Lit Review (Results Section)

Relationships of Race and Socioeconomic Status to Postpartum Depressive Symptoms in Rural African American and Non-Hispanic White Women

Christyn L. Dolbier • Taylor E. Rush •

Latoya S. Sahadeo • Michele L. Shaffer •

John Thorp • The Community Child Health Network Investigators

Published online: 9 September 2012

� Springer Science+Business Media, LLC 2012

Abstract This study examines the potential racial dispar-

ity in postpartum depression (PPD) symptoms among a

cohort of non-Hispanic white and African American women

after taking into consideration the influence of socioeco-

nomic status (SES). Participants (N = 299) were recruited

from maternity clinics serving rural counties, with over-

sampling of low SES and African Americans. The Edin-

burgh Postnatal Depression Scale (EPDS) was administered

1 and 6 months postpartum, and subjective SES scale at

6 months postpartum. Demographic information was col-

lected during enrollment and 1 month postpartum, with

updates at 6 months postpartum. Separate logistic regres-

sions were conducted for 1 and 6 month time points

for minor-major PPD (EPDS C 10) and major PPD

(EPDS [ 12); with marital status, poverty, education, sub- jective SES, and race predictors entered in block sequence.

After including all other predictors, race was not a signifi-

cant predictor of minor-major or major PPD at 1 or 6 months

postpartum. Subjective SES was the most consistent pre-

dictor of PPD, being significantly associated with minor-

major PPD and major PPD at 6 months postpartum, with

higher subjective SES indicating lower odds of PPD, even

after accounting for all other predictors. This study shows

that significant racial disparities were not observed for

minor-major or major PPD criteria at 1 or 6 months post-

partum. The most consistent and significant predictor of

PPD was subjective SES. Implications of these findings for

future research, as well as PPD screening and intervention

are discussed.

Keywords Postpartum depression � Race � Subjective socioeconomic status � Health disparity � Objective socioeconomic status

Introduction

For women, the postnatal period is the most vulnerable time

for depression than any other time in their lives [1]. In

research on this topic, postpartum depression (PPD) is

commonly characterized as major and minor depressive

symptom levels occurring within the months following

childbirth, with major PPD referring to a diagnosis of or

symptom level related to a form of clinical depression and

minor PPD to a less severe yet still impairing form [1].

Estimates of the prevalence of PPD range from 5 to 25 % or

more depending on whether major and/or minor PPD are

assessed, the population studied, as well as the method and

timing of assessment [1]. Given there are approximately four

million live births annually in the United States (US) [2], this

equates to a minimum of roughly two hundred thousand

women suffering from PPD annually. This maternal suffer-

ing translates into an estimated economic burden of $44

billion annually in the US [3], and deleterious effects asso-

ciated with mother’s health [4, 5], infant health and devel-

opment [6], and mother-infant attachment [7].

While racial disparities have been documented in a

variety of physical and mental health conditions, studies on

C. L. Dolbier (&) � T. E. Rush East Carolina University, Greenville, NC, USA

e-mail: dolbierc@ecu.edu

L. S. Sahadeo � J. Thorp University of North Carolina, Chapel Hill, Chapel Hill, NC,

USA

M. L. Shaffer

Penn State Hershey College of Medicine, Hershey, PA, USA

123

Matern Child Health J (2013) 17:1277–1287

DOI 10.1007/s10995-012-1123-7

the prevalence of racial disparity in PPD have provided

mixed results. Some studies report African American

women have higher rates of PPD than non-Hispanic whites

[8–10], while others have reported no racial differences

[11–13]. These conflicting results may be due to the diffi-

culty of differentiating the confounding effects of race

versus socioeconomic status (SES) since African Ameri-

cans are over-represented in low SES, and a lack of con-

sistency in the method and timing of assessing PPD.

Research on traditional objective indicators of SES

(income, education, occupational status) indicates these

inter-linking factors can influence the development of PPD

[14]. For instance, mothers with lower income, education,

and employment status have a greater likelihood of

developing PPD, perhaps because they commonly are

younger, have lower social support, and are more likely to

be single parents [15]. Given the strong relationship of SES

with physical and mental health, researchers have begun to

explore possible mechanisms for this relationship. For

instance, psychosocial processes related to feelings of rel-

ative deprivation and social anxiety may at least partly

explain the SES-health relationship [16]. One such process

is subjective SES, one’s perceived position in the social

hierarchy [17]. Subjective SES is associated with physical

and mental health, and in some cases, is a stronger pre-

dictor than objective indicators of SES [17–19]. Thus,

subjective SES seems to contribute something unique in

the prediction of health outcomes. However, subjective

SES has not been studied in relation to PPD.

An understudied factor often related to race and SES that

may also relate to PPD is the type of area in which people

live (e.g., rural, suburban, urban). Most PPD research has

focused on urban, suburban, and national (mixed) samples,

while the specific challenges of rural settings (e.g., low

community support, low access to appropriate services,

limited transportation, isolated conditions) may influence

PPD [20]. Thus, PPD may affect rural women to a greater

extent [20], a finding supported by a recent study of low

income rural women [12].

The purpose of the current study is to determine whether

disparities in PPD symptoms exist between African Ameri-

can and non-Hispanic white rural women, and whether these

differences are accounted for by objective and subjective

SES, as well as marital status (a noted PPD risk factor) [21].

