Maternal and Child Nursing Discussion

Maternal and Child Nursing Discussion

Maternal and Child Nursing Discussion

Rates and Predictors of Postpartum Depression by Race and Ethnicity: Results from the 2004 to 2007 New York City PRAMS Survey (Pregnancy Risk Assessment Monitoring System)

Cindy H. Liu • Ed Tronick

Published online: 25 October 2012

� Springer Science+Business Media New York 2012


Permalink:…rsing-discussion/ ‎

Abstract The objective of this study was to examine

racial/ethnic disparities in the diagnosis of postpartum

depression (PPD) by: (1) identifying predictors that account

for prevalence rate differences across groups, and (2) com-

paring the strength of predictors across groups. 3,732 White,

African American, Hispanic, and Asian/Pacific Islander

women from the New York City area completed the Preg-

nancy Risk Assessment Monitoring System from 2004 to

2007, a population-based survey that assessed sociodemo-

graphic risk factors, maternal stressors, psycho-education

provided regarding depression, and prenatal and postpartum

depression diagnoses. Sociodemographic and maternal

stressors accounted for increased rates in PPD among Blacks

and Hispanics compared to Whites, whereas Asian/Pacific

Islander women were still 3.2 times more likely to receive a

diagnosis after controlling for these variables. Asian/Pacific

Islanders were more likely to receive a diagnosis after their

providers talked to them about depressed mood, but were less

likely than other groups to have had this conversation. Pre-

natal depression diagnoses increased the likelihood for PPD

diagnoses for women across groups. Gestational diabetes

decreased the likelihood for a PPD diagnosis for African

Americans; a trend was observed in the association between

having given birth to a female infant and increased rates of

PPD diagnosis for Asian/Pacific Islanders and Whites. The

risk factors that account for prevalence rate differences in

postpartum diagnoses depend on the race/ethnic groups

being compared. Prenatal depression is confirmed to be a

major predictor for postpartum depression diagnosis for all

groups studied; however, the associations between other

postpartum depression risk factors and diagnosis vary by

race/ethnic group. Maternal and Child Nursing Discussion

Keywords Postpartum depression � Health status disparities � Asian Americans � Prenatal depression � Gestational diabetes


Postpartum depression (PPD) is a serious health concern

affecting approximately 13 % of all women [1]. At least

19.2 % of women experience depression within 12 months

after giving birth [2]. The associations between prenatal

depression and PPD depression are well documented [3–5].

Psychosocial factors including high stress, low social sup-

port, and low marital satisfaction are also predictors [4, 5].

Surprisingly little is known about the extent to which

postpartum depression varies by race and ethnicity, given the

effects of culture on the experiences and manifestations of

depression [6, 7]. This dearth of information on postpartum

depression in ethnic minorities is well recognized. In a

published review of maternal depression, the Agency for

Healthcare Research and Quality found ‘‘screening instru-

ments [to be] poorly representative of the U.S. population,’’

and that ‘‘populations [from studies] were overwhelmingly

Caucasian’’ [8]. A review by O’Hara found that meta-anal-

yses on postpartum depression had omitted race and eth-

nicity as risk factors for postpartum depression [4].

Research studies on postpartum depression that have

included ethnic minorities generally compare African

C. H. Liu (&) Beth Israel Deaconess Medical Center, Harvard Medical School,

75 Fenwood Road, Boston, MA 02115, USA


E. Tronick

Child Development Unit, University of Massachusetts,

100 Morrissey Blvd, Boston, MA 02125, USA



Matern Child Health J (2013) 17:1599–1610

DOI 10.1007/s10995-012-1171-z


Americans and Hispanics with Whites. In these studies,

group differences in prevalence rates have shown to be

inconsistent. Across studies, the rates of postpartum

depression in African American and Hispanic women were

found to be higher [9], lower [10], or no different [11]

compared to Whites. What accounts for observed racial and

ethnic differences in prevalence is unclear. In some studies,

sociodemographic risk variables were associated with

higher levels of depressive symptomatology among Afri-

can Americans, raising the possibility that sociodemo-

graphic variables rather than race and ethnicity account for

different levels of postpartum depression [12–14]. In con-

trast, others have shown greater levels of depressive

symptomatology among African Americans and Hispanics

than Whites, after accounting for sociodemographic factors

[9]. While certain social factors could increase risk, some

factors might buffer against postpartum depression within

groups. For instance, low income foreign-born Hispanic

women with social support exhibited lower rates of post-

partum depression [15], whereas bilingual Hispanic women

were at greater risk than those who spoke only Spanish

[11]. It is possible that factors such as social support or

nativity and its effect on the likelihood of postpartum

depression differ by race/ethnicity because they express

different meanings or incur different implications for each

group. Moreover, stigmas about psychological problems

and help-seeking may have an effect on identifying post-

partum depression, resulting in a subsequent effect on

reported prevalence of postpartum depression rates [6, 16].

Given the mixed picture across groups, this study aimed to

systematically determine the extent to which prevalence

rates across race and ethnicity are explained by factors

associated with postpartum depression.

