Chapter 6: Maternal Mental Health

Maternal Mental Health

“In the future I would like to have more information about how to help prevent postpartum depression.” Depression and anxiety are common mental health conditions with potential for considerable impairment not only in the general population, but also in pregnant and postpartum women and other subpopulations. We examined the extent to which survey participants experienced symptoms for these two conditions, during pregnancy and in the postpartum period, and whether they obtained counseling or treatment for mental or emotional health.

PHQ-4 Background

PHQ-4 Development, and Use Within Survey

“There was no discussion of the possibility of postpartum depression following birth and how to deal with it.” We included the Patient Health Questionnaire for Depression and Anxiety (PHQ-4) Kroenke, K., Spitzer, R.L., Williams, J.B.W., & Löwe, B. (2009). An Ultra-Brief Screening Scale for Anxiety and Depression: The PHQ-4. Psychosomatics, 50(6), 613–621. Retrieved 2 April 2018, from here in our survey questionnaire. This consists of two subscales, each with two questions to assess depression and anxiety, respectively. These “ultra-brief” screeners have been separately validated as a two-question Patient Health Questionnaire (PHQ-2) screener and a two-question General Anxiety Disorder (GAD-2) screener, and validated in combination as PHQ-4. The PHQ-2, the GAD-2 and the more recent PHQ-4 are respected tools that are widely used in clinical practice. In clinical settings, a positive screen for depression or anxiety is generally followed by either referral for direct clinical assessment by a qualified mental health professional or use of a more extensive screening tool. While not diagnostic of depression and anxiety, they have been shown to be closely related to formal diagnoses and to be highly correlated with other well-established functional status instruments. Depression and anxiety can independently affect functionality and can occur together. The composite PHQ-4 is considered to be a marker of psychological distress. It has been studied in the general population and in many distinctive populations, but we are not aware of previous studies of PHQ-4 in childbearing women.

PHQ-4 identifies symptoms of anxiety and depression in the 2 weeks before administration of the instrument. We contacted our study participants in the postpartum period and asked the four questions in two contexts: “during your recent pregnancy” and “in the past 2 weeks” with reference to the time of completing the survey. We positioned the pregnancy questions earlier in the questionnaire with other questions about pregnancy, and questions about “the past 2 weeks” later among questions about postpartum views and experiences. Survey participants completed questionnaires when their index babies were from 2 to 11 months old.

PHQ-4 Content and Scoring

Table 10 reproduces the PHQ-4 questions. Response choices were “never,” “sometimes,” “usually” and “always.” These responses are scored 0 to 3, with possible score for each subscale of 0 to 6. Scores of 3 and higher are considered a positive screen and an indication of the presence of symptoms for each subscale.

When used as a composite with potential scores ranging from 0 to 12, developers recommend the following gradations of potential severity of psychological distress: 0 to 2 – normal, 3 to 5 – mild, 6 to 8 – moderate and 9 to 12 – severe. In a primary care population, increasing levels of severity were associated with substantial declines in functioning on all six subscales of the Short Form General Health Survey (SF-20): mental health, social functioning, general health perception, role functioning, bodily pain and physical functioning.


Table 10


Positive Screens for Anxiety and Depression

Prenatal and Postpartum Scores on GAD-2 and PHQ-2

“There is lots of emphasis on being pregnant after the age of 37. At times, the concern adds unnecessary stress on the mother. … The radiologist added undue worry. I have friends around the same age who have experienced tremendous stress brought about by overly concerned practitioners.” When asked to recall their feelings during pregnancy, 21% of survey participants met the screening criteria for anxiety, and 11% met screening criteria for depression. Rates of positive screens for both conditions were lower when postpartum women were asked to respond to the four questions with respect to the 2 weeks prior to the survey: 9% for anxiety and 7% for depression (Table 11).


Table 11


While we cannot definitively explain the decline in positive screens and symptoms between pregnancy and in the two postpartum weeks before responding to the survey for both conditions, plausible reasons for future investigation include one or more of the following:

  • Measurement: different impact on responses to “over the last 2 weeks” and “during your recent pregnancy” when asked in the same survey, including the possibility that responses to questions about pregnancy are filtered through a respondent’s present situation.
  • Natural history: true decline over time, with postpartum survey completion occurring up to 11 months after birth, including the possibility that any anxiety about the birth process and whether the baby would be born healthy would primarily occur in the prenatal period.
  • Intervention: effect of counseling or treatment, which respondents experienced at higher rates in the postpartum period than during pregnancy at all elevated levels of distress.
  • Intervention: effect of postpartum use of medications for anxiety and/or depression that women may not have felt comfortable taking during pregnancy.
  • Possible protective effect of breastfeeding against maternal mood disorders. Figueiredo, B., Dias, C.C., Brandão, S., Canário, C., & Nunes-Costa, R. (2013). Breastfeeding and postpartum depression: state of the art review. Jornal de Pediatria, 89(4), 332-338. Retrieved 31 May 2018, from here;

