ArticleHow Much Does Low Socioeconomic Status Increase the Risk of Prenatal and Postpartum Depressive Symptoms in First-Time Mothers?
Introduction
Research suggests that women are more likely than men to develop a major affective mood disorder in their lifetime (Burt & Stein, 2002). Moreover, the risk of developing a depressive disorder increases substantially during the prenatal and postpartum period (Burt & Stein, 2002). This is understandable given the adaptation and transition from pregnancy and postpartum to motherhood. Meleis and Trangenstein's (1994) transition theory describes the addition of a new family member as a situational transition that causes multiple changes within the family. One of the major changes includes redefinition of each person's role within the family, for example, the nonparental to parental role. The transition and role change can be especially difficult for the first-time mother, who may have little or no past experience to draw upon.
Postpartum affective mood disorders are well documented in the literature and affect women worldwide. The three postpartum affective mood disorders most often discussed in the literature include the blues, postpartum depression (PPD), and postpartum psychosis. Of the three postpartum mood disorders, blues is the most common and affects between 26% and 85% of all postpartum women (Altshuler et al., 2001, Beck et al., 1992). Presenting within the first few days postpartum, the blues are transitory in nature and treatment is rarely needed. Postpartum psychosis is the most uncommon but most severe of the three postpartum mood disorders and requires immediate hospitalization and inpatient treatment. Symptoms can present within the first 48 to 72 hours after giving birth and include agitation, pressured speech, hallucinations, delusions, inability to sleep, and confusion (Gale and Harlow, 2003, Sichel, 2000).
As with the postpartum blues, the prevalence rate of PPD differs greatly across studies, ranging from 4.5% to 28% (Scottish Intercollegiate Guidelines Network, 2007). This variation is due in part to the differences in sample race/ethnicity, demographics, data collection points, and method of measuring depressive symptoms. The Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV; American Psychiatric Association, 1994) defines PPD as a constellation of specific symptoms occurring in the first few weeks postpartum. The temporal boundaries of PPD are still under debate; however, experts define PPD as the onset of a depressive episode between 2 weeks and 12 months after giving birth (O'Hara and Swain, 1996, Sichel and Driscoll, 2002, The Marcé Society, 2006). Timely diagnosis and treatment for PPD is essential because symptoms can lead to poor maternal–infant bonding and disrupt the infant's own emotional and cognitive development if left untreated (Beck, 1995, Beck, 1998, Edhborg et al., 2001, Field et al., 1990, Grace et al., 2003, Murray, 1992). Other detrimental effects of untreated PPD include poor social relationships and interpersonal interactions, substance abuse, infanticide, and suicide (Kelly et al., 2001, Lindgren, 2001, Spinelli, 2004).
Risk factors identified in the development of PPD include hormonal changes, antenatal depression, lack of social support, marital status, child care stress, adolescent pregnancy, poor relationship satisfaction, infant temperament, and low self-esteem (Beck, 1996, Beck, 2001, Goyal et al., 2009, Hendrick et al., 1998, Logsdon and Usui, 2001, McGrath et al., 2008, Studd and Panay, 2004). Low socioeconomic status (SES) is often associated with lack of social support, low self-esteem, younger age, and absence of spousal financial and social support (Beck, 1996, Beck, 2001, Hendrick et al., 1998, Logsdon and Usui, 2001, McGrath et al., 2008, Studd and Panay, 2004). These risk factors are biopsychosocial in nature and the complexities of their interactions require a framework to better explore these factors and their contribution to the stress of transitioning to a maternal role and identity for the first-time mother (Goyal, 2007, Goyal et al., 2009)
Although biological changes after childbirth are the same to some degree for all women, SES is unique for each new mother and her family. The birth of a child can be joyful, demanding, and stressful for all parents (Muslow, Caldera, Pursley, Reifman, & Huston, 2002). How a new mother copes with the challenges of motherhood is also very individual and can be addressed within Lazarus and Folkman's (1984) theory of stress, appraisal, and coping. This theory considers an individual's efforts to manage stressors that are taxing or potentially exceeding their resources. Women with low SES are at greater risk of developing both antenatal depression and PPD (Beeber and Miles, 2003, Beeghly et al., 2003, Rich-Edwards et al., 2006). Furthermore, women with lower incomes are less likely to have adequate access to mental health services and are least likely to report symptoms of depression to health care professionals (Kimerling and Baumrind, 2005, Song et al., 2004).