This study uniquely includes Asian/Pacific Islander

(API) women within the U.S. As the fastest growing ethnic

minority group, over 16 million APIs are estimated to be

living in the U.S [17, 18]. The research on API postpartum

experiences is limited, which is striking given that API

women may hold several risk factors.

If psychiatric history is a major predictor, API women

may be at greatest risk: those between the ages of

15–24 years have the highest rate of depression and su-

icidality compared to any other ethnicity, gender, or age

[19–21]. One study showed APIs to be at lower risk for

postpartum depressive symptoms compared to Whites,

African Americans, and Hispanics [14], while another

study reported a greater percentage of APIs with post-

partum symptoms compared to White Americans [22].

Analyses conducted by the New York City Department of

Health and Mental Hygiene on data from the 2004 to 2007

New York City (NYC) Pregnancy Risk Assessment Mon-

itoring System (PRAMS) revealed a higher rate of PPD

diagnoses among APIs compared to other groups [23–25].

From the most recent sample in 2007, 10.4 % of API

received a PPD diagnosis compared to 1.7 % of non-His-

panic White women [26]. These findings suggest a poten-

tial risk for postpartum depression in APIs.

This study examines racial/ethnic disparities in PPD

diagnosis by identifying predictors accounting for preva-

lence differences. Because previous studies have either

focused mostly on small samples of one group, or did not

examine these risk factors by race/ethnicity, we hypothe-

size that associations of risk factors and PPD differ by race/

ethnic group. The risk factors evaluated were selected

based on the current literature [27–31]. Our study also

sought to explain disparities in PPD rates from a published

report by the NYC Department of Health and Mental

Hygiene. We utilized the study’s comprehensive popula-

tion-based dataset. We also sought to determine the

strength of predictors within each group and differences

across groups. Accordingly, we stratified our analyses by

race/ethnicity. Determining the strength of predictors by

group is essential for identifying individuals most at risk,

and may inform the possible causes of depression for dif-

ferent groups. Unique to this study was the use of diagnosis

as an outcome measure, the inclusion of information on

whether providers talked to women about depressed mood,

and an adequate sample size of APIs. This allowed us to

also examine disparities in psycho-education and diagnosis

across groups.



This study used the NYC PRAMS from 2004 to 2007, a

population-based survey administered to postpartum

women from NYC. Coordinated by the Centers for Disease

Control and Prevention and state health departments,

PRAMS’ goal is to monitor maternal behaviors and expe-

riences of women before, during, and after live birth

pregnancies. The dataset was provided by the NYC

Department of Health and Mental Hygiene (DOHMH).

The participants were part of an ongoing population-

based random sampling of NYC live births. NYC mothers

of approximately 180 infants with registered birth certifi-

cates that gave birth during the previous 2–4 months were

contacted for participation monthly. Eighty-three percent

responded by mail and 17 % by phone. The sample was

randomized without replacement and stratified by birth

weight. The final dataset was weighted for stratification,

nonselection, and nonresponse.

According to the DOHMH, a total of 4,813 responses

were received with response rates of at least 70 % from

July to December of 2004, May to December of 2005, and

1600 Matern Child Health J (2013) 17:1599–1610




January to December of 2006. A rate of 65 % was achieved

from January to December of 2007. For 2004–2005,

responses were weighted to represent 138,266 live births.

For 2006 and 2007, responses represented 119,079 and

122,222 live births, respectively. Based on the DOHMH

analysis, respondents differed from non-respondents on

some key sociodemographic variables (p \ .05). APIs compared to other racial and ethnic groups, younger

women, and women with less education were less likely to

respond to the survey.


The birth certificate provided information on maternal race/

ethnicity and nativity (i.e., U.S. or non-U.S. born mothers).

Women were classified as Hispanic or non-Hispanic based

on self-report. Non-Hispanic women were categorized in

one of the following groups: White, African American,

Asian/Pacific Islander, and American Indian/Alaskan

Native. Maternal age, nativity (U.S. Born versus Foreign

Born) and education (categorized as: 0–8, 9–11, 12, 13–15,

and[16 years) were based at the time of infant birth from information in the birth certificate. Mean infant age at the

time of survey completion was 9.7 months; there were no

significant differences in infant age across groups.

The PRAMS survey itself provided information for

remaining variables. To obtain income, women were asked

to indicate ‘‘total household income before taxes in the

12 months before the new baby was born’’ by checking off

one of the following options:\$10,000, $10,000–$14,999, $15,000–$19,999, $20,000–$24,999, $25,000–$34,999,

$35,000–$49,999, $50,000–$74,999, and[$75,000. Stress- ful events during pregnancy were obtained by ‘‘yes’’ or

‘‘no’’ responses to events that may have occurred during

the last 12 months before the new baby was born. Exam-

ples include ‘‘I moved to a new address,’’ ‘‘I had a lot of

bills to pay,’’ ‘‘I got separated or divorced from my hus-

band or partner,’’ and ‘‘Someone very close to me died.’’

