an overreactive mom. \u003c/p\u003e\n\u003cp\u003eFor many participants, these experiences contributed to a loss of agency and an erosion of trust in the healthcare system. Several described a withdrawal from care or the perception of an inability to advocate for themselves as a direct consequence of feeling ignored by providers. One participant (+CNAE/+PMHD) shared that she felt that self-advocacy and getting second opinions were not options for her, despite her intuition that something was wrong. She said, \u0026ldquo;Um, I really just like basic self-advocacy and like reaching out and getting second opinions, um, when I knew something was wrong and that I wasn\u0026rsquo;t being listened to. I felt helpless.\u0026rdquo; These women\u0026rsquo;s accounts underscore how failures in provider engagement can catalyze and compound emotional distress, especially for those already navigating PMHDs, reinforcing a dangerous cycle of marginalization and psychological vulnerability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInternal and External Attribution of Helplessness and Powerlessness\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants across the sample articulated nuanced understandings of the concepts of helplessness and powerlessness. All participants described the two concepts as being related, yet distinct. Notably, however, their attributions of these states\u0026mdash;whether perceived as internally or externally driven\u0026mdash;varied systematically by PMHD status. Among participants who screened positive for at least one PMHD, helplessness was consistently articulated as being an internal experience\u0026mdash;originating from diminished self-efficacy, confidence, or perceived psychological failure\u0026mdash;whereas powerlessness was attributed to external forces, such as provider behavior or systemic inadequacies. One mother (+CNAE/+PMHD) described,\u003c/p\u003e\n\u003cp\u003eI felt helpless when I believed I couldn\u0026rsquo;t advocate for myself; my self-confidence was at its lowest point. This was completely different from when I was powerless. I felt powerless when I didn\u0026rsquo;t believe I had the ability to even say what my needs were. The people in the room with me had taken that right away from me. \u003c/p\u003e\n\u003cp\u003eSimilar reflections were offered by several other participants, where helplessness was attributed to being an internal feeling, and powerlessness was an external attribution. One woman (+CNAE/+PMHD) summed this up as, \u0026ldquo;Helplessness is internal, personal; and powerlessness is something someone took away from you.\u0026rdquo; In particular, powerlessness was consistently described as being a process where something was taken away from the participant. One participant (-CNAE/+PMHD) stated, \u0026ldquo;Powerlessness I feel like is something that like was just taken away from me.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eIn contrast, most participants who screened positive for CNAE but negative for PMHDs described these concepts in reverse. Among this group, helplessness was more often associated with external conditions or interpersonal interactions, while powerlessness reflected a perceived lack of internal capacity to effect change. One woman (+CNAE/-PMHD) illustrated this as, \u0026ldquo;... powerlessness maybe being a little bit more like internal, um, like there\u0026rsquo;s nothing in your own personal power that you can really do to make the situation better.\u0026rdquo; Women in this group consistently described interpersonal interactions as being a catalyst for feelings of helplessness, and feelings of powerlessness as being rooted within their own circle of influence. One woman (+CNAE/-PMHD) described, \u003c/p\u003e\n\u003cp\u003eHelpless, I feel like, is more based on the people around you. You\u0026rsquo;re screaming in the room like, \u0026ldquo;\u0026lsquo;Help me. Help me. Help me.\u0026rdquo; and they\u0026rsquo;re just, you know, kind of ignoring you, but powerless is more like within yourself. \u003c/p\u003e\n\u003cp\u003eThese attributional differences may reflect different psychological frameworks or coping mechanisms adopted by women depending on the presence or absence of PMHDs. While women who experience PMHDs may internalize distress more deeply\u0026mdash;interpreting failures or challenges as personal shortcomings\u0026mdash;women without PMHDs may be more likely to externalize distress, placing responsibility on external systems or actors. These patterns offer important insights into how mental health symptoms can shape the cognitive and emotional processing of adversity and, by extension, affect help-seeking and recovery for PMHDs. \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe learned helplessness hypothesis contends that because of repeated exposures to negative events or situations, individuals internalize the belief that they have no influence on the outcomes they experience and they are subject to the influence of the situations and environment around them no matter how negative or unpleasant they are (Seligman, 1972). Learned helplessness has been widely studied in the context of other factors that can influence mental health conditions, including health literacy, social support, child poverty, and cumulative risk exposure (Evans \u0026amp; Cassells, 2014; Hao et al., 2022; Xie et al., 2023). The learned helplessness hypothesis was originally written in the context of depression (Seligman, 1972), but the commonality of experience expressed by women in this study and the themes that emerged from the data suggests the hypothesis extends to other PMHDs.