Perinatal mood and anxiety disorders (PMADs) including prenatal depression (PND) and postpartum depression (PPD) can have a profound adverse impact on the well-being of mothers, newborns, and entire families. It is estimated that 20%-25% of women experience depressive symptoms during pregnancy or the postpartum period. To curtail rates and severity of PMADs, the American College of Obstetricians and Gynecologists (ACOG), The American College of Nurse Midwives, the U.S. Preventive Services Task Force, and the American Academy of Pediatrics (AAP) all encourage screening for perinatal depression and anxiety. In the absence of universal screening, one small study found that only 20% of mothers reported their symptoms of depression to a provider prior to being diagnosed.
The importance of screening is well understood in the public health literature, and growing attention is being given to disparities in delivery of care and their relationship to worsened outcomes in racial and ethnic minorities, and those with other minority statuses. For example, a 2016 meta-analysis of studies of mammography found Black and Hispanic women had significantly lower odds of utilizing screening mammography compared to their white counterparts. This is critically important, as African-American patients are both more likely to be diagnosed at later stages of breast cancer and 42% more likely to die of breast cancer than white patients. These findings and those from studies in other areas of medicine and public health give rise to the question: do disparities exist in perinatal screening for PMADs, in regards to race and other personal factors?
Perinatal Depression Screening: Findings from a Large Health System
The US Preventive Services Task Force, Council on Patient Safety in Women’s Healthcare, and American College of Obstetrics and Gynecologists all recommend that pregnant patients be screened at least once during pregnancy and again during the postpartum period, but this is not the reality for many patients. According to a recent study, screening rates for prenatal depression and postpartum depression (PPD) varied widely, from as low as 24% to as high as 100%, depending on the individual clinic. Clinic differences accounted for approximately 25-30% of the variance in screening rates; however, socioeconomic status, preferred language, history of depression, number of prenatal visits, and race were also significantly associated with rates of screening. This study was a collaboration between the Minnesota-based Mother Baby Clinical Service Line (MBCSL) and Mother Baby Mental Health Program (MBMHP). Researchers selected patients who had delivered at an Allina Health hospital and had at least 3 prenatal visits at one of 35 Allina Health clinics. With a sample of 7,548 patients, the researchers were able to use electronic health record (EHR) data to determine depression screening prevalence and its associated disparities.
During pregnancy, 65.1% of patients were screened for depression, and screening was evenly distributed across the three trimesters. However, the percentage of patients screened ranged from 34% to 100% depending on the clinic. The variance in screening was not entirely attributable to clinic practices. A history of depression or anxiety prior to pregnancy, number of prenatal visits, and preferred language being English were all significantly associated with higher rates of screening for prenatal depression.
The prevalence of PPD screening was similar to screening during pregnancy, as 64.4% of women were screened. Screening prevalence ranged from 24.8% to 95.6%, depending on the clinic. Although more of the variance in PPD screening was attributable to clinic standards, there were more disparities associated with PPD screening than prenatal depression screening. Women were less likely to be screened for PPD if they were African-American (adjusted odds ratio, aOR 0.81), Asian (aOR 0.64), or otherwise non-white (Native American, multi-racial, aOR 0.44). Lower rates of screening were also observed in those who were insured with Medicare or Medicaid, younger than 24, or were non-native English speakers. These disparities are especially concerning because low-income and African-American women are more likely to experience perinatal depression, yet according to this study, they are missing out on much needed screening and opportunities for early intervention.
The authors stressed that screening alone is not enough to help pregnant patients. Clinicians need to be ready to intervene or make referrals when a patient is depressed. Healthcare systems that combine screening and interventions are more successful at improving maternal health outcomes. To increase and standardize screening, the MBMHP team now provides education and training for providers to help them address and treat perinatal mental health concerns. They also added depression screening rates to their system quality review scorecard which is reviewed by the Allina Health System’s OB Quality Committee. The authors were unable to measure screening prevalence after adopting these measures, but they recommended that other health systems implement universal screening for all providers.
The Bottom Line
Further research is needed to crystallize the link between screening and health outcomes, but it is reasonable to assume that racial and other disparities in perinatal screening for PMADs may have a significant impact on disparities in mental health outcomes. Screening remains a critically important component of prenatal care. Furthermore, as recently discussed in a New YorkTimes article on the link between COVID-19 and PMADs, the global pandemic has already shown to disproportionately affect black and Latino communities. In the absence of universal and culturally-appropriate screening, it is possible that COVID-19 could exacerbate and amplify existing disparities.
Juliana Byanyima and Heather Anne Harmon, MPH
Sidebottom A, Vacquier M, LaRusso E, Erikson D, Hardeman R. (2020). Perinatal depression screening practices in a large health system: identifying current state and assessing opportunities to provide more equitable care. Arch Women’s Mental Health