Neighborhood disadvantage linked to postpartum depression

Kaiser Permanente analysis finds the association differs by race and ethnicity

Mothers living in neighborhoods with greater economic disadvantage are more likely to experience depression after giving birth, according to a Kaiser Permanente analysis published in JAMA Network Open.

The increased risk varied by race or ethnicity, and suggested that neighborhood disadvantage could be a contributor in inequities in postpartum depression between white and Black individuals.

“Postpartum depression is a common complication of childbirth and carries serious health risks for the mother and child,” said lead author Ticara Onyewuenyi, MD, MPH, an ob-gyn resident physician with The Permanente Medical Group. “Our findings demonstrate that the risk of postpartum depression is elevated for individuals living in neighborhoods with both high and moderate disadvantage. As clinicians it’s important to identify contributors of this kind of disparity, so that we are aware of them when we are caring for patients in the clinic.”

The study looked at 122,995 Kaiser Permanente Northern California patients who had given birth between 2012 and 2017; 12.5% of them had a diagnosis of postpartum depression (depression during the first year after giving birth). The researchers defined neighborhood disadvantage using an index that accounts for several neighborhood socioeconomic status factors such as educational and employment status, poverty, and housing quality.

Previous studies have established a link between neighborhood disadvantage and depression in the general population, but evidence was lacking on whether this extended to a vulnerable group of people, postpartum patients. This is the first study to explore the association among 3 factors: neighborhood disadvantage, race and ethnicity, and depression.

The study found people with postpartum depression were more likely to live in areas with more economic disadvantage (28% versus 21%).

Black individuals had a 30% increased risk of postpartum depression compared with white individuals, while Asian individuals had a 52% lower risk, and Hispanic mothers 8% lower risk.

The researchers then added a third layer to their analysis: considering how race or ethnicity might factor into postpartum depression and neighborhood deprivation. And they found differences among people with different backgrounds.

Among Black individuals, as neighborhood disadvantage increased, the risk of postpartum depression increased (in a dose-response fashion); Black individuals living in high disadvantaged areas had a 60% increased risk of depression compared to Black individuals in the least disadvantaged neighborhoods.

The study found neighborhood disadvantage linked to postpartum depression among white and Asian individuals to a lesser degree, and did not find the association for Hispanic patients.

This study was part of a project by senior author Lyndsay Avalos, PhD, MPH, a research scientist with the Kaiser Permanente Division of Research, exploring mental health before, during, and after pregnancy. This work has found differences in prevalence of mental health diagnoses and treatment initiation by race and ethnicity, and Avalos said it was important to explore the reasons for those differences more specifically.

Potential interventions

The researchers found that Black individuals were more likely to live in neighborhoods of higher disadvantage. The authors said the reasons for a link between higher rates of postpartum depression among Black individuals was likely “multifactorial and complex.”

“Systemic factors and discriminatory practices such as redlining and housing discrimination, inequitable access to education, employment discrimination, disproportionate rates of incarceration, and health disparities add a tremendous burden onto the normal stressors of life,” they wrote. “Lifestyle factors such as food intake patterns, sleep status, exercise, and physical activity can significantly affect postpartum depression.”

 

These findings highlight the importance of looking in the electronic health record to learn more about the patient we are seeing.

—Ticara Onyewuenyi, MD, MPH

 

The authors suggested targeted collaboration with community organizations to provide psychosocial interventions delivered by trained community peers to assist Black new mothers. They also recommended wider use of depression screening for pregnant patients and culturally appropriate interventions.

“On the provider level, these findings highlight the importance of looking in the electronic health record to learn more about the patient we are seeing,” Onyewuenyi said. “We can take a moment to see where they live and what that could tell us about the challenges they face as we address their mental health.”

A strength of the study, Avalos said, was that it covers a time period soon after Kaiser Permanente Northern California began screening all pregnant and postpartum patients for depression, providing both the opportunity to accurately identify and provide support to patients along with data for researchers to study mental health during and after pregnancy.

The study was funded by a Kaiser Permanente Community Health grant and the National Institutes of Health.

Additional co-authors were Kelli Peterman, MPH, Charles P. Quesenberry, PhD, Nerissa Nance, MPH, Ann-Marie Surmava, MBA, of the Division of Research; Eve Zaritsky, MD, and Bria L. Pettway, MD, of The Permanente Medical Group; and Miranda L. Ritterman Weintraub, PhD, MPH, of Kaiser Permanente Northern California Graduate Medical Education.

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About the Kaiser Permanente Division of Research

The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow us @KPDOR.