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Abstract

Purpose: This article provides a review of published evidence-based guidance about culturally sensitive assessment and treatment intervention strategies addressing perinatal depression in black American women. Culturally sensitive approaches focus more on the woman’s environment than on her race and thus may improve access to treatment for perinatal depression by increasing health literacy. Methods: The authors abstracted evidence-based guidance from articles published between November 2005 and September 2011, including only articles specifically analyzing a discrete sample of black American women during pregnancy or within 6 months postpartum. They also examined research on unique cultural characteristics of black American women. To obtain relevant studies, the authors searched for research literature indexed in PubMed, using key terms associated with 2 systematic reviews of prevalence and risk factors for perinatal depression and additional keywords as used in the articles found. They abstracted the focus, design and methods, population, and results for each article in a table; discussed the findings; and suggested assessment and intervention strategies based on the studies’ results. Findings: Sixteen articles from 13 journals provide compelling evidence of culture-based risk factors for perinatal depression for black American women and information to guide culturally sensitive assessments and interventions. The literature provides a rich compendium of relevant and useful implications for clinical practice in assessing and addressing depression among pregnant black American women. Conclusions: Primary care providers may want to incorporate culturally sensitive screening questions to early identify and facilitate treatment interventions for depressive symptoms in their pregnant black American patients.

Keywords

perinatal depression black American women risk factors cultural sensitivity African American

Depression is a common complication during pregnancy, and clinical practitioners need to be aware of the latest evidence-based guidance for its detection and treatment options. As pointed out and well referenced by several researchers, depression during pregnancy negatively affects the woman, the family, and the neonate.^1-4 These cited works have found, for example, that depression may be linked to low birth weight, preterm birth, poor mother-infant interaction, and below-normal heart rate variability. Those evidence-based facts do not escape clinical practitioners or their patients,^5-7 but navigating the literature and synthesizing it for optimal use in patient care can be a daunting and time-consuming task for health practitioners. Thus, this article provides a synthesis of evidence-based information associated with black American women from the perspective of culture rather than race. Specifically, it will help clinical practitioners to think about black pregnant patients more from a cultural perspective than a racial perspective when assessing or addressing depression during pregnancy.

Since 2005, studies have provided increasingly useful information on prevalence and incidence of perinatal depression,^1,4,8,9 urging screening and referral to reduce the negative outcomes associated with this common complication of pregnancy. More information is available about the factors that predict perinatal depression, such as poverty, lack of education, and family pressures. Evidence suggests that women of the black race may have more exposure to a larger number of those risk factors,⁶ placing them at higher risk for serious depression during pregnancy compared to their white Hispanic/Latina, white non-Hispanic/non-Latina, and Asian sisters.¹⁰ While this suggests a possible race-related factor for depression, the focus of current research is shifting more precisely to the cultural risk factors than on the racial affiliation. To date, we found no studies of the prevalence of perinatal depression among a large, socioeconomically diverse cohort of black American women.

As sociocultural changes occur among racial groups and cultural affiliations more richly imbue studies with race as a factor, researchers have begun to attend more carefully to cultural factors within racial groups that may affect health status. One example of culture- versus race-based studies is the way in which white Hispanic and white Latina cultures are studied. Hispanic populations from Mexico and Latina populations from Latin American countries have different cultural heritages, akin to the cultures of White Americans and White Europeans or White populations from Africa. Researchers examining cultural issues among racial and ethnic groups are more recently differentiating between black women of the U.S. culture and black women from other nations, such as Africa, Haiti, and Europe. This nuance slightly complicated our review because it was unclear whether black or African American study participants in selected articles were associated strictly with a black American cultural framework. To the best possible extent, we maintained a focus on black women who lived in a recognizable American culture, such as inner-city Philadelphia or New York.

Black American women may possess distinguishing cultural characteristics that reflect their social heritage and family expectations and traditions, including their family role, educational experiences, economic status, and health literacy.¹¹ In fact Rosenthal et al posit that black American women have a long history of exposure to gendered racism, contradictory societal pressures regarding childbearing and motherhood, and stereotyping. In a deductive discussion of published interdisciplinary studies, Rosenthal and Lobel constructed a biosocial anthropological lens that illuminates those social factors that strongly predict disparate birth outcomes for this population.

