Many new mothers experience what is euphemistically referred to as the “baby blues,” which is characterized by relatively mild and transient depression in the early days or weeks after delivery.¹ However, 10% to 20% of new mothers will develop perinatal mood and anxiety disorders (PMAD), which is characterized by more severe depressive symptoms that may persist for months.^2,3 PMAD is usually characterized by depression, but in 1 or 2 out of 1000 new mothers, more severe postpartum psychosis requiring immediate hospitalization and treatment may develop.⁴ 

All pregnant women are at risk of developing PMAD, but various subpopulations may be more vulnerable to PMAD based on obstetric variables, psychological factors, or socioeconomic conditions. 

Vulnerability to PMAD Based on Obstetric Factors
A survey of 1.135 million women residing in 138 countries identified several maternal subgroups with increased vulnerability to PMAD.⁵ PMAD risk decreased with advancing maternal age, with the exception of mothers aged ≥ 40 years with twins, who had a particularly high risk.⁵ In general, mothers aged ≤25 years, first-time mothers, and mothers of twins had an increased risk of PMAD. There was no significant difference in PMAD occurrence based on the baby’s gender.⁵ 

New mothers with obstetric complications are also at increased PMAD risk. Those who had induced rather than spontaneous labor, or cesarean rather than vaginal delivery have been found to have an increased PMAD risk.⁶ The duration of labor and administration of an epidural anesthesia have also been associated with PMAD severity.⁶  

Psychological Factors that Confer Vulnerability
Mothers with preexisting psychiatric conditions are more vulnerable to PMAD. In particular, women with depression and anxiety before pregnancy, depression and anxiety during pregnancy, and/or a history of premenstrual syndrome may be predisposed to the hormonal changes associated with PMAD.^7,8

A history of trauma also confers increased vulnerability to PMAD. Survivors of intimate partner violence⁷ or women with a history of sexual abuse^7,9 are at increased risk. However, even in ostensibly healthy relationships, a woman’s pregnancy and impending parenthood call for a reorganization of priorities and routines that can adversely impact a marital relationship, increasing PMAD risk.⁶ Lack of paternal involvement may predispose a mother to PMAD.¹⁰

Socioeconomic Factors
Rates of PMADs are higher in low-income and uninsured women; and in minority communities particularly among Black, Hispanic, Native American, and Asian/Pacific Islander women.¹¹ Moreover, belonging to a minority community can amplify the impact of other risk factors. According to the National Alliance on Mental Illness, Black women have a higher risk of PMAD because they are more likely to be exposed to structural issues such as low income or educational level, living in stressful environments, and have histories of trauma.¹² Additionally, Black women may experience food insecurity and may lack health insurance or access to quality care.¹² Similarly, some Hispanic women face similar structural issues with respect to PMAD diagnosis and care due to lower socioeconomic status, education, and health care access, with the added impediment of language barriers.¹³ 

Cultural beliefs impact access to PMAD care, as Black and Hispanic communities may distrust the health care system or be more sensitive to stigma around mental illnesses.^12,13

Addressing PMAD in Vulnerable Communities
Although obstetric factors may not be modifiable, recognition that young or first-time mothers, mothers of twins, and mothers who experience difficult deliveries may be more susceptible can allow for heightened monitoring for PMAD in these groups, resulting in earlier diagnosis and more timely intervention in affected women. 

There is also a need not only for intensified screening, but for a more comprehensive approach to wellness in expectant mothers with specific life histories, and psychological risk factors.⁴ In particular, programs that focus on screening for and addressing domestic violence, and increasing social protection for women, are central to PMAD prevention and care.^9,14 Clinicians should be cognizant of the needs of minority communities and embrace practices that reduce mistrust. For example, it has been proposed that clinicians who encourage participation of patients in health care decision-making can forge productive partnerships with otherwise skeptical patients.¹⁵

However, some unmet needs in vulnerable populations remain beyond clinicians’ immediate control and require structural remedies. Although expansion of health care coverage through the Affordable Care Act has reduced health care disparities based on race and ethnicity, structural disparities nonetheless remain.¹⁶ Strengthening the health care marketplace to further shore up gaps in access to care is essential for improving PMAD care in minority communities.¹⁶ Such efforts are likely to require public health initiatives, such as a study being launched by the New York State Office of Mental Health to investigate disparities in PMAD screening and care in minority communities, and how best to address them.¹⁷ 
 
