Maternal and Child Health Journal, Vol. 9, No. 1, March 2005 ( C© 2005)DOI: 10.1007/s10995-005-2448-2

Prevalence of Postpartum Depressionin a Native American Population

Lisa Baker, PhD, LCSW,1,2 Sandra Cross, EdD,1 CHES, Linda Greaver, MA,1

Gou Wei, PhD,1 Regina Lewis, ADBA,1 and Healthy Start CORPS1

Objectives: Data were collected on postpartum depression from 151 women, ages 16–40 yearswho received postpartum health services from a rural obstetrical clinic in North Carolinabetween September 2002 and May 2003. Reflective of the racial and socio-economic make-up of the county, 60.9% of the sample were American Indian (Lumbee tribe) 25.8% wereAfrican American and 13.3% were Caucasian or other. Methods: The Postpartum Depres-sion Screening Scale (PDSS) was utilized to explore the prevalence of postpartum depres-sion requiring clinical intervention in a largely unexplored population, minority women.Results: The incidence of postpartum depression symptoms was over 23%, which is signif-icantly higher than even the most liberal estimates in other populations. As with previousliterature on risk factors, the sample demonstrates a strong association between symptomsof depression, history of depression and receiving treatment for depression. Conclusions:The PDSS proved to be a clinically useful tool in this setting. Findings support the impor-tance of implementing routine screening protocols to guide practice and implement supportservices.

KEY WORDS: postpartum; depression; PDSS; native American.

INTRODUCTION

The postpartum period is marked by profoundphysical and emotional changes for the mother.While the concept of postpartum depression or post-partum blues is not new, recent attention to othertypes of postpartum emotional responses, includingpostpartum psychosis, anxiety disorders, and evenpost traumatic stress response highlights the impor-tance of effective screening. The absence of newtools for screening postpartum depression, alongwith the lack of literature reflecting the incidenceof postpartum depression in minority populationshas driven research agendas to evaluate current

1University of North Carolina at Pembroke, Pembroke, NorthCarolina.

2Correspondence should be addressed to Dr. Lisa Baker, Depart-ment of Sociology, Social Work, and Criminal Justice, Universityof North Carolina at Pembroke, P.O. Box 1510, Pembroke, NorthCarolina 28372; e-mail: Lisa.Baker@uncp.edu.

methods of screening in historically underrepre-sented populations.

Postpartum depression is a psychological disor-der affecting between 10 and 15% of women duringthe postpartum period (1, 2, 15). It includes symp-toms such as sadness, tearfulness, lack of motivation,diminished interest in food or self-care, trouble con-centrating, and loss of interest in the new baby. Incontrast, postpartum blues affects as many as 70%of new mothers who exhibit transitory symptoms(not progressing past two weeks postpartum) includ-ing tearfulness, mood swings, and feelings of sad-ness. While most symptoms of postpartum depres-sion manifest prior to 6 weeks, diagnostic guidelinesinclude manifestations up to one year postpartum. Itis of special concern that postpartum depression con-tinues to be significantly under-diagnosed and under-treated, given the potentially profound affect on themother-infant dyad and family system (1, 17). Meta-analysis on data examining the interaction betweendepressed mothers and their infants supports that

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22 Baker, Cross, Greaver, Wei, Lewis, and Corps

depressed mothers show less affectionate behavior,respond less to infant cues, and withdraw, or havehostile/intrusive interactions with their infants (1).Leifman (3) discusses the affect that maternal de-pression has on mother–infant interaction, and re-ports an association between maternal depressionand engaging in risk taking behaviors with the childsuch as not administering vitamins to the child, ma-ternal tobacco smoking, and not using appropriatechild safety restraints.

While postpartum depression is often diagnosedin women with no identified risk factors, recent lit-erature examines the presence of psychosocial riskfactors in certain populations. Known risk factorsfor postpartum depression include a prior history ofpostpartum depression, a prior history of depressionor bipolar disorder, a history of severe premenstrualsyndrome, a family history of depression, and recentstressful events (2). Additional documented risk fac-tors include child-care stress, poor social support, lowself-esteem and decreased marital satisfaction (4, 5).

To date, literature primarily describesCaucasian, middle-class populations, leaving ascarcity of available research exploring minoritypopulations. Logsdon and Usui (5) conducted astudy examining psychosocial predictors of postpar-tum depression in groups of middle-class, Caucasianwomen, and lower-class African American womenand found no significant differences among thegroups for predictors of postpartum depression.Amankwaa (6) conducted her qualitative study ontwelve African American women with a history ofpostpartum depression in order to address the gapin literature discussing women of non European-American background. Her study reiterated theneed for culturally sensitive depression screeningalong with an acknowledgement that cultures handlepsychosocial disorders and symptoms differently.

