Race/ethnicity and perinatal depressed mood

Abstract

This study examined the extent to which race/ethnicity is a risk factor for depressed mood in late pregnancy and the early postpartum period apart from its relationship with other demographic and infant outcome variables. Data obtained from 26,877 women with newborns in Iowa indicate that 15.7% endorsed a single depression item. Logistic regression results indicate that race/ethnicity was a significant predictor of depressed mood, controlling for age, marital status, income and educational level, and infant health outcome. Compared to White women, African-American women were significantly more likely to report depressed mood (OR51.25, 95% CI51.03–1.52). Hispanic women were significantly less likely to report being depressed (OR50.74, 95% CI50.61–0.88). The role of social support in understanding these findings is explored.

Full text

BRIEF REPORT
Race/ethnicity and perinatal depressed mood
LISA S. SEGRE
Psychology Department, University of Iowa, Iowa, USA
MARY E. LOSCH
Department of Psychology and Center for Social and Behavioral Research, University of Northern
Iowa, Iowa, USA
MICHAEL W. O’HARA
Psychology Department, University of Iowa, Iowa, USA
Abstract This study examined the extent to which race/ethnicity is a risk factor for
depressed mood in late pregnancy and the early postpartum period apart from its relationship
with other demographic and infant outcome variables. Data obtained from 26,877 women
with newborns in Iowa indicate that 15.7% endorsed a single depression item. Logistic
regression results indicate that race/ethnicity was a significant predictor of depressed mood,
controlling for age, marital status, income and educational level, and infant health outcome.
Compared to White women, African-American women were significantly more likely to report
depressed mood (OR51.25, 95% CI51.03–1.52). Hispanic women were significantly less
likely to report being depressed (OR50.74, 95% CI50.61–0.88). The role of social support in
understanding these findings is explored.
Introduction
Although the prevalence of perinatal depression in the general population is well-
established (Gaynes et al., 2005; O’Hara & Swain, 1996), the question of whether this
disorder differentially affects women from specific racial or ethnic groups remains open.
The significant negative effects of maternal depressed mood on children (Gelfand & Teti,
1990; Murray et al., 1996) underscores the importance of identifying at-risk mothers.
Address for correspondence: Lisa S. Segre, Department of Psychology, University of Iowa, Iowa City, IA 52246,
USA. Tel: +1 319 335 2442; Fax: +1 319 335 0191; Email: lisa-segre@uiowa.edu
Received: 14 July 2005. Accepted: 2 December 2005.
JOURNAL OF REPRODUCTIVE AND INFANT PSYCHOLOGY,
VOL. 24, NO. 2, MAY 2006, pp. 99–106
ISSN 0264-6838/print/ISSN 1469-672X/online/06/020099-08
#
2006 Society for Reproductive and Infant Psychology
DOI: 10.1080/02646830600643908

