Original article| Volume 21, ISSUE 4, P304-313, July 2011

Poor Prepregnancy and Antepartum Mental Health Predicts Postpartum Mental Health Problems among US Women: A Nationally Representative Population-Based Study

Published:February 25, 2011DOI:



      Mental health problems disproportionately affect women, particularly during the childbearing years. However, there is a paucity of research on the determinants of postpartum mental health problems using representative US populations. Taking a life course perspective, we determined the potential risk factors for postpartum mental health problems, with a particular focus on the role of mental health before and during pregnancy.


      We examined data on 1,863 mothers from 11 panels of the 1996–2006 Medical Expenditure Panel Survey. Poor postpartum mental health was defined using self-reports of mental health conditions, symptoms of mental health conditions, or global mental health ratings of “fair” or “poor.”


      Of the women included, 9.5% reported experiencing postpartum mental health problems, with over half of these women reporting a history of poor mental health. Poor prepregnancy mental health and poor antepartum mental health both independently increased the odds of having postpartum mental health problems. Staged multivariate analyses revealed that poor antepartum mental health attenuated the relationship between prepregnancy and postpartum mental health problems. Additionally, significant disparities exist in women’s report of postpartum mental health status.


      Although poor antepartum mental health is the strongest predictor of postpartum mental health problems, prepregnancy mental health is also important. Accordingly, health care providers should identify, treat, and follow women with a history of poor mental health because they are particularly susceptible to postpartum mental health problems. This will ensure that women and their children are in the best possible health and mental health during the postpartum period and beyond.
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      1. Agency for Healthcare Research and Quality (AHRQ). (2010). Medical Expenditure Panel Survey (MEPS). Available: Accessed December 3, 2010.