Current literature recognizes postpartum de-pression screening as an emerging standard of care,although screening is not routinely implemented(7, 8) literature discussing elements of the perina-tal period among native American women is espe-cially limited. Long and Curry (9) conducted a quali-tative study examining the beliefs of native Americanwomen about prenatal care. Their findings discussedthe different views of traditional care during preg-nancy and the Western model of care prescribed to-day, in the context of assimilation. To the authorsknowledge there have been no studies that exam-ined routine screening for postpartum depression ina predominately native American community uti-

lizing the Postpartum Depression Screening Scale(PDSS). The purpose of the present study is to ex-amine the prevalence of postpartum depression ina native American community utilizing cut-offs es-tablished by the Postpartum Depression ScreeningScale.

METHODS

Postpartum clients at an area health clinic withinRobeson County are screened by a clinic caseworkerat the 6-week postpartum visit utilizing the Postpar-tum Depression Screening Scale (PDSS) by Beckand Gable (10). Clients are screened as a part ofthe case management component of the HealthyStart Corps program (funded by U.S. Health Re-sources Service Administration). The Healthy StartCorps, housed at the University of North Carolina atPembroke in Southeastern North Carolina, providesfollow-up postpartum services for mothers with high-risk psychosocial issues. Clients are provided with thescreening instrument after completing an informedconsent outlining the possible risks and benefits ofscreening. Prior to implementation, procedures andforms required for screening received approval fromthe Institutional Review Board at the University ofNorth Carolina at Pembroke. Completed screeningforms are scored by the caseworker and transferredto the Healthy Start Corps worker for data storage,collection, and follow-up services when indicated.

SAMPLE CHARACTERISTICS

The subjects involved in this analysis include151 women, aged 16 to 40 years (M = 23.47, SD =9.95) receiving postpartum health services from a ru-ral obstetrical clinic from September 2002 to May2003. A convenience sample was obtained includingall women receiving postpartum services currentlyenrolled in the prenatal Baby Love program. Samplesize was pre-determined to include eight months ofscreening data. Pregnancies ranged from primigravi-das to multiparity of seven (M = 2.08, SD = 1.10).Women were more likely to have delivered vaginally(67.6%) than via Cesarean section (32.4%), and werealso more likely to be bottle-feeding (83.8%) than ex-clusively breast feeding (6.5%) or breast-bottle com-bination feeding (9.5%). Reflective of the racial andsocio-economic make-up of the County, 60.9% ofthe sample were American Indian (Lumbee tribe)(N = 92), 25.8% were African American, and 13.3%

Postpartum Depression 23

Caucasian or other. Furthermore, 80.7% (N = 121)had a high school education or less, 72.2% were sin-gle and 18.5% were married. While no data werecollected on financial status, this community is onethat struggles with issues of poverty and high ratesof unemployment, leading to overall lower socio-economic status of residents. Data on previous de-pression history indicates that 84.8% (N = 128) ofwomen reported no previous depression, with 91.4%of the total sample stating that they had never beentreated for depression.

INSTRUMENTATION

Three measures were considered for utilizationwith the population. The most widespread instru-ment to date for screening postpartum depression isthe Edinburgh Postnatal Depression Scale (EPDS)(14). While this scale has documented reliability incertain populations, some critics have raised con-cerns about the cultural specificity of the languageand the exclusion of certain diagnostic criteria for de-pression (10, 11, 12). The Beck Depression Inven-tory (BDI-II) (13) has been frequently used in lit-erature exploring postpartum depression, and eventhough it has well-documented reliability and valid-ity in measuring generalized depression, the languageis general, and not reflective of the postpartum pe-riod. Given the limitations of these two measures,a decision was made to utilize the Postpartum De-pression Screening Scale (PDSS) by Beck and Gable(2002). The PDSS is a 35-item self-report measurewhich can be completed within five to ten minutesby the respondent, and requires a third grade readinglevel. The instrument utilizes a seven-item short scaleto indicate whether or not the respondent needs tocomplete the full scale. In the present sample 31.8%(N = 48) of clients completed the full scale.

Higher scores on the PDSS indicate higher de-grees of depressive symptoms. Total scores are inter-preted using three cut-off scores indicating 1) normaladjustment, 2) significant symptoms of postpartumdepression, and 3) positive screening for major post-partum depression. The PDSS has previously estab-lished reliability and validity with internal consis-tency estimates yielding Cronbach’s coefficient alphaof 0.98 for total score, and content alphas of 0.80 to0.91 (10). In previous studies, analysis of convergentvalidity correlated scores of the PDSS with the EPDSand BDI-II showed the following: r = 0.79, p < .001,and r = 0.81, p < .001 respectively (10).