To address inconsistencies in the method and timing of

PPD assessment, one of the most valid and widely tested

instruments for PPD assessment, the Edinburgh Postnatal

Depression Scale (EPDS), was used at 1 and 6 months

postpartum. The EPDS has been used with diverse racial and

SES populations, and has a significant level of sensitivity

(proportion of depressed women correctly identified) and

specificity (proportion of non-depressed women correctly

identified) based on cut-off scores [22, 23].

Methods

This study is part of a larger study, the first being conducted

by the Community Child Health Network (CCHN), a group

of community organizations and universities partnering

with the Eunice Kennedy Shriver National Institute of Child

Health and Human Development and the National Institute

of Nursing Research to gain new insights into reasons for

disparities in maternal health and child development. The

goals of the network’s first study are to examine the factors

associated with maternal allostatic load (a possible factor in

adverse pregnancy outcomes), and to evaluate the usefulness

of community-partnered participatory research for con-

ducting research on health disparities. These goals are being

achieved through a community-academic partnered, multi-

site observational study examining how stress and resilience

factors interact with biological factors to result in racial

disparities in birth outcomes The CCHN study sites include

three urban (Baltimore, Los Angeles, Washington, DC), one

mixed urban-suburban (Lake County, IL), and one rural

(Eastern North Carolina, ENC). The analyses included here

are based on the ENC site.

Participants

The sample was an availability sample obtained from a

seven-county geographical catchment area in ENC (Bertie,

Edgecombe, Greene, Martin, Pitt, Tyrrell and Washington

counties). Women were recruited prenatally from maternity

clinics and through perinatal community outreach by the

research team and Eastern Baby Love Plus Maternity Care

Coordinators and Community Health Advocates.

Participants met the following inclusion criteria: (1)

18–40 years old; (2) African American or non-Hispanic

white; (3) resided in the catchment area for at least

6 months at time of delivery; and (4) live birth of greater

than or equal to 20 weeks of gestation. Exclusion criteria

included: (1) unable to give informed consent; (2) unable to

fully understand requirements of the study in English; (3)

four or more children; (4) incarcerated or otherwise unable

to participate in the study in a home, community or clinical

setting; and (5) surgically sterile or desired to be surgically

sterilized following the birth. The ENC site oversampled

low SES and African American women to help ensure the

majority of the CCHN total sample was comprised of low

SES and minority women.

At the time of this analysis, 433 participants were

enrolled in the study. Only participants who had completed

both the 1 and 6 months postpartum interviews were

included in the analyses. This excluded 86 (20 %) women

who had missed the window for completing the 6 months

postpartum interview, and 48 (11 %) for whom the window

was still open but who had yet to complete the interview.

1278 Matern Child Health J (2013) 17:1277–1287

123

Overall demographics of the ENC sample (N = 299,

69 %) are shown in Table 1. The majority of the sample

were African American (69 %), categorized as having

household income at or below the federal poverty threshold

(60 %), and were not employed at 1 month (63 %) or

6 months (57 %) postpartum. The largest percentage had

more than a high school education (43 %), and was in a

relationship (but not married) at enrollment (54 %),

1 month (48 %) and 6 months (47 %) postpartum.

Procedures

This study was conducted in accordance with ethical treat-

ment of human research participants after approvals by the

Institutional Review Boards at the participating institutions

were obtained. Women were ‘‘pre-enrolled’’ prenatally or

enrolled postnatally after completing an eligibility interview

and contacted within 1 month postpartum to complete a birth

interview (T0). A 90-min face-to-face interview was con-

ducted during home visits at 1 month (T1, window

2–16 weeks) and 6 months (T2, window 24–39 weeks)

postpartum. Interviewers resided in the catchment area,

underwent extensive training, and were matched with par-

ticipants based on race. Gift cards for completion of the T0

($20), T1 ($25), and T2 ($25) interviews were provided.

Measures

Demographics

Race and ethnicity were determined using two self-identifi-

cation questions included in the T0 eligibility interview that

were recommended by the US Office of Management and

Budget. First, individuals were asked to identify their eth-

nicity as ‘‘Hispanic or Latino’’ or ‘‘Not Hispanic or Latino.’’

Individuals who identified as Hispanic or Latino were

excluded from the analyses (n = 2). Then they were asked to

select one or more racial designations. Individuals who

answered yes to at least one of the two races of focus for the

ENC site (African American, non-Hispanic white) were

eligible for the study. Participants who indicated they were

multi-racial (n = 7) were included using their primary race

designation (4 African American, 3 non-Hispanic white).

Marital status was categorized as being married, in a rela-

tionship, or not in a relationship, and was determined using

questions from the T0 interview about the participant’s

relationship with the father of the baby or other romantic

interest, with updates requested during the T1 and T2 inter-

views. The T1 interview included education questions,

specifically how many years of school completed and highest

degree earned. The T1 interview also included employment

questions, with updates requested during the T2 interview.

Poverty

The T1 interview also included questions regarding

household income and number of people in the household.

Using responses to these questions, the following three

poverty categories were derived based on the US Census

Bureau, Weighted Average Poverty Thresholds 2009 [24],

which vary according to the size of the household without

requiring information on the number of related children

under 18 years: (1) B100 % federal poverty level (FPL)

(indicating income at or less than poverty threshold); (2)

101–200 % FPL; and (3)[200 % FPL. When a participant did not know or refused to report household income

(n = 53), poverty status was imputed based on her receipt

of Medicaid and/or public assistance [food stamps;

Women, Infants, and Children’s Program (WIC); Tempo-

rary Assistance to Needy Families (TANF)]. If she did not

receive any of these, she was categorized as[200 % FPL. If she only received WIC or Medicaid, she was categorized

as 101–200 % FPL. If she received food stamps or TANF,

she was categorized as B100 % FPL.