        • Baron R.M.
        • Kenny D.A.
        The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations.
        Journal of Personality and Social Psychology. 1986; 51: 1173-1182
        • Beck C.T.
        Predictors of postpartum depression: An update.
        Nursing Research. 2001; 50: 275-285
        • Blom E.A.
        • Jansen P.W.
        • Verhulst F.C.
        • Hofman A.
        • Raat H.
        • Jaddoe V.W.V.
        • et al.
        Perinatal complications increase the risk of postpartum depression. The Generation R study.
        British Journal of Obstetrics and Gynaecology. 2010; : 9-13
        • Borowsky S.J.
        • Rubenstein L.V.
        • Meredith L.S.
        • Camp P.
        • Jackson-Triche M.
        • Wells K.B.
        Who is at risk of nondetection of mental health problems in primary care?.
        Journal of General Internal Medicine. 2000; 15: 381-388
        • Chaudron L.H.
        • Kitzman H.J.
        • Szilagyi P.G.
        • Sidora-Arcoleo K.
        • Anson E.
        Changes in maternal depressive symptoms across the postpartum year at well child care visits.
        Ambulatory Pediatrics. 2006; 6: 221-224
        • Chaudron L.H.
        • Klein M.H.
        • Remington P.
        • Palta M.
        • Allen C.
        • Essex M.J.
        Predictors, prodromes and incidence of postpartum depression.
        Journal of Psychosomatic Obstetrics and Gynecology. 2001; 22: 103-112
        • Chaudron L.H.
        • Szilagyi P.G.
        • Campbell A.T.
        • Mounts K.O.
        • McInerny T.K.
        Legal and ethical considerations: Risks and benefits of postpartum depression screening at well-child visits.
        Pediatrics. 2007; 119: 123-128
        • Chaudron L.H.
        • Szilagyi P.G.
        • Kitzman H.J.
        • Wadkins H.I.M.
        • Conwell Y.
        Detection of postpartum depressive symptoms by screening at well-child visits.
        Pediatrics. 2004; 113: 551-558
        • Cohen J.
        • Monheit A.
        • Beauregard K.
        • Cohen S.
        • Lefkowitz D.
        • Potter D.
        • et al.
        The Medical Expenditure Panel Survey: A national health information resource.
        Inquiry. 1996; 33: 373-389
        • Cooper L.A.
        • Gonzales J.J.
        • Gallo J.J.
        • Rost K.M.
        • Meredith L.S.
        • Rubenstein L.V.
        • et al.
        The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients.
        Medical Care. 2003; 41: 479-489
        • Dietz P.M.
        • Williams S.B.
        • Callaghan W.M.
        • Bachman D.J.
        • Whitlock E.P.
        • Hornbrook M.C.
        Clinically identified maternal depression before, during, and after pregnancies ending in live births.
        The American Journal of Psychiatry. 2007; 164: 1515-1520
        • Evans R.G.
        • Stoddart G.L.
        Producing health, consuming health care.
        Social Science & Medicine. 1990; 31: 1347-1363
        • Evins G.G.
        • Theofrastous J.P.
        • Galvin S.L.
        Postpartum depression: A comparison of screening and routine clinical evaluation.
        American Journal of Obstetrics and Gynecology. 2000; 182: 1080-1082
        • Feinberg E.
        • Smith M.V.
        • Morales M.J.
        • Claussen A.H.
        • Smith D.C.
        • Perou R.
        Improving women’s health during internatal periods: Developing an evidenced-based approach to addressing maternal depression in pediatric settings.
        Journal of Women’s Health. 2006; 15: 692-703
        • Fleishman J.A.
        • Zuvekas S.H.
        Global self-rated mental health: Associations with other mental health measures and with role functioning.
        Medical Care. 2007; 45: 602-609
        • Gavin N.I.
        • Gaynes B.N.
        • Lohr K.N.
        • Meltzer-Brody S.
        • Gartlehner G.
        • Swinson T.
        Perinatal depression: A systematic review of prevalence and incidence.
        Obstetrics and Gynecology. 2005; 106: 1071-1083
        • Gaynes B.N.
        • Gavin N.I.
        • Meltzer-Brody S.
        • Lohr K.N.
        • Swinson T.
        • Gartlehner G.
        • et al.
        Perinatal depression: Prevalence, screening accuracy, and screening outcomes. Evidence Report/Technology Assessment No. 119. (No. AHRQ Publication No. 05-E006-2).
        Agency for Healthcare Research and Quality, Rockville, MD2005
        • Georgiopoulos A.M.
        • Bryan T.L.
        • Wollan P.
        • Yawn B.P.
        Routine screening for postpartum depression.
        The Journal of Family Practice. 2001; 50: 117-122
        • Gjerdingen D.
        • Crow S.
        • McGovern P.
        • Miner M.
        • Center B.
        Postpartum depression screening at well-child visits: Validity of a 2-question screen and the PHQ-9.
        Annals of Family Medicine. 2009; 7: 63-70
        • Gjerdingen D.
        • Yawn B.
        Postpartum depression screening: Importance, methods, barriers, and recommendations for practice.
        Journal of the American Board of Family Medicine. 2007; 20: 280-288
        • Goodman J.
        Postpartum depression beyond the early postpartum period.
        Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2004; 33: 410-420
        • Goodman S.
        • Gotlib I.
        Risk for psychopathology in the children of depressed mothers: A developmental model for understanding mechanisms of transmission.
        Psychological Review. 1999; 106: 458-490
        • Gordon T.E.J.
        • Cardone I.A.
        • Kim J.J.
        • Gordon S.M.
        • Silver R.K.
        Universal perinatal depression screening in an Academic Medical Center.
        Obstetrics and Gynecology. 2006; 107: 342-347
        • Gotlib I.H.
        • Whiffen V.E.
        • Mount J.H.
        • Milne K.
        • Cordy N.I.
        Prevalence rates and demographic characteristics associated with depression in pregnancy and the postpartum.
        Journal of Consulting and Clinical Psychology. 1989; 57: 269-274
        • Goyal D.
        • Gay C.
        • Lee K.A.
        How much does low socioeconomic status increase the risk of prenatal and postpartum depressive symptoms in first-time mothers?.
        Women’s Health Issues. 2010; 20: 96-104
        • Grace S.L.
        • Evindar A.
        • Stewart D.E.
        The effect of postpartum depression on child cognitive development and behavior: A review and critical analysis of the literature.
        Archives of Women’s Mental Health. 2003; 6: 263-274
        • Hahm H.C.
        • Ozonoff A.
        • Gaumond J.
        • Sue S.
        Perceived discrimination and health outcomes: A gender comparison among Asian-Americans nationwide.