    Kendall-Tackett, K. (2015). A new paradigm for depression in new mothers: the central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. International Breastfeeding Journal, 2(6). Retrieved 31 May 2018 from here

Subgroup Variation in Positive Screens for Anxiety and Depression

“After giving birth, I was full of anxiety. They should have someone to comfort women feeling that way.” Figures 62 and 63 show subgroup differences in the proportion of women screening positive for the two conditions and two time periods.

For prenatal depression, a notably higher proportion of Black women met the screening cutoff than other racial/ethnic groups (p < .01). For depression during pregnancy, women with Medi-Cal coverage were more likely to screen positive than women with private insurance (p < .01).

Relationship Between Depression and Anxiety, During Pregnancy and in the Postpartum Period.

“More attention needs to be paid to ‘postpartum depression’ and anxiety disorders after birth.” Table 12 indicates a strong relationship between positive screens for depression and anxiety in the prenatal period. Only 4% of women who did not meet the screening cutoff for prenatal anxiety met the criteria for prenatal depression, while almost 2 in 5 (38%) who met the anxiety screening criteria also met the screening criteria for depression risk.


Table 12


As shown in Table 13, a similar relationship exists between screening scores on the depression and anxiety scales in the postpartum period, with only 2% of women meeting the depression criteria when they did not meet the anxiety criteria. More than half of women who met the postpartum anxiety risk screening criteria also met the depression criteria.


Table 13


Relationship Between Prenatal and Postpartum Anxiety and Between Prenatal and Postpartum Depression

“After birth, I cried for weeks. I felt so down I had no support from my OB doctor. I didn’t get to see her after 6 weeks. It would be nice if there was more support for new mommies.” There is also a strong relationship between screening scores for both anxiety and depression during the different time periods. Once again, it is important to recognize that the questions on prenatal and postpartum mental health were both administered to women in the postpartum period when they were asked to recall their feelings prenatally, so some of the overlap may be related to women viewing their prenatal moods through their current experiences.

In terms of the relationship between prenatal and postpartum anxiety, a woman who screened positive for anxiety in the prenatal period was more than five times as likely (27% compared to 5%) to have symptoms of anxiety in the postpartum period than women without anxiety symptoms prenatally (Table 14).


Table 14


In terms of depression, the difference is quite pronounced, with 31% of women meeting the prenatal criteria also screening positive for depression in the postpartum assessment, compared with only 3% of women who did not meet the criteria for prenatal depression (Table 15).


Table 15


Psychological Distress Symptom Severity

“There has to be more of an emphasis on postnatal care and catching early signs of postpartum depression, anxiety, and a mother’s lack of connection to her baby. It is sad that there is not enough of a discussion or research on postpartum depression and a lack of normalizing this illness. More women would come forward, in my opinion, if it was normalized and spoken of immediately after the birth of a child.” The composite PHQ-4 scale can be used as a marker for severity of psychological distress. Prenatally, 4% of all survey participants met screening criteria for severe psychological distress. An additional 10% were in the moderate range, and 28% were in the mild range. The remaining 58% were in the normal range.

When looking at subgroups, Black women were particularly affected in comparison with other racial/ethnic groups, with more than 1 in 4 Black women scoring in the severe or moderate range for psychological distress during pregnancy (p < .01). Likewise, women with Medi-Cal scored as having more severe and moderate psychological distress prenatally than women with private insurance (p < .01) (Figure 64).

In the postpartum period, 2% of survey participants scored at the level of severe psychological distress, while another 5% were in the moderate range and 19% were in the mild range. Three-quarters (75%) were in the normal range.

Subgroup differences in the postpartum period were not statistically significantly different, though 11% of Black women scored as having moderate (7%) or severe (4%) levels of distress (Figure 65).

Consulting a Professional for Mental Health Support

“Since having experienced postpartum depression I have come to discover that many of my friends have had the same experience. I would have been able to get treatment much sooner if it had been discussed sooner in the hospital.” We asked all women if they had received any counseling or treatment for their emotional or mental well-being during their pregnancy or in the postpartum period. One in nine (11%) reported she had gotten help during pregnancy, while 13% reported receiving postpartum support. There was a strong interrelationship between the two, with 70% of women who received prenatal help also receiving support in the postpartum period, while only 5% of women who did not receive prenatal support reported getting help postpartum.