Subjective SES

The T2 interview included the MacArthur Scale of Sub-

jective Social Status (SES version), designed to capture

one’s sense of relative social standing across the objective

SES indicators [20]. Respondents view a picture of a lad-

der, with each rung labeled with a number from ‘‘1’’ at the

bottom to ‘‘10’’ at the top. It is explained to them that the

ladder represents where the people in the US stand, with

those at the top being people who are the best off (with the

most money, education, and respected jobs), and people at

the bottom being people who are the worst off (with the

least money, education, and respected jobs). Respondents

indicate the number that corresponds to the rung where

they think they stand compared to all the other people in

the US. This measure has demonstrated adequate test–ret-

est reliability and predictive validity [25].

Postpartum Depression Symptoms

The T1 and T2 interviews included the EPDS, which

consists of 10 questions that ask about the experience of

various symptoms of depression (e.g., felt sad or miserable,

so unhappy that had difficulty sleeping) during the past

7 days [22]. Respondents answer each question on a

4-point scale indicating lower to higher levels of the par-

ticular symptom. Question 10 asks about thoughts of

harming oneself. Cronbach’s alpha for the T1 EPDS was

0.83 and for the T2 EPDS was 0.85. Cut-off scores on the

EPDS were used to categorize participants as: (1) negative

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Table 1 Descriptive Statistics of Study Variables Overall and by Race

Categorical Variables Overall (N = 299) African American (n = 206) Non-Hispanic white (n = 93) p

Frequency (percentage) Frequency (percentage) Frequency (percentage)

PPD (1 month postpartum)a

Minor PPD (scores 10–12) 19 (6.9) 16 (8.5) 3 (3.4) 0.124

Major PPD (scores 13 ?) 29 (10.5) 23 (12.2) 6 (6.9) 0.180

Minor–major PPD (scores 10 ?) 48 (17.5) 39 (20.7) 9 (10.3) 0.035

PPD (6 months postpartum)

Minor PPD (scores 10–12) 25 (8.4) 17 (8.3) 8 (8.6) 0.540

Major PPD (scores 13 ?) 27 (9.0) 21 (10.2) 6 (6.5) 0.206

Minor–major PPD (scores 10 ?) 52 (17.4) 38 (18.4) 14 (15.1) 0.294

Race

African American 206 (69)

Non-Hispanic white 93 (31)

Marital status (enrollment)b

Not in a relationship 52 (17) 47 (23) 5 (5) \0.0001 In a relationship 161 (54) 124 (60) 37 (40)

Married 85 (29) 34 (17) 51 (55)

Marital status (1 month postpartum)c

Not in a relationship 71 (24) 65 (32) 6 (6) \0.0001 In a relationship 141 (48) 104 (51) 37 (40)

Married 84 (28) 34 (17) 50 (54)

Marital status (6 months postpartum)

Not in a relationship 75 (25) 66 (32) 9 (10) \0.0001 In a relationship 142 (47) 108 (52) 34 (37)

Married 82 (27) 32 (16) 50 (54)

Poverty status (1 month postpartum)

B100 % FPL 179 (60) 136 (66) 43 (46) \0.0001 101–200 % FPL 73 (24) 53 (26) 20 (22)

[200 % FPL 47 (16) 17 (8) 30 (32) Employment status (1 month postpartum)

Working 47 (16) 31 (15) 16 (17) 0.210

On leave 64 (21) 39 (19) 25 (27)

Unemployed 188 (63) 136 (66) 52 (56)

Employment status (6 months postpartum)

Working 127 (42) 85 (41) 42 (45) 0.253

On leave 1 (\ 1) 0 (0) 1 (1) Unemployed 171 (57) 121 (59) 50 (54)

Highest degree (1 month postpartum)d

Less than high school 47 (16) 35 (17) 12 (13) 0.007

High school 124 (42) 95 (46) 29 (31)

More than high school 127 (43) 75 (37) 52 (56)

Continuous variables Overall (N = 299) African American (n = 206) Non-Hispanic white (n = 93) p

Mean (standard deviation) Mean (standard deviation) Mean (standard deviation)

EPDS (1 month postpartum)a 5.50 (±4.84) 5.75 (±5.08) 4.97 (±4.23) 0.211

EPDS (6 months postpartum) 4.76 (±4.86) 4.77 (±4.92) 4.72 (±4.74) 0.933

Subjective SES (6 months postpartum) 5.1 (±1.7) 5.1 (±1.8) 5.2 (±1.4) 0.612

Years of school (1 month postpartum) 13.2 (±2.2) 13.0 (±2.0) 13.6 (±2.7) 0.052

1280 Matern Child Health J (2013) 17:1277–1287

123

screen for PPD or non-symptomatic (scores of 0–9); (2)

positive screen for minor PPD (scores of 10–12); or (3)

positive screen for major PPD (scores of 13–30) or EPDS

item 10 responded to affirmatively indicating any suicidal

thoughts regardless of EPDS total score [22, 23]. The

sensitivity and specificity of this measure at the 10-point

cut-off are 83.6 and 88.3 %, respectively. The sensitivity

and specificity at the 13-point cut-off are 58.5 and 97.5 %,

respectively [26].

