Utilization of Psychiatric Services by Postpartum Women
in a Predominantly Minority, Low-Socioeconomic-Status,
Urban Population
ABSTRACT
Purpose: Certain psychiatric illnesses are more common in women than in men, in
particular during the postpartum period. The purpose of this retrospective study is to
report on the utilization of health care services related to psychiatric diagnoses in an inner
city community health organization in Houston, Texas with a largely Hispanic population
of low socioeconomic status. Methods: We reviewed 18,423 patient encounters
distributed over 5,731 patients who delivered and were followed-up for postpartum care.
The frequency and timing of postpartum mental health diagnoses was reviewed. Results:
A total of 286 women had at least one mental health diagnosis (5%). The rates in white,
black, and hispanic women were 12%, 8%, and 5% respectively (p<.05). White women
were 2.5 times more likely (95% CI 1.24, 5.07), and blacks were 1.62 times more likely
(95% CI 1.09, 2.40) to have a mental health diagnosis as compared to Hispanic women.
The most common diagnoses were mood disorders (64%) followed by anxiety disorders
(29%). The majority (87%) of the cases were diagnosed after 4 weeks postpartum.
Conclusions: The postpartum mental health diagnosis rate seen here is lower than might
be expected, particularly among Hispanic women. Earlier estimates of postpartum
depression range from 6-13%, and estimates of postpartum psychiatric disorders range
from 15% to 29%. One possible explanation for the lower rates seen here is that mental
illness is under-diagnosed in this largely minority population. Alternatively, Hispanic
women may utilize social supports or other mechanisms that reduce their risk of
postpartum mental illness.
INTRODUCTION
Certain psychiatric illnesses such as major depression, generalized anxiety disorder, and
rapid cycling bipolar disorder affect women more commonly than men during their
lifetimes (Blehar et al. 1998; Kessler 2003; Wittchen 2002). The postpartum period is a
particularly high-risk period for women to experience a new onset or recurrent major
depressive mood episode or an exacerbation of their disorder (Vesga-López et al. 2008;
Viguera et al. 2000).
Depression is one of the most disabling disorders among women of childbearing age
(WHO 2002). A recent Agency for Healthcare Research and Quality (AHRQ) review
(Gavin et al. 2005; Gaynes et al. 2005) found that the point prevalence of postpartum
depression ranged from 6.5% to 12.9% at different times during the first year postpartum.
This estimate is somewhat lower than those found in prior systematic reviews, most
likely for methodological reasons, such as the exclusion of studies that assessed
depression based on self-report screens alone.
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Other mental health illnesses may occur after childbirth. Postpartum psychosis is
relatively rare event with an estimated incidence of 1.1 to 4.0 cases per 1,000 deliveries
(Gaynes et al. 2005; Valdimarsdóttir et al. 2009). The prevalence of psychiatric disorders
in the postpartum period reported in the literature ranges from 15% to 29% (Andersson et
al. 2003; Andersson et al. 2006; Kelly et al. 2001a; Kelly et al. 2001b; Kim et al. 2006;
Vesga-López et al. 2008). In a national study of over 14,000 women, a 12 month
prevalence of 25.7% was seen for any psychiatric disorder postpartum, lower than the
prevalence rate of 30.1% seen among non-pregnant women (Vesga-López et al. 2008).
There is evidence that pregnant women with psychiatric disorders are under-diagnosed
and under-treated in primary care settings (Kelly et al. 2001; Marcus et al. 2003; Spitzer
et al. 2000). The under-diagnosis and treatment of mental illness during pregnancy and
child rearing has negative implications on the mother’s well-being as well as the
psychological and physical development of the child. The impact of untreated maternal
depression can contribute to poor cognitive development, behavioral problems during
childhood and adolescence and even manifest health implications into the next generation
(Deave et al. 2008; Halligan et al. 2007; Weissman et al. 2006b), while treatment of
depressed mothers has been shown to benefit their children (Weissman et al. 2006a;
Wickramaratne et al. 2011).
Surprisingly little is known about the rates of postpartum depression among minority
women, particularly Hispanic and Native American women, and in women of low
socioeconomic status (Liu and Tronick 2012; Wei et al. 2008; Yonkers et al. 2001), and
even less data is available about ethnic differences in rates of all mental health diagnoses.