\u003c/p\u003e\n\u003cp\u003eWomen in this study who screened positive for at least one PMHD often described experiencing feelings of helplessness during pregnancy and/or childbirth, and they also described how their mental health reinforced those feelings. For participants who did not experience feelings of helplessness prenatally or during childbirth but screened positive for at least one PMHD, these feelings still resonated with them as being part of their journey with PMHDs. In these cases, women would experience symptoms of PMHDs and then experience feelings of helplessness. These feelings would feed back into worsened symptoms of PMHDs, creating a cyclical relationship. It was common for participants to describe feeling trapped within the cycle of helplessness and PMHDs, feeling helpless in their situation and having no will to change the outcomes they faced because they felt helpless.\u003c/p\u003e\n\u003cp\u003eThe second theme is related to findings from other scholars where women were often unsatisfied with the care that they received during the perinatal period (Creech, 2024). When women are dissatisfied with the care they receive during pregnancy, it has been linked with poorer physical and mental health outcomes and lower attendance at prenatal visits (Britton, 2012; Creech, 2024). Unfortunately, these kinds of experiences were common amongst study participants and their experiences resulted in feelings beyond the level of dissatisfaction. The stories told by study participants during the interviews included instances of repeated presentation to providers of concerns related to pregnancy or postpartum, and a stillbirth where a woman was kept in a labor and delivery room and exposed to the sounds of crying infants and happy families arriving to visit. All these experiences exacerbated feelings associated with disempowerment, according to study participants. \u003c/p\u003e\n\u003cp\u003eScholars have cited several reasons for diminished provider engagement across all specialties of medicine, including obstetrics, that include limited time and resources, communication barriers, burnout, and inadequate training (Fleming et al., 2017). However, no amount of work constraints should lead to women feeling helpless and powerless during their pregnancy and birthing experiences. It is imperative that women\u0026rsquo;s experiences with their healthcare providers during the perinatal period prioritize dignity and reinforce women\u0026rsquo;s sense of autonomy and self-efficacy. \u003c/p\u003e\n\u003cp\u003eWithin the psychology literature, helplessness is defined as, \u0026ldquo;the belief that there is nothing anyone can do to improve a bad situation\u0026rdquo; (Wallston, 2015, p. 819). In comparison, powerlessness is defined as, \u0026ldquo;lacking the ability to control outcomes\u0026rdquo; (Dow et al., 2022, para. 4). For the third theme, women who screened positive for at least one PMHD articulated an internal attribution for helplessness, while powerlessness was given an external attribution. This was the reverse for women who did not screen positive for at least one PMHD, as they attributed helplessness to being external and powerlessness to being internal. Based on some definitions for helplessness and powerlessness, this is neither an alignment or misalignment with the definitions of these concepts; however, the contradiction between the two groups of women warrants more inquiry. \u003c/p\u003e\n\u003cp\u003eIt is interesting to consider the layers that could be contributing to the flipped attribution that was observed in the third theme when examining the additional context that can be added when taking into account other concepts, such as shame and guilt. Extant literature shows that individuals who experience high levels of PMHDs experience high levels of shame and guilt (Biggs et al., 2023; Staneva et al., 2017). Shame and guilt are attributed to internal feelings (Eisenberg, 2000). Scholars have also linked feelings of shame and guilt to feelings of helplessness (Tilghman-Osborne et al., 2008). It is possible that associations between shame, guilt, and helplessness, may be applicable in the context of PMHDs and the added exploration of shame and guilt in future research might lend itself to more refined definitions of helplessness and powerlessness among women who experience PMHDs and women who do not.\u003c/p\u003e\n\u003cp\u003eThe three themes identified in this paper create a multifaceted picture of the complexity surrounding feelings of helplessness and powerlessness in both the presence and absence of PMHDs. The findings demonstrate how individual psychological processes, systemic provider behaviors, and broader emotional experiences\u0026mdash;such as shame and guilt\u0026mdash;interact in ways that may shape women\u0026rsquo;s mental health trajectories during the perinatal period. The cyclical nature of helplessness, its reinforcement through inadequate care, and its association with internalized emotions such as shame and guilt suggest that interventions to improve perinatal mental health must extend beyond clinical symptom management to address relational, structural, and emotional contributors. Furthermore, the inversion of helplessness and powerlessness attributions between those with and without PMHDs represents a novel area of inquiry and highlights the need for deeper exploration of attributional processes in this population. Taken together, these findings underscore the importance of holistic, empathetic, and