Available research is uninformative because race/ethnicity is either confounded with
other demographic characteristics (Logsdon & Usui, 2001; Yonkers et al., 2001; Zayas
et al., 2003) or the studies are limited to lower income women (Hobfoll et al., 1995; Ritter
et al., 2000). The two studies with adequate samples report conflicting results. Although
Gross et al. (2002) found nonsignificant differences among racial groups, the stringent
depression classification criteria may have obscured significant results. Given the strong
bivariate trend (11.6% of African-American women versus 5% of White women were
classified as depressed); race may have been a significant risk factor using a less
conservative depression classification. In contrast, Howell et al. (2005) found significantly
increased risk of depression in African-American (OR52.16) and Hispanic (OR51.89)
women relative to White women, controlling for major demographic differences.
The present study capitalized on the availability of a large, economically
heterogeneous and demographically representative sample to examine the relationship
between race/ethnicity and self reported depressed-mood during a period encompass-
ing late pregnancy and the early postpartum period. As in Gross et al. (2002) and
Howell et al. (2005), the mood assessment was brief: one item assessing the core
symptom of depressed mood.
Method
Participants
Data for this study were collected as part of the Iowa Barriers to Prenatal Care Project,
a cooperative venture among all of Iowa’s maternity hospitals, the Statewide Perinatal
Program, and the Iowa Department of Public Health. Participants were 32,495 English
speaking women with newborns who gave birth in one of Iowa’s maternity hospitals
and who completed the Barriers surveillance questionnaire in 2001 and 2002.
Measure
Depressed mood. The Barriers questionnaire assessed a broad range of health indicators
and required approximately 10 minutes to complete. Women were identified as
‘depressed’ if they positively endorsed the item: ‘have you felt sad or miserable much of
the time over the past two weeks’. This item assesses two critical features of syndromal
depression: the core symptom of sad mood and duration of at least two weeks.
Demographics. Women provided the following demographic information: race/ethnicity
(by choosing White, Black, American Indian/Native Alaskan, Hispanic, or Asian/
Pacific Islander), educational level, total family income, marital status, and age. Two
indices of birth outcome were obtained: birth weight and whether the infant left the
hospital with the mother.
Procedure
The study procedure and questionnaire were approved by the University of Northern
Iowa’s Institutional Review Board. The questionnaire was distributed to all maternity
hospitals in Iowa (N598). Informed consent was obtained from all subjects. Except in
the case of a mother who was too ill to complete the questionnaire, the hospital staff
member in charge of obtaining birth certificate information invited all women with
100 L. S. SEGRE ET AL.

newborns to participate. The questionnaire was completed in the hospital approxi-
mately 24 hours after delivery. Women with Cesarean deliveries completed it
approximately 2 days post-delivery.
Statistical analyses
SPSS (2003) was used to examine the overall return rate, the demographic
characteristics of the sample, the prevalence of depressed mood overall, and the
prevalence of depressed mood by each demographic characteristic. Hierarchical logistic
regression was used to assess whether race/ethnicity was independently associated with
the endorsement of the single depression item.
Results
The response rate (questionnaires returned/total births in the state) for 2001 and 2002
was 43%, or 32,495 completed questionnaires. The Barriers sample closely matched
the overall statewide profile of births (Iowa Department of Public Health, 2001, 2002).
This report is based on a reduced sample of 26,877 cases with complete data for two
reasons. Some respondents did not identify their race/ethnicity. The Spanish
translation of the questionnaire did not include the depression item. Therefore the
181 Hispanic women who completed the Spanish version of the questionnaire
(representing 12% of the Hispanic participants) did not complete this item. As
indicated in Table 1, women who provided complete data were slightly more likely to
Table 1. Percentage of women with complete and missing data within each demographic category.
Percentage of women with
complete data (N526,877)
Percentage of women with
missing data (N53803)
Age
,20 8.9 11.2
20–30 66.6 63.6
31–35 19.2 16.8
.35 7.6 8.5
Race/Ethnicity
White 91.2 88.5
Black 2.2 2.5
Asian/Pacific Islander 1.6 1.9
American Indian/Native Alaskan 1.4 1.3
Hispanic 5.7 3.7
Income
,$10,000 12.7 15.4
$10,000–$19,000 12.0 13.0
$20,000–$29,000 12.8 12.8
$30,000–$39,000 14.2 13.9
$40,000–$49,000 13.6 13.1
$50,000+ 34.8 31.8
Education
,HS 11.2 14.6
High School 25.6 27.2
Some College 35.1 33.7
Bachelor’s Degree 22.1 19.5
Graduate or Professional Degree 5.9 5.0
RACE/ETHNICITY AND PERINATAL DEPRESSED MOOD 101

