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
services.
KEY WORDS: postpartum; depression; PDSS; native American.

INTRODUCTION methods of screening in historically underrepre-

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

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C 2005 Springer Science+Business Media, Inc.
22
depressed mothers show less affectionate behavior,
respond less to infant cues, and withdraw, or have
hostile/intrusive interactions with their infants (1).
Leifman (3) discusses the affect that maternal de-
pression has on mother–infant interaction, and re-
ports an association between maternal depression
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.
While postpartum depression is often diagnosed
in women with no identified risk factors, recent lit-
erature examines the presence of psychosocial risk
factors in certain populations. Known risk factors
for postpartum depression include a prior history of
postpartum depression, a prior history of depression
or bipolar disorder, a history of severe premenstrual
syndrome, a family history of depression, and recent
stressful events (2). Additional documented risk fac-
tors include child-care stress, poor social support, low
self-esteem and decreased marital satisfaction (4, 5).
To date, literature primarily describes
Caucasian, middle-class populations, leaving a
scarcity of available research exploring minority
populations. Logsdon and Usui (5) conducted a
study examining psychosocial predictors of postpar-
tum depression in groups of middle-class, Caucasian
women, and lower-class African American women
and found no significant differences among the
groups for predictors of postpartum depression.
Amankwaa (6) conducted her qualitative study on
twelve African American women with a history of
postpartum depression in order to address the gap
in literature discussing women of non European-
American background. Her study reiterated the
need for culturally sensitive depression screening
along with an acknowledgement that cultures handle
psychosocial disorders and symptoms differently.
Current literature recognizes postpartum de-
pression screening as an emerging standard of care,
although screening is not routinely implemented
(7, 8) literature discussing elements of the perina-
tal period among native American women is espe-
cially limited. Long and Curry (9) conducted a quali-
tative study examining the beliefs of native American
women about prenatal care. Their findings discussed
the different views of traditional care during preg-
nancy and the Western model of care prescribed to-
day, in the context of assimilation. To the authors
knowledge there have been no studies that exam-
ined routine screening for postpartum depression in
a predominately native American community uti-
Baker, Cross, Greaver, Wei, Lewis, and Corps
lizing the Postpartum Depression Screening Scale
(PDSS). The purpose of the present study is to ex-
amine the prevalence of postpartum depression in
a native American community utilizing cut-offs es-
tablished by the Postpartum Depression Screening
Scale.
METHODS
Postpartum clients at an area health clinic within
Robeson County are screened by a clinic caseworker
at the 6-week postpartum visit utilizing the Postpar-
tum Depression Screening Scale (PDSS) by Beck
and Gable (10). Clients are screened as a part of
the case management component of the Healthy
Start Corps program (funded by U.S. Health Re-
sources Service Administration). The Healthy Start
Corps, housed at the University of North Carolina at
Pembroke in Southeastern North Carolina, provides
follow-up postpartum services for mothers with high-
risk psychosocial issues. Clients are provided with the
screening instrument after completing an informed
consent outlining the possible risks and benefits of
screening. Prior to implementation, procedures and
forms required for screening received approval from
the Institutional Review Board at the University of
North Carolina at Pembroke. Completed screening
forms are scored by the caseworker and transferred
to the Healthy Start Corps worker for data storage,
collection, and follow-up services when indicated.
SAMPLE CHARACTERISTICS
The subjects involved in this analysis include
151 women, aged 16 to 40 years (M = 23.47, SD =
9.95) receiving postpartum health services from a ru-
ral obstetrical clinic from September 2002 to May
2003. A convenience sample was obtained including
all women receiving postpartum services currently
enrolled in the prenatal Baby Love program. Sample
size was pre-determined to include eight months of
screening data. Pregnancies ranged from primigravi-
das to multiparity of seven (M = 2.08, SD = 1.10).
Women were more likely to have delivered vaginally
(67.6%) than via Cesarean section (32.4%), and were
also more likely to be bottle-feeding (83.8%) than ex-
clusively breast feeding (6.5%) or breast-bottle com-
bination feeding (9.5%). Reflective of the racial and
socio-economic make-up of the County, 60.9% of
the sample were American Indian (Lumbee tribe)
(N = 92), 25.8% were African American, and 13.3%
Postpartum Depression
Caucasian or other. Furthermore, 80.7% (N = 121)
had a high school education or less, 72.2% were sin-
gle and 18.5% were married. While no data were
collected on financial status, this community is one
that struggles with issues of poverty and high rates
of unemployment, leading to overall lower socio-
economic status of residents. Data on previous de-
pression history indicates that 84.8% (N = 128) of
women reported no previous depression, with 91.4%
of the total sample stating that they had never been
treated for depression.