With this type of emerging research on conditions that seem to be culturally unique to black American women, we were interested in what evidence-based guidance might be available to help clinical practitioners with culturally sensitive screening and intervention strategies for this population. Thus, the primary aim of this study was to provide a practical synthesis of available evidence to help practitioners formulate culturally sensitive approaches to assessment, rather than using a strictly race-based approach with their pregnant black American patients.

In a 2005 systematic review of prevalence and incidence of perinatal depression, Gavin et al presented a review of 28 articles published in a 25-year period.¹² Those articles provided insufficient evidence to suggest that a woman’s risk for depression is greater at any point in time pre- or postpartum or during perinatal periods compared to nonchildbearing times. While that review provided no specific guidance to practitioners regarding screening or addressing perinatal depression by racial or cultural groups, it did underscore the role of socioeconomic status in perinatal depression. Gavin et al also underscored the tendency of self-report questionnaires to overestimate prevalence of depression. The main conclusions of that review were that future research needed to (1) clarify whether risk for depression during pregnancy is any higher than during nonchildbearing years, (2) improve our understanding of differences between discrete populations, and (3) develop more sensitive and specific screening and relevant interventions.

Eight months before that review, however, the same group prepared a report for the Agency for Healthcare Research and Quality in which they indicated that “fairly accurate and feasible screening measures” were available to detect depression in perinatal women.¹³ Thus, as of late 2005, a clinical practitioner who read both the review and the agency report might have been more alert to depressive symptoms generally across the course of pregnancy but might have had difficulty determining which screening method would be the most parsimonious, sensitive, and specific for discrete populations of pregnant patients. Although neither the Gavin nor Gaynes work addressed culturally related factors predicting perinatal depression, each noted that the prevalence rates of depression were higher in studies that considered adverse socioeconomic factors. On the heels of these 2005 publications, Howell et al found that black women were 2 times more likely to have depressive symptoms than Caucasian non-Latina women.¹⁴

In a more recent review, in January 2010, Lancaster et al found 7 factors significantly associated with a greater likelihood of depression during pregnancy.¹⁵ These factors included Medicaid status, domestic violence, lower income and education, being single, and poor interpersonal relationships.¹² In addition to those, Seng et al in 2011 reported significantly greater risks for traumatic life events, including interpersonal violence, low socioeconomic status, and poor health behaviors among black compared to nonblack women.¹⁶

Other literature can also be helpful to practitioners interested in detecting and addressing depressive symptoms in their pregnant patients of the black race. For example, in 2012, Gonzalez et al reported that not only do few Americans with depression obtain care but that the lowest rates of treatment occur among Mexicans and African Americans.¹⁷ Another indication of health disparities among racial groups was underscored in a 2011 study that found that black women appeared to have fivefold-increased odds of havingantenatal depression compared to their White non- Hispanic, Asian/Pacific Islander, and Latina sisters.¹⁸

Before 2005, there were 2 published studies that reported no significant differences between white and black low-income, inner-city pregnant women on depression or social factors associated with their depression scores. And while those studies did not identify specific risk factors, they did introduce the idea that sociocultural factors might help to explain perinatal depression more than race-related factors.^19,20 This new attention to sociocultural factors was addressed again in the following year, when Boyd et al found that depression was strongly related to negative life events. Two years later, in 2008, a study examined perceived barriers to discussing depression with providers and found that women who had significantly higher depression scores were more likely to have discussed their symptoms with a provider.³ However, less than a quarter of the black women in that study had a discussion with their provider about depression, and 81% of the time that a discussion did occur, it was the provider who had initiated the discussion.

The literature provides a rich compendium of relevant and useful information on assessing and addressing the impact of depression on black mothers and their children, using culturally-sensitive approaches.

Methods

Our review focuses on the literature in perinatal depression among black American women that has been published in peer-reviewed journals since 2005. To begin our search, we relied on 2 important benchmark systematic reviews on perinatal depression, both of which were published in the Journal of Obstetrics & Gynecology, 5 years apart. One review, published in 2005, focused on the prevalence and incidence of perinatal depression.¹² The second review, published in 2010, examined the literature for risk factors for depressive symptoms during pregnancy.¹⁵ Neither review focused on race- or culture-related factors or on special subpopulations. However, from those reviews, we were able to construct an initial list of articles that included and analyzed depressive symptoms in a discrete sample of black American women during pregnancy or within 6 months postpartum.

