Postpartum Depression, 2018: 1 in 8 New Mothers Had Symptoms — and Many Were Not Asked

Perinatal depression — depression during or after pregnancy — is a common complication of pregnancy. Mental health conditions underlie about 9% of pregnancy-related deaths. Postpartum depression is linked to less breastfeeding, weaker mother–infant bonding, and a higher chance of developmental delays in the baby; untreated, it can harm the mother's health and cause sleeping, eating and behavior problems for the infant. Treated well, both mother and child benefit.

What the guidelines say

• The U.S. Preventive Services Task Force recommends depression screening for all adults, including pregnant and postpartum women, and counseling for those at increased risk of perinatal depression.
• The American College of Obstetricians and Gynecologists recommends screening for depression and anxiety at least once in the perinatal period, plus a full assessment of mood at the comprehensive postpartum visit.
• The American Academy of Pediatrics recommends screening mothers for postpartum depression during well-child visits.

The data

CDC analyzed 2018 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) in 31 sites with response rates of at least 55%. Women with a recent live birth are sampled from birth certificates and surveyed 2–6 months after delivery (4 months on average).

• Postpartum depressive symptoms (PDS): answering "always" or "often" to either of two questions adapted from the Patient Health Questionnaire-2 — how often since the birth they had felt down, depressed or hopeless, or had little interest or pleasure in doing things.
• Provider inquiry: whether a doctor, nurse or other health care worker asked if they were feeling down or depressed at prenatal visits and at the postpartum checkup.

Symptoms

13.2% — about one in eight — reported PDS, from 9.7% in Illinois and 10.3% in Massachusetts to 19.4% in West Virginia and 23.5% in Mississippi. In 16 long-reporting sites, PDS rose slightly but significantly from 2012 to 2018 (0.22 percentage points a year). Reported an average of four months after birth, the symptoms appear to persist.

PDS was above 20% among women who:

• were 19 or younger;
• were American Indian or Alaska Native;
• smoked during or after pregnancy;
• experienced intimate partner violence before or during pregnancy;
• reported depression before or during pregnancy;
• or whose infant had died.

It was also higher among women who were 20–24, Black or Asian/Pacific Islander, had 12 years of schooling or less, were unmarried, took part in WIC, had Medicaid at delivery, or breastfed for under 8 weeks.

Were women asked?

• Asking was more common postpartum than prenatally, overall and in 21 of 31 sites — perhaps reflecting ACOG's emphasis on postpartum assessment and weaker evidence for screening in pregnancy.
• Prenatally, younger, less-educated and unmarried women, those on WIC or Medicaid, smokers and those with prior depression were more often asked; so were Black, Hispanic and American Indian/Alaska Native women, compared with white and Asian/Pacific Islander women.
• Still, one in five women did not report being asked at a prenatal visit, and one in eight were not asked postpartum.

Why it matters

• Symptoms are a warning sign, not a diagnosis: a positive screen should lead to further assessment for a major depressive episode, backed by systems for diagnosis, treatment and follow-up. Among women of reproductive age, as many as 60% with a recent major depressive episode went undiagnosed, and only half were treated.
• Postpartum care should be an ongoing process, tailored to each woman, with a comprehensive visit covering physical, social and psychological well-being, and follow-up for chronic conditions.
• Providers can give women and their families timely education about perinatal depression, and health systems can build screening and linkage to care into quality improvement.
• States are acting too: programs such as Massachusetts Child Psychiatry Access Program for Moms build obstetric providers' capacity, the Health Resources and Services Administration has funded seven states for real-time psychiatric consultation, care coordination and training, and Healthy Start, home visiting and Title V programs can help.

Limitations

1. Results cover only women with a recent live birth in the included sites.
2. Symptoms were self-reported and are not a clinical diagnosis.
3. Symptoms that ended before, or began after, the survey were missed.
4. Answers are open to recall and social desirability bias.
5. The survey shows whether providers asked, not whether recommended screening and referral actually took place.

Sources

Based on "Vital Signs: Postpartum Depressive Symptoms and Provider Discussions About Perinatal Depression — United States, 2018," by Brenda L. Bauman, Jean Y. Ko, Shanna Cox and colleagues, Morbidity and Mortality Weekly Report 69(19), Centers for Disease Control and Prevention; a work of the United States government in the public domain.