INSTRUMENTATION
Three measures were considered for utilization
with the population. The most widespread instru-
ment to date for screening postpartum depression is
the Edinburgh Postnatal Depression Scale (EPDS)
(14). While this scale has documented reliability in
certain populations, some critics have raised con-
cerns about the cultural specificity of the language
and the exclusion of certain diagnostic criteria for de-
pression (10, 11, 12). The Beck Depression Inven-
tory (BDI-II) (13) has been frequently used in lit-
erature exploring postpartum depression, and even
though it has well-documented reliability and valid-
ity in measuring generalized depression, the language
is general, and not reflective of the postpartum pe-
riod. Given the limitations of these two measures,
a decision was made to utilize the Postpartum De-
pression Screening Scale (PDSS) by Beck and Gable
(2002). The PDSS is a 35-item self-report measure
which can be completed within five to ten minutes
by the respondent, and requires a third grade reading
level. The instrument utilizes a seven-item short scale
to indicate whether or not the respondent needs to
complete the full scale. In the present sample 31.8%
(N = 48) of clients completed the full scale.
Higher scores on the PDSS indicate higher de-
grees of depressive symptoms. Total scores are inter-
preted using three cut-off scores indicating 1) normal
adjustment, 2) significant symptoms of postpartum
depression, and 3) positive screening for major post-
partum depression. The PDSS has previously estab-
lished reliability and validity with internal consis-
tency estimates yielding Cronbach’s coefficient alpha
of 0.98 for total score, and content alphas of 0.80 to
0.91 (10). In previous studies, analysis of convergent
validity correlated scores of the PDSS with the EPDS
and BDI-II showed the following: r = 0.79, p < .001,
and r = 0.81, p < .001 respectively (10).
23
RESULTS
In order to obtain a description of sample char-
acteristics such as age, parity, and race, means and
percentages were calculated. In exploring relation-
ships between variables, the chi square statistic was
utilized with the Sommer’s d to explore strength of
significant relationships. For the purpose of analysis,
the categories of significant symptoms and major
postpartum depression were collapsed forming two
cutoffs for score interpretation including normal
adjustment and significant symptoms/postpartum de-
pression. Chi square analysis revealed two variables
that appeared to affect scores; history of depression
and history of being treated for depression. T-tests
were conducted to further explore the relationship
between these variables. The Pearson product-
moment correlation test was utilized to explore
possible correlation between the linear independent
variables of age, level of education, and number of
pregnancies.
The purpose of implementing routine screening
for postpartum depression in this community was to
explore the prevalence of the disorder in a predomi-
nately Native American population. The score range
for the current sample is 7–173 (M = 32.76, SD =
37.17). While most respondents (76.8%) scored
within the normal range, a high number scored within
the range for significant symptoms of postpartum de-
pression (10.6%), and 12.6% (N = 19) scored posi-
tive for symptoms of major postpartum depression,
yielding a combined prevalence rate of 23.2%.
There were no statistically significant results
among the two groups of normal adjustment
and significant symptoms/postpartum depression by
race χ2 (3, N = 151) = 3.56, p = 0.313, marital sta-
tus χ2 (5, N = 116) = 6.51, p = 0.259, type of deliv-
ery (vaginal or cesarean section) χ2 (1, N = 148) =
0.0, p = 0.991, or method of infant feeding χ2 (2, N =
148) = 0.31, p = 0.857. There was no significant cor-
relation between the total score and the variables
of age r = −0.017, p = 0.837, highest level of educa-
tion, r = −0.29, p = 0.728, and number of pregnan-
cies r = −0.040, p = 0.630.
As reported previously in literature on post-
partum depression, there were significant results on
scores obtained through analysis of the effect of
history of depression and history of being treated
for depression. For history of depression χ2 (1, N =
151) = 0.628, p = 0.012, with Sommer’s d = −0.201,
p = 0.038, and history of treatment for depression
χ2 (1, N = 151) = 4.22, p = 0.040, with Sommer’s
24
d = 0.154, p = 0.104. In order to explore this ef-
fect on total score means, t-tests were computed for
the two variables of history of depression and his-
tory of treatment for depression and total scores.
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
without a history of depression (N = 128, M = 29.06)
t(26.37, 151) = 2.38, p = 0.025 (equal variances not
assumed by Levene’s Test for Equality of Variances).
The differences also held for those with a history of
being treated for depression. Those who had a his-
tory of being treated for depression had a mean to-
tal score 31.74 points higher (M = 61.77) than those
without a history of being treated for depression
(M = 30.03) and those differences were statistically
significant t(13.17, 151) = 2.28, p = .040.
