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Pregnancy Risk Assessment Monitoring System (PRAMS): PRAMS and
Postpartum Depression |
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Postpartum Depression
Depression among mothers in the months after delivery has surfaced as an
important maternal and child health concern. Data from three states indicate
that nearly 12% of women reported being moderately depressed after they
delivered their baby, and 6% reported being very depressed after delivery.1
In addition to directly influencing the emotional wellbeing of mothers,
postpartum depression (PPD) has been shown to affect marital relationships,
mother–infant bonding, and infant behavior.1–4
PRAMS and Self-Reported Postpartum Depression
Data from the Pregnancy Risk Assessment Monitoring System (PRAMS) can be used
to estimate the prevalence of self-reported postpartum depression (SRPPD*)
and identify trends in and risk factors for SRPPD. PRAMS data can also be
used to monitor progress toward meeting the Healthy People 2010 developmental
objective to reduce PPD.5
In 2000, seven states (Alaska, Louisiana, Maine, New York, North Carolina,
Utah, and Washington) collected information about SRPPD using PRAMS† (Figure
1). The following analysis is based on responses to the question, “In the
months after your delivery, would you say that you were a) not depressed at
all, b) a little depressed, c) moderately depressed, d) very depressed, or e)
very depressed and had to get help?” The responses were collapsed into three
depression categories: none (a), low to moderate (b or c), and severe (d or
e).
*Because the question used in PRAMS does not correspond to
a clinical definition or diagnosis of depression, we refer to this measure as
SRPPD rather than PPD.
†The Pregnancy Risk Assessment Monitoring System (PRAMS) is part of CDC’s
program to reduce rates of infant mortality and low birth weight. PRAMS is an
ongoing state-level, population-based surveillance system that identifies and
monitors selected maternal experiences and behaviors before, during, and
after pregnancy. Each state uses the same standardized protocol that involves
a mail questionnaire with telephone follow-up to survey mothers who recently
gave birth. Responses are then weighted to be representative of all women who
gave birth in each state during that year.
![Figure 1 PRAMS states in 2000 with depression question](images/PPD_Figure1.gif)
Figure 1: Map of PRAMS States in 2000 that represent states with the
depression question and states without the depression question.
PRAMS states in 2000 with the depression question include the following:
• Alaska
• Louisiana
• Maine
• New York, excluding New York City
• North Carolina
• Utah
• Washington
PRAMS states in 2000 without the depression question include the
following:
• Alabama
• Arkansas
• Colorado
• Florida
• Georgia
• Hawaii
• Illinois
• Michigan
• Nebraska
• New Mexico
• Ohio
• Oklahoma
• South Carolina
• Vermont
• West Virginia
Figure 1 shows the 22 states that participated in
PRAMS in 2000. In April 2001, 10 additional states or areas joined the PRAMS
surveillance system: Maryland, Minnesota, Mississippi, Montana, New Jersey,
North Dakota, Oregon, Rhode Island, Texas, and New York City.
PRAMS Data on Self-Reported Postpartum Depression
In 2000, the percentage of PRAMS respondents with severe SRPPD ranged from
5.1% in Washington to 8.9% in Louisiana; the percentage with low to moderate
depression ranged from 48.9% in New York to 62.3% in Utah; and the percentage
with no depression ranged from 31.0% in Utah to 44.6% in New York (Table
1).
