Depression and other psychiatric disorders during the postpartum period have significant clinical implications for both women and their infants (1
). Although existing primary care and epidemiological research offers needed information for enhanced referral and care, research assessing depressive symptoms throughout the postpartum period and evaluating subsequent health implications for both women and their children is needed (2
). This study was designed to assist Family Physicians and other primary care providers in identifying women at risk for postpartum depression, and to evaluate the potential role that postpartum depression may play in subsequent clinical encounters with employed mothers or their child.
Nearly one third of this sample of employed mothers (32.7%) reported significant depressive symptoms at four months postpartum. This estimate is higher than the 10 – 15% point prevalence estimates reported in a previous review of the postpartum depression literature (2
) and the 15% prevalence rate reported from a nationally-representative sample (4
). The heightened rate of significant depressive symptoms in this study could reflect three possibilities. First, the elevated rate could reflect the added strain of combining full-time work and family and the subsequent elevated risk for depression experienced by working mothers (30
). Second, recognizing that mood and anxiety symptoms frequently co-occur (32
), it is possible that the CES-D was picking up on symptoms of both disorders. Consistent with this possibility, Vesga-Lopez and colleagues (4
) reported that 27.5% of postpartum women reported any mood or anxiety disorder. Third, it is possible the CES-D produced too many false positives, perhaps due to elevated somatic symptoms (34
). Although future research will need to explore each explanation, the bottom line remains the same: a substantial proportion of working mothers of infants experience elevated mental health symptoms several months beyond the typical observation period for postpartum depression.
Being classified as having significant depressive symptoms was not equally distributed in our sample. Mothers who were younger, African American, had less than a college degree, were unmarried and/or living in poverty were more likely to show significant depressive symptomatology. These results, which are consistent with previous research not focused on working mothers of infants (4
), suggest that some women are more vulnerable to postpartum depression, perhaps because of insufficient preparation for motherhood, or because of insufficient social or financial supports to help shoulder the task of working full-time while also caring for an infant(36
). It is important that health care providers remain cognizant of these factors so as to more accurately identify women at risk for postpartum depression. Early identification and referral are important to minimize morbidity (5
). Further, monitoring potential depression among women who return to work provides a strong opportunity for patient-centered care because evidence suggests that mothers would like their prenatal and postpartum health care providers to discuss issues surrounding return to work after childbirth (17
The primary contribution of this study is the observed associations between depressive symptoms at 4-months postpartum and subsequent infant and maternal health-related quality of life. Bivariate results showed a higher incidence of gastrointestinal symptoms in children of mothers with significant depressive symptoms than in children of mothers without significant symptoms. These results are similar to effects described by Moses-Kolko and Roth (37
) and they are congruent with research by others (38
) indicating that maternal postpartum depression predicted higher incidence of infant diarrhea. Our multivariate longitudinal analyses also indicated robust associations between significant maternal depressive symptoms and two domains of infant health-related quality of life, infant pain or discomfort and the extent to which infant health concerned the mother. These results are consistent with previous research indicating that postpartum depression was associated with poorer infant health and development (6
). Given the nature of these self-report data, it is not clear if infants of mothers with significant depressive symptoms were, in fact, experiencing more pain and discomfort, or whether these mothers somaticized their infants’ behavior. Regardless, primary health care providers need to be attentive to maternal depression because it will likely result in greater infant health visits; either because the infant is genuinely sick or because the mother believes the child is sick. Indeed, previous evidence suggests that postpartum maternal depression is associated with greater use of health services for infants (8
Analyses revealed little evidence that elevated depressive symptoms during the postpartum period had lasting implications for working mothers’ physical and mental health-related quality of life. Null effects were surprising in light of results from previous research suggesting that postpartum depression predicted excess weight retention (11
), poorer functional status (7
), and greater somatic complaints (12
). Nevertheless, it is possible that the effects of elevated depressive symptoms on health-related quality of life is attenuated for women who self-select back into the fulltime labor force (39
), or that the sheer demands of working fulltime while mothering an infant allows little opportunity for compromised role performance or other domains of health-related quality of life assessed by SF-12. Although replication research and subsequent explorations of possible explanations are needed, these results suggest that significant depressive symptoms may be less debilitating among working mothers than among women more generally.
A primary strength of this study is the longitudinal data, which allowed us to analyze the effects of maternal depressive symptoms during the postpartum period over an extended period of time, providing a unique contribution to the postpartum depression literature. The vast majority of previous longitudinal research on postpartum depression only covers the first few months postpartum, with most only considering the first six weeks of postnatal care. This project, on the other hand, extended 16 months after the infants were born, providing a glimpse at the impact of maternal depression even further into the infant’s life. Furthermore, we analyzed both mother and child health outcomes in relation to maternal depressive symptoms in the postpartum period. There is a lack of previous research that looks at effects on both the mother and child.
Nevertheless, the limitations of this study need acknowledgement. An important limitation is reliance on single sources of data. Although assessment of infant health and well-being ultimately rests on proxy report, heavy reliance on parental report raises potential response biases. Future research using stronger, more clinically endorsed assessments would contribute to this body of research. A second limitation is that our sample only included European and African Americans. There were no other races or ethnicities included in the sample frame, so we do not have information to determine whether other groups of mothers would be more or less likely to screen positive for postpartum depression. Results tell us that African American mothers may be more susceptible to postpartum depression, but we cannot be sure whether or not this trend is similar for other minorities. A third limitation is that there were 104 mothers in the sample frame who could not be contacted thus were not able to participate which may have produced some selection biases.
Limitations notwithstanding, the cross-sectional results of this study suggest that postpartum depression is associated with poorer infant and maternal health-related quality of life. The data clearly suggest that that a large proportion of working mothers experience elevated symptoms of depression, and our longitudinal results show that that significant depressive symptoms during the postpartum period predicts subsequent poorer infant health-related quality of life. Even though further research is needed to determine if the observed relationship is causal, it is likely that lower levels of infant health-related quality of life will elicit additional health care seeking for the child. Consistent with the a basic precept of Family Medicine that effective treatment of an individual requires broader consideration of the family, it is important that health care providers screen and consider the role of postpartum depression when diagnosing and creating a treatment plan for the child.