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HOW MUCH DOES LOW SOCIOECONOMIC STATUS INCREASE
THE RISK OF PRENATAL AND POSTPARTUM DEPRESSIVE
SYMPTOMS IN FIRST-TIME MOTHERS?
Deepika Goyal, PhD, RN, FNP
a,
*, Caryl Gay, PhD
b
, and Kathryn A. Lee, RN, PhD, FAAN
b
a
California State University, San Jose, School of Nursing, San Jose, California
b
University of California, San Francisco, Department of Family Health Care Nursing, San Francisco, California
Received 27 January 2009; revised 10 November 2009; accepted 11 November 2009
Objective. To examine socioeconomic status (SES) as a risk factor for depressive symptoms in
late pregnancy and the early postpartum period. A secondary objective was to determine
whether SES was a specific risk factor for elevated postpartum depressive symptoms beyond
its contribution to prenatal depressive symptoms.
Design. Quantitative, secondary analysis, repeated measures, descriptive design.
Setting. Participants were recruited from paid childbirth classes serving upper middle class
women and Medicaid-funded hospitals serving low-income clients in Northern California.
Participants. A sample of 198 first-time mothers was assessed for depressive symptoms in their
third trimester of pregnancy and at 1, 2, and 3 months postpartum.
Main Outcome Measure. Depressive symptoms were measured with the Center for Epidemio-
logical Studies-Depression (CES-D) Scale.
Results. Low SES was associated with increased depressive symptoms in late pregnancy and at
2 and 3 months, but not at 1 month postpartum. Women with four SES risk factors (low monthly
income, less than a college education, unmarried, unemployed) were 11 times more likely than
women with no SES risk factors to have clinically elevated depression scores at 3 months post-
partum, even after controlling for the level of prenatal depressive symptoms.
Conclusion. Although new mothers from all SES strata are at risk for postpartum depression,
SES factors including low education, low income, being unmarried, and being unemployed
increased the risk of developing postpartum depressive symptoms in this sample.
Introduction
Research suggests that women are more likely than
men to develop a major affective mood disorder in
their lifetime (Burt & Stein, 2002). Moreover, the risk of
developing a depressive disorder increases substan-
tially during the prenatal and postpartum period
(Burt & Stein, 2002). This is understandable given
the adaptation and transition from pregnancy and
postpartum to motherhood. Meleis and Trangenstein’s
(1994) transition theory describes the addition of a new
family member as a situational transition that causes
multiple changes within the family. One of the major
changes includes redefinition of each person’s role
within the family, for example, the nonparental to
parental role. The transition and role change can be
especially difficult for the first-time mother, who may
have little or no past experience to draw upon.
Postpartum affective mood disorders are well docu-
mented in the literature and affect women worldwide.
The three postpartum affective mood disorders most
often discussed in the literature include the blues, post-
partum depression (PPD), and postpartum psychosis.
Of the three postpartum mood disorders, blues is the
most common and affects between 26% and 85% of
This research was supported by NIH/NINR, Grant # 1 RO1
NR045345 and a doctoral fellowship from the Betty & Gordon Moore
Foundation.
* Correspondence to: Deepika Goyal, RN, PhD, FNP, San Jose
State University School of Nursing, One Washington Square, San
Jose, CA 95192. Phone: 408-924-3149; fax: 408-924-3135.
E-mail: dgoyal@son.sjsu.edu.
Copyright Ó2010 by the Jacobs Institute of Women’s Health. 1049-3867/10 $-See front matter.
Published by Elsevier Inc. doi:10.1016/j.whi.2009.11.003
www.whijournal.com
Women’s Health Issues 20 (2010) 96–104
all postpartum women (Altshuler et al, 2001; Beck,
Reynolds, & Rutowski, 1992). Presenting within the
first few days postpartum, the blues are transitory in
nature and treatment is rarely needed. Postpartum
psychosis is the most uncommon but most severe of
the three postpartum mood disorders and requires im-
mediate hospitalization and inpatient treatment.
Symptoms can present within the first 48 to 72 hours
after giving birth and include agitation, pressured
speech, hallucinations, delusions, inability to sleep,
and confusion (Gale & Harlow, 2003; Sichel, 2000).