Table 1. Prevalence of Three Levels of
Self-Reported
Postpartum Depression in Seven PRAMS States, 2000 |
|
None % (CI)* |
Low to
Moderate % (CI)* |
Severe
%
(CI)* |
Alaska |
39.8
(36.9–42.7) |
54.9
(51.9–57.8) |
5.4
(4.1–6.7) |
Louisiana |
40.8
(38.3–43.3) |
50.3
(47.7–52.9 |
8.9
(7.4–10.4) |
Maine |
41.4
(38.2–44.7) |
50.8
(47.5–54.1) |
7.7
(5.9–9.5) |
New York† |
44.6
(41.1–48.2) |
48.9
(45.3–52.5) |
6.5
(4.7–8.3) |
North
Carolina |
42.2
(39.1–45.2) |
49.4
(46.3–52.5) |
8.5
(6.7–10.2) |
Utah |
31.0
(28.1–34.0) |
62.3
(59.3–65.4) |
6.7
(5.1–8.2) |
Washington |
41.0
(37.6–44.5)
|
53.8
(50.3–57.3) |
5.1
(3.8–6.5) |
* CI=95% confidence interval
† Data do not include New York City
Table 1: PRAMS Surveillance Data from 2000 of the Prevalence of Three
Levels of Self-Reported Postpartum Depression in Seven PRAMS States
Alaska
- 39.8%, confidence interval 36.9–42.7%, reported no postpartum
depression
- 54.9%, confidence interval 51.9–57.8%, reported low to moderate
postpartum depression
- 5.4% confidence interval 4.1–6.7%, reported severe depression
Louisiana
- 40.8%, confidence interval 38.3–43.3%, reported no postpartum
depression
- 50.3%, confidence interval 47.7–52.9%, reported low to moderate
postpartum depression
- 8.9%, confidence interval 7.4–10.4%, reported severe depression
Maine
- 41.4%, confidence interval 38.2–44.7%, reported no postpartum
depression
- 50.8%, confidence interval 47.5–54.1%, reported low to moderate
postpartum depression
- 7.7%, confidence interval 5.9–9.5%, reported severe depression
New York
- 44.6%, confidence interval 41.1–48.2%, reported no postpartum
depression
- 48.9%, confidence interval 45.3–52.5%, reported low to moderate
postpartum depression
- 6.5%, confidence interval 4.7–8.3%, reported severe depression
North Carolina
- 42.2%, confidence interval 39.1–45.2%, reported no postpartum
depression
- 49.4%, confidence interval 46.3–52.5%, reported low to moderate
postpartum depression
- 8.5%, confidence interval 6.7–10.2%, reported severe depression
Utah
- 31.0%, confidence interval 28.1–34.0%, reported no postpartum
depression
- 62.3%, confidence interval 59.3–65.4%, reported low to moderate
postpartum depression
- 6.7%, confidence interval 5.1–8.2%, reported severe depression
Washington
- 41.0%, confidence interval 37.6–44.5%, reported no postpartum
depression
- 53.8%, confidence interval 50.3–57.3%, reported low to moderate
postpartum depression
- 5.1%, confidence interval 3.8–6.5%, reported severe depression
These data represent the responses of 453,186 women who gave birth to a live
infant in these seven states in 2000; overall, 7.1% (32,176) reported severe
depression after delivery and more than half (233,844) reported low to
moderate depression. Women with fewer than 12 years of education, those who
were Medicaid recipients, and those who delivered low-birth-weight babies
were most likely to report severe depression. In addition, women who
experienced physical abuse during pregnancy and women who reported emotional,
partner-related, financial, or traumatic stress were more likely than other
women to report being severely depressed (Table 2).
Because more than half of new mothers reported being depressed, health
care providers should speak with their patients about PPD during prenatal
care and well-baby visits.
Table 2. Prevalence of Three Levels of
Self-Reported Postpartum
Depression Among PRAMS Participants in Seven States,* by