These events were counted and categorized into the fol-

lowing: 0, 1–2, 3–5, and 6–13 events. A ‘‘yes’’ or ‘‘no’’

response was also used to obtain information on following:

gestational diabetes (‘‘High blood sugar (diabetes) that

started during this pregnancy’’), social support from partner

(responses of ‘‘My husband or partner’’ to the question

‘‘During your most recent pregnancy, who would have

helped you if a problem had come up’’), NICU (Neonatal

Intensive Care Unit) (‘‘After your baby was born, was he or

she put in an intensive care unit?’’), unintended pregnancy

(‘‘When you got pregnant with your new baby, were you

trying to get pregnant?’’). The NYC PRAMS included

additional questions related to depression. Mothers were

asked to respond ‘‘yes’’ or ‘‘no’’ regarding prenatal

depression (‘‘At any time during your most recent

pregnancy, did a doctor, nurse, or other health care worker

diagnose you with depression?’’), and discussion about

mood (‘‘At any time during your most recent pregnancy or

after delivery, did a doctor, nurse, or other health care

worker talk with you about ‘‘baby blues’’ or postpartum

depression?’’). In addition, mothers were asked about PPD

diagnosis (‘‘Since your new baby was born, has a doctor,

nurse, or other health care worker diagnosed you with

depression?’’). The response to this item was the outcome

variable used for the analyses in this study.

The language of the survey (English or Spanish version)

was also noted.


Covariates included maternal age, household income,

maternal education, nativity, and infant age at the time the

mother completed the questionnaire. Variables considered

as potential stressors included: gestational diabetes,

stressful events, social support, NICU, intention for preg-

nancy, and prenatal depression. Discussion about mood

served as an additional predictor of PPD diagnosis.

Responses with missing variables of interest for this

study were eliminated. Variables with less than a 100 %

response rate included household income (86.9 %),

maternal education (99.3 %), maternal age (97.0 %), and

PPD diagnosis (99.4 %) resulting in an unweighted study

sample of 3,732.

Statistical Analyses

To account for the stratified and weighted sample, the data

was analyzed using the complex samples module of SPSS

version 17.0 (SPSS Inc., Chicago, IL). A non-race stratified

model was conducted to determine the likelihood of

receiving a PPD diagnosis for each race/ethnic group with

Whites as the reference group. A series of four logistic

regression models were employed where the variables of

interest (race/ethnicity, sociodemographic, stressors, and

discussion about mood) were sequentially added to the

model, allowing incremental examination of the variables’

effects in identifying factors that explain racial/ethnic

disparities in PPD.

Prevalence estimates within each group were generated

according to predictors. To compare the characteristics of

those with and without PPD and to understand associated

predictors, race-stratified logistic regressions incorporated

all predictors, with sociodemographic variables as covari-

ates. Adjusted odds ratios for each predictor were gener-

ated by race/ethnic group. Note that our models failed to

converge with the inclusion of language, nativity, and

NICU variables because of low cell sizes; thus, these

variables were dropped from our analyses. Unless

Matern Child Health J (2013) 17:1599–1610 1601




otherwise noted, all reported proportions represent weigh-

ted averages.


Compared to other groups, API women showed the highest

rate for PPD, followed by Hispanics and African Ameri-

cans. White women had the lowest rate of PPD. The high

rate of a PPD diagnosis among API women is consistent

with previous analyses from this dataset, which utilized a

larger sample size than the dataset here, as this set includes

only women with complete data on the predictor variables.

Other racial/ethnic differences among assessed variables

are presented (Table 1).

A major objective was to determine whether sociode-

mographic variables, stressor variables, and discussion

about mood accounted for PPD differences. In the unad-

justed model, likelihood estimates indicate that API women

were 4.6 times more likely and Hispanic women 2.7 times

more likely than Whites to receive a PPD diagnosis.

African American were 1.7 times more likely to receive the

diagnosis than Whites, although this was not statistically

significant (Table 2). Once sociodemographic factors were

entered, African Americans were no more likely to receive

a diagnosis than Whites. For Hispanics, the greater likeli-

hood for a diagnosis compared to Whites was less pro-

nounced after accounting for sociodemographic factors and

was eliminated with the inclusion of stressors. The diag-

nosis likelihood was slightly reduced for APIs after

accounting for sociodemographic factors, and significantly

reduced with stressor variables, although diagnosis likeli-

hood was still more than double the rate of Whites and

African Americans. In contrast to the other groups, diag-

nosis likelihood for APIs increased to 3.2 times relative to

Whites, after accounting for reports of having discussed

mood with a provider. Prenatal depression was by far the

strongest predictor for all women compared to other

stressors, although women who gave birth to females were

more likely to receive a diagnosis than women with male

infants. Overall, those who had a discussion about mood

were also more likely to receive a diagnosis.

Profiles of women with PPD diagnoses compared to

women without a diagnosis differed by race/ethnicity. The

majority of White women reporting a PPD diagnosis

received a postgraduate education, while API and African

American women with the diagnosis tended to be high

school graduates. Approximately half of the White women

with PPD had household incomes above $75,000 per year.