patient-centered care models that not only validate women\u0026rsquo;s concerns but actively work to disrupt cycles of learned helplessness and disempowerment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs with all studies, this study faced some limitations. The first limitation relates to sampling and the study sample. Despite nearly two-thirds (\u003cem\u003en\u003c/em\u003e=198) of the participants in the larger study indicating they were interested in participating in an interview, the majority of invitations for an interview went unacknowledged. Despite efforts to group women into three categories based on their reports of disempowerment and PMHDs, it is possible that women in the study only represent a portion of possible experiences surrounding helplessness and powerlessness during the perinatal period. Additionally, given the limited racial diversity in the study sample, experiences of women who identify with a race or ethnicity other than White are largely missing from the data. Scholars have found that Black, Hispanic, and Asian women are more likely to experience mistreatment during pregnancy or birth (Vedam et al., 2019); experience lower levels of respect, have less say in decision-making, and feel more pressure to accept interventions (Vedam et al., 2018); and experience \u0026ldquo;obstetric racism\u0026rdquo; (Davis, 2019) than their White counterparts. These kinds of experiences would add significant and nuanced depth to the data that was not present given the racial and ethnic similarities in this study population. Finally, it was presupposed that helplessness and powerlessness were conceptually different and distinguishable to study participants; this may have introduced bias as well. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings from this study illuminate the complex, cyclical relationship between helplessness and PMHDs, revealing these experiences as mutually reinforcing processes shaped by personal attributions, systemic interactions, and broader sociocultural dynamics. The data suggest that helplessness is not an incidental byproduct of PMHDs, but is a potential driver of their persistence and severity\u0026mdash;one that is deeply embedded in women\u0026rsquo;s lived experiences of pregnancy, childbirth, and the postpartum period. This underscores the need for public health and clinical strategies that move beyond symptom management to address the cognitive, relational, and structural factors that sustain this cycle. \u003c/p\u003e\n\u003cp\u003eFrom a public health perspective these results reinforce the necessity of incorporating assessments of helplessness and powerlessness into standard perinatal care. Screening protocols should be expanded to include experiential and cognitive markers, not solely symptom checklists, particularly in populations at heightened risk due to trauma histories, structural inequities, or prior experiences of medical dismissal. The downstream effects of PMHDs on maternal functioning, infant development, and family stability make early detection and disruption of helplessness cycles a pressing public health priority. Community-based programs, peer support networks, and culturally responsive outreach may be particularly valuable in identifying and engaging those who internalize distress and may otherwise be reluctant to seek care. \u003c/p\u003e\n\u003cp\u003eClinically, the narratives presented in this study expose a persistent gap in provider engagement during critical moments of vulnerability. Reports of dismissal, minimization, or procedural insensitivity\u0026mdash;such as failing to relocate bereaved mothers away from the sounds of crying infants\u0026mdash;were not isolated incidents, but emblematic of systemic shortcomings in perinatal care. Such lapses are not only failures of interpersonal care but breaches in patient safety, trust, and dignity. Addressing this requires structural reforms: embedding trauma-informed and empowerment-based approaches into clinical training, ensuring mental health professionals are integrated into perinatal teams, and institutionalizing practices that actively solicit and validate maternal concerns. Environmental and relational contexts must be recognized as core determinants of psychological outcomes, not peripheral considerations. \u003c/p\u003e\n\u003cp\u003eThe results of this study highlight the critical need for interprofessional collaboration in perinatal care to address the complex interplay between psychological, relational, and structural factors influencing maternal mental health. Women\u0026rsquo;s experiences of helplessness and powerlessness were often exacerbated by fragmented care and inadequate provider engagement, underscoring the importance of integrated teams that include obstetric, nursing, and mental health professionals. Collaborative practice models can ensure that mental health screening and intervention occur alongside routine obstetric care, reducing delays in treatment and improving continuity of support. Interprofessional education should be prioritized to foster shared understanding of empowerment principles, trauma-informed care, and communication strategies that validate patient concerns. By embedding mental health specialists within perinatal care teams and promoting joint decision-making, healthcare systems can create a more holistic, patient-centered approach that mitigates feelings of disempowerment and enhances maternal autonomy and well-being. \u003c/p\u003e\n\u003cp\u003eThe inversion of attributional patterns for helplessness and powerlessness between