There was a strong relationship between meeting the screening criteria for anxiety or depression and reported support from a professional. For women meeting the screening criteria for either anxiety or depression during pregnancy, the reported level of receiving help was twice that of those not meeting the criteria. For women in the postpartum period, the chances were more than three times higher that those meeting the screening criteria were receiving help. Nonetheless, among women with positive anxiety or depression screens during pregnancy, only about 1 in 5 reported receiving help; and among women with positive screens in the postpartum period, only about 1 in 3 reported receiving help. About 1 woman in 10 reported that she had received counseling for emotional or mental well-being while not screening positive for these conditions (Table 16).


Table 16


“There needs to be more measures taken to prevent PPD and places for mothers to go for help without feeling stigmatized for it.” Figure 66 depicts the proportion of women screening positive for the two conditions who did not and did receive counseling or treatment for emotional or mental well-being, during pregnancy and since giving birth. As noted, about 1 in 5 received such help during pregnancy, and about 1 in 3 since giving birth, with the great majority therefore not getting such help.

“I was feeling bad . ... I was crying and a nurse came in and saw me and they did a questionnaire to know if I was going through post-partum depression.” Figure 67 shows the proportion of women receiving counseling or treatment at each PHQ-4 level of severity of psychological distress, both during pregnancy and since giving birth. For both time periods, women’s use of such services increased as the severity of distress increased (p < .01 in each case). At each level of severity, a greater proportion got help postpartum compared with during pregnancy. A small proportion of women (7% prenatal; 8% postpartum) with normal levels of psychological distress received such help, and the percentage receiving help only rose to as high as 28% during pregnancy and 50% postpartum for women reporting a severe level of psychological distress.

While receiving prenatal or postpartum counseling was not significantly related to type of insurance (14% for private; 12% Medi-Cal), there were differences across racial/ethnic groups in terms of postpartum counseling, with White women (17%) most likely to report counseling followed by Black women (15%), Latinas (11%) and Asian and Pacific Islander women (9%) (p < .01).

Using Medication for Anxiety and Depression

We asked women if they were taking any medications for anxiety or depression at the time of the survey, and 5% reported that they were. This varied strongly by the postpartum mental health as measured by PHQ-4 severity categories, with only 2% in the normal range taking medication compared with 45% who were in the severe range (p < .01). Likewise, those who met the screening criteria for postpartum anxiety (25%) or depression (27%) were far more likely to be taking medication than those who did not meet the screening criteria for either problem (3% each) (p < .01). As noted above, while those who most clearly met the screening criteria for a mental health problem were far more likely to be taking medications, fewer than half of those women in the most severe category of the PHQ-4 were on medications for their problems. When asked if their medication was for anxiety or depression, a majority (60%) of those taking medication reported it was for both.

Not surprisingly, there was a strong relationship between women getting professional help and women taking medications. More than 1 in 4 (27%) of women receiving postpartum counseling reported taking medications compared with only 1% among women not in counseling. A demographic pattern similar to that for receipt of counseling was seen in terms of taking medications, with a non-significant difference in medication use by types of insurance coverage (private 6%; Medi-Cal 4%) and larger differences across racial/ethnic groups, with White women most likely to take medication (10%) compared to Black women (4%), Latina women (3%) and Asian and Pacific Islander women (2%) (p < .01).

Social Support and Psychological Distress

“New moms need to feel more supported when they are dealing with postpartum depression.” In Chapter 5, we discussed respondents’ reports of their access to sources of emotional and practical support since giving birth. There was a clear relationship between receiving such support and PHQ-4 level of severity of psychological distress. Among those in the “normal” category, 62% of the women reported receiving emotional support “always.” The rate of receiving such support “always” dropped across PHQ-4 categories, with 41% in the “mild” severity category, 38% in the “moderate” severity category and 25% in the “severe” category reporting they always had emotional support (p < .01). A similar pattern was seen in terms of practical support. Combining the emotional and practical support variables, we found 54% of respondents who reported always receiving both emotional and practical support were in the “normal” PHQ-4 category, while less than 1% in the “severe” category reported always receiving both types of support (p < .01).

Overall, it appears that very large proportions of childbearing women who were facing apparent mental health challenges were not receiving standard forms of treatment and also had limited sources of emotional and practical support.