References:
1.    Berglund J. Treating postpartum depression: beyond the baby blues. IEEE Pulse. 2020;11(1):17-20. doi:10.1109/MPULS.2020.2972723
2.    Puspitasari AJ, Heredia D, Weber E, et al. Perinatal mood and anxiety disorder management in multicenter community practices: clinicians’ training, current practices and perceived strategies to improve future implementation. J Prim Care Community Health. 2021;12:2150132721996888. doi:10.1177/2150132721996888
3.    Wang Z, Liu J, Shuai H, et al. Mapping global prevalence of depression among postpartum women. Transl Psychiatyr. 2021;11(1):543. doi:10.1038/s41398-021-01663-6
4.    Osborne LM. Recognizing and managing postpartum psychosis: a clinical guide for obstetric providers. Obstet Gynecol Clin North Am. 2018;45(3):455-468. doi:10.1016/j.ogc.2018.04.005 
5.    Bradshaw H, Riddle JN, Salimgaraev R, Zhaunova L, Payne JL. Risk factors associated with postpartum depressive symptoms: a multinational study. J Affect Disord. 2022;301:345-351. doi:10.1016/j.jad.2021.12.121
6.    Smorti M, Ponti L, Pancetti F. A comprehensive analysis of post-partum depression risk factors: the role of socio-demographic, individual, relational, and delivery characteristics. Front Public Health. 2019;7:295. doi:10.3389/fpubh.2019.00295 
7.    Ghaedrahmati M, Kazemi A, Kheirabadi G, Ebrahimi A, Bahrami M. Postpartum depression risk factors:  a narrative  review. J Educ Health Promot. 2017;6:60. doi:10.4103/jehp.jehp_9_16
8.    Silverman ME, Reichenberg A, Savitz DA, et al. The risk factors for postpartum depression: a population-based study. Depress Anxiety. 2017;34(2):178-187. doi:10.1002/da.22597
9.    Akinbode TD, Pedersen C, Lara-Cinisomo S. The price of pre-adolescent abuse: effects of sexual abuse on perinatal depression and anxiety. Matern Child Health J. 2021;25(7):1083-1093. doi:10.1007/s10995-020-03088-x 
10.    Zhang Y, Razza R. Father involvement, couple relationship quality, and maternal postpartum depression: the role of ethnicity among low-income families. Matern Child Health J. 2022;26(7):1424-1433. doi:10.1007/s10995-022-03407-4
11.    Bauman BL, Ko JY, Cox S, et al. Vital signs: postpartum depressive symptoms and provider discussions about perinatal depression – United States, 2018. MMWR Morb Mortal Wkly Rep. 2020;69(19):575-581. doi:10.15585/mmwr.mm6919a2
12.    Kilgoe A. Addressing the increased risk of postpartum depression for black women. National Alliance on Mental Illness. Published July 26, 2021. Accessed September 26th, 2022. https://www.nami.org/Blogs/NAMI-Blog/July-2021/Addressing-the-Increased-Risk-of-Postpartum-Depression-for-Black-Women
13.    Sampson M, Torres MIM, Duron J, Davidson M. Latina immigrants’ cultural beliefs about postpartum depression. Affilia. 2017;33(2):1-13. doi:10.1177/0886109917738745 
14.    Ankerstjerne LBS, Laizer SN, Andreasen K, et al. Landscaping the evidence of intimate partner violence and postpartum depression: a systematic review. BMJ Open. 2022;12(5):e051426. doi:10.1136/bmjopen-2021-051426
15.    Bazargan M, Cobb S, Assari S. Discrimination and medical mistrust in a racially and ethnically diverse sample of California adults. Ann Fam Med. 2021;19(1):4-15. doi:10.1370/afm.2632
16.    Hayes S, Riley P, Radley DC, McCarthy, D. Reducing racial and ethnic disparities in access to care: has the Affordable Care Act made a difference? The Commonwealth Fund. Published August 24, 2017. Accessed September 26, 2022. https://www.commonwealthfund.org/publications/issue-briefs/2017/aug/reducing-racial-and-ethnic-disparities-access-care-has
17.    Brouk SG. Senator Brouk announces major maternal mental health legislation signed into law during minority mental health month. New York State Senate. Published July 20, 2022. Accessed September 26, 2022. https://www.nysenate.gov/newsroom/press-releases/samra-g-brouk/senator-brouk-announces-major-maternal-mental-health