Statistical Analysis

Descriptive statistics were prepared for all variables

including frequencies and percentages for categorical

variables and means and standard deviations for continuous

variables. Demographic and study variables were com-

pared between African American and non-Hispanic white

women using X2 or Fisher’s exact tests (when expected cell

counts were too sparse for X2 tests to be appropriate) for

categorical variables and two-sample t tests, for quantita-

tive variables. PPD was defined as a binary variable in two

ways: (1) combining minor and major PPD for comparison

with non-symptomatic (minor-major PPD), and (2) com-

bining non-symptomatic and minor PPD for comparison

with major PPD (major PPD). Logistic regression was used

to examine the association between PPD and race after

accounting for the relationships between PPD and poverty

status, education, subjective SES, and marital status. Sep-

arate models were constructed for the 1 and 6 months

postpartum time points for minor-major PPD and major

PPD. Twenty-two mothers were excluded in the analyses

for the 1 month postpartum time point, as the interview

was completed at less than 2 weeks postpartum. Models

were constructed in four steps, sequentially adding in the

variables of interest with race as the primary predictor of

interest being added in the final step: (1) current marital

status; (2) current marital status, poverty status, and edu-

cation; (3) current marital status, poverty status, education,

and subjective SES; and (4) current marital status, poverty

status, education, subjective SES, and race. Exact logistic

regression methods were used when the number of PPD

cases was too small for traditional logistic regression

methods. Findings were considered statistically significant

for p \ 0.05. Analyses were conducted using SPSS (IBM Corporation, Somers, NY) and SAS (SAS Institute Inc.,

Cary, NC).

Results

Descriptive Statistics and Univariate Race Comparisons

Demographics of the sample by race are shown in Table 1.

Compared to non-Hispanic white participants, African

American participants were significantly younger (t =

-4.67, p \ 0.0001), poorer (X2 = 28.15, p \ 0.0001), less educated (X2 = 9.85, p = 0.01), and less likely to be

married at enrollment or one or 6 months postpartum

(X2 = 49.19, 49.93, and 50.32, respectively, all p\ 0.0001). African American and non-Hispanic white participants did

not differ with respect to subjective SES at 6 months post-

partum (t = -0.51, p = 0.61) or employment status at 1 or

6 months postpartum (X2 = 3.12, p = 0.21 and Fisher’s

exact table probability = 0.02, p = 0.25, respectively).

Descriptive statistics for the EPDS and minor, major, and

minor-major PPD categories at 1 and 6 months postpartum

for the overall sample and by race are shown in Table 1,

along with univariate tests for differences by race. At

1 month postpartum the mean EPDS score for the overall

sample was 5.5 (±4.8), with 6.9 % of participants having a

positive screen for minor PPD, 10.5 % having a positive

screen for major PPD, and 17.5 % having a positive screen

for minor or major PPD. African American participants had

a higher mean EPDS score 1 month postpartum compared

to non-Hispanic white participants, but this was not a sig-

nificant difference (t = 1.25, p = 0.21). A significantly

greater percentage of African American participants fell in

the minor-major PPD category (20.7 %) at 1 month post-

partum compared to non-Hispanic white participants

(10.3 %) (X2 = 4.46, p = 0.03). A similar pattern was

observed for minor PPD (African American 8.5 %, non-

Hispanic white 3.4 %) and major PPD (African American

Table 1 continued

Continuous variables Overall (N = 299) African American (n = 206) Non-Hispanic white (n = 93) p

Mean (standard deviation) Mean (standard deviation) Mean (standard deviation)

Age in years (enrollment) 23.6 (±4.7) 22.7 (±4.2) 25.6 (±5.3) \0.0001

FPL federal poverty level, EPDS Edinburgh Postnatal Depression Scale a 2 missing, 22 excluded who completed T1 at \2 weeks postpartum b 1 missing c 3 missing d 1 missing

Matern Child Health J (2013) 17:1277–1287 1281

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12.2 %, non-Hispanic white 6.9 %) at 1 month postpartum,

but were not significant (X2 = 2.37, p = 0.12; X2 = 1.80,

p = 0.18, respectively).

At 6 months postpartum, the mean EPDS score for the

overall sample decreased to 4.8 (±4.9) with 8.4 % of

participants having a positive screen for minor PPD, 9.0 %

having a positive screen for major PPD, and 17.4 % having

a positive screen for minor or major PPD. The mean EPDS

scores decreased at 6 months postpartum for both African

American and non-Hispanic white participants, with a

greater decrease observed for African American partici-

pants; there was no significant difference in 6 month

postpartum EPDS scores by race (t = 0.09, p = 0.93). The

percentage of African American participants in the minor

PPD category at 6 months postpartum decreased, while

the percentage of non-Hispanic white participants in this

category increased. This led to a change in the racial pat-

tern for minor PPD at this time point, with a greater per-

centage of non-Hispanic white participants having a

positive screen compared to African American participants,

however, this difference was not significant (Fisher’s exact

table probability = 1.00, p = 0.54). The percentage of

African American participants in the major PPD category

at 6 months postpartum decreased and the percentage of

non-Hispanic white participants in this category stayed the

same; the overall pattern remained the same (greater per-

centage of African Americans than non-Hispanic whites),

but was not significant (Fisher’s exact table probabil-

ity = 0.39, p = 0.21). For the minor-major PPD category

at 6 months postpartum, the percentage of African Amer-

ican participants decreased, while the percentage of non-

Hispanic whites increased; the overall pattern remained the

same (greater percentage of African Americans than non-

Hispanic whites), but was not significant (Fisher’s exact

table probability = 0.51, p = 0.29).