Selected Demographic Characteristics and Risk Factors, 2000 |
|
None
% (CI)† |
Low to Moderate
% (CI)† |
Severe
% (CI)† |
Overall |
41.3
(39.8–42.8) |
51.6
(50.1–53.1) |
7.1
(6.4–7.9) |
Age (years) |
<20 |
34.0 (29.6–38.3) |
57.1 (52.5–61.7) |
8.9 (6.4–11.4) |
20–24 |
37.5 (34.6–40.4) |
52.4 (49.4–55.4) |
10.0 (8.2–11.9) |
25–34 |
43.2 (41.1–45.2) |
51.0 (49.0–53.1) |
5.8 (4.9–6.7) |
35+ |
47.0 (42.9–51.2) |
47.6 (43.5–51.8) |
5.3 (3.4–7.3) |
Race |
White |
41.1 (39.4–42.8) |
52.3 (50.5–54.0) |
6.6 (5.8–7.4) |
Black |
42.2 (38.6–45.7) |
48.3 (44.7–52.0) |
9.5 (7.4–11.6) |
Other |
39.2 (34.0–44.4) |
52.1 (46.9–57.3) |
8.7 (5.9–11.6) |
Hispanic ethnicity |
Yes |
44.9 (39.8–50.0) |
46.7 (41.6–51.7) |
8.4 (5.7–11.2) |
No |
40.3 (38.7–41.9) |
52.6 (51.0–54.2) |
7.1 (6.3–7.9) |
Education |
<12 years |
39.0 (35.3–42.7) |
50.7 (46.9–54.4) |
10.3 (8.1–12.5) |
12 years |
39.2 (36.6–41.8) |
52.7 (50.1–55.4) |
8.0 (6.6–9.4) |
>12 years |
43.3 (41.2–45.4) |
51.3 (49.2–53.4) |
5.4 (4.4–6.3) |
Medicaid recipient |
No |
43.4 (41.5–45.3) |
51.6 (49.7–53.5) |
5.0 (4.2–5.9) |
Yes |
37.8 (35.4–40.2) |
51.7 (49.2–54.1) |
10.5 (9.1–12.0) |
Infant birth weight |
<2500g |
34.9 (32.0–37.7) |
53.7 (50.7–56.7) |
11.4 (9.8–13.1) |
≥2500g |
41.7 (40.1–43.2) |
51.5 (49.9–53.1) |
6.8 (6.0–7.6) |
Physical abuse during pregnancy |
Yes |
16.2 (11.6–20.8) |
61.9 (55.1–68.7) |
21.9 (15.8–28.0) |
No |
42.6 (41.0–44.1) |
51.0 (49.5–52.6) |
6.4 (5.7–7.1) |
Stress during pregnancy‡ 6 |
Emotional |
Yes |
36.9 (34.4–39.4) |
54.1 (51.5–56.6) |
9.0 (7.6–10.5) |
No |
43.7 (41.9–45.6) |
50.2 (48.3–52.0) |
6.1 (5.2–7.0) |
Partner-related |
Yes |
28.8 (26.4–31.1) |
57.6 (55.1–60.2) |
13.6 (11.8–15.3) |
No |
47.9 (46.1–49.7) |
48.4 (46.5–50.2) |
3.8 (3.1–4.5) |
Financial |
Yes |
34.9 (33.0–36.9) |
55.1 (53.1–57.2) |
9.9 (8.7–11.2) |
No |
48.7 (46.5–50.9) |
47.4 (45.2–49.6) |
3.9 (3.1–4.7) |
Traumatic |
|
|
|
Yes |
30.7 (27.5–33.9) |
54.3 (50.8–57.7) |
15.0 (12.6–17.5) |
No |
44.0 (42.3–45.6) |
50.8 (49.2–52.5) |
5.2 (4.5–5.9) |
Overall |
41.3
(39.8–42.8) |
51.6
(50.1–53.1) |
7.1
(6.4–7.9) |
Age (years) |
<20 |
34.0 (29.6–38.3) |
57.1 (52.5–61.7) |
8.9 (6.4–11.4) |
20–24 |
37.5 (34.6–40.4) |
52.4 (49.4–55.4) |
10.0 (8.2–11.9) |
25–34 |
43.2 (41.1–45.2) |
51.0 (49.0–53.1) |
5.8 (4.9–6.7) |
35+ |
47.0 (42.9–51.2) |
47.6 (43.5–51.8) |
5.3 (3.4–7.3) |
Race |
White |
41.1 (39.4–42.8) |
52.3 (50.5–54.0) |
6.6 (5.8–7.4) |
Black |
42.2 (38.6–45.7) |
48.3 (44.7–52.0) |
9.5 (7.4–11.6) |
Other |
39.2 (34.0–44.4) |
52.1 (46.9–57.3) |
8.7 (5.9–11.6) |
Hispanic ethnicity |
Yes |
44.9 (39.8–50.0) |
46.7 (41.6–51.7) |
8.4 (5.7–11.2) |
No |
40.3 (38.7–41.9) |
52.6 (51.0–54.2) |
7.1 (6.3–7.9) |
Education |
<12 years |
39.0 (35.3–42.7) |
50.7 (46.9–54.4) |
10.3 (8.1–12.5) |
12 years |
39.2 (36.6–41.8) |
52.7 (50.1–55.4) |
8.0 (6.6–9.4) |
>12 years |
43.3 (41.2–45.4) |
51.3 (49.2–53.4) |
5.4 (4.4–6.3) |
Medicaid recipient |
No |
43.4 (41.5–45.3) |
51.6 (49.7–53.5) |
5.0 (4.2–5.9) |
Yes |
37.8 (35.4–40.2) |
51.7 (49.2–54.1) |
10.5 (9.1–12.0) |
Infant birth weight |
<2500g |
34.9 (32.0–37.7) |
53.7 (50.7–56.7) |
11.4 (9.8–13.1) |
≥2500g |
41.7 (40.1–43.2) |
51.5 (49.9–53.1) |
6.8 (6.0–7.6) |
Physical abuse during pregnancy |
Yes |
16.2 (11.6–20.8) |
61.9 (55.1–68.7) |
21.9 (15.8–28.0) |
No |
42.6 (41.0–44.1) |
51.0 (49.5–52.6) |
6.4 (5.7–7.1) |
Stress during pregnancy‡ 6 |
Emotional |
Yes |
36.9 (34.4–39.4) |
54.1 (51.5–56.6) |
9.0 (7.6–10.5) |
No |
