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Maternal and Child Health Journal, Vol. 9, No.

1, March 2005 (
C 2005)

DOI: 10.1007/s10995-005-2448-2

Prevalence of Postpartum Depression

in a Native American Population

Lisa Baker, PhD, LCSW,1,2 Sandra Cross, EdD,1 CHES, Linda Greaver, MA,1
Gou Wei, PhD,1 Regina Lewis, ADBA,1 and Healthy Start CORPS1

Objectives: Data were collected on postpartum depression from 151 women, ages 16–40 years
who received postpartum health services from a rural obstetrical clinic in North Carolina
between September 2002 and May 2003. Reflective of the racial and socio-economic make-
up of the county, 60.9% of the sample were American Indian (Lumbee tribe) 25.8% were
African American and 13.3% were Caucasian or other. Methods: The Postpartum Depres-
sion Screening Scale (PDSS) was utilized to explore the prevalence of postpartum depres-
sion requiring clinical intervention in a largely unexplored population, minority women.
Results: The incidence of postpartum depression symptoms was over 23%, which is signif-
icantly higher than even the most liberal estimates in other populations. As with previous
literature on risk factors, the sample demonstrates a strong association between symptoms
of depression, history of depression and receiving treatment for depression. Conclusions:
The PDSS proved to be a clinically useful tool in this setting. Findings support the impor-
tance of implementing routine screening protocols to guide practice and implement support
KEY WORDS: postpartum; depression; PDSS; native American.

INTRODUCTION methods of screening in historically underrepre-

sented populations.
The postpartum period is marked by profound Postpartum depression is a psychological disor-
physical and emotional changes for the mother. der affecting between 10 and 15% of women during
While the concept of postpartum depression or post- the postpartum period (1, 2, 15). It includes symp-
partum blues is not new, recent attention to other toms such as sadness, tearfulness, lack of motivation,
types of postpartum emotional responses, including diminished interest in food or self-care, trouble con-
postpartum psychosis, anxiety disorders, and even centrating, and loss of interest in the new baby. In
post traumatic stress response highlights the impor- contrast, postpartum blues affects as many as 70%
tance of effective screening. The absence of new of new mothers who exhibit transitory symptoms
tools for screening postpartum depression, along (not progressing past two weeks postpartum) includ-
with the lack of literature reflecting the incidence ing tearfulness, mood swings, and feelings of sad-
of postpartum depression in minority populations ness. While most symptoms of postpartum depres-
has driven research agendas to evaluate current sion manifest prior to 6 weeks, diagnostic guidelines
include manifestations up to one year postpartum. It
is of special concern that postpartum depression con-
University of North Carolina at Pembroke, Pembroke, North tinues to be significantly under-diagnosed and under-
treated, given the potentially profound affect on the
Correspondence should be addressed to Dr. Lisa Baker, Depart-
ment of Sociology, Social Work, and Criminal Justice, University
mother-infant dyad and family system (1, 17). Meta-
of North Carolina at Pembroke, P.O. Box 1510, Pembroke, North analysis on data examining the interaction between
Carolina 28372; e-mail: depressed mothers and their infants supports that

C 2005 Springer Science+Business Media, Inc.
22 Baker, Cross, Greaver, Wei, Lewis, and Corps