As with the postpartum blues, the prevalence rate of
PPD differs greatly across studies, ranging from 4.5%
to 28% (Scottish Intercollegiate Guidelines Network,
2007). This variation is due in part to the differences
in sample race/ethnicity, demographics, data collec-
tion points, and method of measuring depressive
symptoms. The Diagnostic and Statistical Manual of
Mental Disorders 4th Edition (DSM-IV;American Psy-
chiatric Association, 1994) defines PPD as a constella-
tion of specific symptoms occurring in the first few
weeks postpartum. The temporal boundaries of PPD
are still under debate; however, experts define PPD
as the onset of a depressive episode between 2 weeks
and 12 months after giving birth (O’Hara & Swain,
1996; Sichel & Driscoll, 2002; The Marce
´Society,
2006). Timely diagnosis and treatment for PPD is es-
sential because symptoms can lead to poor maternal–
infant bonding and disrupt the infant’s own emotional
and cognitive development if left untreated (Beck,
1995, 1998; Edhborg, Lundh, Seimyr, & Widstrom,
2001; Field, Healy, Goldstein, & Guthertz, 1990; Grace,
Evindar, & Stewart, 2003; Murray, 1992). Other detri-
mental effects of untreated PPD include poor social
relationships and interpersonal interactions, sub-
stance abuse, infanticide, and suicide (Kelly, Zatzick,
& Anders, 2001; Lindgren, 2001; Spinelli, 2004).
Risk factors identified in the development of PPD
include hormonal changes, antenatal depression, lack
of social support, marital status, child care stress, ado-
lescent pregnancy, poor relationship satisfaction, infant
temperament, and low self-esteem (Beck, 1996, 2001;
Goyal, Gay, & Lee, 2009; Hendrick, Altshuler, & Suri,
1998; Logsdon & Usui, 2001; McGrath, Records,
& Rice, 2008; Studd & Panay, 2004). Low socioeconomic
status (SES) is often associated with lack of social sup-
port, low self-esteem, younger age, and absence of
spousal financial and social support (Beck, 1996, 2001;
Hendrick et al., 1998; Logsdon & Usui, 2001; McGrath
et al., 2008; Studd & Panay, 2004). These risk factors
are biopsychosocial in nature and the complexities of
their interactions require a framework to better explore
these factors and their contribution to the stress of tran-
sitioning to a maternal role and identity for the first-
time mother (Goyal, 2007; Goyal et al., 2009)
Although biological changes after childbirth are the
same to some degree for all women, SES is unique for
each new mother and her family. The birth of a child
can be joyful, demanding, and stressful for all parents
(Muslow, Caldera, Pursley, Reifman, & Huston, 2002).
How a new mother copes with the challenges of moth-
erhood is also very individual and can be addressed
within Lazarus and Folkman’s (1984) theory of stress,
appraisal, and coping. This theory considers an indi-
vidual’s efforts to manage stressors that are taxing or
potentially exceeding their resources. Women with
low SES are at greater risk of developing both antenatal
depression and PPD (Beeber & Miles, 2003; Beeghly
et al., 2003; Rich-Edwards et al., 2006). Furthermore,
women with lower incomes are less likely to have ad-
equate access to mental health services and are least
likely to report symptoms of depression to health
care professionals (Kimerling & Baumrind, 2005;
Song, Sands, & Wong, 2004).
Few researchers specifically set out to determine
how demographic factors such as income, education,
and age correlate with postpartum mood disorders.
Even fewer studies have compared affluent and low-
income women longitudinally from the prenatal
period through 3 months postpartum. Therefore, the
overall purpose of this study was to examine SES as
a risk factor for depressive symptoms among women
in late pregnancy through their third month postpar-
tum. A secondary objective was to determine which
of the four components of SES (income, marital status,
education level, employment) was a specific risk factor
for elevated postpartum depressive symptoms beyond
their initial contribution to prenatal depression.
Literature Review
The research evidence for a relationship between SES
and depressive symptoms during the childbearing
period is conflicting. Some studies suggest that low
SES contributes to the development of PPD and that
a higher SES is protective against PPD, whereas others
report that low SES has very little influence on the de-
velopment of PPD. A recent report compiled by the
Center for Health Statistics (2008) estimated that 1 in
5 women would suffer from PPD in her lifetime, with
the risk magnified in younger, less educated, low-
income women, who were recipients of Medicaid.
Low income and low occupational prestige were sig-
nificant predictors of PPD in a logistic regression anal-
ysis to determine the specific role of social status in the
development of PPD (Segre, O’Hara, Arndt, & Stuart,
2007). Severity of depressive symptoms was assessed
in a cross-sectional sample of 4,332 postpartum women
at an average of 4.6 months postpartum. Twelve per-
cent of the women screened positive for PPD, with
a higher prevalence in unmarried, younger, multipa-
rous women with low income and in those without
a college education (Segre et al., 2007).