Next we examined the references in the retained articles to identify relevant works that were criterion omitted in the 2 benchmark systematic reviews. Finally, to update the literature through September 2011, we searched PubMed, one of the most definitive and reliable indexes for medical literature, for English-language articles using these combinations of terms: “perinatal depression” and “race and ethnicity”; “birth outcomes” and “black and African American”; “culturally-sensitive assessment” and “perinatal depression.” We reviewed each article’s abstract, methods, and findings as needed to retain only those that specifically included and analyzed a discrete sample of black American women. We then reviewed the references of those retained articles to identify other studies addressing black American culture and perinatal depression that may not have been captured by our search.

Results

We retained 16 articles from 13 journals published since November 2005 that met the inclusion criteria (see Table 1). Taken together, these articles provide compelling evidence that race-related risk factors underscore the importance of using culturally sensitive questions and developing culturally sensitive interventions for perinatal depression among black American women.

Table 1.

Selected Details of Reviewed Studies

First Author	Study Focus	Design and Methods	Population: Location	Implications for Practice Based on Study Results
2005
Howell¹⁴	The role of health status and social context in postpartum depression among 3 racial/ethnic groups	Cross-sectional study using a telephone survey	655 postpartum women of black (16%), white non-Latina (55%), and Latina (29%) origins, 2 to 6 weeks postpartum: New York urban medical center	Black women were 2 times more likely to have depressive symptoms than white non-Latina women. All racial and ethnic groups shared similar symptom predictors.
Jesse¹	The risk and protective factors related to midpregnancy depression	Cross-sectional study using in-person interviews	130 pregnant women of the black (62%) and white races in low-income groups: Indiana urban clinic	Stress, low socioeconomic status, poor social support, and high religiosity were associated with depressive symptoms with no differences between the 2 racial groups.
2006
Boyd³	Factors associated with depression considering mother-infant interaction, life events, and breast feeding	Randomized controlled trial with 3 groups: 2 treatment groups and usual care only	89 postpartum women of black (56%) and white Latina (42%) racial/ethnic origins: Community Health Center, Philadelphia	Depression is related to negative life events. No differences were noted between the 2 racial groups.
Holzman⁸	Prevalence of depression midpregnancy and differences in life circumstances among sub groups and race/ethnic groups	Cross-sectional study using self-administered questionnaires	1321 pregnant women from black (24.7%), white (68.9%), and “other” racial groups: 52 clinics in 5 Michigan communities enrolled in the Pregnancy Outcomes and Community Health Study	Economic problems and exposure to adverse life experiences in adult years were strongest predictors of depression. Black women reported significantly more depression and social problems than white women.
McKee²²	Effectiveness of interventions to reduce depression during pregnancy and postpartum	Randomized controlled trial, 2 groups: 1 intervention and 1 usual care	187 pregnant and postpartum women of black (43%), and white Latina races/ethnicities: community health center, New York City	Both interventions reduced depression with equal effectiveness. Differences between racial groups were not tested.
Rich-Edwards⁹	Differences in sociodemographic predictors of depression in perinatal women in race/ethnic groups	Cohort study using repeated in-person interviews	1278 pregnant and postpartum women of black (9%), white non-Latina (78%), and Latina, Asian, and other races/ethnicities: Boston urban and suburban areas	Black, Latina, and younger women were more likely to report depressive symptoms. Primary predictor variables were poor social support, financial hardship, and being single.
2007
Westdahl¹⁰	The influence of social support and social conflict on depressive symptoms to develop brief clinical screening tools to detect psychosocial risks	Cross-sectional study using multiple questionnaires	1047 pregnant women of black (80%), white-Latina (13%), and white non-Latina origins: inexact locations	Lack of social support and high degrees of social conflict predict depression during pregnancy. Clinical assessment of social support and conflict can identify at-risk women.
2008