Among APIs, Hispanics, and African Americans, more

women with PPD had less than $15,000 of household

income per year than those without a diagnosis (Table 3).

With regard to stressors, we found a significantly higher

rate of gestational diabetes among those with PPD than

those without PPD, but only for White women. However,

after controlling for sociodemographic variables through

our race-stratified adjusted model, gestational diabetes did

not significantly predict PPD in White, API, or Hispanic

women (Table 4). In fact, African American women with

gestational diabetes were less likely to receive a diagnosis

of PPD.

Compared to those without PPD, there was a higher

percentage among APIs and Hispanics with the diagnosis

who had an unintended pregnancy. In addition, the

majority of APIs with PPD had a diagnosis of prenatal

depression compared to the other groups. Stressful events

were not associated with greater likelihood for PPD, but

API women who reported having 6–13 stressful events

were significantly more likely to have PPD, a rate that was

statistically significant. The association between prenatal

depression and PPD persisted for all groups, even after

controlling for sociodemographic variables.

Overall, there was a higher rate of women with PPD

who had a discussion about mood with their providers than

women without the diagnosis. However, the association

between PPD and discussion about mood with providers

was specific to only API and African American women in

the adjusted model.

Women from all groups who received a diagnosis of

PPD were more likely to have given birth to females

although the differences were not statistically significant.

However, having a female infant seemed to slightly

increase the likelihood of a PPD diagnosis among White

and API women based on the race-stratified analyses.


This study assessed PPD estimates and identified predictors

of PPD as defined by women’s reports of receiving a

diagnosis from a health care provider. We included API

women and used race-stratified analyses, allowing us to

determine whether predictors varied by race/ethnicity.

This study also sought to identify factors that explained

racial/ethnic disparities obtained in a previous analysis of

the dataset by the NYC Department of Health and Mental

Hygiene. As with other studies, we found that sociode-

mographic factors accounted for the higher rates of PPD

among African Americans and Hispanics. Based on such

findings, some have argued for prevention or intervention

programs to provide resources (e.g., financial support,

education) in addressing the racial/ethnic disparities of

PPD for African Americans and Hispanics [12]. However,

unlike other studies that primarily assessed reported

symptoms [9, 12, 14], we used the diagnosis of PPD as the

1602 Matern Child Health J (2013) 17:1599–1610




outcome measure. This raises the possibility that sociode-

mographic status accounts for the rates at which one

receives a diagnosis; in our study, African Americans and

Hispanics with lower sociodemographic statuses were less

likely to receive a diagnosis compared to Whites. If race/

ethnic disparities are found among rates of diagnosis, then

the diagnostic process may be another area to target for

improvement among lower sociodemographic status


Among ethnic minorities in our study, API women were

the most likely to receive a PPD diagnosis, and unlike

African Americans and Hispanics, the likelihood of

receiving a PPD diagnosis for APIs remained significantly

higher even after accounting for other variables (e.g.,

sociodemographic factors). Prenatal depression was asso-

ciated with PPD for all groups in our study, but the like-

lihood was highest for APIs. Although psychiatric history

for depression was not available, the strong association

between prenatal depression and PPD observed among the

API women in our sample adds to the growing concern of

depression experiences and its effects on API women

during motherhood [19–21]. A number of factors specific

to API women’s experiences are potentially associated

with later postpartum mood. The high rate of depression

and suicidal ideation during adolescence and young

adulthood may reflect family and societal pressures faced

by young women to uphold high academic standards and

traditional gender roles [32]. These young women likely

must negotiate their cultural values and beliefs when

assuming a mother’s identity [33, 34]. In addition, the

cultural preference for male infants may affect PPD.

Table 1 Weighted percentage distribution of mothers who recently gave birth that completed the NYC PRAMS from 2004 to 2007, by

characteristic, according to race/ethnicity

White Asian/



Hispanic Black

(n = 1,043) (n = 425) (n = 1,253) (n = 1,027)

