Prevalence and Associated Risk Factors of Postpartum Depression among Mothers in Pennsylvania, United States: An Analysis of the Pregnancy Risk Assessment Monitoring System (PRAMS) Data, 2012-2015

Introduction

Postpartum depression (PPD) is the most common morbidity among new mothers. PPD is associated with adverse infant and maternal health outcomes including lower breastfeeding initiation rates and early breastfeeding cessation,^1,2 poor mother-child bonding and interactions,^3,4 and infant developmental disorders or impaired child development.^5,6 Murray et al. indicated children of mothers suffering from PPD are at higher risk of emotional, behavioral, and psychological problems as well as cognitive and language developmental delays in early infancy.⁷ Josefsson et al. indicated women with a history of PPD, if untreated, were approximately 6 times more likely to have recurrent depressive symptoms compared to those without PPD and they were also more likely to experience physical and mental illness later in life.⁸ Women with PPD should receive treatment as early as possible. Unfortunately, PPD is underrecognized and undertreated due to the stigma associated with this illness, mothers' lack of knowledge, and mothers' reluctance to use psychotropic medications during the breastfeeding period.⁹

Understanding the epidemiology of PPD is important for PPD detection, prevention, and control strategies. While there are unpublished data about the prevalence of PPD, no publication is available about PPD prevalence and risk factors contributing to PPD specifically for Pennsylvania. Results from this study are important for public health officials in Pennsylvania to estimate the burden of PPD for the large northeastern state with approximately 140,000 resident births annually, including sub-populations at a higher risk for PPD for targeted interventions. This study aims to determine the prevalence of PPD and identify potential risk factors associated with PPD among mothers who delivered live-born infant(s) in Pennsylvania.

Methods

Results

Prevalence of Postpartum Depression

A total of 4,022 women were identified as eligible during 2012-2015. The mean age was 29 years [inter-quartile range (IQR): 25-33], 79.2% of the population were in the age group of 20-34 years, and 72.0% were white. The overall prevalence of PPD was 12.1% (515 mothers); the prevalence was 12.4% (108) in 2012, spiked to 14.8% (156) in 2013, then significantly declined to 10.9% (127) and 10.1% (124) for 2014 and 2015 (p=0.03), Figure 1.

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Figure 1:

Prevalence of postpartum depression (PPD), Pennsylvania, 2012-2015

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Discussion

The impact of PPD is deleterious to the mother, developing infant, and family when it is unrecognized and untreated.^14,15 Our study aimed to determine the prevalence and identify potential risk factors associated with PPD among new mothers in Pennsylvania.

We reported the overall PPD prevalence of 12. 1 % for the entire period of 2012-2015: the prevalence was 12.4%, 14.8%, 10.9%, and 10. 1% for 2012, 2013, 2014, and 2015, respectively. This is higher than the 2012 overall national prevalence of 11.5% reported by Ko and colleagues.¹⁶ PPD can be severe and symptoms can be experienced up to 12 months after delivery.¹⁷ Findings from recent studies indicate declines in the prevalence of PPD in recent years.^16,18 For example, Ko et al. reported a decline in the prevalence of PPD from 14.8% in 2004 to 12.6% in 2008, then to 9.8% in 2012 for 13 U.S. states; and the overall prevalence of PPD was 11.5% in 2012 for 27 U.S. states.¹⁶ Our results support this conclusion overall despite a small spike in 2013. Possible factors contributing to the recent decline in PPD include better identification of risk factors for depression and improved screening and treatment before and during pregnancy. Given an estimate of 140,000 live births per year and a PPD prevalence of 12.1%, the annual burden of PPD in Pennsylvania is around 16,940 mothers. Our unpublished data (PRAMS phase 7, years 2012-2015) indicate that 57.7% of pregnancies in Pennsylvania are unintended and unintended pregnancy increased the risk for PPD.¹⁹ The high number of new mothers suffering from PPD, in addition to the high rate of unintended pregnancy, suggest increased awareness of PPD is a key first step to tackle PPD.

Findings from recent studies show depression in the prenatal period was an independent predictor of PPD.^20,21,22 Our findings further confirm women with depression before getting pregnant were approximately four times more likely to suffer from symptoms of PPD compared with those who did not have depression, suggesting screening for depression during prenatal care visits, postpartum visits, or during the infant's well-child visit is critical among new mothers, especially among those who have a history of depression. The American College of Obstetricians and Gynecologists (ACOG) suggests screening for PPD as an essential part of the mother's 4-6 week postpartum visit, and women can also be screened by pediatricians at their infants' well-child visits; health care providers screen for a mother's depressive symptoms at least once during pregnancy or postpartum, using a validated screening tool.²³ In our study, 12.4% of the interviewed mothers reported depression before getting pregnant. This high prevalence in combination with a 4-fold increased risk for PPD among mothers with a history of depression suggests a critical need for timely screening, proper referral, and appropriate treatment for depression for Pennsylvania women during pregnancy and the postpartum period. The U.S. Preventive Services Task Force recommends all pregnant and postpartum women be screened for depression.²⁴ In 2019, the American Academy of Pediatrics recommended screening of mothers for depression at the 1-, 2-, 4-, and 6-month well-child visits; that health care providers use community resources for the treatment and referral of the mother with depression; and provide support for the maternal-child relationship, including breastfeeding support.²²

The association between PPD and being abused during or before pregnancy was reported in recent studies.^18,20 Intimate partner violence can lead to severe complications including premature delivery, vaginal bleeding, miscarriage, physical injury, or death of the mother or infant.²⁵ We defined “being abused before or during pregnancy” based on the responses to two questions regarding the time right before or during the most recent pregnancy: “During the 12 months before you got pregnant or during your most recent pregnancy, did your husband/partner push, hit, slap, choke, or physically hurt you in any other way?” Our data reported 3.8% of the women were abused, which is lower than a recent report of 6% by Chas et al.²⁶ However, we found mothers who were abused during or before pregnancy had a 3.5-fold increased risk for PPD compared with mothers who were not abused, highlighting a need for routine screening of all women for intimate partner violence in Pennsylvania. Identifying women experiencing abuse and referring them to domestic violence services or programs is critical for PPD prevention.