O’Mahen⁶	Perceived barriers to treatment for perinatal depression	Cross-sectional study using multiple questionnaires	108 perinatal women of black (51%) and white racial groups: Michigan	Black women expressed more confidence than white women in treatment from a pastor. Black women also had less confidence in family or friend support and antidepressants than white women.
2009
Jacob²	Relationship between maternal stress and heart rate variability in neonates as an indication of autonomic nervous system development and resilience in 2 groups of depressed and nondepressed black mothers	Cohort study using questionnaires and laboratory tests	87 newborn babies of low-income black women	Neonates whose mothers had a history of depression and life stressors had significantly lower heart rate variability. Depression during pregnancy may adversely affect the developing autonomic nervous system.
Ley²³	Components of the Healthy Start Initiative that are responsive to perinatal black women	Report of Healthy Start model methods and outcomes	1426 perinatal women of the black race: Pittsburgh/Allegheny and Fayette County Healthy Start, Inc., Pennsylvania	Healthy Start programs may be successful due to integrating mental health and primary care, more social support, and participant involvement, among other factors.
Price²⁴	Validity and benefits of a culturally sensitive assessment of perinatal depression	Validation study using 2 interviews and combinations of portions from different assessment questionnaires	139 pregnant and postpartum women of black (95.7%), and white non-Latina races	There is value in assessing culturally subtle conditions that may not be sufficiently measured in standardized questionnaires.
2010
Hodgkinson²⁶	Examination of the impact of depressive symptoms on birth outcomes of infants born to adolescents	Existing data from medical records of patients enrolled in Teen Alliance for Prepared Parenting in Washington, DC	297 pregnant teens: 224 (76%) black and white-Latina	Despite a significantly lower mean birth weight for infants of mothers with depressive symptoms and suicidal thoughts or attempts compared to those with depressive symptoms but no suicide ideation, infants born to mothers with depressive symptoms tended to weigh more than those born to mothers with no symptoms.
2011
Liu⁷	Examination of factors associated with provider-patient conversations about depression	Mail and telephone interviews of all women, with a total of 4813 respondents	3597: 971 black (27%), white non-Latina (28%), white Latina, and Asian/Pacific Islander women participating in the New York City PRAMS study (2004-2007)	Content of the conversation was not defined, only measurement was whether at any time during the pregnancy or postpartum, a provider asked about “baby blues” or “postpartum depression.” Younger women and women who used clinics under local health care payment programs were more likely to have had such a conversation.
Molina²⁵	Examination of risk and protective factors of depressive symptoms among urban high-risk black pregnant women	Telephone interview with a cross-sectional sample of women at baseline before being randomized in a larger randomized controlled trial: the Health Outcomes of Pregnancy Education, of the DC Initiative to Reduce Infant Mortality in Minority Populations, Washington, DC	1044 black women from 6 community prenatal clinics in Washington, DC	Most significant factors associated with depression included less than high school education, more intimate partner violence, unhappiness with the pregnancy, less emotional support from others, and poor coping skills.
Rosenthal¹¹	Definition of an elevated risk paradigm for adverse birth outcomes for black women, considering medial-social stress, dissonance in societal pressures, and stereotyping.	Inductive reasoning and theory development through a review of research in psychology, sociology, culture, health status, and birth outcomes for black women in the United States	No study participants	Research associated with pregnancy and birth outcomes for black women should include psychological, sociological, cultural, policy, and attribution factors to better understand the influences of the medical-social context of health care on women’s perception of care and health decisions.
Seng¹⁶	Examination of disparity in posttraumatic stress disorder diagnosis among prenatal primigravida black women	Cross-sectional data as part of a larger cohort study of the effects of posttraumatic stress disorder on obstetric and postpartum outcomes (STACY Project)	1577: 709 black (45%), white non-Latina (46%), white Latina, Asian, and other races at maternity clinics in 3 health systems in the Midwestern United States	Black women reported significantly higher prevalence of lifetime trauma, posttraumatic stress disorder symptoms, more substance abuse during pregnancy, and less mental health care.