        Women’s Health Issues. 2010; 20: 350-358
        • Halfon N.
        • Hochstein M.
        Life course health development: An integrated framework for developing health, policy, and research.
        The Milbank Quarterly. 2002; 80: 433-479
        • Hayes D.K.
        • Ta V.M.
        • Hurwitz E.L.
        • Mitchell-Box K.M.
        • Fuddy L.J.
        Disparities in self-reported postpartum depression among Asian, Hawaiian, and Pacific Islander Women in Hawaii: Pregnancy Risk Assessment Monitoring System (PRAMS), 2004–2007.
        Maternal and Child Health Journal. 2010; 14: 765-773
        • Hearn G.
        • Iliff A.
        • Jones I.
        • Kirby A.
        • Ormiston P.
        • Parr P.
        • et al.
        Postnatal depression in the community.
        The British Journal of General Practice. 1998; 48: 1064-1066
        • Heneghan A.M.
        • Silver E.J.
        • Bauman L.J.
        • Stein R.E.
        Do pediatricians recognize mothers with depressive symptoms?.
        Pediatrics. 2000; 106: 1367-1373
        • Hoff R.A.
        • Bruce M.L.
        • Kasl S.V.
        • Jacobs S.C.
        Subjective ratings of emotional health as a risk factor for major depression in a community sample.
        The British Journal of Psychiatry. 1997; 170: 167-172
        • Huang Z.J.
        • Wong F.Y.
        • Ronzio C.R.
        • Yu S.M.
        Depressive symptomatology and mental health help-seeking patterns of U.S.- and foreign-born mothers.
        Maternal and Child Health Journal. 2007; 11: 257-267
        • Kim J.J.
        • Gordon T.E.J.
        • {La Porte} L.M.
        • Adams M.
        • Kuendig J.M.
        • Silver R.K.
        The utility of maternal depression screening in the third trimester.
        American Journal of Obstetrics and Gynecology. 2008; 199 (509.e501–e505)
        • Kirpinar I.
        • Gözüm S.
        • Pasinlioğlu T.
        Prospective study of postpartum depression in eastern Turkey prevalence, socio-demographic and obstetric correlates, prenatal anxiety and early awareness.
        Journal of Clinical Nursing. 2010; 19: 422-431
        • Maram B.S.
        Perinatal Report in response to Public Act 93-0536.
        Illinois Department of Healthcare and Family Services, Springfield2008
        • Mawani F.N.
        • Gilmour H.
        Validation of self-rated mental health.
        Health Reports. 2010; 21: 61-75
        • Mayberry L.J.
        • Horowitz J.A.
        • Declercq E.
        Depression symptom prevalence and demographic risk factors among U.S. women during the first 2 years postpartum.
        Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2007; 36: 542-549
        • McWilliams J.M.
        Health consequences of uninsurance among adults in the United States: Recent evidence and implications.
        The Milbank Quarterly. 2009; 87: 443-494
        • Miranda J.
        • Cooper L.A.
        Disparities in care for depression among primary care patients.
        Journal of General Internal Medicine. 2004; 19: 120-126
        • Misra D.P.
        • Guyer B.
        • Allston A.
        Integrated perinatal health framework. A multiple determinants model with a life span approach.
        American Journal of Preventive Medicine. 2003; 25: 65-75
        • Mora P.A.
        • Bennett I.M.
        • Elo I.T.
        • Mathew L.
        • Coyne J.C.
        • Culhane J.F.
        Distinct trajectories of perinatal depressive symptomatology: Evidence from growth mixture modeling.
        American Journal of Epidemiology. 2009; 169: 24-32
        • Morris-Rush J.K.
        • Freda M.C.
        • Bernstein P.S.
        Screening for postpartum depression in an inner-city population.
        American Journal of Obstetrics and Gynecology. 2003; 188: 1217-1219
        • Murphy A.M.
        Informational notice: Screening for perinatal depression.
        Illinois Department of Public Aid, Springfield2004
        • O’Hara M.
        • Swain A.
        Rates and risk of postpartum depression—A meta-analysis.
        International Review of Psychiatry. 1996; 8: 37-54
        • Olson A.L.
        • Dietrich A.J.
        • Prazar G.
        • Hurley J.
        • Tuddenham A.
        • Hedberg V.
        • et al.
        Two approaches to maternal depression screening during well child visits.
        Journal of Developmental and Behavioral Pediatrics. 2005; 26: 169-176
        • Pignone M.P.
        • Gaynes B.N.
        • Rushton J.L.
        • Burchell C.M.
        • Orleans C.T.
        • Mulrow C.D.
        • et al.
        Screening for depression in adults: A summary of the evidence for the U.S. Preventive Services Task Force.
        Annals Internal Medicine. 2002; 136: 765-776
        • Robertson E.
        • Grace S.
        • Wallington T.
        • Stewart D.E.
        Antenatal risk factors for postpartum depression: A synthesis of recent literature.
        General Hospital Psychiatry. 2004; 26: 289-295
        • Scholle S.
        • Haskett R.
        • Hanusa B.
        • Pincus H.
        • Kupfer D.
        Addressing depression in obstetrics/gynecology practice.
        General Hospital Psychiatry. 2003; 25: 83-90
        • Seehusen D.A.
        • Baldwin L.-M.
        • Runkle G.P.
        • Clark G.
        Are family physicians appropriately screening for postpartum depression?.
        The Journal of the American Board of Family Practice. 2005; 18: 104-112
        • Spitzer R.L.
        • Kroenke K.
        • Williams J.B.
        Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire.
        Journal of the American Medical Association. 1999; 282: 1737-1744
        • Witt W.
        • Deleire T.
        • Hagen E.
        • Wichmann M.
        • Wisk L.
        • Spear H.
        • et al.
        The prevalence and determinants of antepartum mental health problems among women in the USA: A nationally representative population-based study.
        Archives of Women’s Mental Health. 2010; 13: 425-437
        • Witt W.
        • Keller A.
        • Gottlieb C.
        • Litzelman K.
        • Hampton J.
        • Maguire J.
        • et al.
        Access to Adequate Outpatient Depression Care for Mothers in the USA: A Nationally Representative Population-Based Study.
        Journal of Behavioral Health Services and Research, Oct 17. 2009; ([Epub ahead of print])
        • Yonkers K.A.
        • Wisner K.L.
        • Stewart D.E.
        • Oberlander T.F.
        • Dell D.L.
        • Stotland N.
        • et al.
        The management of depression during pregnancy: A report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists.
        General Hospital Psychiatry. 2009; 31: 403-413


