A new study is painting a bleak picture of what motherhood does to women’s self-esteem, highlighting the need for emotional care across the reproductive spectrum and for all people who may become pregnant.

The study, forthcoming in the Journal of Personality and Social Psychology, examines self-esteem and relationship satisfaction before and after childbirth. Researchers from Tilburg University in the Netherlands, University of California, Davis, and the Norwegian Institute of Public Health focused on a sample of nearly 85,000 Norwegian mothers, who filled out questionnaires during their pregnancies and for the first three years of their child’s life.

The results aren’t exactly pretty. “Self-esteem decreased during pregnancy, increased until the child was six months old and then gradually decreased over the following years,” the study’s authors note. Moms with 3-year-olds—a demographic notorious for its challenging behavior—fared especially poorly, their self-esteem taking a nosedive.

Researchers also noted that “parenthood has unique effects on romantic relationship satisfaction,” with first-time mothers in the study experiencing particularly sharp decreases in satisfaction immediately after childbirth, followed by more gradual declines over subsequent years. What’s more, the data indicates that changes in relationship satisfaction and self-esteem are correlated.

In other words, the effects of transitioning to parenthood extend way beyond the physical, including interpersonal changes. All this makes the case for enhanced emotional support during pregnancy and throughout the first three (or more) years of parenting.

“When someone experiences a significant shift in identity, such as becoming someone’s mother, the psyche has to adjust. Simply because someone is a mother doesn’t mean that they always identify as a mother,” Corinne Laird, a psychotherapist and professor at Columbia University, told Rewire. “This means that the rest of the world has already shifted their perception of who you are before you’ve had a chance to catch up. It’s disorienting.”

While many moms (myself included) can attest to this disorientation, not all emotional responses to parenthood are created equal. External factors, largely out of individuals’ control, may also affect people who’ve recently given birth. For example, Norwegian mothers enjoy family-friendly policies (like paid parental leave, affordable child care, and universal health care) which, as the study’s authors note, “might buffer” them from more extreme declines in self-esteem. Conversely, expectant and new mothers in the United States face a dearth of institutional support—especially if they are low-income and/or a person of color.

“I can say categorically that, especially in the United States, we don’t support pregnant women or new mothers,” said Jennie Joseph, a midwife and the founder and executive director of Commonsense Childbirth Inc. “There is a dearth of emotional and mental health care or support.”

The situation is more dire for transgender or gender-nonconforming people who give birth, who are often overlooked in research and conversations around parenting. Thankfully, parents like Trevor MacDonald, author of Where’s the Mother?: Stories From A Transgender Dad, are helping to raise the visibility of trans folks’ experiences, particularly those who nurse.

Leah Torres, a Salt Lake City, Utah-based OB-GYN and abortion provider, agrees that more must be done to emotionally support people before, during, and after childbirth. “We don’t [address emotional care] well, but I think we try,” she said. “A lot of factors are at play: lack of insurance, inability to take time off work or obtain child care in order to go to more frequent appointments, social stigma preventing people from seeking help, and a paucity of qualified health professionals to care for any given population.”

These barriers become all the more daunting when you layer on economic adversity and cultural biases (something the Norwegian study doesn’t take into consideration), which can influence a patient’s emotional health. “I work with a lot of women of color and low-income women of all colors … low-income women are already in a bit of dire straits as far as their self-esteem,” Joseph said. “Women of color are dealing with untold numbers of concerns and microaggressions, and in this current climate, abject fear. Not just for themselves, but for their children, their partners, their family members.”

Indeed, racial discrimination severely undermines Black women’s health. Black women are three to four times more likely than white women to die from pregnancy-related causes, and as Rewire previously reported, “The chronic stress of living in poverty—of knowing a missed paycheck could leave you in dire straits, of not having enough to make ends meet—is killing Black women who choose to become pregnant and give birth.”

So how can the health-care community overcome these hurdles to provide more robust emotional care? For starters, by taking a more holistic approach to patient-centered care.

“Ideally, social workers or other mental health-care professionals would be working alongside OB-GYNs,” said Laird. “While this may be the case in some hospital settings, interventions tend to be focused on assessing the presence of domestic violence during pregnancy and a brief conversation based on the outcome of a postpartum depression screening, post-birth.”

This simply isn’t enough. Luckily, professionals like Joseph go above and beyond to ensure patients feel supported from the get-go. “We’ve made it our mission to provide emotional, mental health, and social support,” she said. “Active listening, recognition of traumatized patients, all in addition to providing a standard of medical care … we have created supports throughout our work whereby each patient is individually supported. Helping hands and listening ears are a standard part of care at our clinics.”

Although the study focuses solely on pregnant women and mothers, it’s worth noting that all people deserve compassionate care regardless of where they fall on the reproductive spectrum—including those who have experienced pregnancy loss and who have sought abortion care for unwanted pregnancies.

For bereaved parents, this means going beyond the standard postpartum care. “Many offices offer personal connections via follow-up calls, but not all. Best practice indicates direct contact with the woman beyond the depression scale can make a significant difference,” said Susanne Fuhrman, a perinatal bereavement counselor in New Jersey. “Compassion and welcoming dialogue can be vital to revealing warning signs that a mom might need support. This is all tied in with sense of self-worth. A woman who does not feel worthy of help will often not reach out for it. Reach out to her instead.”

As for those who seek abortion care, support can likewise come in many forms, such as abortion doulas who, as writer Kelsey Miller at Refinery29 explains, “provide informational, emotional, and physical support throughout the procedure, and sometimes immediately before and after.”

It’s also imperative that practitioners don’t stigmatize patients who terminate pregnancies. While the vast majority of people feel relief after having an abortion, many feel “silenced by stigma, and are unable to share their story, and in turn, fully process what happened. If we didn’t have the stigma associated with abortion, women could get the public support they so deserve, if they need it. Abortion is health care,” said Fuhrman.