43.7 (41.9–45.6) |
50.2 (48.3–52.0) |
6.1 (5.2–7.0) |
Partner-related |
Yes |
28.8 (26.4–31.1) |
57.6 (55.1–60.2) |
13.6 (11.8–15.3) |
No |
47.9 (46.1–49.7) |
48.4 (46.5–50.2) |
3.8 (3.1–4.5) |
Financial |
Yes |
34.9 (33.0–36.9) |
55.1 (53.1–57.2) |
9.9 (8.7–11.2) |
No |
48.7 (46.5–50.9) |
47.4 (45.2–49.6) |
3.9 (3.1–4.7) |
Traumatic |
|
|
|
Yes |
30.7 (27.5–33.9) |
54.3 (50.8–57.7) |
15.0 (12.6–17.5) |
No |
44.0 (42.3–45.6) |
50.8 (49.2–52.5) |
5.2 (4.5–5.9) |
* Alaska, Louisiana, Maine, New York, North Carolina, Utah,
and Washington
† CI = 95% confidence interval
‡ The four types of stress were defined as follows:
emotional—a very sick family member had to go into the hospital or someone
close to the respondent died;
partner-related—the respondent separated or divorced from her
husband/partner, she argued more than usual with her husband/partner, or her
husband/partner said he didn’t want her to be pregnant;
financial—the respondent moved to a new address, her husband/partner lost his
job, she lost her job, or she had a lot of bills she couldn’t pay;
traumatic—the respondent was homeless, she was involved in a physical fight,
she or her husband/partner went to jail, or someone close to her had a
problem with drinking/drugs
Table 2: PRAMS Surveillance Data from 2000 of the Prevalence of Three
Levels of Self-Reported Postpartum Depression Among PRAMS Participants in
Seven States, by Selected Demographic Characteristics and Risk Factors
Overall
- 41.3, confidence interval 39.8–42.8%, reported no postpartum
depression
- 51.6%, confidence interval 50.1–53.1%, reported low to moderate
postpartum depression
- 7.1% confidence interval 6.4–7.9%, reported severe depression
By Age
- Less than 20, 34.0%, confidence interval 29.6–38.3%, reported no
postpartum depression; 57.1%, confidence interval 52.5–61.7%, reported low
to moderate postpartum depression; 8.9%, confidence interval 6.4–11.4%,
reported severe depression
- Age 20–24, 37.5%, confidence interval 34.6–40.4%, reported no
postpartum depression; 52.4%, confidence interval 49.4–55.4%, reported low
to moderate postpartum depression; 10.0%, confidence interval 8.2–11.9%,
reported severe depression
- Age 25–34, 43.2%, confidence interval 41.1–45.2%, reported no
postpartum depression; 51.0%, confidence interval 49.0–53.1%, reported low
to moderate postpartum depression; 5.8%, confidence interval 4.9–6.7%,
reported severe depression
- Age 35 plus, 47.0%, confidence interval 42.9–51.2%, reported no
postpartum depression; 47.6%, confidence interval 43.5–51.8%, reported low
to moderate postpartum depression; 5.3%, confidence interval 3.4–7.3%,
reported severe depression
By Race
- White, 41.1%, confidence interval 39.4–42.8%, reported no postpartum
depression; 52.3%, confidence interval 50.5–54.0%, reported low to
moderate postpartum depression; 6.6%, confidence interval 5.8–7.4%,
reported severe depression
- Black, 42.2%, confidence interval 38.6–45.7%, reported no postpartum
depression; 48.3%, confidence interval 44.7–52.0%, reported low to
moderate postpartum depression; 9.5%, confidence interval 7.4–11.6%,
reported severe depression
- Other, 39.2%, confidence interval 34.0–44.4%, reported no postpartum
depression; 52.1%, confidence interval 46.9–57.3%, reported low to
moderate postpartum depression; 8.7%, confidence interval 5.9–11.6%,
reported severe depression
By Hispanic Ethnicity
- Yes, 44.9%, confidence interval 39.8–50.0%, reported no postpartum