depressed mothers show less affectionate behavior, lizing the Postpartum Depression Screening Scale
respond less to infant cues, and withdraw, or have (PDSS). The purpose of the present study is to ex-
hostile/intrusive interactions with their infants (1). amine the prevalence of postpartum depression in
Leifman (3) discusses the affect that maternal de- a native American community utilizing cut-offs es-
pression has on mother–infant interaction, and re- tablished by the Postpartum Depression Screening
ports an association between maternal depression Scale.
and engaging in risk taking behaviors with the child
such as not administering vitamins to the child, ma-
ternal tobacco smoking, and not using appropriate
child safety restraints.
Postpartum clients at an area health clinic within
While postpartum depression is often diagnosed
Robeson County are screened by a clinic caseworker
in women with no identified risk factors, recent lit-
at the 6-week postpartum visit utilizing the Postpar-
erature examines the presence of psychosocial risk
tum Depression Screening Scale (PDSS) by Beck
factors in certain populations. Known risk factors
and Gable (10). Clients are screened as a part of
for postpartum depression include a prior history of
the case management component of the Healthy
postpartum depression, a prior history of depression
Start Corps program (funded by U.S. Health Re-
or bipolar disorder, a history of severe premenstrual
sources Service Administration). The Healthy Start
syndrome, a family history of depression, and recent
Corps, housed at the University of North Carolina at
stressful events (2). Additional documented risk fac-
Pembroke in Southeastern North Carolina, provides
tors include child-care stress, poor social support, low
follow-up postpartum services for mothers with high-
self-esteem and decreased marital satisfaction (4, 5).
risk psychosocial issues. Clients are provided with the
To date, literature primarily describes
screening instrument after completing an informed
Caucasian, middle-class populations, leaving a
consent outlining the possible risks and benefits of
scarcity of available research exploring minority
screening. Prior to implementation, procedures and
populations. Logsdon and Usui (5) conducted a
forms required for screening received approval from
study examining psychosocial predictors of postpar-
the Institutional Review Board at the University of
tum depression in groups of middle-class, Caucasian
North Carolina at Pembroke. Completed screening
women, and lower-class African American women
forms are scored by the caseworker and transferred
and found no significant differences among the
to the Healthy Start Corps worker for data storage,
groups for predictors of postpartum depression.
collection, and follow-up services when indicated.
Amankwaa (6) conducted her qualitative study on
twelve African American women with a history of
postpartum depression in order to address the gap SAMPLE CHARACTERISTICS
in literature discussing women of non European-
American background. Her study reiterated the The subjects involved in this analysis include
need for culturally sensitive depression screening 151 women, aged 16 to 40 years (M = 23.47, SD =
along with an acknowledgement that cultures handle 9.95) receiving postpartum health services from a ru-
psychosocial disorders and symptoms differently. ral obstetrical clinic from September 2002 to May
Current literature recognizes postpartum de- 2003. A convenience sample was obtained including
pression screening as an emerging standard of care, all women receiving postpartum services currently
although screening is not routinely implemented enrolled in the prenatal Baby Love program. Sample
(7, 8) literature discussing elements of the perina- size was pre-determined to include eight months of
tal period among native American women is espe- screening data. Pregnancies ranged from primigravi-
cially limited. Long and Curry (9) conducted a quali- das to multiparity of seven (M = 2.08, SD = 1.10).
tative study examining the beliefs of native American Women were more likely to have delivered vaginally
women about prenatal care. Their findings discussed (67.6%) than via Cesarean section (32.4%), and were
the different views of traditional care during preg- also more likely to be bottle-feeding (83.8%) than ex-
nancy and the Western model of care prescribed to- clusively breast feeding (6.5%) or breast-bottle com-
day, in the context of assimilation. To the authors bination feeding (9.5%). Reflective of the racial and
knowledge there have been no studies that exam- socio-economic make-up of the County, 60.9% of
ined routine screening for postpartum depression in the sample were American Indian (Lumbee tribe)
a predominately native American community uti- (N = 92), 25.8% were African American, and 13.3%
Postpartum Depression 23

