Birth Matters: Examining Contextual Risk and Protective Factors for Maternal Postpartum Depression

Abstract

The transition into motherhood can be a challenging time for many women as they traverse the vast physical, social, and emotional changes that occur during pregnancy, birth, and the postpartum period. Postpartum depression (PPD) is one of the most common complications after childbirth. Not only is PPD a debilitating condition that severely disrupts a mother’s day to day functioning, but it can negatively impact child development and family health and has many broad implications for public health. While the etiology of PPD is still unclear in the research literature, it is likely a constellation of biological, environmental, and cultural risk factors coupled with psychosocial life stressors that impact the risk of PPD. The focus of my dissertation is the gap in research in understanding how events that occur during birth itself and contextual factors around birth may increase the risk of maternal PPD. This dissertation consists of three epidemiological studies that leverage national and statewide data from the Pregnancy Risk Assessment and Monitoring System (PRAMS). Quantitative analytic methods were employed to assess how multiple contextual factors in the birthing experience may act as risk or protective factors for maternal PPD.

In Chapter 1, we investigated how having a cesarean section (C-section) delivery influenced the risk of post-partum depressive symptoms, using a large and nationally representative sample of women. In this study, we found that women in the study sample who had a first-time C-sections had higher odds of having post-partum depressive symptoms compared to women who had a vaginal delivery. These findings persisted even after adjusting for clinically relevant covariates and the most prominent risk factors for post-partum depression. These results were consistent and similar among first-time mothers and mothers with no prior history of depression.

In Chapter 2, focusing on a different contextual factor during birth, we investigated whether utilizing a midwife or doula, as opposed to standard obstetric care, impacted a mother’s risk of having a surgical cesarean delivery. From our quantitative analysis we found that women in the study sample who had care from a doula or midwife had a modest decrease in risk of a C-section compared to women who did not have doula or midwifery support. This decrease in risk was most noticeable for women who had previously had a C-section, as women who had a doula or midwife were more likely to successfully have a vaginal birth after cesarean (VBAC) compared to women who did not.

In the final study in Chapter 3, we examined the intersectional relationship and collective influence of racial and ethnic identity and maternal nativity on risk of experiencing PPD symptoms. From the quantitative analyses, we found that the prevalence and risk of PPD symptoms varied significantly by race/ethnicity and nativity status, with the highest risk present among those born outside of the US. Most racial/ethnic minority mothers in our sample, both US-born and non-US born, had a higher risk of PPD symptoms compared to US-born non-Hispanic White mothers. From the stratified analyses we found that most immigrant mothers had higher risk of PPD symptoms compared to their US-born racial/ethnic counterparts. These differences in risk remained even after accounting for socioeconomic, medical, and mental health risk factors. The potential explanatory pathways and reasons for the stark disparities in maternal postpartum depression observed in our study by nativity and race/ethnicity are elaborated upon in our discussion.

When these dissertation studies are taken together, the findings illustrate how birth context can matter for maternal mental health. From the first study, it was evident that the method of delivery and birth can be a protective or risk factor for PPD symptoms. The second study expanded these findings to suggest that the type of birth attendant impacts the method of birth. The last study illustrated how where the mother herself was born mattered for postpartum mental health and recovery. This research fills gaps in the current research literature on contextual risk factors and protective predictors of PPD in US women. It adds to a growing body of research in this area that ultimately may lead to improvements in maternal health and wellbeing.