women with and without PMHDs represents novel findings with direct implications for intervention design. For women with PMHDs, helplessness was often internalized, aligning with the learned helplessness hypothesis and reflecting entrenched self-blame, shame, and guilt\u0026mdash;emotions that can impede recovery and engagement with care. For women without PMHDs, helplessness was more often externalized, associated with situational or systemic factors, while powerlessness reflected a lack of internal capacity to effect change. This suggests that interventions must be tailor to cognitive and emotional orientations: attribution retraining, self-compassion practices, and shame reduction may benefit those with internalized helplessness, while advocacy skill-building and systems navigation support may be more relevant for those who externalize helplessness.\u003c/p\u003e\n\u003cp\u003eFraming these results within the learned helplessness hypothesis expands its application in the perinatal context, extending beyond depression to encompass a broader range of PMHDs. The findings also affirm empowerment theory as a complementary framework, offering a pathway for disrupting helplessness cycles through the restoration of agency, self-efficacy, and control. The alignment between these conceptual frameworks and the lived experiences of participants strengthens the case for interventions that operate simultaneously at the intrapersonal, interpersonal, and systemic levels. \u003c/p\u003e\n\u003cp\u003eThe findings of this study underscore the need for systemic changes in both educational preparation and policy frameworks to address experiences of helplessness and powerlessness during the perinatal period. From an educational perspective, curricula for nursing, midwifery, and obstetric training should integrate empowerment theory as a foundational concept to help providers recognize and mitigate disempowering experiences. In addition, trauma-informed care and mental health competency training must be expanded beyond symptom checklists to include experiential markers such as helplessness and powerlessness, which were shown to be deeply intertwined with PMHD trajectories. Communication skills training should emphasize active listening, validation, and shared decision-making to prevent provider disengagement\u0026mdash;a recurrent theme in participants\u0026rsquo; narratives. Interprofessional education that brings together obstetric and mental health professionals can foster collaborative care models, while embedding reflexivity and cultural humility within training programs can help providers critically examine biases and systemic factors influencing patient experiences. \u003c/p\u003e\n\u003cp\u003ePolicy implications are equally significant. Routine perinatal assessments should incorporate screening for helplessness and powerlessness alongside standard mental health evaluations to identify women and heightened risk for PMHDs. Policies that mandate documentation of patient concerns and provider responses can enhance accountability and reduce dismissive practices that contribute to disempowerment. Structural reforms should prioritize embedding mental health specialists within perinatal care teams to ensure timely intervention and integrated support. Accreditation standards must also include patient-centered care requirements that safeguard autonomy and dignity, such as environmental accommodations for bereaved mothers. Finally, public health campaigns should aim to raise awareness about helplessness and powerlessness as risk factors for PMHDs, promoting early help-seeking and community engagement in maternal mental health. \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis research calls for a shift in perinatal mental health care\u0026mdash;from a narrow biomedical focus on symptom reduction to a holistic approach that acknowledges and addresses the psychological, relational, and structural determinants of distress. Breaking the cycle of learned helplessness requires coordinated, multi-level strategies: validating women\u0026rsquo;s concerns in real time; equipping providers with resources, skills, and accountability to engage meaningfully; embedding empowerment principles into all aspects of care delivery; and fostering environments where maternal autonomy and dignity are safeguarded as fundamental rights. By reframing helplessness and powerlessness not merely as consequences, but as active drivers of PMHDs, public health and clinical systems can more effectively prevent, mitigate, and resolve these conditions\u0026mdash;ensuring that the perinatal experience is defined not by constraint and despair, but by agency, connection, and resilience.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding \u003c/strong\u003e- Funding for this project was provided by the Health Resources and Services Administration.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e - SH: Conceptualization, Methodology, Analysis, Investigation, Original Draft, Review \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability \u003c/strong\u003e- Data is available upon request to the author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe author has no conflicts of interest to disclose. This study was approved by the IRB at South Dakota State University.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll participants provided consent for participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was approved by the South Dakota State University IRB.