RESULTS

In order to obtain a description of sample char-acteristics such as age, parity, and race, means andpercentages were calculated. In exploring relation-ships between variables, the chi square statistic wasutilized with the Sommer’s d to explore strength ofsignificant relationships. For the purpose of analysis,the categories of significant symptoms and majorpostpartum depression were collapsed forming twocutoffs for score interpretation including normaladjustment and significant symptoms/postpartum de-pression. Chi square analysis revealed two variablesthat appeared to affect scores; history of depressionand history of being treated for depression. T-testswere conducted to further explore the relationshipbetween these variables. The Pearson product-moment correlation test was utilized to explorepossible correlation between the linear independentvariables of age, level of education, and number ofpregnancies.

The purpose of implementing routine screeningfor postpartum depression in this community was toexplore the prevalence of the disorder in a predomi-nately Native American population. The score rangefor the current sample is 7–173 (M = 32.76, SD =37.17). While most respondents (76.8%) scoredwithin the normal range, a high number scored withinthe range for significant symptoms of postpartum de-pression (10.6%), and 12.6% (N = 19) scored posi-tive for symptoms of major postpartum depression,yielding a combined prevalence rate of 23.2%.

There were no statistically significant resultsamong the two groups of normal adjustmentand significant symptoms/postpartum depression byrace χ2(3, N = 151) = 3.56, p = 0.313, marital sta-tus χ2(5, N = 116) = 6.51, p = 0.259, type of deliv-ery (vaginal or cesarean section) χ2(1, N = 148) =0.0, p = 0.991, or method of infant feeding χ2(2, N =148) = 0.31, p = 0.857. There was no significant cor-relation between the total score and the variablesof age r = −0.017, p = 0.837, highest level of educa-tion, r = −0.29, p = 0.728, and number of pregnan-cies r = −0.040, p = 0.630.

As reported previously in literature on post-partum depression, there were significant results onscores obtained through analysis of the effect ofhistory of depression and history of being treatedfor depression. For history of depression χ2(1, N =151) = 0.628, p = 0.012, with Sommer’s d = −0.201,p = 0.038, and history of treatment for depressionχ2(1, N = 151) = 4.22, p = 0.040, with Sommer’s

24 Baker, Cross, Greaver, Wei, Lewis, and Corps

d = 0.154, p = 0.104. In order to explore this ef-fect on total score means, t-tests were computed forthe two variables of history of depression and his-tory of treatment for depression and total scores.There were statistically significant differences be-tween the mean scores for those groups with a his-tory of depression (N = 23, M = 53.35) and thosewithout a history of depression (N = 128, M = 29.06)t(26.37, 151) = 2.38, p = 0.025 (equal variances notassumed by Levene’s Test for Equality of Variances).The differences also held for those with a history ofbeing treated for depression. Those who had a his-tory of being treated for depression had a mean to-tal score 31.74 points higher (M = 61.77) than thosewithout a history of being treated for depression(M = 30.03) and those differences were statisticallysignificant t(13.17, 151) = 2.28, p = .040.

DISCUSSION

The purpose of this study was to determine theprevalence of depressive symptoms that may requiresome form of clinical intervention, utilizing a currentscreening instrument that had not previously beenused with a predominately native American popu-lation. Although there is some minor variation, lit-erature supports an overall incidence of postpartumdepression between 10 and 15% in the general pop-ulation (1, 2, 15). In the present sample size, the in-cidence of symptoms of postpartum depression wasover 23%.

In support of previous literature on risk factors,our sample demonstrates a strong association be-tween symptoms of depression and history of depres-sion and being treated for depression (2). This infor-mation holds clinical importance as a way to targetinterventions towards women presenting with a pre-natal history of depression. These results also holdsociocultural significance given that the economic cli-mate of the study area is affected by high rates ofunemployment, significantly impacting the psychoso-cial functioning of family systems. Limitations of thisstudy include the lack of data on additional variablessuch as maternal health, use of illegal substances, to-bacco or alcohol use, or family dysfunctions that mayimpact psychosocial functioning. It is important tonote that the PDSS is a screening, not diagnostic,tool.

The findings highlight the importance of imple-menting routine screening protocols, thus enablingcommunities and health care professionals to address

the needs of individual patients and provide the nec-essary information to ensure follow-up services andsupport for a larger population. The PDSS proved tobe a useful instrument for use in this clinical setting.

ACKNOWLEDGMENTS

Research approved by the Healthy StartCORPS of Pembroke, North Carolina and theInstitutional Review Board at the University ofNorth Carolina at Pembroke. This project is fundedby the national Healthy Start Program, US Depart-ment of Health and Human Services, Maternal andChild Health Bureau. The authors state that thismanuscript represents original work that has notpreviously been published.

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