be older, White, and with higher income and educational levels. However, these
differences were modest in magnitude.
Overall, 15.7% of the women responded ‘yes’ to the single depression item. The
positive endorsement rate within each demographic characteristic and infant health
category is provided in Table 2. Positive endorsement rates of the single depression
item were highest for those 19 years or younger, those with few economic resources,
those who had not completed high school, the unmarried, and mothers who left the
hospital without their infant or who had infants that weighed less than five pounds.
African-American women and American Indian/Native Alaskan women were more
likely to endorse the single depression item compared to White women.
Hierarchical logistic regression analysis was used to determine the relationship
between race/ethnicity and the endorsement of the single depression item, controlling
Table 2. Percentage of women endorsing the single depression item within categories of demographic and child
outcome variables.
Percent
Age
,18 20.5
18–19 21.9
20–25 18.5
26–30 14.6
31–35 13.3
.35 13.3
Race/Ethnicity
White 15.5
Black 25.2
Asian/Pacific Islander 11.5
American Indian/Native Alaskan 22.9
Hispanic 15.3
Income
,$10,000 24.3
$10,000–$19,000 20.0
$20,000–$29,000 18.8
$30,000–$39,000 15.3
$40,000–$49,000 13.7
$50,000+ 10.8
Education
,HS 22.2
High School 20.1
Some College 15.6
Bachelor’s Degree 9.5
Graduate or Professional Degree 5.9
Marital status
Married 13.3
Not Married 21.6
Baby going home with mother
Yes 15.3
No 21.8
Baby’s weight
,2268 g 19.1
2268–3175 g 17.3
.3175 g 15.4
102 L. S. SEGRE ET AL.

for other demographic and infant health outcome variables. Income, educational level,
marital status, age, and the infant health status variables were entered into the
regression equation as well as race/ethnicity. The full model is shown in Table 3. The
results reveal several significant risk factors for endorsing the single depression item:
less than college education, having an annual income below $30,000, being single, not
having the infant go home with the mother, and being African-American. In contrast,
Hispanic women were significantly less likely than White women to endorse the
depression item, while endorsement rates for Native American/Alaskan and Asian
women did not significantly differ from that of White women. Neither age nor infant
birth-weight was a significant predictor of positively endorsing this item.
Discussion
African-American and Native American women reported much more depression than
White, Hispanic, and Asian women. When important social factors such as age,
income, education, marital status, and baby’s health were controlled in a logistic
regression, African-American women still emerged with significantly increased risk for
reporting depressed mood in late pregnancy and the early postpartum period. Given
that, in 2003, African-Americans accounted for nearly 600,000 of the approximately
four million births in the United States (Henry J. Kaiser Family Foundation, 2003), an
Table 3. Logistic regression results (full model): coefficients (C), odds ratios (OR), and confidence intervals (CI)
for demographic and infant health outcome variables as predictors of endorsement of a single depression item.
CORCI
Age 0.04 1.04 1.00–1.08
Education
,HS 0.72*** 2.40 1.78–2.35
High School 0.66*** 1.92 1.72–2.14
Some College 0.43*** 1.54 1.39–1.70
College Graduate
Income
,$10,000 0.48*** 1.54 1.36–1.75
$10,000–$19,000 0.29*** 1.33 1.18–1.50
$20,000–$29,000 0.31*** 1.36 1.21–1.52
$30,000–$39,000 0.14 1.15 1.02–1.28
$40,000–$49,000 0.08 1.08 0.96–1.21
$50,000+
Married –1.9*** 0.82 0.75–0.90
Baby not going home 0.45*** 1.56 1.37–1.79
Baby weight
,2268 g –0.10 0.90 0.72–1.13
2268–3175 g –0.02 0.982 0.91–1.05
.3175 g
Race/Ethnicity
Asian Pacific Islander –0.28 0.75 0.56–1.00
Black 0.23** 1.25 1.03–1.52
American Indian Native Alaskan 0.08 1.08 0.83–1.40
Hispanic –0.30*** 0.74 0.61–0.88
White
*P(0.05; **P(0.01; ***P(0.001.
RACE/ETHNICITY AND PERINATAL DEPRESSED MOOD 103