\u0026nbsp;\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eI would like to acknowledge the guidance and mentorship provided by Lynette Renner, Ph.D., Mini Choy-Brown Ph.D., Joseph Merighi, Ph.D., and Susan Marshall Mason, Ph.D.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003eAssociation of American Medical Colleges. (2024). Maternal Mental Health. Retrieved June 30 \u003c/p\u003e\n\u003cp\u003efrom https://www.aamc.org/about-us/mission-areas/health-care/maternal-mental-health#:~:text=Mental%20health%20conditions%20are%20the%20most%20common,conditions%2C%2075%25%20are%20left%20untreated%20and%20undiagnosed \u003c/p\u003e\n\u003cp\u003eBeck, C. T. (2004). 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Wright (Ed.), International \u003c/p\u003e\n\u003cp\u003eEncyclopedia of the Social \u0026amp; Behavioral Sciences (Second Edition) (pp. 819-821). \u003c/p\u003e\n\u003cp\u003eElsevier. https://doi.org/10.1016/B978-0-08-097086-8.14070-X \u003c/p\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipant Demographics (N=18)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"432\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003en\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 23-28\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 29-34\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 35-40\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 45-52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e27.8\u003c/p\u003e\n \u003cp\u003e38.9\u003c/p\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eWhite\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Native American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e88.9\u003c/p\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eHispanic/Latino\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Non-Hispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003cp\u003e94.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$0-49,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$50,000-99,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$100,000-149,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$150,000-199,999\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;$200,000 or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e27.8\u003c/p\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003cp\u003e16.7\u003c/p\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Medicaid\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Indian Health Service\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Private\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Associate\u0026rsquo;s Degree\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bachelor\u0026rsquo;s Degree\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Master\u0026rsquo;s Degree\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Doctoral/Professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003cp\u003e38.8\u003c/p\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003e\u003cem\u003eBirthing Experience and Mental Health (N=18)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"511\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth Location\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hospital\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Birthing Center\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Home\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e83.3\u003c/p\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth Modality\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eVaginal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Cesarean Section (C-Section)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e61.1\u003c/p\u003e\n \u003cp\u003e38.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Previous Live Births\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSelf-Reported Experiencing Birth Trauma\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e55.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExperienced Birth Trauma and Screened Positive for at Least One Perinatal Mental Health Disorder\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevalence of Perinatal Mental Health Disorders\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003cp\u003eObsessive Compulsive Disorder\u003c/p\u003e\n \u003cp\u003eBipolar Disorder\u003c/p\u003e\n \u003cp\u003ePsychosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003cp\u003e44.4\u003c/p\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePrevalence of Helplessness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 269px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevalence of Powerlessness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 79px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003e\u003cem\u003eQualitative Matrix Comparing Themes by Groups with Exemplar Quotes\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1: +CNAE / +PMHD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2: -CNAE / +PMHD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 3: +CNAE / -PMHD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eCyclical Relationship Between Helplessness and PMHDs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eProbably the hardest thing for me has been feeling helpless during my birth, then being diagnosed with depression and anxiety, nothing working to treat that depression and anxiety, and feeling helpless in my ability to change my mental health or even wanting to change it.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eKnowing what I\u0026rsquo;m feeling is irrational\u0026hellip; not being able to change how I feel. I mean, that\u0026rsquo;s extreme helplessness. I mean, I feel like that\u0026mdash;that\u0026rsquo;s anxiety to me.