depression; 46.7%, confidence interval 41.6–51.7%, reported low to
moderate postpartum depression; 8.4%, confidence interval 5.7–11.2%,
reported severe depression
- No, 40.3%, confidence interval 38.7–41.9%, reported no postpartum
depression; 52.6%, confidence interval 51.0–54.2%, reported low to
moderate postpartum depression; 7.1%, confidence interval 6.3–7.9%,
reported severe depression
By Education
- Less than 12 years, 39.0%, confidence interval 35.3–42.7%, reported no
postpartum depression; 50.7%, confidence interval 46.9–54.4%, reported low
to moderate postpartum depression; 10.3%, confidence interval 8.1–12.5%,
reported severe depression
- 12 years, 39.2%, confidence interval 36.6–41.8%, reported no
postpartum depression; 52.7%, confidence interval 50.1–55.4%, reported low
to moderate postpartum depression; 8.0%, confidence interval 6.6–9.4%,
reported severe depression
- More than 12 years, 43.3%, confidence interval 41.2–45.4%, reported no
postpartum depression; 51.3%, confidence interval 49.2–53.4%, reported low
to moderate postpartum depression; 5.4%, confidence interval 4.4–6.3%,
reported severe depression
By Medicaid Recipient
- No, 43.4%, confidence interval 41.5–45.3%, reported no postpartum
depression; 51.6%, confidence interval 49.7–53.5%, reported low to
moderate postpartum depression; 5.0%, confidence interval 4.2–5.9%,
reported severe depression
- Yes, 37.8%, confidence interval 35.4–40.2%, reported no postpartum
depression; 51.7%, confidence interval 49.2–54.1%, reported low to
moderate postpartum depression; 10.5%, confidence interval 9.1–12.0%,
reported severe depression
By Infant Birth Weight
- Less than 2500 grams, 34.9%, confidence interval 32.0–37.7%, reported
no postpartum depression; 53.7%, confidence interval 50.7–56.7%, reported
low to moderate postpartum depression; 11.4%, confidence interval
9.8–13.1%, reported severe depression
- Equal to or greater than 2500 grams, 41.7%, confidence interval
40.1–43.2%, reported no postpartum depression; 51.5%, confidence interval
49.9–53.1%, reported low to moderate postpartum depression; 6.8%,
confidence interval 6.0–7.6%, reported severe depression
By Physical Abuse During Pregnancy
- Yes, 16.2%, confidence interval 11.6–20.8%, reported no postpartum
depression; 61.9%, confidence interval 55.1–68.7%, reported low to
moderate postpartum depression; 21.9%, confidence interval 15.8–28.0%,
reported severe depression
- No, 42.6%, confidence interval 41.0–44.1%, reported no postpartum
depression; 51.0%, confidence interval 49.5–52.6%, reported low to
moderate postpartum depression; 6.4%, confidence interval 5.7–7.1%,
reported severe depression
By Emotional Stress During Pregnancy
- Yes, 36.9%, confidence interval 34.4–39.4%, reported no postpartum
depression; 54.1%, confidence interval 51.5–56.6%, reported low to
moderate postpartum depression; 9.0%, confidence interval 7.6–10.5%,
reported severe depression
- No, 43.7%, confidence interval 41.9–45.6%, reported no postpartum
depression; 50.2%, confidence interval 48.3–52.0%, reported low to
moderate postpartum depression; 6.1%, confidence interval 5.2–7.0%,
reported severe depression
By Partner-Related Stress During Pregnancy
- Yes, 28.8%, confidence interval 26.4–31.1%, reported no postpartum
depression; 57.6%, confidence interval 55.1–60.2%, reported low to
moderate postpartum depression; 13.6%, confidence interval 11.8–15.3%,
reported severe depression