Multivariable Logistic Regressions

Results of the logistic regressions for minor-major PPD,

modeled separately at 1 and 6 months postpartum are

summarized in Table 2. At 1 month postpartum, education

was a significant predictor of minor-major PPD until the

inclusion of race in the model after which it became

marginal. At 1 month postpartum, current marital status

was a significant predictor of minor-major PPD until the

inclusion of poverty and education in the model after which

it became marginal, and then lost significance after the

inclusion of race in the model. At 6 months postpartum,

subjective SES was significantly associated with minor-

major PPD, even after including all of the other predictors

in the model, with higher subjective SES indicating lower

odds of PPD. At 6 months postpartum, current marital

status was significantly associated with minor-major PPD

until accounting for poverty and education where it became

marginal.

Results of the logistic regression modeling for major

PPD are summarized in Table 3. At 1 month postpartum,

current marital status approached significance as a predic-

tor of major PPD; however, the significance was not

maintained after adding poverty, education, subjective

SES, and race to the model. Current marital status

approached significance as a predictor of major PPD at

6 months postpartum, but lost significance after subjective

SES and race were included in the model. Education

approached significance as a predictor of major PPD at

6 months postpartum. At 6 months postpartum, only sub-

jective SES was significantly associated with major PPD

even with current marital status, poverty, education, and

race in the model, with higher subjective SES indicating

lower odds of PPD.

Discussion

In the current study of rural African American and non-

Hispanic white women, the prevalence rates at 1 and

6 months postpartum of a positive screen for major PPD

(11, 9 %, respectively) and minor-major PPD (18, 17 %,

respectively) are within the range of those reported in

previous research using varying assessment methods and

time points (5–25 % or more) [1] and those reported in

previous studies that assessed PPD using the EPDS at

similar postpartum time points (6.5–34 %) [12, 14, 26–28].

Of comparable studies, only one focused on a rural,

although low income, sample and reported higher rates of

major PPD (15 %) and minor-major PPD (33 %) at

6–8 weeks postpartum [12], The inclusion of high income

women in the current study may help to explain in part the

lower rates of PPD observed. Comparable studies of urban

samples reported slightly lower rates of major PPD (8 %)

6 months postpartum [28] and minor-major PPD (13 %) at

4–6 weeks postpartum [27]. It is possible that the oral

administration of the EPDS in the current study led to

under-reporting of depressive symptoms as has been

observed in previous research [27]. In comparing the cur-

rent study’s results to those of previous comparable studies,

it appears that rural women with varying levels of SES

experience PPD symptoms to a greater extent than women

in urban areas but not as high as those experienced by rural,

low SES women, and that these rates persist up to 6 months

postpartum.

Initial univariate analyses revealed that a significantly

greater percentage of African American participants had

scores that fell into the minor-major PPD category at

1 month postpartum compared to non-Hispanic white

participants. However, after taking marital status, poverty,

1282 Matern Child Health J (2013) 17:1277–1287

123

education, and subjective SES into consideration, there

were no significant racial differences observed in symp-

toms of PPD at 1 or 6 months postpartum. These results

indicate that when focusing on a rural sample such as this

with varying levels of objective and subjective SES, PPD

symptoms may not differ between African American and

non-Hispanic white women at 1 and 6 months postpartum.

These results are consistent with most of the other studies

that assessed PPD using the EPDS at similar time points

[12, 14, 27–29]. No significant racial differences in major

or minor-major PPD were found in a rural, low income

sample at 6–8 weeks postpartum [12], or a national sample

within 6 months postpartum [14]. SES and marital status

were not taken into consideration in the analyses of racial

Table 2 Logistic Regression Modeling of Minor–Major PPD at 1 and 6 months Postpartum

Variable Step 1 Step 2 Step 3 Step 4

Odds Ratio

(95 % CI)

p Odds Ratio

(95 % CI)

p Odds Ratio

(95 % CI)

p Odds Ratio

(95 % CI)

p

Minor–Major PPD 1 month postpartum

Current marital status 0.046 0.066 0.075 0.185

Not in a relationship versus

Married

3.272

(1.256–8.523)

0.015 3.500

(1.189–10.305)

0.023 3.322 (1.131–9.757) 0.029 2.601 (0.842–8.035) 0.097

In a relationship versus

Married

2.556

(1.049–6.226)

0.039 2.897

(1.050–7.994)

0.040 2.884 (1.051–7.914) 0.040 2.525 (0.906–7.039) 0.077

Poverty status 0.175 0.169 0.167

B100 % FPL versus

[200 % FPL 0.394

(0.118–1.318)

0.131 0.402 (0.121–1.338) 0.137 0.389 (0.116–1.303) 0.126

101–200 % FPL versus

[200 % FPL 0.722

(0.219–2.383)

0.593 0.756 (0.230–2.479) 0.644 0.725 (0.220–2.392) 0.597

Education 0.038 0.048 0.052

\High school versus [High school

3.397

(1.312–8.793)

0.012 3.239 (1.247–8.408) 0.016 3.230 (1.240–8.409) 0.016

High school versus

[High school 2.147

(0.947–4.865)

0.067 2.114 (0.931–4.798) 0.074 2.032 (0.892–4.633) 0.092

Subjective SES 0.907 (0.751–1.095) 0.309 0.901 (0.747–1.088) 0.279

Race (African American

versus non-Hispanic white)