Mayberry, Horowitz, and Declercq (2007) studied
more than 1,300 primiparous and multiparous
D. Goyal et al. / Women’s Health Issues 20 (2010) 96–104 97
American women who had all delivered a healthy
infant. Depressive symptoms were assessed at 6-
month intervals (0–6, 7–12, 13–18, and 19–24 months)
and their results suggest that younger, unemployed,
low-income, less educated, multiparous women were
at an increased risk for developing PPD. Moreover,
the severity and duration of depressive symptoms
decreased at higher income levels. A second study
conducted by Rich-Edwards et al. (2006) assessed de-
pressive symptoms mid-pregnancy and again at 6
months postpartum in more than 1,600 women. Re-
sults suggested younger maternal age, lack of a partner,
lower income, and financial hardship were factors as-
sociated with both prenatal and postpartum depres-
sive symptoms. In a meta-analysis that included 84
studies and approximately 3,000 participants Beck
(2001) noted that SES and marital status were addi-
tional predictors of PPD that were not apparent in
her earlier study (Beck, 1996).
Several longitudinal studies have also reported asso-
ciations between low SES and PPD. Beeghly et al.
(2003) assessed depressive symptoms (Center for Epi-
demiological Studies-Depression scale [CES-D]) and
sociodemographic risk profiles in 163 African-Ameri-
can women at 2, 3, 6, 12, and 18 months postpartum.
Among other results, single marital status and low-
income status were significantly related to higher
CES-D scores by women at all assessment periods.
Seguin, Potvin, St-Denis, and Loiselle (1999a) assessed
depressive symptoms in 68 first-time mothers with low
income. A relationship between several stressful life
conditions, including a lack of money and elevated
postpartum depressive symptoms, was noted in first-
time mothers at 6 months postpartum. Moreover,
32% were still reporting elevated depressive symp-
toms at 6 months postpartum. Other research by
Seguin, Potvin, St-Denis, and Loiselle (1999b) com-
pared socioenvironmental factors and postpartum de-
pressive symptoms in 80 low SES and 36 high SES
mothers from 3 to 9 weeks postpartum. Results sug-
gested no difference in depressive symptoms at 3
weeks postpartum. However, at 9 weeks postpartum,
the low SES mothers’ depression scores were elevated
when compared with mothers of higher SES. Hobfoll,
and Ritter, Lavin, Hulsizer, and Cameron (1995) inter-
viewed impoverished, inner-city women twice during
pregnancy (second and third trimester) and at 7 to 9
weeks after birth. The high rate of PPD (23%) was dou-
ble that of middle-class samples, suggesting SES may
be associated with PPD.
In contrast, other researchers have reported that low
SES has very little influence on the development of
PPD. Adewuya, Fatoye, Ola, Ijaodola, and Ibigbami
(2005) found no difference between depressed and
non-depressed Nigerian mothers with regard to
their level of education or SES. Given that all of the
women in the sample were of low SES, this may be
a nonsignificant finding. However, unmarried status
was a predictor of PPD (odds ratio, 3.44; 95% confi-
dence interval, 2.15–5.53). Ross, Campbell, Dennis,
and Blackmore (2006) noted in their meta-analysis
that sociodemographic data are often not reported, or
are adjusted and controlled statistically, thereby
limiting the external validity of the results. Their
meta-analysis included 143 studies with a total of
51,453 women to identify demographic characteristics
of participants in studies of risk factors, treatment, or
prevention of PPD. They reached two conclusions: 1)
most (83%) studies were conducted in Western socie-
ties with a higher percentage of older, white, partnered
women of higher SES; and 2) the proportion of partic-
ipants for whom demographic variables were reported
(maternal age, ethnicity, relationship status, SES)
varied between 18% and 92% (Ross et al., 2006).
Even with the differences in research findings, there
is strong evidence to suggest that women of low SES
have higher risk of developing PPD. Moreover, very
few studies have compared PPD prevalence rates in
low- and high-income primiparas when controlling
for parity and partner status. The current study de-
scribes the relationship of SES to depressive symptoms
during the transition to motherhood for first-time
mothers in partnered relationships. A second objective
was to determine which components of SES are specific
risk factors for PPD beyond the contribution to prena-
tal depression.
Methods
Study Design and Sample
As part of a longitudinal, randomized, clinical trial to
improve parents’ sleep in the first postpartum month,
198 expectant mothers were recruited from childbirth
education classes and prenatal clinics. Eligible mothers
included partnered women expecting their first child,
who were at least 18 years of age, willing to participate,
and able to read and write English. Informed consent
was obtained from each participant, and all women
were paid for their participation. This study was
approved by the institution’s Committee on Human
Research.