Maternal age

\20 2.4a 0.9a 9.9b 6.9c

20–34 70.1a 75.4b 76.8b 73.8a,b

C35 27.5a 23.7a,b 13.3c 19.3b,d

Maternal education

0–8 1.7a 2.7a 11.7b 1.6a

9–11 4.2a 10.7b 19.6c 15.8d

12 22.6a 26.1a 34.4b 32.1b

13–15 16.2a 14.7a 21.1b 28.1c

C16 55.4a 45.8b 13.2c 22.4d


\10,000 10.0a 20.4b 40.3c 29.2d

10,000–14,999 6.7a 15.1b 14.3b 10.3c

15,000–19,999 4.6a 8.0b 8.8b 8.6c

20,000–24,999 4.7a 5.8a 6.8b 9.2c

25,000–34,999 6.8a 5.7a 9.5b 13.2c

35,000–49,999 8.7a 6.0a 6.7a 10.1a

50,000–74,999 12.1a 9.9a 6.3a 10.2a

C75,000 46.4a 29.1b 7.1c 9.0d

Maternal nativity

U.S. born 68.4a 11.1b 34.1c 56.3d

Non-U.S. born 31.1 88.9 65.6 43.0

Missing data 0.5 0 0.3 0.7

Language of questionnaire

English 99.1a 99.5a 51.2b 98.8a

Spanish 0 0 48.5 0

Missing data 0.5 0.5 0.3 1.2


Yes 5.1 5.9 6.4 14.4

No 94.9a 94.1a 93.6a 85.5b

Don’t know 0 0.1 0 0.1


Male 49.3a 52.1a 51.1a 52.0a

Female 50.7 47.9 48.9 48.0


No 92.4 85.1 89.9 89.9

Yes 7.6a 14.9b 10.1c 10.1c


0 45.1a 49.1a 31.6b 26.5c

1–2 41.8a 38.7a 41.5a 42.8a

3–5 12.1a 11.3a 23.3b 25.2b

6–13 1.1a 0.8a 3.6b 5.5c

Social support

No 90.4 90.8 76.9 75.2

Yes 9.6a 9.2a 23.1b 24.8b

Table 1 continued

White Asian/



Hispanic Black

(n = 1,043) (n = 425) (n = 1,253) (n = 1,027)

Intention for pregnancy

No 30.9a 35.1a 59.0b 66.5c

Yes 69.1 64.9 41.0 33.5

Prenatal depression diagnosis

No 97.2 87.6 92.4 94.5

Yes 2.8a 12.4b 7.6c 5.5d

Discussion about mood

No 46.0 61.4 42.7 39.3

Yes 54.0a 38.6b 57.3a,c 60.7c

Postpartum depression diagnosis

No 97.4 89.3 93.6 96.3

Yes 2.6a 10.7b 6.4c 3.7a

Lower case superscripts that differ across each row represent statistically

different values across racial/ethnic groups. Conversely, groups within a

row that share the same superscript demonstrate no statistically significant

difference in values within p \ .05

Matern Child Health J (2013) 17:1599–1610 1603




Table 2 Logistic regression models of race/ethnicity, other sociodemographic factors, stressors, and discussion of mood with provider, with adjusted odds of postpartum depression diagnosis

Model 1 Model 2 Model 3 Model 4



White 1.0 1.0 1.0 1.0

Asian/Pacific Islander 4.6*** 2.6–8.2 4.0*** 2.2–7.2 2.7** 1.4–4.9 3.2*** 1.7–6.0

Hispanic 2.7*** 1.7–4.5 1.8* 1.0–3.1 1.5 0.9–2.7 1.5 0.9–2.7

Black 1.7� 1.0–3.0 1.2 0.6–2.2 0.9 0.5–1.8 0.9 0.4–1.8 Maternal and Child Nursing Discussion

Maternal age

\20 1.0

20–34 0.5 0.3–1.1 0.5 0.2–1.1 0.5 0.2–1.2

C35 0.7 0.3–1.6 0.7 0.3–1.7 0.7 0.3–1.9

Maternal education

0–8 1 1 1

9–11 0.8 0.3–1.9 1.2 0.4–3.2 1.1 0.4–3.0

12 1.0 0.5–2.1 1.6 0.7–4.1 1.6 0.7–4.0

13–15 1.1 0.5–2.5 1.6 0.6–4.2 1.6 0.6–4.3

C16 0.8 0.4–1.8 1.5 0.6–4.0 1.6 0.6–4.2


\10,000 1.0 1.0 1.0

10,000–14,999 1.2 0.7–2.1 1.5* 0.8–2.8 1.5* 0.8–2.8

15,000–19,999 0.8* 0.3–1.6 1.1 0.5–2.4 1.0 0.5–2.2

20,000–24,999 0.5 0.2–1.2 0.6 0.3–1.4 0.6 0.2–1.3

25,000–34,999 0.6 0.3–1.3 0.7 0.3–1.7 0.7 0.3–1.6

35,000–49,999 0.3 0.1–0.7 0.3 0.1–0.9 0.3 0.1–0.8

50,000–74,999 0.4 0.2–0.9 0.5 0.2–1.3 0.5 0.2–1.3

C75,000 0.5 0.3–1.0 0.7 0.3–1.5 0.7 0.3–1.4


Male 1.0 1.0

Female 1.6* 1.1–2.4 1.7* 1.1–2.5


No 1.0 1.0

Yes 0.8 0.4–1.5 0.8 0.4–1.6


0 1.0 1.0

1–2 0.8 0.5–1.3 0.8 0.5–1.3

3–5 1.0 0.6–1.8 1.0 0.6–1.8

6–18 1.8� 0.7–4.9 2.0� 0.8–5.1

Social support

No 1.0 1.0

Yes 1.1 0.7–1.9 1.2 0.7–2.0

Intention for pregnancy

No 1.0 1.0

Yes 1.2 0.8–1.8 1.2 0.8–1.8

Prenatal depression diagnosis

No 1.0 1.0

Yes 17.3*** 10.9–27.5 15.0*** 9.4–23.8

Discussion about mood

No 1.0

Yes 2.6*** 1.6–4.1

� p \ 0.1; * p \ .05; ** p \ .01; *** p \ .001

1604 Matern Child Health J (2013) 17:1599–1610




Table 3 Weighted percentage of mothers who completed the NYC PRAMS from 2004 to 2007, by characteristic according to race/ethnicity and postpartum depression diagnosis