It has been shown that stressful life events and poor social support are major risk factors
for postpartum depression (O'Hara 2009). Furthermore, in general, individuals at a
socioeconomic disadvantage experience higher rates of depression and have more limited
access to health care (Lorant et al. 2003). For these reasons, one might expect that rates
of postpartum depression would be highest in minority, low-income populations. Some
evidence supports this hypothesis. O’Hara et al. found rates of postpartum depression
among low-income women that were twice as high as published rates among middleclass women (O'Hara et al. 1991).
Studies of postpartum depression among Hispanic women have yielded mixed results.
Some studies find lower rates of diagnosed postpartum depression among Hispanic
women, compared to other minority women and to non-Hispanic white women (Baker
and Oswalt 2008; Wei et al. 2008). Other studies show an increased risk of postpartum
depression among Hispanic women compared to other minority women and to nonHispanic white women (Howell et al. 2005; Liu and Tronick 2012). Liu et al. (Liu and
Tronick 2012) found that the elevated risk among Hispanics was less pronounced after
accounting for sociodemographic factors and was eliminated with controlling for
stressors. Savitz et al. reported elevated risk among Hispanics (compared to nonHispanic whites) in New York City but not elsewhere in New York State (Savitz et al.
2011). Yonkers et al. found postpartum depression rates among low-income Latina and
African American women in a low-income community clinic population in Texas to be
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similar to those seen in the literature among middle-class Caucasian women (Yonkers et
al. 2001).
Some of these discrepancies may be due to different screening methodologies (Gaynes et
al. 2005). Additionally, there may be true differences in postpartum depression rates
between Hispanic subgroups (Savitz et al. 2011). The group defined as “Hispanic” is a
very diverse one, and includes varied regions of origin, immigration statuses, English
speaking capabilities, and numbers of generations that the family has been in the U.S.
Any of these factors may influence postpartum depression rates. Likely reasons for an
increased risk of postpartum depression among Hispanic women include the social stress
of poverty, lack of resources, or possibly the stress of discrimination against Hispanic
women (Savitz et al. 2011). However, Hispanic women may be less likely to receive a
mental health diagnosis than white women because of barriers in access to care, such as
language capabilities or health insurance.
Another explanation sometimes given for the decreased risk findings is the “Hispanic
Paradox.” For a broad set of outcomes, including mental health, cancer and diabetes
rates, and infant and general mortality, Hispanics tend to have comparable or better
health outcomes than their white non-Hispanic counterparts, despite having lower
average income and education, factors normally associated with poorer health outcomes
(Markides and Coreil 1986; Morales et al. 2002). The mechanism through which
Hispanic patients are protected from mental health disorders is uncertain. One theory is
that strong family support systems lower the incidence of mental disorders and serve as a
form of therapy, so that the need to seek outside help is decreased. Another view suggests
that Hispanic families are more tolerant of deviant behavior and do not seek professional
help except in severe cases of mental illness (Markides and Coreil 1986).
AHRQ reviewed depression rates from 30 perinatal health studies, including 11 focused
on the postpartum period (Gaynes et al. 2005). The researchers found that the published
studies included only a limited racial and ethnic mix, and had poor power to discriminate
statistically significant differences between ethnic groups. The authors conclude that
“prevalence studies need to better account for the racial and ethnic mix of perinatal
depression in the U.S. population.”
The purpose of this retrospective study is to report on the utilization of health care
services related to psychiatric diagnoses in postpartum women in Harris Health System
(HHS) in Houston, TX. HHS is an inner city community health organization with a
largely Hispanic population of low socioeconomic status. Formerly known as Harris
County Hospital District, HHS provides healthcare, including primary care, mental health
care and obstetric and gynecologic care, to women at more than ten outpatient
community clinics. HHS also maintains two hospitals, including a Level 1 Trauma Center
with a specialized psychiatric emergency center and in-patient facility. In 2007, there
were 71,389 deliveries in Harris County, which includes Houston, the fourth largest city
in the United States (Texas Department of State Health Services 2008). 10,181 of those
babies were delivered in HHS (unpublished data).
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Socioeconomic indicators for Harris County and Houston suggest a population at high
risk for serious illness (Houston Department of Health and Human Services 2009), with
higher proportions of residents living below the poverty level and lower high school
graduation rates, compared to the United States as a whole. Disparities in income and
education are seen among ethnic groups, with blacks and Hispanics showing lowest
income and educational attainment. Furthermore, Harris County and Houston have a high
proportion of foreign born residents and residents who do not speak English at home,
high rates of uninsured individuals and individuals enrolled in Medicaid, and 19 areas
designated as medically underserved areas in 2007 (Houston Department of Health and
Human Services 2009).
