Study reveals underdiagnosis and inequities in postpartum depression treatment

Pregnancy and childbirth can be significant stressors on mental health. Nearly one in eight people who have given birth develop postpartum depression, according to the Centers for Disease Control and Prevention. More than just the "baby blues," postpartum depressive symptoms can lead to adverse outcomes for birthing people and families, and treatment requires effective screening, diagnosis and management.

New research from the UNC Gillings School of Global Public Health and the Columbia University Mailman School of Public Health, published today online and in the April print issue of Health Affairs, has uncovered significant underdiagnosis and undertreatment of postpartum depressive symptoms. As part of her dissertation, this study was led by Sarah Haight, MPH, doctoral candidate in epidemiology at the Gillings School in collaboration with Jamie Daw, PhD, assistant professor of Health Policy and Management at the Mailman School. The researchers also found stark racial and ethnic inequities in treatment for those with postpartum depressive symptoms.

The research drew on data from a novel survey led by Daw at Columbia University that followed up with 4,542 postpartum people who had a live birth in 2020 in seven jurisdictions: Kansas, Michigan, New Jersey, Pennsylvania, Utah, Virginia and New York City. The researchers found that 11.8% of those sampled reported postpartum depressive symptoms at 2-6 months postpartum. However, only 1 in 4 individuals with depressive symptoms received a perinatal mood and anxiety disorder (PMAD) diagnosis, and one in two reported receiving some form of mental health care in the first year postpartum.

The study found that while there were no statistical differences in PMAD diagnoses based on race or ethnicity, among those with depressive symptoms, 67% of white respondents received postpartum mental health treatment compared to only 37% of Hispanic and Black respondents and 19.7% of respondents who identified as Asian, Native Hawaiian, Pacific Islander, Southwest Asian, Middle Eastern or North African.

Our study in concert with existing work shows that Asian, Black and Latine birthing people, who may be at the greatest risk of postpartum depression, are the least likely to receive any form of postpartum mental health care – illustrating stark racial and ethnic inequities in how postpartum depression is identified and managed in the U.S."

Sarah Haight, MPH, doctoral candidate in epidemiology at the Gillings School

"Previous studies on PMAD symptoms, diagnosis, and treatment have typically focused only on the early postpartum period. By following people through the postpartum year, our findings elucidate how many individuals with mental health symptoms fall through the cracks and don't ever receive the care they need," said Daw.

The study findings suggest that policies that require and reimburse universal mental health screening at postpartum visits, ensure connections to care, reduce gaps in postpartum insurance coverage, and require clinician training in culturally responsive resources could improve equity of postpartum depression diagnosis and care in the U.S.

Birthing people undergo physical, mental and social upheaval during the perinatal and postpartum periods. Caring for a newborn, managing hormonal changes, and navigating existing social, financial or relational situations – each can place a burden on mental health that PMAD can magnify, according to the researchers. PMAD is linked to low social support, less closeness and warmth with partners, stunted infant growth, delayed infant cognitive and language development, poor infant sleep, compromised maternal-infant attachment, and difficulty initiating or maintaining breastfeeding.

"Half of pregnancy-related deaths in the U.S. occur in the postpartum year and mental health conditions are the second leading cause of deaths in the late postpartum period. Improving equitable access to PMAD diagnosis and treatment is thus critical to addressing the maternal health crisis in the U.S.," said Daw.

"Our findings document disparities in care, but more work is needed to investigate how structural and interpersonal racism may explain these observed inequities and what efforts are needed to address these mechanisms and their harmful effects," said Haight.

The study is part of the Health Affairs April 2024 issue on perinatal mental health and well-being, which explores the impacts of perinatal mental health on parents, infants and children and how policies can intervene to help. Haight and Daw, along with fellow experts and co-authors, will be part of a virtual symposium on Wednesday, April 3 at 1:00 p.m. ET