1.736 (0.743–4.055) 0.202

Minor–Major PPD 6 months postpartum

Current marital status 0.011 0.070 0.103 0.088

Not in a relationship

versus Married

3.915

(1.346–11.385)

0.012 3.288

(1.048–10.316)

0.041 2.605 (0.823–8.249) 0.104 2.889 (0.869–9.604) 0.083

In a relationship

versus Married

4.480

(1.671–12.014)

0.003 3.509

(1.193–10.320)

0.023 3.179 (1.096–9.221) 0.033 3.407 (1.146–10.129) 0.027

Poverty status 0.362 0.455 0.455

B100 % FPL versus

[200 % FPL 1.257

(0.362–4.360)

0.719 1.383 (0.398–4.809) 0.610 1.418 (0.407–4.944) 0.583

101–200 % FPL versus

[200 % FPL 0.680

(0.175–2.638)

0.577 0.808 (0.209–3.125) 0.757 0.832 (0.214–3.229) 0.791

Education 0.425 0.537 0.506

\High school versus [High school

1.621

(0.640–4.106)

0.309 1.477 (0.577–3.784) 0.416 1.493 (0.582–3.831) 0.405

High school versus

[High school 1.626

(0.758–3.487)

0.212 1.534 (0.708–3.321) 0.278 1.572 (0.723–3.419) 0.253

Subjective SES 0.766 (0.632–0.928) 0.006 0.766 (0.632–0.928) 0.007

Race (African American

versus non-Hispanic white)

0.789 (0.373–1.670) 0.536

CI confidence interval, FPL federal poverty level; models were constructed in four steps, increasing the number of predictors at each step:

Step 1—marital status; Step 2—marital status, poverty status, and education; Step 3—marital status, poverty status, education, and subjective

SES; and Step 4—marital status, poverty status, education, subjective SES, and race

Matern Child Health J (2013) 17:1277–1287 1283

123

differences in PPD in either of these studies. In two studies

of urban samples, initial racial differences in major PPD at

6 months postpartum [28] and minor-major PPD at

4–6 weeks postpartum [27] whereby African American

women had higher rates than non-Hispanic white women

were either accounted for by financial hardship [28] or not

confirmed after a clinical interview confirmation of PPD

[27]. Other studies identified in the literature as examining

racial differences in PPD show mixed results [8–11, 13, 30,

31], however, are not comparable given different PPD

assessment methods and assessment time points. Similar to

other comparable studies, the results of the current study

suggest that any initial racial differences in PPD that are

observed do not appear to maintain significance once SES

or confirmation of a clinical diagnosis is taken into

account.

Table 3 Logistic Regression Modeling of Major PPD at 1 and 6 months Postpartum

Variable Step 1 Step 2 Step 3 Step 4

Odds Ratio

(95 % CI)

p Odds Ratio

(95 % CI)

p Odds Ratio

(95 % CI)

p Odds Ratio

(95 % CI)

p

Major PPD 1 month postpartum

Current marital status 0.057 0.265 0.221 0.245

Not in a relationship

versus Married

2.994

(0.743–12.070)

0.123 1.793

(0.374–11.552)

0.642 1.767

(0.367–11.408)

0.659 1.530

(0.297–10.436)

0.847

In a relationship

versus Married

4.515

(1.291–15.796)

0.018 2.664

(0.720–14.892)

0.184 2.709

(0.731–15.169)

0.174 2.521

(0.666–14.313)

0.231

Poverty status 0.172 0.173 0.173

B100 % FPL versus

[200 % FPL 4.108

(0.577–Infinity)

0.182 4.117

(0.582–Infinity)

0.179 4.007

(0.570–Infinity)

0.188

101–200 % FPL versus

[200 % FPL 5.266

(0.726–Infinity)

0.110 5.379

(0.747–Infinity)

0.104 5.166

(0.720–Infinity)

0.113

Education 0.879 0.878 0.912

\High school versus [High school

1.357

(0.352–4.913)

0.805 1.301

(0.335–4.739)

0.864 1.304

(0.336–4.755)

0.861

High school versus

[High school 1.189

(0.434–3.423)

0.897 1.177

(0.429–3.389)

0.916 1.156

(0.419–3.342)

0.948

Subjective SES 0.922

(0.731–1.154)

0.478 0.917

(0.727–1.146)

0.445

Race (African American

versus non-Hispanic white)

1.380

(0.484–4.453)

0.556

Major PPD 6 months postpartum

Current marital status 0.059 0.098 0.173 0.161

Not in a relationship

versus Married

12.461

(1.555–99.885)

0.018 10.678

(1.239–92.008)

0.031 7.698

(0.891–66.491)

0.064 8.411

(0.931–76.014)

0.058

In a relationship

versus Married

10.286

(1.338–79.061)

0.025 8.128

(0.977–67.637)

0.053 6.819

(0.836–55.614)

0.073 7.202

(0.867–59.809)

0.068

Poverty status 0.390 0.442 0.434

B100 % FPL versus

[200 % FPL 2.235

(0.253–19.736)

0.469 2.890

(0.324–25.797)

0.342 2.968

(0.333–26.493)

0.330

101–200 % FPL versus

[200 % FPL 1.078

(0.105–11.032)

0.949 1.622

(0.156–16.831)

0.686 1.668

(0.160–17.344)