Procedure
Women were studied in their homes during their last
month of pregnancy and at 1, 2, and 3 months postpar-
tum. Mothers randomly assigned to the intervention
group (n¼117) were given strategies to improve their
postpartum sleep, and mothers assigned to the control
group (n¼81) were given comparable attention from
the research team in the form of information on how
to eat a healthy diet. Although there was no group dif-
ference on any depression measure, group assignment
was included as a covariate in all multivariate
analyses.
D. Goyal et al. / Women’s Health Issues 20 (2010) 96–10498
Measures
Sociodemographic measures. During their third trimester,
participants were asked to provide information regard-
ing age, race, ethnicity, education, employment, and
household income. Income was reported as an estimate
of either monthly or annual household income. Postpar-
tum information included type of delivery (cesarean or
vaginal), infant gender, and maternal work status.
Depressive symptoms. The CES-D scale is widely used to
screen for depressive symptoms in the general popula-
tion and in women before and after childbirth (Radloff,
1977). The instructions ask respondents to think about
the past week and check the response that best
describes how often they felt or behaved this way.
Responses range from 0 (rarely/none or ,1day)to3
(most/all the time or 5–7 days). To account for re-
sponse bias, four items are positive feelings that are re-
verse coded. The total score ranges between 0 and 60,
with a higher score representing more frequent depres-
sive symptoms. A score of 16 or higher is suggested as
a risk factor for depressive illness and need for clinical
evaluation (Radloff, 1977). For the purpose of this anal-
ysis, this cutoff was used as an indicator of prenatal or
postpartum ‘‘depression risk.’’ The CES-D was admin-
istered at each of the four assessments. The CES-D has
been found to have adequate sensitivity to detect major
depression and good internal consistency and test–
retest reliability in postpartum first-time mothers
(Beeghly et al., 2002; Beeghly et al., 2003). In the current
sample, the Cronbach alpha coefficient was .86 in the
third trimester and .85 at 3 months postpartum.
Although the CES-D has strong psychometric proper-
ties and provides a reliable estimate of depressive
symptom severity, it is important to note that a score
of 16 or above is not the equivalent of a PPD diagnosis.
Data Analysis
The sample was split into two groups based on
monthly household income (,$3,000 and $3,000).
This cutoff corresponds to approximately 200% of the
Federal Poverty Level for 3-person families at the
time the data were collected and to 50% of the median
household income in San Francisco. This income level
is somewhat higher than that used in other studies but
takes into account the relatively high cost of living
in the San Francisco Bay Area. Descriptive statistics
were used to describe sample characteristics, and inde-
pendent t-tests and chi-square tests were used to iden-
tify group differences on continuous and categorical
outcomes, respectively. Repeated measures analysis
of variance was used to evaluate the pattern of CES-D
scores over time among women in higher and lower
income groups, controlling for group assignment. A
square-root transformation was used to normalize
CES-D scores and meet the homogeneity of variance
assumption for analysis. Logistic regression was used
to determine the unique contribution of SES factors
(income, marital status, education level, employment)
to postpartum depressive symptoms after controlling
for prenatal depressive symptoms and randomized
group assignment. Analyses were conducted using
SPSS 14.0 (SPSS, Inc, Chicago, IL) and all tests used
a significance level of .05 and 95% confidence interval.
Results
Sample Characteristics
Of the 304 women enrolled in the larger study, 27 were
excluded from the analysis because they did not have
a partner, 44 were excluded because of missing prena-
tal or postpartum CES-D data, and 18 women were
excluded owing to incomplete income data. An addi-
tional 17 women were excluded because of a history
of mood disorder before pregnancy; this analysis
focused on prenatal and postpartum depressive symp-
toms and not chronic depression. Sample characteris-
tics and descriptive data for the 198 women in the
final sample are presented in Table 1. Most participants
reported their household income as being within
a given range (e.g., ,$1,000 per month or $60,000–
$74,999 per year) rather than as an exact figure. The
median annual income category was $45,000 to
$59,999, and annual household incomes ranged from
below $12,000 to higher than $150,000. On average,
those with monthly household incomes less than
$3,000 were significantly younger and more ethnically
diverse than those with higher incomes. Women in the
lower income group also tended to live in larger house-
holds and were less likely to be college educated, mar-
ried, or employed. The income groups had similar
cesarean delivery rates and a comparable proportion
of the women in each group had returned to work by
3 months postpartum. Prenatal data were collected
a mean of 3.2 61.5 weeks before delivery and postpar-
tum data were collected 3.2 61.4 , 7.8 61.4 , and 12.1 6
1.4 weeks after delivery.