White Asian/Pacific Islander Hispanic Black


(n = 1,010) (n = 33) (n = 383) (n = 42) (n = 1,162) (n = 91) (n = 979) (n = 48)

Maternal age

\20 2.3 5.9 1 0 9.6 13.4 6.2 25.2*** 20–34 70.4 62 74.1 86.1� 77.7 63.7** 74.2 63.4�

C35 27.4 32.1 24.9 13.9 12.6 22.9** 19.6 11.5


Maternal education

0–8 1.7 0 2.4 4.9 11.5 15.8 1.7 0.7

9–11 4 9 10.6 11.4 19.3 23 15.9 12.5

12 22.9 12.1 23 52.8*** 34.9 25.9� 31.4 49.3***

13–15 16.5 5.3 14.5 16.5 20.7 27.7 28.2 26.2

C16 54.9 73.6� 49.5 14.3*** 13.6 7.6 22.8 11.4


\10,000 9.9 15.4 18.7 34.2* 40.1 44.2 28.6 46.9*** 10,000–14,999 6.7 4.7 14.8 18.2 13.5 27*** 9.8 21.8***

15,000–19,999 4.8 0 7.3 13.5 9.1 5.3 8.4 14.9*

20,000–24,999 4.8 0 6 4.5 6.7 8.5 9.6 0.6**

25,000–34,999 7 0.5 4.6 15.3 9.7 5.8 13.5 4.8*

35,000–49,999 8.5 15.1 6.7 0.3 7.1 0.5* 10.5 1.7**

50,000–74,999 12.1 11.5 10.7 3.6 6.5 4.4 10.6 0.5**

C75,000 46.2 52.7 31.3 10.3** 7.3 4.3 9 8.8

Maternal nativity

U.S. born 68.4 66.7 12.3 100*** 35.0 23.1* 56.4 54.2

Non-U.S. born 31.1 30.3 87.7 0 64.7 76.9 42.9 45.8

Missing data 0.5 0.3 0 0 0.3 0 0.7 0

Language of questionnaire

English 99.2 97.0 99.5 100 50 46.2 98.8 100

Spanish 0 0 0.1 0 50 53.8 1.1 0

Missing data 0.8 3.0 0.4 0 0 0 0.1 0 Maternal and Child Nursing Discussion


No 94.9 94.2 93.6 98.1 93.7 91.9 85.7 82.3

Yes 5.1 5.8 6.3 1.9 6.3 8.1 14.3 17.3

Don’t know 0 0 0.1 0 0 0 0.1 0.5


Male 49.5 40.2 53.2 43 51.7 43.8 52.3 44.7

Female 50.5 59.8 46.8 57 48.3 56.2 47.7 55.3


No 92.5 90 85.6 81.4 90.2 86.2 89.6 98.9

Yes 7.5 10* 14.4 18.6 9.8 13.8 10.4 1.1


0 45.6 26.4* 47.6 61.2 31.6 30.8 27 12.5**

1–2 41.4 54.3 39.9 28.8 42.6 25 42.9 39.4

3–5 12 14.2 12.1 5.4 22.7 32.1 24.6 41.2

6–13 1 5.1* 0.4 4.5** 3 12.1 5.4 6.9

Social support

No 9.4 15.3 8.6 13.7 22.7 28.3 24.6 31.4

Yes 90.6 84.7 91.4 86.3 77.3 71.7 75.4 68.6

Intention for pregnancy

Matern Child Health J (2013) 17:1599–1610 1605




Chinese women with a female infant were more likely to

experience PPD [35, 36]. In another study on Indian

women, having a female infant increased the effects of

other risk factors [37]. Recent findings have also demon-

strated a greater likelihood for Asian women to develop

gestational diabetes, which is associated with PPD [38–40].

Other explanations for Asian American depression in the

literature range from biological [41] to social [42]. Toge-

ther, these explanations may represent a general vulnera-

bility for depression generalizing to API women’s

depressed mood during the postpartum period. Future

studies in PPD research may want to specifically examine

the association between psychiatric history and PPD by

race/ethnicity to determine if psychiatric history predicts

PPD more strongly in API women. Maternal and Child Nursing Discussion

Furthermore, discussing depressed mood with providers

increased the likelihood for women to receive a diagnosis.

This was especially true for APIs where the likelihood of

receiving a diagnosis was 3.2 times more than White

women after our analyses considered such discussions as a

factor. These high rates could reflect the quality of the

diagnostic processes that take place between API women

and their providers. The use of a diagnostic criterion by the

NYC PRAMS to assess PPD is unlike other prevalence

studies that typically use structured assessments for PPD

(e.g., a single question on depressive mood during preg-

nancy, multiple items covering symptomatology, etc.) [9,

12–14]. APIs tend to endorse somatic experiences rather

than psychological symptoms [43, 44]. Conversations with

a provider could increase sensitivity during the assessment,

thus facilitating a positive diagnosis. Increased research on

the diagnostic process within a health care setting would

greatly enhance understanding of how dialogues between

provider and patient result in diagnoses. In particular,

future research should consider differences in the charac-

teristics of providers and clinics among those who did and

did not receive a PPD diagnosis, and the nature of the

actual exchanges occurring between providers and patients.