Few researchers specifically set out to determine how demographic factors such as income, education, and age correlate with postpartum mood disorders. Even fewer studies have compared affluent and low-income women longitudinally from the prenatal period through 3 months postpartum. Therefore, the overall purpose of this study was to examine SES as a risk factor for depressive symptoms among women in late pregnancy through their third month postpartum. A secondary objective was to determine which of the four components of SES (income, marital status, education level, employment) was a specific risk factor for elevated postpartum depressive symptoms beyond their initial contribution to prenatal depression.
The research evidence for a relationship between SES and depressive symptoms during the childbearing period is conflicting. Some studies suggest that low SES contributes to the development of PPD and that a higher SES is protective against PPD, whereas others report that low SES has very little influence on the development of PPD. A recent report compiled by the Center for Health Statistics (2008) estimated that 1 in 5 women would suffer from PPD in her lifetime, with the risk magnified in younger, less educated, low-income women, who were recipients of Medicaid. Low income and low occupational prestige were significant predictors of PPD in a logistic regression analysis to determine the specific role of social status in the development of PPD (Segre, O'Hara, Arndt, & Stuart, 2007). Severity of depressive symptoms was assessed in a cross-sectional sample of 4,332 postpartum women at an average of 4.6 months postpartum. Twelve percent of the women screened positive for PPD, with a higher prevalence in unmarried, younger, multiparous women with low income and in those without a college education (Segre et al., 2007).
Mayberry, Horowitz, and Declercq (2007) studied more than 1,300 primiparous and multiparous American women who had all delivered a healthy infant. Depressive symptoms were assessed at 6-month intervals (0–6, 7–12, 13–18, and 19–24 months) and their results suggest that younger, unemployed, low-income, less educated, multiparous women were at an increased risk for developing PPD. Moreover, the severity and duration of depressive symptoms decreased at higher income levels. A second study conducted by Rich-Edwards et al. (2006) assessed depressive symptoms mid-pregnancy and again at 6 months postpartum in more than 1,600 women. Results suggested younger maternal age, lack of a partner, lower income, and financial hardship were factors associated with both prenatal and postpartum depressive symptoms. In a meta-analysis that included 84 studies and approximately 3,000 participants Beck (2001) noted that SES and marital status were additional predictors of PPD that were not apparent in her earlier study (Beck, 1996).
Several longitudinal studies have also reported associations between low SES and PPD. Beeghly et al. (2003) assessed depressive symptoms (Center for Epidemiological Studies-Depression scale [CES-D]) and sociodemographic risk profiles in 163 African-American women at 2, 3, 6, 12, and 18 months postpartum. Among other results, single marital status and low-income status were significantly related to higher CES-D scores by women at all assessment periods. Seguin, Potvin, St-Denis, and Loiselle (1999a) assessed depressive symptoms in 68 first-time mothers with low income. A relationship between several stressful life conditions, including a lack of money and elevated postpartum depressive symptoms, was noted in first-time mothers at 6 months postpartum. Moreover, 32% were still reporting elevated depressive symptoms at 6 months postpartum. Other research by Seguin, Potvin, St-Denis, and Loiselle (1999b) compared socioenvironmental factors and postpartum depressive symptoms in 80 low SES and 36 high SES mothers from 3 to 9 weeks postpartum. Results suggested no difference in depressive symptoms at 3 weeks postpartum. However, at 9 weeks postpartum, the low SES mothers' depression scores were elevated when compared with mothers of higher SES. Hobfoll, and Ritter, Lavin, Hulsizer, and Cameron (1995) interviewed impoverished, inner-city women twice during pregnancy (second and third trimester) and at 7 to 9 weeks after birth. The high rate of PPD (23%) was double that of middle-class samples, suggesting SES may be associated with PPD.