Depressive Symptoms by Income Group
Table 2 illustrates that lower income was associated
with higher depression risk, but the increased risk
was not consistent over time. The lower income group
reported significantly more depressive symptoms than
the higher income group prenatally, but at 1month
postpartum, the two groups reported similar levels of
depressive symptoms. At 2 and 3 months, the lower in-
come group was again reporting more depressive
symptoms than the higher income group.
The pattern of depressive symptoms over time for
both income groups is illustrated in Figure 1. Although
depressive symptoms generally improved from the
prenatal assessment to the third month postpartum
and the lower income group generally reported more
D. Goyal et al. / Women’s Health Issues 20 (2010) 96–104 99
depressive symptoms than the higher income group,
the pattern over time differed for the two groups.
The lower income group improved relatively steadily,
whereas the higher income group had an increase in
symptoms at one month postpartum before their
symptoms began to improve. A repeated measures
analysis of variance controlling for group assignment
indicated main effects for time (F[3,192] ¼16.95; p,
.001; partial eta squared ¼.21) and income (F[1,194] ¼
6.93; p¼.009; partial eta squared ¼.03), reflecting
the general trends for depressive symptoms to
improve over time and for the low-income group to
report more depressive symptoms than the
high-income group. However, a significant time-by-in-
come interaction effect (F[3,192] ¼2.76; p¼.044; partial
eta squared ¼.04) indicated that the pattern of depres-
sive symptoms over time differed for the two income
groups and that the effect of income varied over
time. The randomized group assignment (control or
intervention) main and interaction effects were not
significant.
The Influence of Prenatal Depression Risk
Given that a history of prenatal depression has been
shown to be a strong predictor of PPD (Beck, 1996,
2001; Logsdon & Usui, 2001), the frequency of elevated
postpartum depressive symptom scores was calcu-
lated separately for women with low and high prenatal
CES-D scores. As illustrated in Figure 2, women with
high prenatal depression risk (CES-D 16) were
more likely than those with low prenatal depression
risk to have elevated depression scores at 1, 2, and 3
months postpartum (c
2
[1] ¼19.9 to 32.5; all p,.001).
Table 1. Sample Demographic Characteristics by Income Group (n¼198)
Variable Low Income
y
(n¼81) High Income
z
(n¼117) Statistic
Age 26.3 66.0 32.6 64.2 t(132) ¼8.77***
Race/ethnicity c
2
(4) ¼36.56***
Black/African-American 11% 2% c
2
(1) ¼8.06**
Hispanic/Latina 22% 7% c
2
(1) ¼9.93**
Asian 36% 21% c
2
(1) ¼5.71*
White/Caucasian 23% 63% c
2
(1) ¼30.43***
Mixed or other race 7% 8% NS
Marital status (all partnered) 32% 87% c
2
(1) ¼63.54***
College graduate 30% 89% c
2
(1) ¼73.54***
Household size 3.9 62.8 2.2 60.5 t(184
x
)¼6.46***
Initial employment rate
{
28% 80% c
2
(1) ¼53.43***
Working 3 mos postpartum 16% 21% NS
Cesarean birth rate 32% 27% NS
y
Low income ¼monthly household income ,$3,000.
z
High income ¼monthly household income $3,000.
x
Separate variance t-test, degrees of freedom adjusted for unequal variances.
{
Employment rate includes employed women on maternity leave.
*p,.05.
** p,.01.
*** p,.001.
Table 2. Prenatal and Postpartum Depression Scores and Risk by
Income Group (n¼198)
Variable
Lower
Income
y
(n¼81)
Higher
Income
z
(n¼117) Statistic
Mean CES-D scores
x
Prenatal 14.1 68.3 10.6 68.0 F(1,194) ¼10.70**
1 month postpartum 12.8 68.8 12.4 66.6 NS
2 months postpartum 10.6 67.0 8.5 67.1 F(1,194) ¼3.96*
3 months postpartum 10.9 67.5 8.0 67.2 F(1,194) ¼7.54**
Risk for depression
{
Prenatal 35% 17% c
2
(1) ¼7.96**
1 month postpartum 28% 29% NS
2 months postpartum 21% 12% NS
3 months postpartum 25% 9% c
2
(1) ¼8.47**
y
Lower income ¼monthly household income ,$3,000.
z
Higher income $3,000.
x
Analyses control for the nonsignificant effect of group assignment.