MATERIALS AND METHODS
We investigated the types of mental health diagnoses documented in the year after
childbirth. Figure 1 shows the study protocol. A dataset that contained 18,423 records of
patient encounters among all women who gave birth in 2007 and returned for follow-up
care in the year following delivery (5,731 patients) was obtained from HHS’s electronic
medical records system. Every one of these medical records was reviewed, and all ICD-9
codes that represent a postpartum mental health diagnosis were included in the analysis
(564 records).
When multiple mental health diagnoses were made over multiple visits in the course of
the year, we collapsed the data to describe the diagnosis most clearly. Thus, women who
had similar diagnoses in the same category throughout multiple encounters were counted
under their most severe diagnosis. For example, a woman with “Major Depression
Unspecified” and “Adjustment Disorder with Depressed Mood” would be counted under
the former category only. However, women with two diagnoses in dissimilar categories,
such as substance abuse and bipolar disorder, were put in a distinct category of “multiple
diagnoses.”
The timing of depression onset was also investigated. There is no category for postpartum
depression in the Diagnostic and Statistical Manual-IV (APA 2000). However, the DSMIV does include a modifier, “postpartum onset”. In order for a mood disorder or brief
psychotic episode to receive this modifier, the onset of the episode must be within four
weeks postpartum. For analysis purposes, when multiple visits with psychiatric diagnoses
were merged to form one encounter, the earliest date of the visit was counted.
Relative risks and 95% confidence intervals were calculated using R statistical software
(R core team 2012) to compare rates of mental health diagnoses between ethnic groups
and age categories. Institutional review board approval for this study was obtained from
HHS and Baylor College of Medicine. The data collected represent all women who
delivered a child and pursued some form of medical follow-up care in HHS.
RESULTS
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The characteristics of women included in this analysis are shown in Table 1. Most
patients were Hispanic (90%), and the next most common ethnic group was black (6%).
Three percent of women were Asian, while whites and other races each represented about
1%. Women ranged in age from 13 to 47 years, and the mean age was 28, with a standard
deviation of 6.
Of the 5731 women who delivered babies in HHS and presented for postpartum followup, 286 (5%) had at least one documented mental health diagnosis. The percentages
among white and black women (12% (n=7), and 8% (n=25), respectively) were
statistically significantly higher than those seen among Hispanic women (5%, n=249).
White women were 2.5 times more likely than Hispanic women to have a mental health
diagnosis (95% CI 1.24, 5.07), and black women were 1.62 times more likely than
Hispanic women to have a mental health diagnosis (95% CI 1.09, 2.40; Table 1). Since
age was not associated with mental health diagnosis rates, relative risks and 95%
confidence intervals are not presented in Table 1. 51 women (~1% of total) had more
than one mental health diagnosis.
The distribution of postpartum diagnoses is shown in Table 2. The most common
diagnoses were mood disorders (64%), followed by anxiety disorders (29%). 87% of
patients with a mental health diagnosis did not receive the diagnosis until after 4 weeks
postpartum (Table 3). For all types of disorders, a majority of cases (77% - 94%) were
diagnosed after 4 weeks postpartum (Table 3).
DISCUSSION AND CONCLUSION
This is one of the first studies to examine postpartum mental health diagnosis rates in a
low-income and largely Hispanic community. The rate of postpartum mental health
diagnosis reported here in Harris County Hospital District was 5%, lower than what we
had expected. Rates of mental health diagnoses seen were statistically significantly higher
among white and black women (12% and 8%, respectively) compared to Hispanic
women (5%). The previous literature on this issue is mixed, with some studies showing
lower rates of postpartum depression among low-income Hispanic populations, and
others showing higher rates.
One possible explanation for the low rate of postpartum depression and other mental
illness reported here, particularly among Hispanic women, is under-diagnosis. There is
evidence that women with psychiatric disorders are under-diagnosed and under-treated in
primary care settings (Kelly et al. 2001; Marcus et al. 2003; Spitzer et al. 2000). It seems
likely that the women who presented for routine care to HHS either did not complain of
depression or anxiety or were not asked about their mental state. Reasons for this may
include the lack of a formal screening program, short visit times, and language barriers.