- No, 47.9%, confidence interval 46.1–49.7%, reported no postpartum
depression; 48.4%, confidence interval 46.5–50.2%, reported low to
moderate postpartum depression; 3.8%, confidence interval 3.1–4.5%,
reported severe depression
By Financial Stress During Pregnancy
- Yes, 34.9%, confidence interval 33.0–36.9%, reported no postpartum
depression; 55.1%, confidence interval 53.1–57.2%, reported low to
moderate postpartum depression; 9.9%, confidence interval 8.7–11.2%,
reported severe depression
- No, 48.7%, confidence interval 46.5–50.9%, reported no postpartum
depression; 47.4%, confidence interval 45.2–49.6%, reported low to
moderate postpartum depression; 3.9%, confidence interval 3.1–4.7%,
reported severe depression
By Traumatic Stress During Pregnancy
- Yes, 30.7%, confidence interval 27.5–33.9%, reported no postpartum
depression; 54.3%, confidence interval 50.8–57.7%, reported low to
moderate postpartum depression; 15.0%, confidence interval 12.6–17.5%,
reported severe depression
- No, 44.0%, confidence interval 42.3–45.6%, reported no postpartum
depression; 50.8%, confidence interval 49.2–52.5%, reported low to
moderate postpartum depression; 5.2%, confidence interval 4.5–5.9%,
reported severe depression
Recommendations
In Guidelines for Perinatal Care,7 the American Academy of Pediatrics and
the American College of Obstetricians and Gynecologists recommend that
- Pregnant women be educated about PPD during the third trimester.
- Obstetricians/gynecologists consult with their patients about their
risk for psychiatric illness during the postpartum period.
Sources of Information
- Gross KH, Wells CS, Radigan-Garcia A, Dietz PM. Correlates of
self-reports of being very depressed in the months after delivery: results
from the Pregnancy Risk Assessment Monitoring System. Matern Child
Health J 2002;6(4):247–53.
- Kumar R, Robson KM. A prospective study of emotional disorders in
childbearing women. B J Psychiatry 1984;144:35–47.
- Murray L, Fiori-Cowley A, Hooper R, Cooper P. The impact of postnatal
depression and associated adversity on early mother-infant interactions
and later infant outcome. Child Dev 1996;67(5):2512–26.
- Field T. Maternal depression effects on infants and early
interventions. Prev Med 1998;27(2):200–3.
- U.S. Department of Health and Human Services. Healthy People 2010.
2nd ed. With Understanding and Improving Health and Objectives for
Improving Health. 2 vols. Washington, DC: U.S. Government Printing Office,
2000.
- Ahluwalia IB, Merritt R, Beck LF, Rogers M. Multiple lifestyle and
psychosocial risks and delivery of small for gestational age infants.
Obstet Gynecol 2001;97:649–56.
- American Academy of Pediatrics and American College of Obstetricians
and Gynecologists. Guidelines for Perinatal Care, 5th ed.
Washington, DC: American Academy of Pediatrics, 2002.
Acknowledgments
Brooke Kinniburgh, Brian Morrow, Leslie Lipscomb, and the PRAMS Working
Group
To learn more or to order copies of this publication, write or call—Centers
for Disease Control and Prevention 4770 Buford Highway NE, Mailstop K-22
Atlanta, GA 30341–3717
Telephone: 770-488-6260
Learn more about PRAMS:
http://www.cdc.gov/PRAMS/index.htm
Produced: June 2004
Page last reviewed: 6/22/07
Page last modified: 8/29/06
Content source: Division
of Reproductive Health,
National Center for Chronic
Disease Prevention and Health Promotion |
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