Perinatal depression is defined as depression which has either originated during pregnancy or one year post child birth. The overall prevalence of perinatal depression is estimated to be 14.5% percent of all the pregnancies in the United States. The estimated prevalence of perinatal depression in African American women is higher than white women.
Perinatal depression is multi factorial. Major risk factors for perinatal depression are undiagnosed depression in the antenatal period, existing major depressive disorder, past history of pregnancy with post-partum depression. The main risk factors hypothesized are low socio-economic status, social isolation, increased prevalence of intimate partner violence, increased number of unwanted pregnancies, increased religiosity, cultural factors such as stigma associated with seeking mental health services, lack of social support and social disengagement, increased high risk behavior such as smoking, alcoholism and drug abuse during pregnancy, increased prevalence of HIV/AIDS and self perceived discrimination.
Studies show that African American women from inner city areas have GED education and a few women have a college degree. Unwanted pregnancy in teenage, lack of access to emergency contraceptives, and decreased utilization of abortion services are the causes for higher rates of high school dropouts in these women. Food, housing and job insecurities are more often seen in women from inner city. Odd work hours, lack of insurance or under insurance, high strain jobs have adverse effects on the health of the mother. Unsafe neighbourhoods and lack of supermarkets can limit the access to fresh fruits and vegetables. Most women depend on food stamps for their monthly groceries.
Poor Health, Depression
Social isolation reported by women with perinatal depression. Studies show that most women are single mothers with no boyfriends or husbands. Lack of social support and social disengagement are other social barriers experienced by these women. Lack of knowledge on parenting, nutrition, contraception during pregnancy, services available through programs like Healthy Start, WIC and how to navigate through these systems for health care are the major areas where support services are either missing or not easily available.
Many African American women are either victims of physical, emotional, sexual or more than one form of intimate partner violence. Rape and incest are very commonly reported forms of sexual abuse. Intimate partner violence can result in low self esteem and make women more prone to depression during pregnancy. Also, perpetrators are more likely to be drug abusers and may forcefully expose the women to drugs.
The unmet need for emergency contraceptive in African American women is higher than white women. The rate of elective abortions in African American women is lower than white women. The barriers to emergency contraceptive are cost, lack of information about the timing of emergency contraceptive use, cultural barriers such as guilt and shame. It is estimated that the prevalence of unwanted pregnancy in the United States is 50%. The average age of motherhood in African American women is in early 20s versus late 20s and mid 30s for white women. Also of all the uninsured or underinsured mothers, majority are African American.
Studies suggest that African American women prefer psychotherapy compared to pharmacotherapy. Black women are more likely to attend church than white women and they approach religious leaders in the church for support. Increased religiosity is one of the driving reasons for decreased and less frequent abortions in African American women and increased number of unwanted pregnancies. Many orthodox catholic churches do not sanction contraceptive use in any form and promote abstain only methods for contraception. Some studies suggest that utilizing mental health is perceived as a social stigma in African American women especially among Haitians.
High risk behaviors such as smoking and using street drugs during pregnancy are more prevalent in African American women. These women are more likely to have past history of involvement in drug trafficking and many have pending eviction or utility cuts. It is difficult to tease out whether depression caused the use of drugs or the use of drugs caused depression.
Public Health impact
Complications of perinatal depression are placental abnormalities, spontaneous abortions and pre-eclampsia. Depressed mothers have poor mother to child attachment and breast feed less frequently. Perinatal depression increases maternal morbidity and decreases overall well being by causing daily life impairment. Depressed mothers have increased pre term birth associated with high rates of low births. The infants of depressed mothers have higher prevalence of perinatal birth complications and more frequent NICU admissions. Some studies suggest that these infants may face developmental issues and may not grow to appropriate percentile for age. As depressed mothers feed their infants less frequently, there can be an increased risk of diarrhea due to bottle feeds.
Healthy Start Initiative is a federal initiative to provide mental health services for low income African American women. poor referral and use of mental health services
Including support services for mental health
The barriers experienced by the African American women can be structural, knowledge based and attitudinal. The structural barriers can range from lack of coverage by insurance, inability to pay, inadequate child care, transportation difficulties and distance to travel to clinic. The commonly seen knowledge barriers are lack of time, not knowing whom to contact, how to set up and appointment, not knowing what treatment might be the best for oneself. The attitudinal barriers include worrying what others would think, concerns about effective help one can get, lack of family support for getting the treatment and difficulty in becoming motivated to seek treatment.
Problem solving education
Medication is temporary
Skills can be used over life time
Negative life events can influence mental health
Case managers can play the role of problem solving education
Administration of BECK test. Mild to moderate depression can be eligible for the problem solving education. Severe depression can be provided with engagement interview to help navigate through mental health service
Describe problem solving education
Describe engagement interview
Focus groups case managers, women receiving problem solving education, engagement interview
Culturally acceptable, more open ended
Provides something for everybody
Decreases the burden on community mental health centres
Can improve the utilization of mental health services
Breast feeding support groups
Social support group
Policy level funding to train the case managers
Church based activities
Education on contraception
Breastfeeding, abortion support groups
Weak problem solving skills and life problems make a person more prone to depression. There is also reverse causation, as depression increases, the ability to identify and solve problem decreases. Problem solving skills will empower the women to have a sense of control on their problems and use them in the future to prevent depression. Problem solving therapy will help women identify their problems and find realistic solutions to them. It will also provide women with a systematic problem-solving strategy.
"Engagement interview is an individualized, psychosocial intervention, based on an integration of principles and techniques of ethnographic interviewing (EI) and motivational interviewing (MI)." This methodology can address cultural barriers experienced by low income women and offer a therapeutic strategy to engage women in mental health services. The interview is based on open ended questions technique and is delivered over 45 to 60 minutes to meet the specific needs of the client. The motivational components address working with ambivalence. Ethnographic principles on the other hand help to explore in a non judgmental manner the values and experiences of the clients.
- Gaynes BN, G.N., Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, Brody S, and M. WC., Perinatal depression: prevalence, screening accuracy, and screening outcomes. Evid Rep Technol Assess (Summ), 2005 Feb. 119: p. 1-8.
- Sit DK, F.C., Svidergol D, White J, Wimer M, Bish B, Wisner KL, Best practices: an emerging best practice model for perinatal depression care. Psychiatr Serv., 2009 Nov. 60(11): p. 1429-31.
- O'Mahen, H.A. and H.A. Flynn, Preferences and perceived barriers to treatment for depression during the perinatal period. J Womens Health (Larchmt), 2008. 17(8): p. 1301-9.