The “Hispanic Paradox” describes an interesting framework through which to consider
our results. The causes of this paradox remain poorly understood, but several
explanations have been posited which may be at work here. The Hispanic community of
HHS may have strong social support networks, which are known to be protective against
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postpartum depression (O'Hara 2009). Place of birth may also be a factor. Some of the
women included in this study may have benefited from different birth and neonatal
practices outside of the U.S. at the time of their own birth. More research is required to
better understand whether and how these hypotheses apply to the population served by
Harris County Hospital District.
One limitation of our study is that data was not available regarding income, education
level, employment status, marital status, place of birth, and immigration status for the
women included in this analysis. It is possible that one of these factors is a better
explanation than ethnicity for the differences in mental health diagnosis rates that we
observed.
A second limitation of the study is that the sample was restricted to women who had
some postpartum follow-up. This sample represents only 50% of the births in HHS in
2007, since half of women who gave birth in 2007 had no postpartum follow-up in HHS.
It is possible that these women were treated for mental health disorders elsewhere. A
more likely explanation may be that many of these women encountered barriers in access
to health care shortly after giving birth. In Texas, a pregnant woman with income below a
certain level is eligible for Medicaid benefits only during pregnancy and for two months
after birth (Texas Health and Human Services Commission 2012). It is possible that
women included in this analysis did not return for postpartum care after their Medicaid
benefits ran out.
There are several steps that could be taken to improve the ability of hospital systems to
ensure that postpartum depression is not being underdiagnosed or undertreated. First,
when implementing a screening program, it makes sense to start thinking about mood
disorders during pregnancy, especially in a high volume, clinic setting such as HHS
where many women come for prenatal care but may not follow-up after childbirth. An
important risk factors for postpartum depression is depression during pregnancy,
particularly during the third trimester (Evans et al. 2001; O'Keane and Marsh 2007).
Involving pediatricians in the recognition of postpartum depression may be another part
of the system-wide approach to capturing and effectively treating depressed women.
While these women may not seek out treatment for themselves, they are more likely to
bring their newborn in a 2 weeks health checkup and for immunizations at 8 weeks and
beyond.
There is no category for postpartum depression in the Diagnostic and Statistical ManualIV (APA 2000). The DSM-IV-TR does include a modifier, “postpartum onset,” that is
applied if the episode begins within 4 weeks of childbirth. However, most women do not
receive any postpartum care within 4 weeks of delivery. Their only contact with a
medical professional is likely to be with a pediatrician for the two-week newborn visit.
Proposed revisions for the DSM-V-TR, to be released in April 2013, include changing
the postpartum modifier to 6 months (APA 2012).
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Even if under-diagnosed and under-treated, mental health disorders account for
significant morbidity in women of childbearing age and this affects families as well.
Perhaps it is not just an issue of referring these women to mental health providers but
empowering primary care providers to treat mental illness in these women. When
working with low-income families, it is crucial to choose medication that the mother will
be able to afford even when Medicaid expires after childbirth. It is also important to plan
for unexpected pregnancies when choosing medication and to discuss the risks and
benefits of taking a psychotropic medication in the event of another pregnancy.
More research is needed to better understand the true rates of postpartum depression in
low-income and Hispanic women. It seems prudent to implement better screening
procedures in this potentially high-risk population of women, such as involving
pediatricians in screening and extending screening to the pre-pregnancy period. A referral
process, including a treatment plan for the positive screens, would also be well advised. If
the low rates reported here remain even after such measures have been put in place, then
perhaps we can learn a lesson from the women of Harris County and other Hispanic
populations, and implement some of their practices in other populations to reduce
postpartum depression rates. Such a step would benefit many women and their families.
ACKNOWLEDGEMENTS
This investigation was supported by a grant from the Women’s Fund for Health and
Education Research, and partly supported with the resources and facilities of the Houston
VA HSR&D Center of Excellence (HFP90-020). The views expressed are those of the
authors and not necessarily those of the Department of Veterans Affairs, US government
or Baylor College of Medicine. We thank Roxanne Bloomquist at HHS for her assistance
in obtaining the data and Elizabeth Lowenthal for helpful comments on the manuscript.
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FIGURE LEGENDS
Figure 1. Study Protocol
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