Caucasian or other. Furthermore, 80.7% (N = 121) RESULTS

had a high school education or less, 72.2% were sin-
gle and 18.5% were married. While no data were In order to obtain a description of sample char-
collected on financial status, this community is one acteristics such as age, parity, and race, means and
that struggles with issues of poverty and high rates percentages were calculated. In exploring relation-
of unemployment, leading to overall lower socio- ships between variables, the chi square statistic was
economic status of residents. Data on previous de- utilized with the Sommer’s d to explore strength of
pression history indicates that 84.8% (N = 128) of significant relationships. For the purpose of analysis,
women reported no previous depression, with 91.4% the categories of significant symptoms and major
of the total sample stating that they had never been postpartum depression were collapsed forming two
treated for depression. cutoffs for score interpretation including normal
adjustment and significant symptoms/postpartum de-
pression. Chi square analysis revealed two variables
INSTRUMENTATION that appeared to affect scores; history of depression
and history of being treated for depression. T-tests
Three measures were considered for utilization were conducted to further explore the relationship
with the population. The most widespread instru- between these variables. The Pearson product-
ment to date for screening postpartum depression is moment correlation test was utilized to explore
the Edinburgh Postnatal Depression Scale (EPDS) possible correlation between the linear independent
(14). While this scale has documented reliability in variables of age, level of education, and number of
certain populations, some critics have raised con- pregnancies.
cerns about the cultural specificity of the language The purpose of implementing routine screening
and the exclusion of certain diagnostic criteria for de- for postpartum depression in this community was to
pression (10, 11, 12). The Beck Depression Inven- explore the prevalence of the disorder in a predomi-
tory (BDI-II) (13) has been frequently used in lit- nately Native American population. The score range
erature exploring postpartum depression, and even for the current sample is 7–173 (M = 32.76, SD =
though it has well-documented reliability and valid- 37.17). While most respondents (76.8%) scored
ity in measuring generalized depression, the language within the normal range, a high number scored within
is general, and not reflective of the postpartum pe- the range for significant symptoms of postpartum de-
riod. Given the limitations of these two measures, pression (10.6%), and 12.6% (N = 19) scored posi-
a decision was made to utilize the Postpartum De- tive for symptoms of major postpartum depression,
pression Screening Scale (PDSS) by Beck and Gable yielding a combined prevalence rate of 23.2%.
(2002). The PDSS is a 35-item self-report measure There were no statistically significant results
which can be completed within five to ten minutes among the two groups of normal adjustment
by the respondent, and requires a third grade reading and significant symptoms/postpartum depression by
level. The instrument utilizes a seven-item short scale race χ2 (3, N = 151) = 3.56, p = 0.313, marital sta-
to indicate whether or not the respondent needs to tus χ2 (5, N = 116) = 6.51, p = 0.259, type of deliv-
complete the full scale. In the present sample 31.8% ery (vaginal or cesarean section) χ2 (1, N = 148) =
(N = 48) of clients completed the full scale. 0.0, p = 0.991, or method of infant feeding χ2 (2, N =
Higher scores on the PDSS indicate higher de- 148) = 0.31, p = 0.857. There was no significant cor-
grees of depressive symptoms. Total scores are inter- relation between the total score and the variables
preted using three cut-off scores indicating 1) normal of age r = −0.017, p = 0.837, highest level of educa-
adjustment, 2) significant symptoms of postpartum tion, r = −0.29, p = 0.728, and number of pregnan-
depression, and 3) positive screening for major post- cies r = −0.040, p = 0.630.
partum depression. The PDSS has previously estab- As reported previously in literature on post-
lished reliability and validity with internal consis- partum depression, there were significant results on
tency estimates yielding Cronbach’s coefficient alpha scores obtained through analysis of the effect of
of 0.98 for total score, and content alphas of 0.80 to history of depression and history of being treated
0.91 (10). In previous studies, analysis of convergent for depression. For history of depression χ2 (1, N =
validity correlated scores of the PDSS with the EPDS 151) = 0.628, p = 0.012, with Sommer’s d = −0.201,
and BDI-II showed the following: r = 0.79, p < .001, p = 0.038, and history of treatment for depression
and r = 0.81, p < .001 respectively (10). χ2 (1, N = 151) = 4.22, p = 0.040, with Sommer’s
24 Baker, Cross, Greaver, Wei, Lewis, and Corps

d = 0.154, p = 0.104. In order to explore this ef- the needs of individual patients and provide the nec-
fect on total score means, t-tests were computed for essary information to ensure follow-up services and
the two variables of history of depression and his- support for a larger population. The PDSS proved to
tory of treatment for depression and total scores. be a useful instrument for use in this clinical setting.
There were statistically significant differences be-
tween the mean scores for those groups with a his-
tory of depression (N = 23, M = 53.35) and those ACKNOWLEDGMENTS
without a history of depression (N = 128, M = 29.06)
t(26.37, 151) = 2.38, p = 0.025 (equal variances not Research approved by the Healthy Start
assumed by Levene’s Test for Equality of Variances). CORPS of Pembroke, North Carolina and the
The differences also held for those with a history of Institutional Review Board at the University of
being treated for depression. Those who had a his- North Carolina at Pembroke. This project is funded
tory of being treated for depression had a mean to- by the national Healthy Start Program, US Depart-
tal score 31.74 points higher (M = 61.77) than those ment of Health and Human Services, Maternal and
without a history of being treated for depression Child Health Bureau. The authors state that this
(M = 30.03) and those differences were statistically manuscript represents original work that has not
significant t(13.17, 151) = 2.28, p = .040. previously been published.

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