The American College of Obstetricians and Gynecologists (ACOG) now recommends screening for perinatal depression, stating that “clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standard, validated tool.” Having the backing of ACOG is certainly a big step in the right direction. But as we move toward universal screening, we must make sure that screening is seamlessly connected to follow-up and treatment.
What we have seen over and over is that most women with perinatal depression, including those identified through screening in obstetric practices, do not get appropriate treatment for their symptoms. A recent study from Dagner and colleagues explores the socioeconomic and racial/ethnic factors access to mental health services after delivery.
In this study, researchers used cross-sectional data from the Listening to Mothers II Survey, a survey of women’s childbearing experiences in the United States. The survey recruited 1573 women, aged 18-45 years, who spoke English and had given birth the past year. Depressive symptoms were measured using the Postpartum Depression Screening Scale (PDSS-SF).
The prevalence of depressive symptoms in this population was high, with 61.7% of the mothers meeting the threshold for minor or major depression: 40.1% with PDSS scores of 14–21 and 21.6% with PDSS scores of 22–35. Although sampling techniques were used to obtain a nationally representative sample, the prevalence of depressive symptoms in this study is much higher than observed in other cross-sectional studies.
Women were asked whether or not they sought postpartum consultation for mental health issues. About 19% of mothers sought mental health consultations. The severity of depressive symptoms influenced the likelihood of mothers to seek help, such that women who met the threshold for depression on the PDSS-SF scale (18.2% of those scoring 14 to 21; 37.0% of those scoring 22 to 35) sought mental health consultations than those who did not meet the threshold (9.2% of those scoring 7 to 10; 10.1% of those scoring 11 to 13).
Latinas were much less likely to seek mental health consultations than Whites (OR 0.39). Mothers who were employed full-time or part-time prior to childbirth were less likely to seek consultations than non-employed mothers (OR 0.62 and OR 0.52, respectively). Mothers with household incomes of $50,000-$74,999 were more likely to seek consultations than those with incomes of less than $25,000 (OR 2.20).
Understanding Health Disparities in Perinatal Women with Mental Health Issues
The findings of this study are consistent with other studies in the general population which demonstrate racial and ethnic disparities in the use of mental health services in the United States. This study hints at some of the obstacles to seeking and accessing mental health services, but further study is required to better understand these health disparities and to develop programs to address the needs of perinatal women of ethnic and racial minorities.
Does the problem occur at the level of screening? Are we doing enough to increase awareness of perinatal mental health issues among all women? According to a recent study, women from ethnic and racial minorities are less likely to be screened for postpartum depression, with rates of screening lower in African-American (adjusted odds ratio, aOR 0.81), Asian (aOR 0.64), or otherwise non-white (Native American, multi-racial, aOR 0.44) women. The same study also observed lower rates of screening in those who were insured with Medicare or Medicaid, younger than 24, or were non-native English speakers.
Barriers to accessing care also contribute to disparities in the use of mental health services. Even under the best of circumstances, it can be difficult to access care when there is such a limited number of perinatal mental health providers. Language and cultural barriers, distrust of traditional healthcare and medical institutions, and exposure to discrimination during the clinical encounter may make women less likely to seek and engage in treatment. There may also be differences in perceptions of stigma associated with seeking mental health care as a new mother.
This study also hints at some of the economic barriers to accessing care. Women who are unemployed are more likely to seek care, suggesting that women who are employed may not be able to take time off from work or fear economic repercussions if they seek care for themselves. The finding that women with higher household incomes are more likely to seek care may be related to their ability to afford care, greater flexibility in their work situation, and/or access to childcare, transportation, and other support services.
Multiple studies have demonstrated higher rates of perinatal depression in women belonging to racial/ethnic minorities, recent non-English speaking immigrants, and women living in poverty. While these are the women at greatest risk for perinatal depression and their children may have the greatest vulnerability to the downstream effects of maternal depression on development and well-being, these are the women who are the least likely to seek and engage in mental health services.
Ruta Nonacs, MD PhD
Dagher RK, Pérez-Stable EJ, James RS. Socioeconomic and racial/ethnic disparities in postpartum consultation for mental health concerns among US mothers. Arch Womens Ment Health. 2021 Oct; 24(5): 781-791.