{
Percentage of CES-D scores 16.
*p,.05.
** p,.01.
0
4
8
12
16
Pregnancy 1mo PP 2mo PP 3mo PP
Time
Depressive Symptoms
(CES-D score)
Low income group
High income group
Cut-off for depression risk
Figure 1. Depressive symptoms over time by income group
(n¼198).
D. Goyal et al. / Women’s Health Issues 20 (2010) 96–104100
Regression Models to Predict PPD Risk
Because the previous analyses indicated that prenatal
and postpartum depressive symptom risk were
strongly associated and that both were associated with
income, logistic regression analyses were conducted to
determine whether low income was a specific risk factor
for postpartum depressive symptoms beyond its contri-
bution to prenatal depressive symptoms. Separate
models were evaluated for predicting depression risk
(CES-D 16) at 1, 2, and 3 months postpartum. Income
group was included in each model, while controlling for
prenatal depression risk and randomized group assign-
ment. As expected, prenatal depression risk was
associated with depression risk at each postpartum as-
sessment, and group assignment was not a significant
predictor at any time point. Income group was not a sig-
nificant predictor of depression risk at 1 or 2 months
postpartum, but was associated with increased depres-
sion risk at 3 months postpartum. The regression model
predicting depression risk at 3 months postpartum is
summarized as Model 1 in Table 3. The overall model
explained between 15.6% (Cox and Snell r
2
) and 26.9%
(Nagelkerke r
2
) of the variance in PPD risk and was sta-
tistically significant (c
2
[3] ¼33.5; p,.001), indicating
that income group was able to distinguish between
women with high and low risk for depression at 3
months postpartum.
Given that income is only one dimension of SES and
requires interpretation with respect to household re-
sources, geography, and cost of living, the relationship
of other SES indicators (education, employment, and
marital status) to prenatal and postpartum depressive
symptoms was also evaluated. Having less than a
college education, being unemployed, and being
unmarried were individually associated with depres-
sive symptoms in late pregnancy and at 3 months post-
partum (all p,.01). Like income, these factors were
unrelated to depressive symptoms at 1 and 2 months
postpartum. Given the lack of association between
SES risk factors and depressive symptoms at 1 and 2
months postpartum, subsequent analyses focused on
predicting depression risk at 3 months postpartum only.
To determine the unique contribution of each SES
risk factor to depression risk at 3 months postpartum,
all four were included in a logistic regression
analysis controlling for prenatal depression risk and
randomized group assignment (see Model 2 in Table 3).
As expected, prenatal depression risk continued to be
a significant predictor, but of the four SES indicators,
only marital status made a significant contribution to
the model. The results indicate that unmarried, first-
time mothers were 2.9 times more likely than married
women to have an elevated depression score at 3
months postpartum, even after controlling for prenatal
depression risk and group assignment. The overall
model explained between 18.3% (Cox and Snell r
2
)
and 31.5% (Nagelkerke r
2
) of the variance in PPD risk
and was significant (c
2
[6] ¼40.0; p,.001), suggesting
that Model 2 was a slightly better fit for the data than
Model 1. The lack of significance among the other
SES risk factors was likely due to the high intercorrela-
tion between income, education, employment, and
marital status (c
2
[1] ¼11.8 to 73.5; all p,.001).
Finally, an exploratory analysis was conducted to
evaluate the possibility of cumulative risk associated
with multiple SES risk factors. An SES risk score was
calculated as the total number of SES indicators (in-
come ,$3,000 per month, less than college education,
unemployed, and unmarried) for each woman. The
SES risk scores ranged from 0 (no risk factors) to 4
(all risk factors). When included in the regression
model, the SES risk score was a significant predictor,
even after controlling for prenatal depression risk
7%
21%
9%
42%
38%
54%
0%
20%
40%
60%
1mo PP 2mo PP 3mo PP
% with High Postpartum
Depressive Risk (CES-D 16)
Low prenatal depression risk
High prenatal depression risk
≥
Figure 2. Postpartum depression risk by prenatal depression risk
(n¼198).