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u003cem\u003eNot strongly represented; most narratives in this group focused on situational helplessness rather than cyclical mental health patterns.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eHelplessness or Powerlessness Due to Lack of Provider Engagement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMy blood pressures were like through the roof crazy\u0026hellip; Every time I would call OB triage, they would tell me to come in\u0026hellip; and they would do nothing\u0026hellip; This all made me feel so powerless. During those weeks of psychosis\u0026hellip; I went to the emergency room several times\u0026hellip; I\u0026rsquo;m telling them all these things, and they would prescribe me a sleep medicine\u0026hellip; I was powerless.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eUm, I really just like basic self-advocacy and like reaching out and getting second opinions\u0026hellip; when I knew something was wrong and that I wasn\u0026rsquo;t being listened to. I felt helpless.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eHelpless, I feel like, is more based on the people around you. You\u0026rsquo;re screaming in the room like, \u0026lsquo;Help me. Help me. Help me.\u0026rsquo; and they\u0026rsquo;re just, you know, kind of ignoring you.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eInternal vs. External Attribution of Helplessness and Powerlessness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eI felt helpless when I believed I couldn\u0026rsquo;t advocate for myself; my self-confidence was at its lowest point. This was completely different from when I was powerless. I felt powerless when\u0026hellip; the people in the room with me had taken that right away from me. Helplessness is internal, personal; and powerlessness is something someone took away from you.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003ePowerlessness I feel like is something that like was just taken away from me.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026hellip;powerlessness maybe being a little bit more like internal, um, like there\u0026rsquo;s nothing in your own personal power that you can really do to make the situation better.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-9595534/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9595534/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePerinatal mental health disorders (PMHDs) affect approximately one in five U.S. women and are associated with significant maternal and infant morbidity. Experiences of helplessness (internal belief that action is futile) and powerlessness (externally imposed lack of control) may play distinct roles in shaping PMHD trajectories. However, these concepts are often conflated, and little is known about how they are experienced or differentiated by women during the perinatal period.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing a phenomenological qualitative design, this study explored women\u0026rsquo;s lived experiences of helplessness and powerlessness in relation to PMHDs. Eighteen postpartum women, recruited from a larger survey study and stratified by combinations of PMHD status and responses to questions about helplessness and powerlessness, participated in 67\u0026ndash;174 minute semi-structured interviews. Data were thematically analyzed using comparative analysis and analytic induction. Trustworthiness was enhanced through reflexive journaling, member checking, and intercoder reliability (Cohen\u0026rsquo;s κ\u0026thinsp;=\u0026thinsp;0.82).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree themes emerged: (1) a cyclical relationship between helplessness and PMHD symptoms; (2) helplessness and powerlessness brought on by a lack of provider engagement in perinatal care; and (3) internal and external attributions of helplessness and powerlessness\u0026mdash;women with PMHDs tended to internalize helplessness and externalize powerlessness, while women without PMHDs reversed these attributions.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eFindings illuminate complex psychological, relational, and structural pathways linking helplessness, powerlessness, and PMHDs. Addressing PMHDs effectively requires care models that validate women\u0026rsquo;s experiences, strengthen autonomy, and disrupt cycles of learned helplessness. Attributional differences by PMHD status suggest novel intervention targets for enhancing empowerment in perinatal care.\u003c/p\u003e","manuscriptTitle":"Women’s Experiences of Helplessness and Powerlessness During the Perinatal Period","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-06 19:13:40","doi":"10.21203/rs.3.rs-9595534/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3c64637b-2a58-4561-ae03-3e9f7b940a8e","owner":[],"postedDate":"May 6th, 2026","published":true,"recentEditorialEvents":[{"type":"editorAssigned","content":"","date":"2026-05-05T11:51:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-05T11:50:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Women's Mental Health","date":"2026-05-02T17:12:18+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T19:13:40+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-06 19:13:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9595534","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9595534","identity":"rs-9595534","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}