0.668

Education 0.078 0.079 0.076

\High school versus [High school

0.186 (0.022–1.575) 0.123 0.157 (0.018–1.358) 0.093 0.158 (0.018–1.362) 0.093

High school versus

[High school 1.690 (0.658–4.341) 0.276 1.544 (0.592–4.025) 0.374 1.578 (0.602–4.133) 0.353

Subjective SES 0.726 (0.563–0.937) 0.014 0.725 (0.562–0.937) 0.014

Race (African American

versus non-Hispanic white)

0.809 (0.286–2.287) 0.689

CI confidence interval, FPL federal poverty level; models were constructed in four steps, increasing the number of predictors at each step: Step 1—marital

status; Step 2—marital status, poverty status, and education; Step 3—marital status, poverty status, education, and subjective SES; and Step 4—marital

status, poverty status, education, subjective SES, and race

1284 Matern Child Health J (2013) 17:1277–1287

123

Subjective SES was the most consistent predictor of

PPD symptoms, predicting major and minor-major PPD at

6 months postpartum. While one other identified study

found a negative relationship between subjective SES and

depression measured using items from the General Health

Questionnaire 30 in male and female London civil service

employees [32], the present study is the first we are aware

of to examine the relationship between subjective SES and

PPD symptoms. The present study’s results suggest that

women who see themselves as less well-off in terms of

income, education, and occupation in comparison to others

may be at a higher risk of developing PPD. This could be

due to these women experiencing greater distress as a result

of their perceived inferior circumstances. For instance, they

may perceive themselves as having lower self-worth and

self-efficacy than other women, feel unable to adequately

provide for their families as well as themselves, and/or

view their current life situations as unlikely to change,

leaving them feeling hopeless and helpless (hallmark

indicators of depression). That the relationship could be

bidirectional (e.g., a woman experiencing depressive

symptoms may be more likely to perceive her SES position

as worse than others) raises the issue of a confounding

effect of depressive symptoms on the appraisal of one’s

subjective SES. However, research has demonstrated that

the appraisal of one’s subjective SES is not significantly

impacted by psychological biases [32] including negative

affect [25], which has conceptual overlap with depressive

symptoms. The observed relationship between subjective

SES and negative affect is more likely the result of the

influence of low subjective SES on negative affect rather

than the reverse [25, 33]. This research supports the idea

that low subjective SES increases the risk for PPD symp-

toms, perhaps in part by increasing negative affect in the

ways described above.

The significance of subjective SES for positive screen

for minor-major and major PPD at 6 months postpartum,

and that its inclusion in the regression models often

reduced the influence of indicators of objective SES sug-

gests that one’s perceived social status may provide pre-

dictive value that is not accounted for by the more

commonly used objective indicators of SES when exam-

ining factors related to PPD. This finding is consistent with

prior research relating SES to other health outcomes [19,

20, 22], but is the first report of an examination of sub-

jective SES in relation to PPD. It would be prudent for

future researchers to include both objective and subjective

measures of SES when trying to understand relative con-

tributions of race and SES in examining racial disparities in

health, especially in rural populations where SES and race

can be easily entangled.

Marital status was a significant predictor of PPD in our

study, but only when entered by itself in the first step of the

minor-major PPD regressions. When poverty status and

education were included, marital status became non-signif-

icant, and in most cases became even more non-significant

with the addition of subjective SES and race. This pattern

suggests that the other predictors, particularly poverty status

and education, may help to account for the initial observed

relationship between marital status and PPD.

Limitations

There were several limitations inherent in this study.

Although the use of established cut-offs using the EPDS for

assessment of PPD is consistent with much PPD research,

it only enables the determination of the likelihood of a

clinical diagnosis of PPD, not an actual diagnosis. Another

limitation is that subjective SES was only assessed at

6 months postpartum, so its relationship with PPD at

1 month postpartum should be interpreted with caution.

However, the MacArthur Scale of Subjective Social Status

has demonstrated adequate test–retest reliability, suggest-

ing this may not be a major concern [25]. As indicated

earlier, depressive symptoms could confound the appraisal

of subjective SES, so assessing both variables prospec-

tively will help elucidate how these variables affect one

another. In addition, that the assessments of subjective SES

and PPD were both via questionnaires, the strength of the

relationship between these two variables may be overesti-

mated given same source bias. However, previous research

showing negative affect has similar relationships with both

objective and subjective SES suggests that same-source

bias may not be a large concern [25]. Also, a potential

confound that was not included in these analyses due to

over-fitting the regression models was the variable preterm

birth (PTB). Racial disparities in PTB are well established

in the literature, with African American women exhibiting

significantly higher rates than non-Hispanic White women

(one in five births and one in 8–9 births, respectively) [34].

PTB has been shown to be directly correlated with

increased risk of PPD [35]; therefore future studies should

take this variable into account. However, exploratory

analyses that included PTB in the first step of the multi-

variable modeling showed that PTB did not affect the

significance of the variables currently presented. A statis-

tical limitation was that the number of cases of positive

screens for major PPD was not large, and thus the level of

power to detect significant effects in the logistic regression

models may be limited. As evidenced by the large 95 %

confidence intervals, the estimated odds ratios have low

precision. It is important to note that poverty status was

derived from household size, which was not asked directly,

and household income, which was not always provided.

Household size was estimated from a series of questions

detailing if the participant lived with parents, children,

Matern Child Health J (2013) 17:1277–1287 1285

123

other family members, and non-family members, which

could lead to an under-reporting of household size. As

previously described, when a participant did not know or

refused to report household income, poverty status was

imputed based on her receipt of Medicaid and/or public

assistance. Lastly, a small percentage of the sample (4 %)

reported taking medication for depression during the

6 months postpartum interview. These participants were

more likely to be non-Hispanic white, married, and

unemployed.