adjusted odds ratio of 1.25 means that an additional nearly 20,000 cases of depression
are solely attributed to ethnicity. Because African-American women often do not seek
treatment for depression (Alvidrez, 1999), these women, their partners, and children
are at special risk for the ill effects of maternal depression. In contrast to the case for
African-American women and consistent with the Hispanic Paradox (Farley et al., 2005;
Markides & Coreil, 1986), Hispanic women were at significantly decreased risk for
reporting depressed mood after adjusting for the study covariates.
What might account for the difference in risk for postpartum depression mood
between African-American and Hispanic women? Social support emerges as a potential
explanatory variable. It is negatively correlated with maternal depression (Dunkel-
Schetter et al., 1996) in all ethnic groups (Howell et al., 2005). Having a supportive
partner, which appears to be particularly protective (O’Hara, 1986), also varies by
racial/ethnic group, with Hispanic women reporting the highest levels of partner
support followed by White and then African-American women, who report very low
levels of emotional support from the baby’s father (Dunkel-Schetter et al., 1996).
Hispanic women often have additional social support, particularly in their roles as
mothers. La familia, or the centrality of family, is well documented in the Hispanic
immigrant culture (Callister & Birkhead, 2002). In stark contrast, African-American
women endure the dual vulnerability of having significant less partner support and
more stressful lives than White and Hispanic women (Jackson-Triche et al., 2000),
perhaps accounting for their increased risk.
There were several limitations with the current study. First, since the data did not
permit separating White from Black Hispanics, race and ethnicity are confounded for
Hispanic women. Second, while being Hispanic was a protective factor in the current
study, it was a risk factor in the study by Howell et al. (2005). The samples of these two
studies likely differed both in terms of amount of acculturation and country of origin.
Those in the Howell et al. (2005) study were from New York and therefore were
primarily from Puerto Rico (Markides & Coreil, 1986), while the current sample is
primarily from Mexico. To clarify the relationship of Hispanic ethnicity to maternal
depressed mood, future research needs to account for birthplace and level of
acculturation/recency of immigration as these factors are known to affect mental
health outcome (Callister & Birkhead, 2002).
Finally, the one-item assessment of depressed mood limits conclusions about the
relationship of ethnicity to clinically significant maternal depression. However, given the
large sample of the present study and the comprehensive control for potential
confounding variables, there is little reason to believe that the present results would not
be replicated. Additionally, our findings of a significant correlation between single
depression items and total scores on both the Beck Depression Inventory (Beck et al.,
1961) and the Edinburgh Postnatal Depression Scale (Cox et al., 1987), 0.65 and 0.71,
respectively, suggests that a single depression item may be a robust substitute for the
entire scale (O’Hara & Stuart, 2005). Future research needs to replicate the findings of
the current study using more sophisticated depression assessments and/or by following-
up women who positively endorse a single screening item to determine its clinical
significance.
Ultimately, the current findings as well as those reported by Howell et al. (2005),
suggest that there are significant racial/ethnic disparities to be addressed with mental
health care in the immediate postpartum period. In the same way that African-
American babies are handicapped by relatively high rates of low birth weight and
104 L. S. SEGRE ET AL.

premature delivery (Hamilton et al., 2003), they may also be handicapped by relatively
high rates of exposure to maternal depression. In an effort to mitigate these potentially
negative impacts on our next generation of African-American youth, programs such as
the U.S. National Healthy Start Initiative have already incorporated perinatal
depression screening and referral programs into their current case management
protocols (Segre & O’Hara, 2005). Interventions aimed at strengthening protective
social factors and decreasing social risk factors may be especially useful in the care of
African-American women. Our findings suggest that these efforts are well placed and
should be continued.
Acknowledgements
The Iowa Barriers to Prenatal Care Project is funded by the Iowa Department of Public
Health. The views expressed in this manuscript do not necessarily reflect those of the
Department of Public Health or the State of Iowa. This work was also supported by
grant MH59668 from the National Institute of Mental Health, Bethesda, MD (Scott
Stuart, M.D.). The authors would like to thank Charles Lynch, M.D. Ph.D. and
Stephan Arndt Ph.D. for their help with the preparation of this manuscript. Portions of
the data reported here were presented at the 2nd World Congress on Women’s Mental
Health (March 17–20, 2004) in Washington, DC. An extended version of this report is
available upon request.
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