      Whitney P. Witt, PhD, MPH, is an Assistant Professor in the Department of Population Health Sciences at the School of Medicine and Public Health at University of Wisconsin, Madison and the Co-Director of BioPop: Integrative Biopsychosocial Research in Population Health.


      Lauren E. Wisk, BS, is a doctoral student in the Department of Population Health Sciences at the School of Medicine and Public Health at University of Wisconsin, Madison.


      Erika R. Cheng, BS, is a doctoral student in the Department of Population Health Sciences and a master's student at the La Follette School of Public Affairs at the University of Wisconsin, Madison.


      John M. Hampton, MS, is a researcher and statistician for the University of Wisconsin Carbone Cancer Center at the University of Wisconsin, Madison.


      Paul D. Creswell, BA, is a doctoral student in the Department of Population Health Sciences at the School of Medicine and Public Health at University of Wisconsin, Madison.


      Erika W. Hagen, PhD, MS, is a researcher in the Department of Population Health Sciences at the School of Medicine and Public Health at University of Wisconsin, Madison.


      Hilary A. Spear, BA, is a nursing student in the College of Nursing at the University of Colorado, Denver.


      Torsheika Maddox, MS, is a doctoral student in the Department of Sociology and a master's student in the Department of Population Health Sciences at the University of Wisconsin, Madison.


      Thomas DeLeire, PhD, is an Associate Professor in the Department of Population Health Sciences, the La Follette School of Public Affairs, and the Department of Economics at the University of Wisconsin, Madison and the interim Director of the Population Health Institute.