Practical Implications

The prevalence rate of PPD up to 6 months postpartum in

this study’s sample of rural women being higher than that

of urban women highlights the need for routine screening

mechanisms for PPD detection in rural areas. This may be

especially applicable to rural and low SES women, given

their actual and/or perceived limited personal resources and

few opportunities to seek help. Increased screening leads to

increased diagnosis, referral, and treatment, signifying that

screening is a crucial first step toward PPD treatment [36].

The feasibility of PPD screening has been demonstrated

in pediatrician and obstetrician/gynecologist offices and

health departments [36–38]. Additionally, screening could

extend to community-based infant mortality prevention

programs in order to more effectively reach rural popula-

tions. Given its established psychometric properties and

clinical utility, we concur with others who recommend the

EPDS be used as the standard screening measure for PPD

[1, 27], which would further enable comparisons across

studies.

That the most consistent predictor of PPD in this study

was subjective SES focuses attention on it as a possible risk

factor that may be modified through intervention services.

However, before specific interventions can be developed,

findings from this study need replication and further

understanding of why given the same level of objective

SES, rural women who perceive their SES to be lower are

more likely to have PPD symptoms. With this being said,

future avenues for exploration after the problem is more

fully understood include facilitating women’s awareness of

potential resources at their disposal, so they may not feel as

helpless to change their current situation and may help

instill hope that their situations can change for the better;

and enhancing problem-solving skills to help women learn

how to access support and services as well as facilitate

active coping towards presenting problems they are expe-

riencing. Relatedly, given that subjective SES is considered

an average appraisal of the combination of one’s income,

occupation, and education [16], designing interventions to

target improvement on any of these three objective SES

factors should also help improve one’s subjective SES.

Acknowledgment The Community Child Health Network (CCHN) is a community-based participatory research network supported

through cooperative agreements with the Eunice Kennedy Shriver

National Institute of Child Health and Human Development (U

HD44207, U HD44219, U HD44226, U HD44245, U HD44253, U

HD54791, U HD54019, U HD44226-05S1, U HD44245-06S1, R03

HD59584) and the National Institute for Nursing Research (U

NR008929). CCHN reflects joint endeavors of five local sites: (1)

Baltimore: Baltimore City Healthy Start and Johns Hopkins Univer-

sity (Community PI Maxine Vance, Academic PI Cynthia S.

Minkovitz, Project Coordinator Nikia Sankofa, Co-Is Patricia

O’Campo, Peter Schafer); (2) Lake County, Illinois: Lake County

Health Department and Community Health Center and the Northshore

University Health System (Community PI Kim Wagenaar, Academic

PI Madeleine Shalowitz, Project Coordinator Beth Clark-Kauffman,

Co-Is Emma Adam, Greg Duncan*, Chelsea McKinney, Rachel

O’Connell, Alisu Schoua-Glusberg); (3) Los Angeles: Healthy Afri-

can American Families, Cedars-Sinai Medical Center, and University

of California, Los Angeles (Community PI Loretta Jones, Academic

PI Calvin J.Hobel, Co-PIs Christine Dunkel Schetter, Michael C. Lu;

Project Coordinators Mayra Lizzette Yñiguez, Dawnesha Beaver,

Felica Jones); (4) East Carolina University, NC Division of Public

Health, NC Eastern Baby Love Plus Consortium, and University of

North Carolina, Chapel Hill (Community PIs Sharon Evans, Scharina

Oliver*, Richard Woolard, Academic PI John Thorp, Project Coor-

dinators Suzanne Kelly, Latoya S. Sahadeo, Kathryn Salisbury, Co-Is

Julia DeClerque, Christyn Dolbier, Mary Glascoff*, Vijaya Hogan*,

Carol Lorenz, Edward Newton, Belinda Pettiford, Research Partners

Shelia Bunch, Sarah Maddox, Judy Ruffin); and (5) Washington, DC:

Georgetown Center on Health and Education, Washington Hospital

Center, and Developing Families Center (Community PI Loral Pat-

chen, Academic PI Sharon L. Ramey, Academic Co-PI Robin Lanzi,

Project Coordinator Nedaa Timraz, Co-Is Lorraine V. Klerman,

Menachem Miodovnik, Craig T. Ramey, Linda Randolph, Commu-

nity Coordinator Rosalind German). The following individuals also

made critical contributions to CCHN: the Data Coordination and

Analysis Center at the Pennsylvania State University (PI Vernon M.

Chinchilli, Project Coordinator Gail Snyder, Co-Is Rhonda Belue,

Georgia Brown Faulkner*, Marianne Hillemeier, Erik Lehman, Ian

Paul, Jim Schmidt, Michele L. Shaffer, Christy Stetter), Steering

Committee Chairs Mark Phillippe and Elena Fuentes-Afflick*, and

NIH Program Scientists (V. Jeffrey Evans, Tonse Raju) and Program

Officers (Yvonne Bryan*, Michael Spittel, Linda Weglicki, Marian

Willinger). We thank the hospitals and other facilities sponsoring

participant recruitment and the local community advisory boards at

each site. For a detailed overview of CCHN please see the CCHN

public website at http://www.communitychildhealthnetwork.com.

*Indicates those who participated in the planning phase of the CCHN.

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