Postpartum depression

Postpartum depression

Postpartum depression (PPD) is a serious health concern

affecting approximately 13 % of all women [1]. At least

19.2 % of women experience depression within 12 months

after giving birth [2]. The associations between prenatal

depression and PPD depression are well documented [3–5].

Psychosocial factors including high stress, low social sup-

port, and low marital satisfaction are also predictors [4, 5].

Surprisingly little is known about the extent to which

postpartum depression varies by race and ethnicity, given the

effects of culture on the experiences and manifestations of

depression [6, 7]. This dearth of information on postpartum

depression in ethnic minorities is well recognized. In a

published review of maternal depression, the Agency for

Healthcare Research and Quality found ‘‘screening instru-

ments [to be] poorly representative of the U.S. population,’’

and that ‘‘populations [from studies] were overwhelmingly

Caucasian’’ [8]. A review by O’Hara found that meta-anal-

yses on postpartum depression had omitted race and eth-

nicity as risk factors for postpartum depression [4].

Research studies on postpartum depression that have

included ethnic minorities generally compare African

C. H. Liu (&) Beth Israel Deaconess Medical Center, Harvard Medical School,

75 Fenwood Road, Boston, MA 02115, USA

e-mail: [email protected]

E. Tronick

Child Development Unit, University of Massachusetts,

100 Morrissey Blvd, Boston, MA 02125, USA

e-mail: [email protected]


Matern Child Health J (2013) 17:1599–1610

DOI 10.1007/s10995-012-1171-z

Americans and Hispanics with Whites. In these studies,

group differences in prevalence rates have shown to be

inconsistent. Across studies, the rates of postpartum

depression in African American and Hispanic women were

found to be higher [9], lower [10], or no different [11]

compared to Whites. What accounts for observed racial and

ethnic differences in prevalence is unclear. In some studies,

sociodemographic risk variables were associated with

higher levels of depressive symptomatology among Afri-

can Americans, raising the possibility that sociodemo-

graphic variables rather than race and ethnicity account for

different levels of postpartum depression [12–14]. In con-

trast, others have shown greater levels of depressive

symptomatology among African Americans and Hispanics

than Whites, after accounting for sociodemographic factors

[9]. While certain social factors could increase risk, some

factors might buffer against postpartum depression within

groups. For instance, low income foreign-born Hispanic

women with social support exhibited lower rates of post-

partum depression [15], whereas bilingual Hispanic women

were at greater risk than those who spoke only Spanish

[11]. It is possible that factors such as social support or

nativity and its effect on the likelihood of postpartum

depression differ by race/ethnicity because they express

different meanings or incur different implications for each

group. Moreover, stigmas about psychological problems

and help-seeking may have an effect on identifying post-

partum depression, resulting in a subsequent effect on

reported prevalence of postpartum depression rates [6, 16].

Given the mixed picture across groups, this study aimed to

systematically determine the extent to which prevalence

rates across race and ethnicity are explained by factors

associated with postpartum depression.


This study uniquely includes Asian/Pacific Islander

(API) women within the U.S. As the fastest growing ethnic

minority group, over 16 million APIs are estimated to be

living in the U.S [17, 18]. The research on API postpartum

experiences is limited, which is striking given that API

women may hold several risk factors.

If psychiatric history is a major predictor, API women

may be at greatest risk: those between the ages of

15–24 years have the highest rate of depression and su-

icidality compared to any other ethnicity, gender, or age

[19–21]. One study showed APIs to be at lower risk for

postpartum depressive symptoms compared to Whites,

African Americans, and Hispanics [14], while another

study reported a greater percentage of APIs with post-

partum symptoms compared to White Americans [22].

Analyses conducted by the New York City Department of

Health and Mental Hygiene on data from the 2004 to 2007

New York City (NYC) Pregnancy Risk Assessment Mon-

itoring System (PRAMS) revealed a higher rate of PPD

diagnoses among APIs compared to other groups [23–25].

From the most recent sample in 2007, 10.4 % of API

received a PPD diagnosis compared to 1.7 % of non-His-

panic White women [26]. These findings suggest a poten-

tial risk for postpartum depression in API

This study examines racial/ethnic disparities in PPD

diagnosis by identifying predictors accounting for preva-

lence differences. Because previous studies have either

focused mostly on small samples of one group, or did not

examine these risk factors by race/ethnicity, we hypothe-

size that associations of risk factors and PPD differ by race/

ethnic group. The risk factors evaluated were selected

based on the current literature [27–31]. Our study also

sought to explain disparities in PPD rates from a published

report by the NYC Department of Health and Mental

Hygiene. We utilized the study’s comprehensive popula-

tion-based dataset. We also sought to determine the

strength of predictors within each group and differences

across groups. Accordingly, we stratified our analyses by

race/ethnicity. Determining the strength of predictors by

group is essential for identifying individuals most at risk,

and may inform the possible causes of depression for dif-

ferent groups. Unique to this study was the use of diagnosis

as an outcome measure, the inclusion of information on

whether providers talked to women about depressed mood,

and an adequate sample size of APIs. This allowed us to

also examine disparities in psycho-education and diagnosis

across groups.