Research Article: Frequency, trends, and antecedents of severe maternal depression after three million U.S. births

Date Published: February 14, 2018

Publisher: Public Library of Science

Author(s): Urbano L. França, Michael L. McManus, Sharon Dekel.


Postpartum depression carries adverse consequences for mothers and children, so widespread screening during primary care visits is recommended. However, the rates, timing, and factors associated with significant depressive episodes are incompletely understood.

We examined the Healthcare Cost and Utilization Project (HCUP) State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases from California (2005–2011) and Florida (2005–2012). Within 203 million records, we identified 3,213,111 births and all mothers who had hospital encounters for severe depression within 40 weeks following delivery. We identified 15,806 episodes of postpartum depression after 11,103 deliveries among 10,883 unique women, and calculated an overall rate of 36.7 depression- associated hospital visits per 10,000 deliveries. Upward trends were observed in both states, with combined five-year increases of 34%. First depressive events were most common within 30 days of delivery, but continued for the entire observation period. About half (1,661/3,325) of PPD first episodes occurred within 34 days of delivery, 70% (2,329/3,325) by the end of the second month, and 87% (2,893/3,325) before four-months of the delivery. Women with private insurance were less likely to have hospital encounters for depression than women with public insurance and women with depression were much more likely to have had some kind of hospital encounter at some time during their pregnancies. Rates of depression increased with the number of prenatal hospital encounters in a “dose-dependent” fashion: the rate of depression was 17.2/10,000 for women with no prenatal hospital visits, doubling for women with at least one encounter (34.9/10,000), and increasing 7-fold to 126/10,000 for women with three or more encounters during their pregnancies.

Our findings suggest that (1) hospital encounters for post-partum depression are increasing, (2) screening should begin very early and continue for the first year after delivery, and (3) added attention should be given to women who had hospital encounters during their pregnancies.

Partial Text

Untreated maternal depression can have a lasting impact on the health and well-being of children [1]. For this reason, the U.S. Preventative Services Task Force recommends depression screening for pregnant and postpartum women [2] while the American Academy of Pediatrics includes maternal depression within its recommended well-child care schedule [3]. Supporting this recommendation, the Center for Medicare and Medicaid Services has recently emphasized the importance of maternal depression screening and encouraged both Medicaid and non-Medicaid coverage for the practice [4].

We identified 15,806 hospital admissions and emergency visits for depression (8,519 in CA; 7,287 in FL) after 11,103 deliveries among 10,883 unique women. Of these, 3,775 were specifically assigned PPD codes following 3,359 deliveries among 3,325 unique patients. The majority of the encounters, 8,960 (56.7%), consisted of ED visits, 43.2% (6,834) were inpatient admissions, and only 0.01% (12) were in outpatient settings of acute care hospitals. The trends for these conditions are shown in Fig 1, where increases can be seen in both states over the available years. In California during 2006, there were 24.6 hospital encounters per 10,000 deliveries for all depression (PPD: 8.1 per 10,000) and this rate rose 29% to 31.8 per 10,000 deliveries (PPD: 10.9 per 10,000) in 2010 (p < 0.01 for the trends). In Florida, these rates increased 48% from 33.1/10,000 (PPD: 8.2/10,000) in 2006 to 48.9/10,000 (PPD: 14.0/10,000) in 2011 (p < 0.02 for both trends). Combining data from both states, overall 2006–2010 rates rose from 8.1/10,000 to 11.4/10,000 (41%) for PPD and 27.4/10,000 to 36.7/10,000 (34%) for all depression. During the same period, the total number of maternal hospital encounters 40 weeks after delivery increased by 16.9%, from 238,747 (38.4 hospital encounters per 100 deliveries) in 2006 to 258,848 (44.9 hospital encounters per 100 deliveries) in 2010. A higher rate of hospital encounters after delivery, with a higher increase between 2006 and 2010, was observed FL: the rate of hospital encounters was 62.8 per 100 deliveries in FL in 2010, an increase of 19.8% with respect to 2006, compared to 36.1 hospital encounters per 100 deliveries in CA in 2010, an increase of 14.6% during the same period. We defined severe postpartum depression as that marked by symptoms leading to inpatient or outpatient hospital care and then used HCUP data to determine the incidence of severe postpartum depression among 2.6 million women and 3.2 million births. We calculated an overall rate of 36.7/10,000 in 2010 and observed a 34% increase from 27.4/10,000 since 2006. Using synthetic identifiers, we tracked individuals for 40 weeks pre- and post-delivery, observing that hospital encounters for depressive diagnoses were highest in the first month after delivery but continued steadily for 40 weeks thereafter. We also observed that women who had hospital encounters for any reason prior to delivery were much more likely to require hospital care for depression after delivery. Although pre-natal visits for mental health issues most strongly predicted port-delivery depression, regular medical visits were also associated with post-delivery depression in a “dose-dependent” fashion. Finally, uninsured women and those with public insurance were much more likely to appear in hospitals for depression diagnoses than were women with private insurance.   Source:


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