Table 3. Logistic Regression Predicting Depression Risk at 3 Months
Postpartum
Model/Predictors
Odds
Ratio
95% Confidence
Interval
Model 1 – Income group
Intervention group assignment 0.55 0.23–1.33
Prenatal CES-D 16 8.04*** 3.39–19.08
Monthly income ,$3,000 2.52*1.05–6.08
Model 2 – Individual SES risk
Intervention group assignment 0.74 0.29–1.87
Prenatal CES-D 16 7.08*** 2.92–17.20
SES risk factors
Monthly income ,$3,000 0.85 0.22–3.26
Not married 2.90*1.01–8.34
No college education 1.12 0.37–3.41
Unemployed 2.50 0.86–7.26
Model 3 – Cumulative SES risk
Intervention group assignment 0.71 0.27–1.82
Prenatal CES-D 16 6.82*** 2.81–16.52
SES risk score
y
All 4 risk indicators (n¼28) 11.07** 2.06–59.39
3 of the 4 risk indicators (n¼37) 7.58*1.42–40.50
2 of the 4 risk indicators (n¼21) 7.19*1.13–45.64
1 of the 4 risk indicators (n¼37) 6.53*1.20–35.59
No risk indicators (n¼75) Referent
*p,.05.
** p,.01.
*** p,.001.
y
SES risk indicators included monthly income ,$3,000, less than
college education, being unemployed, and being unmarried.
D. Goyal et al. / Women’s Health Issues 20 (2010) 96–104 101
and group assignment. Furthermore, depression risk
increased with each additional SES risk factor. Those
with all 4 SES risk factors (monthly income ,$3,000,
less than college education, unemployed, and unmar-
ried) were 11 times more likely than those with no
SES risk factors to have an elevated depression score
at 3 months postpartum. Model 3 achieved significance
(c
2
[6] ¼41.33; p,.001) and explained between 18.8%
(Cox and Snell r
2
) and 32.5% (Nagelkerke r
2
) of the var-
iance in PPD risk.
Discussion
All new mothers are at risk for developing PPD; in fact,
Postpartum Support International (2009) states that
a common complication of childbirth is depression.
The purpose of this study was to describe depressive
symptoms in partnered pregnant women experiencing
their first birth from the third trimester to 3 months
postpartum, specifically on demographic indicators
associated with SES (low monthly income, less than
a college education, unmarried, unemployed). Because
household income is often higher for partnered
women, and a partner is also a source of social support,
this sample was limited to partnered women, regard-
less of marital status.
Depressive Symptoms
Increased frequency of depressive symptoms was ex-
perienced by both low-income (35%) and high-income
(17%) women in the third trimester. The overall rate
of antenatal depressive symptoms in this sample of
women is comparable with other studies (Austin,
2004; Chaudron, 2003). Significantly more depressive
symptoms in the low-income group suggest that the
third trimester may be more stressful for low-income
women. These findings are worrisome, given that
Kopelman et al. (2008) noted women with antenatal
depressive symptoms were more likely than women
without symptoms to cite barriers to care that included
cost and long waits for treatment, lack of insurance,
and problems with transportation. Pregnant women
with low SES are already at a disadvantage with regard
to resources, which may in part add to their stress and
require additional resources for coping.
At 1 month postpartum, both groups reported similar
levels of depressive symptoms. This was not surprising,
given that all new mothers are going through similar bi-
ological changes as well as adjusting to a new role and
routine with their baby. Moreover, most new mothers,
regardless of race or ethnicity, have additional support
in the first few weeks postpartum. The support comes
in many forms, from help with meals to frequent visits
from well-meaning family and friends.
At 2 and 3 months postpartum, the low-income group
was again reporting significantly more depressive
symptoms than the high-income group. Again, this
may in part be explained by the lack of resources avail-
able to low SES mothers, including access to medical
care, transportation, and partner or spousal support.
The additional social support that was available in the
first few weeks postpartum may have also decreased.
According to CES-D mean scores, 9% to 25% of the part-
nered, first-time mothers in this sample were at risk of
developing PPD at 3 months postpartum. These rates
are similar to the 13% to 20% rates reported in previous
studies (Austin, 2004; Chaudron, 2003; Chen, Chan, Tan,
& Lee, 2004; Kim et al., 2006; O’Hara & Swain, 1996).
This range in prevalence may be due to sampling bias
for factors such as SES, martial status, and parity as
well as timing during postpartum recovery. A popula-
tion-based rate of 20% has been acknowledged for the
United States (Center for Health Statistics, 2008). It is
important to note that CES-D scores significantly
improved from the month before delivery to the third
month postpartum in both groups of women.
Clinical Implications
When both low- and high-income women were com-
bined, 24% (n¼48) scored 16 or higher on the CES-D
in the third month postpartum and 16% (n¼31) scored
16 or higher on the CES-D at 3 months postpartum.