It was particularly striking that approximately half of the

providers did not talk to women about PPD. Racial/ethnic

disparities were also found when assessing these rates.

While the majority of African American, Hispanic, and

White women reported having had a conversation with

their providers, only 38.6 % of API women in our study

reported this. Given that Asians tend to minimize their

psychological distress [6, 16], providers may not realize

distress nor recognize the need to bring up depressed mood.

APIs who had a conversation were 9.1 times more likely to

receive a diagnosis than APIs without, regardless of their

sociodemographic background. Thus, although APIs were

the group most likely to benefit from information about

depressed mood, they were the least likely to be provided

with it. Additionally, African Americans showed the

highest rate of having been presented with information

about mood compared to the other groups; those with a

conversation were 5.8 times more likely to receive a


Altogether, and of greatest concern were the low rates of

assessment for all groups, and especially for APIs. Our

findings suggest that the information presented by a pro-

vider has powerful implications for determining diagnosis,

especially for APIs and African Americans. This finding

has implications for studies obtaining prevalence rates

without considering racial/ethnic disparities within the

screening or diagnostic process. Differences in prevalence

rates may be attributed to the lack of medical information

and treatment opportunities available to certain groups.

Our inclusion of known predictors for PPD in race-

stratified analyses allowed us to compare the strength of

stressors across groups. Most of the group differences in

the predicted likelihood for PPD were not statistically

significant suggesting few group differences in the

Table 3 continued

White Asian/Pacific Islander Hispanic Black


(n = 1,010) (n = 33) (n = 383) (n = 42) (n = 1,162) (n = 91) (n = 979) (n = 48)

No 31.1 26.3 33.4 49.2 58.2 69.8 66.4 67.6

Yes 68.9 73.7 66.6 50.8* 41.8 30.2** 33.6 32.4

Prenatal depression diagnosis

No 98 67.1 93.8 35.8 95 54.4 95.4 71

Yes 2 32.9*** 6.2 64.2*** 5 45.6*** 4.6 29***

Discussion about mood

No 46.5 26.1 66.2 21.1 43.5 30.5 40.5 8.6

Yes 53.5 73.9* 33.8 78.9*** 56.5 69.5** 59.5 91.4***

� p \ 0.1; * p \ .05; ** p \ .01; *** p \ .001

1606 Matern Child Health J (2013) 17:1599–1610

123 Maternal and Child Nursing Discussion


Permalink:…rsing-discussion/ ‎

association between stressors and PPD. Furthermore,

stressful events were not associated with a greater likeli-

hood at a statistical level, with the exception of API

women; those who reported 6-13 stressful events were

significantly more likely to receive a diagnosis. The

explanation may reside in the distribution of reported

stressful events for APIs; compared to other groups, the

majority of API women reported zero stressful events. As

such, the few APIs who disclosed high numbers of stressful

events may have been the most likely to receive a diag-

nosis. APIs may still minimize their experience of stress

despite being asked to state the occurrence of stressful

events given their tendency to minimize psychological

problems in general [6, 16]. Providers may want to inquire

further about actual events and how it affects their API

patients both psychologically and physically.

A number of associations between stressors and PPD

require clarification through further research. There was a

trend for increased PPD rates among API and White

women who gave birth to female infants. Few studies have

included infant gender in PPD studies within the U.S.;

those that have find no association [45, 46]. Given these

studies’ small samples (n \200), any effects may have been too small to detect. One study did find increased self-

esteem in mothers of male infants, although this association

was mediated by paternal support [47]. The statistical trend

in our data may indicate actual preferences for infant

gender, but it could also reflect other factors moderated by

infant gender. Our findings demonstrate the need to include

infant gender in future studies and to identify mechanisms

that explain this association.

In addition, we did not find a general link between

gestational diabetes and PPD, despite a previous study’s

results [39]. When examining groups separately, APIs in

our study were more likely to have gestational diabetes;

however, this did not predict PPD. Instead, we found a

decrease in the likelihood for PPD diagnoses among

African Americans with gestational diabetes. There is

evidence to suggest that African Americans may be less

inclined to disclose symptoms even though providers speak

Table 4 Race/ethnicity stratified logistic regression showing adjusted odds of postpartum depression diagnosis per predictor by race/ethnic group