DISCUSSION
The purpose of this study was to determine the
prevalence of depressive symptoms that may require
some form of clinical intervention, utilizing a current
screening instrument that had not previously been
used with a predominately native American popu-
lation. Although there is some minor variation, lit-
erature supports an overall incidence of postpartum
depression between 10 and 15% in the general pop-
ulation (1, 2, 15). In the present sample size, the in-
cidence of symptoms of postpartum depression was
over 23%.
In support of previous literature on risk factors,
our sample demonstrates a strong association be-
tween symptoms of depression and history of depres-
sion and being treated for depression (2). This infor-
mation holds clinical importance as a way to target
interventions towards women presenting with a pre-
natal history of depression. These results also hold
sociocultural significance given that the economic cli-
mate of the study area is affected by high rates of
unemployment, significantly impacting the psychoso-
cial functioning of family systems. Limitations of this
study include the lack of data on additional variables
such as maternal health, use of illegal substances, to-
bacco or alcohol use, or family dysfunctions that may
impact psychosocial functioning. It is important to
note that the PDSS is a screening, not diagnostic,
tool.
The findings highlight the importance of imple-
menting routine screening protocols, thus enabling
communities and health care professionals to address
Baker, Cross, Greaver, Wei, Lewis, and Corps
the needs of individual patients and provide the nec-
essary information to ensure follow-up services and
support for a larger population. The PDSS proved to
be a useful instrument for use in this clinical setting.
ACKNOWLEDGMENTS
Research approved by the Healthy Start
CORPS of Pembroke, North Carolina and the
Institutional Review Board at the University of
North Carolina at Pembroke. This project is funded
by the national Healthy Start Program, US Depart-
ment of Health and Human Services, Maternal and
Child Health Bureau. The authors state that this
manuscript represents original work that has not
previously been published.
REFERENCES
1. Beck CT. Recognizing and screening for postpartum de-
pression in mothers of NICU infants. Adv Neonatal Care
2003;3(1):37–46.
2. Maryland Department of Health and Mental Hygiene. Post-
partum depression. US: Department of health and human ser-
vices, office of women’s health [online], 2002 Mar [cited 2003,
Sept 10]. Available from http://www.4woman.gov/editor/
apr02/apr02.htm
3. Leiferman J. The effect of maternal depression symptoma-
tology on maternal behaviors associated with child health.
Health Educ Behav 2002;29(5):596–607.
4. Beck CT. Revision of the postpartum depression predictors
inventory. JOGNN 2002;31(4):394–402.
5. Logsdon CM, Usui W. Psychosocial predictors of postpar-
tum depression in diverse groups of women. West J Nurs Res
2001;23(6):563–574.
6. Amankwaa LC. Postpartum depression among African-
American women. Issues Ment Nurs 2003;24:297–316.
7. Georgiopoulos AM, Bryan TL, Wollan P, Yawn BP. Rou-
tine screening for postpartum depression. J Fam Pract [se-
rial online] 2001 Feb [cited 2003 Sept 10];50(2):[1 screen].
Available from http://www.jfponline.com/content/2001/02/
jfp 0201 01170.asp
8. Morris-Rush JK, Freda MC, Bernstein PS. Screening for post-
partum depression in an Inner-city population. Am J Obstet
Gynecol 2003;188:1217–19.
9. Long CR, Curry MA. Living in two worlds: Native
American women and prenatal care. Health Care For
Women International [serial online] 1998 May-Jun [cited 2003
Jun 25];19(3):205–18.
10. Beck CT, Gable RK. Postpartum Depression Screening Scale.
1st ed. Los Angeles (CA): Western Psychological Services,
2002.
11. Mantle, Fiona. Developing a culture-specific tool to assess
postnatal depression in the Indian community. Br J Commun
Nurs 2003;8(4):176–80.
12. PND Training. Strengths and limitations of the Edinburgh
Postnatal Depression Scale. PND Training [online] 2002
[cited 2002, Aug 26]. Available from http://www.pndtraining.
co.uk/articles/SRSB1.htm
Postpartum Depression
13. Beck AT, Steer RA, Brown GK. BDI-II manual. San Antonio
(TX): The Psychological Corporation, 1996.
14. Cox JL, Holden JM, Sagovsky R. Edinburgh Postnatal De-
pression Scale. Br J Psychiatry 1987;150:782–86.
15. American Psychiatric Association. Postpartum depression
[fact sheet], July, 2001.
25
16. Herrick H. Postpartum depression: Who gets help?. Sta-
tistical brief (Report No:24) Raleigh (NC): Department of
Health and Human Services (US), Division of Public Health,
2002.
17. Beck CT. The effects of postpartum depression on maternal-
infant interaction. Nurs Res 1995;44(5):298–304.
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