These rates are consistent with other rates reported in
the literature and similar to what would be expected
in the general population. Prenatal screening for de-
pression is clearly warranted because women with
elevated prenatal CES-D scores are more likely to have
elevated depressive symptomsat 3 months postpartum.
The risk of PPD in women with elevated prenatal CES-D
scores was further increased in those reporting income
below $3000 per month, those who were partnered
but unmarried, those without a college education, and
those who were unemployed before and after giving
birth. Not surprisingly, multiple risk factors compound
the risk of PPD. Health care providers must integrate
depression screening into prenatal patient assessment
throughout the course of pregnancy and through the
first 3 months postpartum or later. More important,
health care providers need to become educated in the
trajectory of postpartum mood disorders and counsel
and refer their patients accordingly. All new mothers
are experiencing similar biological hormonal changes
that can lead to emotional lability and maternity blues
in up to 80% of women. Although 20% of women do
go on to experience depressive symptoms, symptoms
do tend to improve over time for the majority of post-
partum women. Situational transition and adaptation
to the new family member initiates redefinition of roles
within the family which can lead to maladaptation and
stress. All of these issues are important to assess along
with depressive symptoms.
Results from this study suggest that partnered
women with socioeconomic risk factors for depression
(low monthly income, less than a college education,
D. Goyal et al. / Women’s Health Issues 20 (2010) 96–104102
unmarried, unemployed) were nearly 11 times more
likely to develop PPD than primiparas with none of
these risk factors, and there was a clear dose–response
effect reflecting the compounded risk of PPD when
multiple SES risk factors were present. These results re-
flect recent findings in which researchers have utilized
a multi-risk or cumulative risk approach to identify
predictors of PPD (Klier et al., 2008; Oppo et al.,
2009). Moreover, the results from this study are con-
gruent with those of Rich-Edwards et al. (2006), Segre
et al., (2007), and Seguin et al. (1999a, b), which sug-
gested low-income, unemployed, and less educated
women were at an increased risk of developing PPD.
All of these results strengthen the evidence for screen-
ing in all women, especially those who have one or
more SES risk factors.
Research Limitations and Implications
Very few studies specifically set out to examine the ef-
fect of SES on the development of PPD. The strength of
this study include the longitudinal research design and
direct comparison of low- and high-income partnered
women who were all expecting their first child. The
self-selected convenience sample of first-time mothers,
the inclusion of the sleep intervention group, the tim-
ing of their self-report on frequency of depressive
symptoms, and the lack of specific information about
social support limit the generalizability of the findings.
Other limitations include exclusion of unpartnered
women, because it is impossible to account for how
much a partnered relationship might have served as
a protective role. It is also important to consider that
the cutoff of less than $3,000 in monthly household in-
come used to identify those with low income is a rela-
tive number that may apply to the San Francisco area,
but is not necessarily generalizable to the rest of the
population in the United States.
Results from this study indicate that multiple risk
factors likely have a cumulative effect on depressive
symptoms, which may be explained by disparity of
resources between low-income and affluent families.
Future research should include recruitment of multip-
arous women from diverse ethnic and SES back-
grounds. In addition, SES is a vague term that needs
an operational definition with relevance to women
having their first baby, particularly given the potential
fluidity in employment status during the transition to
motherhood. Future research should also include bio-
markers, such as salivary cortisol, that can estimate
the level of stress experienced by first-time mothers
during this transition. Finally, a mixed method design
with the addition of a qualitative interview would
further our understanding of specific issues that low-
income postpartum women experience that may differ
from women with more affluent backgrounds (Ken-
nedy, Beck & Driscoll, 2002) . The stories of women’s
personal experiences will be an invaluable perspective
for designing future interventions by identifying spe-
cific barriers low income women may face in access
to health care and mental health services.
Acknowledgments
The authors express their sincere gratitude to all of the women who
participated in this study and to Annelise Gardner for her recruit-
ment and data collection efforts on the research team.
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Author Descriptions
Deepika Goyal, PhD, RN, FNP, is an Associate
Professor in the School of Nursing at San Jose State
University, San Jose, California. She is also a family
nurse practitioner and works in Los Gatos, California.
Caryl Gay, PhD, is a Research Specialist in the
Department of Family Health Care Nursing at Univer-
sity of California, San Francisco.
Kathryn Lee, RN, PhD, FAAN, CBSM, is a Professor
and the James and Marjorie Livingston Chair in the
Department of Family Health Care Nursing at Univer-
sity of California, San Francisco.
D. Goyal et al. / Women’s Health Issues 20 (2010) 96–104104