White Asian/Pacific Islander Hispanic Black



Male 1.0 1.0 1.0 1.0

Female 2.2� 0.9–5.8 2.6� 0.9–7.2 1.5 0.8–2.7 1.5 0.5–4.1

Diabetes Maternal and Child Nursing Discussion

No 1.0 1.0 1.0 1.0

Yes 1.0 0.3–3.8 0.8 0.2–3.7 1.4 0.6–3.3 0.1** 0.0–0.5


0 1.0 1.0 1.0 1.0

1–2 2.3� 0.8–6.7 0.8 0.3–2.2 0.4* 0.2–0.9 1.8 0.3–10.2

3–5 1.2 0.2–8.5 0.1 0.0–1.1 0.8� 0.4–1.8 3.1 0.4–21.7

6–13 5.2 0.9–30.8 2.7* 0.5–15.8 2.5 0.7–9.7 1.5 0.1–15.6

Social support

No 1.0 1.0 1.0 1.0

Yes 1.6 0.4–6.0 1.9 0.4–9.5 0.9 0.4–1.7 1.5 0.5–4.6

Intention for pregnancy

No 1.0 1.0 1.0 1.0

Yes 0.9 0.3–3.3 2.2 0.8–6.4 1.4 0.7–2.6 0.7 0.2–1.9

Prenatal depression diagnosis

No 1.0 1.0 1.0 1.0

Yes 29.4*** 8.5–101.4 52.1*** 16.4–166.0 15.3*** 7.6–30.9 8.1*** 2.9–22.8

Discussion about mood

No 1.0 1.0 1.0 1.0

Yes 1.7 0.6–4.8 9.1** 2.5–33.4 1.3 0.7–2.6 5.8** 2.1–15.9

Only adjusted odds ratios are presented because race/ethnic stratified analyses did not converge when including unadjusted factors in the model.

This was due to zero to small sample sizes in race 9 sociodemographic contingency tables � p \ 0.1; * p \ .05; ** p \ .01; *** p \ .001

Matern Child Health J (2013) 17:1599–1610 1607




with them about prenatal depression and PPD at a higher

rate [48]. Mistrust and perceived discrimination within the

medical care setting may prevent disclosure about depres-

sion [22, 49]. In particular, some studies have found that

among those with depressive mood accompanied with

diabetes, African Americans were less likely to be recog-

nized as depressed and to receive depression treatment

[49–51]. Given our initial findings, the association between

gestational diabetes and PPD may not be generalizable,

although further research is needed to fully understand the

relationship. Studies that do not stratify by race may

overlook differences in the effect of gestational diabetes on

depression by race/ethnicity. Maternal and Child Nursing Discussion

Interpretation of results should be made with caution in

light of our limitations. As with any self-report, inaccura-

cies in this data are possible given recall problems. In

addition, prenatal and PPD diagnoses were used in our

study. It would have been far preferable to obtain corrob-

orating information from medical records; however, this

information was unavailable within this survey study. It is

possible that providers employed different standards for

diagnoses, which may be reflected in this data, for instance,

the consideration of ‘‘baby blues’’ or the inclusion of dif-

ferent methods to assess depression (e.g., questionnaire,

verbal report). Furthermore, these diagnoses may not nec-

essarily reflect actual depression rates, but as discussed,

may be more of a reflection of provider sensitivity to

detecting symptoms in a particular group. Finally, the race/

ethnic categories are a proxy for a culture, and are com-

prised of heterogeneous subgroups. For instance, the

unique experiences of Chinese, Japanese or Filipino groups

may have been overlooked since they were combined into

one race/ethnic category.


Our results highlight racial/ethnic disparities in PPD and its

diagnosis, inviting a more nuanced approach in the con-

sideration of PPD risk factors. Although we relied on broad

race/ethnic categories, these findings demonstrate at a basic

level, the possibility of differential effects in the risk fac-

tors associated with PPD. Explanations for racial/ethnic

disparities in diagnosis compared to Whites differ by group

and are not necessarily due to sociodemographic status or

stress, factors that usually explain racial/ethnic disparities.

While prenatal depression seems to be a major risk factor

for PPD across all groups, the extent to which a factor is a

‘‘risk’’ for a particular racial/ethnic group needs to be

evaluated. These associations point to the possibility of

group-specific mechanisms leading to a PPD diagnosis.

Universal postpartum depression screening as a single

approach may not be adequate given the role that provider-

patient interactions might have as suggested by these study

findings. Rather, this study broadly reveals a need to con-

sider the diagnostic process between provider-patient by

race/ethnicity to better understand the source of treatment


Acknowledgments The authors would like to acknowledge the NYC Department of Health and Mental Hygiene Bureau of Maternal,

Infant and Reproductive Health PRAMS Team, Bureau of Vital

Statistics, and the CDC PRAMS Team, Program Services and

Development Branch, Division of Reproductive Health. Support

during the preparation of this manuscript was provided through a

grant from the Sackler Foundation for Psychobiological Research and

through the Stuart T. Hauser Clinical Research Training Fellowship



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  • Rates and Predictors of Postpartum Depression by Race and Ethnicity: Results from the 2004 to 2007 New York City PRAMS Survey (Pregnancy Risk Assessment Monitoring System)
    • Abstract
    • Introduction
    • Methods
      • Sample
      • Measures
      • Variables
      • Statistical Analyses
    • Results
    • Discussion
    • Conclusion
    • Acknowledgments
    • References Maternal and Child Nursing Discussion