Several stressors occurring during the 12 months before a new baby was born were examined in our study. These include (1) Partner- related stressors: e.g. argued with husband/partner more than usual, husband/partner did not want the pregnancy, separation or divorce from a husband/partner, extended time away from husband/partner; (2) Financial stressors: e.g. mother lost job, partner lost job, had problems paying bills; (3) Traumatic stressors: e.g. mother or husband/partner went to jail, was homeless; (4) Emotional stressors: e.g. family member was sick, someone close to the mother died. We found financial and partner-related stressors are significant and strong predictors for PPD. For example, mothers who reported “extended time away from husband/partner” had a 2.3 fold increased risk for PPD, “mother lost job” had a 2.1 fold increased risk, “partner did not want the pregnancy” had a 1.7 fold increased risk, and “argued with partner more than usual” had a 1.6 fold increased risk. These findings are consistent with reports from recent studies indicating life stressors within 12 months of giving birth were robust predictors for PPD²⁷ and common life stressors during pregnancy were strongly associated with an increased prevalence of PPD, especially partner-related and financial stressors.²⁸ The findings suggest women should be routinely screened during pregnancy for common stressors, then referred for support services in order to reduce or avoid PPD.

We observed the highest prevalence of PPD in women who are of younger ages (≤ 19 years old), unmarried, had a lower income (≤$15,000), had low educational attainment (high school degree or below), received WIC during pregnancy, had a baby born <2,500 grams, or who had a baby born < 37 weeks. The findings are consistent with results from the previous studies.^16,18,21 Similarly to Salimi et al., we observed Black mothers had a higher proportion of PPD in comparison with other races,²⁹ which is different from the finding reported by Ko et al. in the sample of 27 U.S. states where PPD was highest among mothers of American Indian/Alaska Native or Asian/Pacific Islander race/ethnicity.¹⁶

Women with PPD should receive appropriate treatment to avoid poor health outcomes. Josefsson et al. reported women with a history of untreated PPD were more likely to have recurrent depressive symptoms and experience physical and mental illness later in life, compared with those who did not have PPD,⁸ thus mothers who are considered to have self-reported PPD based on their screening should be administered a full diagnostic interview and receive early diagnosis and treatment. Women with the above risk factors should be targeted for PPD prevention and treatment.

Postpartum depression is a serious condition but treatable with pharmaco-and non-pharmacological therapy; however, it is often underdiagnosed and untreated. Ko et al. reported approximately 60% of women with depressive symptoms do not receive a clinical diagnosis and 50% of diagnosed women do not receive any treatment.³⁰ Regardless of current treatments for PPD which are readily available, seeking help for PPD is underutilized.^31,32,33 Stone et al. reported that only 38% of mothers with PPD sought help in their study.²⁸ These data suggest that efforts toward early detection and referral of women with PPD to appropriate treatment are critical and urgent to reduce the burden of PPD. In addition, primary care physicians must remain alert to the high prevalence of depression in women of childbearing age and embrace routine screening for depression. In Pennsylvania, Title V funds support three programs that screen pregnant and new mothers for depression: home visiting programs, depression screening during a well-child visit, and screening in group prenatal care. Given an estimate of nearly 17,000 mothers with PPD in Pennsylvania, similar models should be expanded focusing on mothers who are at an increased risk for PPD.

Our study has several limitations. First, our data were from Pennsylvania PRAMS, which are based upon self-report, and PPD was not confirmed by a physician diagnosis. In addition, screening questions used in the survey, although validated, have a sensitivity of 58% and a specificity of 85% compared with clinical assessments of major depressive episodes.³⁴ This may have resulted in underestimating the true prevalence of PPD in Pennsylvania. Second, new mothers were asked about symptoms experienced since delivery. The time duration, from the point when symptoms appeared to the point when the mother was interviewed, may range from 2-6 months, so mothers might not have recalled exactly when depression occurred. If the occurrence of depression fell outside of the postpartum period and depression was reported as within the period, PPD prevalence may have been overestimated. Conversely, if the occurrence of depression fell within the postpartum period and depression was not reported, PPD prevalence may have been underestimated. Third, screening questions did not evaluate the severity of PPD; hence, we are not able to determine burdens for drug therapy versus non-drug therapy since many women may only need nonpharmacologic interventions such as psychotherapy, exercise, yoga, acupuncture, and enhanced social support. Finally, Pennsylvania PRAMS has limited data on other mental health aspects such as mental health treatment including antidepressant use, seeking help during pregnancy, or treatment when a mother was identified as having PPD or encountered stressors. Further studies may need to look at how mothers with PPD seek help or treatment as well as the impact of treatment in reducing PPD, particularly with diverse populations.