In contrast, other researchers have reported that low SES has very little influence on the development of PPD. Adewuya, Fatoye, Ola, Ijaodola, and Ibigbami (2005) found no difference between depressed and non-depressed Nigerian mothers with regard to their level of education or SES. Given that all of the women in the sample were of low SES, this may be a nonsignificant finding. However, unmarried status was a predictor of PPD (odds ratio, 3.44; 95% confidence interval, 2.15–5.53). Ross, Campbell, Dennis, and Blackmore (2006) noted in their meta-analysis that sociodemographic data are often not reported, or are adjusted and controlled statistically, thereby limiting the external validity of the results. Their meta-analysis included 143 studies with a total of 51,453 women to identify demographic characteristics of participants in studies of risk factors, treatment, or prevention of PPD. They reached two conclusions: 1) most (83%) studies were conducted in Western societies with a higher percentage of older, white, partnered women of higher SES; and 2) the proportion of participants for whom demographic variables were reported (maternal age, ethnicity, relationship status, SES) varied between 18% and 92% (Ross et al., 2006).
Even with the differences in research findings, there is strong evidence to suggest that women of low SES have higher risk of developing PPD. Moreover, very few studies have compared PPD prevalence rates in low- and high-income primiparas when controlling for parity and partner status. The current study describes the relationship of SES to depressive symptoms during the transition to motherhood for first-time mothers in partnered relationships. A second objective was to determine which components of SES are specific risk factors for PPD beyond the contribution to prenatal depression.
Section snippets
Study Design and Sample
As part of a longitudinal, randomized, clinical trial to improve parents' sleep in the first postpartum month, 198 expectant mothers were recruited from childbirth education classes and prenatal clinics. Eligible mothers included partnered women expecting their first child, who were at least 18 years of age, willing to participate, and able to read and write English. Informed consent was obtained from each participant, and all women were paid for their participation. This study was approved by
Sample Characteristics
Of the 304 women enrolled in the larger study, 27 were excluded from the analysis because they did not have a partner, 44 were excluded because of missing prenatal or postpartum CES-D data, and 18 women were excluded owing to incomplete income data. An additional 17 women were excluded because of a history of mood disorder before pregnancy; this analysis focused on prenatal and postpartum depressive symptoms and not chronic depression. Sample characteristics and descriptive data for the 198
Discussion
All new mothers are at risk for developing PPD; in fact, Postpartum Support International (2009) states that a common complication of childbirth is depression. The purpose of this study was to describe depressive symptoms in partnered pregnant women experiencing their first birth from the third trimester to 3 months postpartum, specifically on demographic indicators associated with SES (low monthly income, less than a college education, unmarried, unemployed). Because household income is often
Acknowledgments
The authors express their sincere gratitude to all of the women who participated in this study and to Annelise Gardner for her recruitment and data collection efforts on the research team.
Deepika Goyal, PhD, RN, FNP, is an Associate Professor in the School of Nursing at San Jose State University, San Jose, California. She is also a family nurse practitioner and works in Los Gatos, California.
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Deepika Goyal, PhD, RN, FNP, is an Associate Professor in the School of Nursing at San Jose State University, San Jose, California. She is also a family nurse practitioner and works in Los Gatos, California.
Caryl Gay, PhD, is a Research Specialist in the Department of Family Health Care Nursing at University of California, San Francisco.
Kathryn Lee, RN, PhD, FAAN, CBSM, is a Professor and the James and Marjorie Livingston Chair in the Department of Family Health Care Nursing at University of California, San Francisco.
This research was supported by NIH/NINR, Grant # 1 RO1 NR045345 and a doctoral fellowship from the Betty & Gordon Moore Foundation.