Trends can be seen in the literature between 1995 and 2010 yielding increasingly helpful insights into screening for and addressing symptoms of depression among black American pregnant women. However, the dispersion of articles published since 2005, across 13 journals, and the critical information being imbedded in each article may make it difficult for health care practitioners to retrieve practical information for practice. This article provides a summary that may be useful to primary care providers in consideration of perinatal depression among their black American patients.

Generally, the most repeated guidance across the 16 articles we reviewed was that culturally sensitive screening should include attention to the stress of poverty, a history of abuse or neglect, not having a partner or spouse, low self-esteem, lifetime trauma, and interpersonal violence. The timing of a depression screening interview—that is, when it occurs during the perinatal period—seems less important than its comprehensiveness.

Discussion

Screening

In 2009, Mitchell et al reported that the rate of false negatives among primary care physicians in detecting depression may outnumber true positives by as much as 3 to 1, yielding an overestimation of depressive symptoms. The more experienced practitioners and those with strong doctor-patient communication skills have been found to be more likely to detect the true presence of depressive symptoms among their pregnant patients. Additionally, researchers investigating the frequency with which physicians ask their pregnant patients about depression found that young black women were more likely to discuss “feeling blue” with their health care provider but that more mature black women were not.⁵ Thus, a combination of doctor-initiated discussion of the signs and symptoms of depression, strong doctor-patient communication skills, and culturally sensitive screening instruments seem the best combination to identify truly at-risk patients.

In the 16 articles we included in the table, 3 used the Beck Depression Inventory, 3 used the Center for Epidemiologic Studies Depression Scale, 1 used the Structured Clinical Interview for Depression, 1 used the Hopkins Symptom Checklist, 3 used the Edinburgh Perinatal Depression Scale, 1 used the Composite International Diagnostic Interview Short Form, 2 used their own set of 2 to 5 questions, and 2 did not use screening questions. Seven perinatal depression screening instruments and their respective sensitivity and specificity rates were listed in the February 2010 opinion (No. 453) from the Committee on Obstetric Practice of the American College of Obstetricians and Gynecologists.²¹ This opinion relied on studies from 2005, 2002, and 1999, and although no one instrument was recommended over another, most of the 7 were deemed to have adequate sensitivity and specificity and were brief enough for practical use.

Treatment Interventions

Interventions most often cited for depression in this population included health and parenting education early in the pregnancy, encouragement in developing social support networks, and improving the home environment as much as possible.^22,23 When concerns arise about possible depression in a black American pregnant patient, the best evidence-based approach is a combination of standardized assessments and culturally sensitive questions that provide sufficient information to shape a culturally sensitive approach to treatment interventions.⁸ Black American women may be less well informed about many aspects of their health during pregnancy and immediately after delivery because of their cultural environment and not because of their racial affiliation. For poor, single, undereducated black women, cultural response to health care may be an inherent barrier to seeking or accepting care for depressive symptoms.⁸

Conclusion

According to the preponderance of research on perinatal depression among black American women published since 2005, it may not be the symptoms of depression per se but the factors placing the woman at risk of these symptoms that practitioners need to address. A self-administered questionnaire may not provide sufficient insight to the woman’s situation to effectively discuss symptoms or provide possibly needed referrals. As described by Price et al, practitioners might consider adding a few questions to a standard screening instrument, such as “Are you feeling like everyone is against you?” rather than “How are you feeling?” By asking if she feels like she has to take care of everything rather than if she has sufficient support extends the interview into the cultural realm.²⁴

Black American women may need to feel empowered to make decisions for themselves and their babies to prevent negative birth outcomes. These women may have substantial social problems, financial worries, or emotional burdens, and openly discussing any of these may alleviate some of the stress, promoting a sense of self-efficacy that can counterbalance depressive symptoms.

Through culturally sensitive screening, practitioners can uncover clues to improve nonpharmacological treatment interventions. For example, asking about the patient’s social and emotional support systems and plans for the future can lead to an overlooked community-based resource referral. Providing education about fetal and infant growth and development, as well as self-care, may permit the woman to ask questions to improve her health status and future maternal role. Culturally sensitive screening and closely related treatment interventions can improve outcomes in this vulnerable culturally unique group of women.^14,15,25,26

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

The authors received no financial support for the research and/or authorship of this article.

Bios

des Anges Cruser is an associate professor in medical education and social and behavioral sciences at the Texas College of Osteopathic Medicine. She has over 35 years of experience in public mental health systems and mentors medical students and residents in behavioral health research.

Linda Asante-Ackuayi is a fellow at the UCLA-Kern Child and Adolescent Psychiatry Fellowship Program. Her research interests include identifying and implementing culturally sensitive interventions to maternal and family mental health problems in an effort to prevent and/or reduce mental illness in children and adolescents.

Sarah Brown is an assistant professor in psychiatry and behavioral health at the Texas College of Osteopathic Medicine. Her research interests include psychiatric services utilization, perinatal depression, and research education.

Estela Cardenas is a research and education project manager serving the Department of Psychiatry and Behavioral Health at the Texas College of Osteopathic Medicine.

David Lee is a research assistant at the University of North Texas Health Science Center.

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Evidence-Based Guidance for Culturally Sensitive Assessment and Interventions for Perinatal Depression in Black American Women

Abstract

Keywords

Methods

Results

Discussion

Screening

Treatment Interventions

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

Bios

References