Postpartum depression is one of the most common conditions affecting new mothers. Symptoms may include depressed mood or loss of interest or pleasure.¹ Approximately 11.5% of women in the United States suffer from postpartum depressive symptoms (PDS).² PDS are associated with future chronic depression,³ reduced quality of life,⁴ lower rates of breastfeeding initiation and duration,^5,6 and, in severe cases, maternal mortality.⁷ PDS and diagnosed postpartum depression can contribute to adverse infant outcomes, including disrupted maternal–infant attachment, impaired mental and motor development, difficult temperament, poor self-regulation, and increased likelihood of hospitalization and mortality.^8,9 To mitigate these outcomes, women with PDS should be identified and treated. Many clinical guidelines recommend depression screening in postpartum women, but timing varies. The U.S. Preventive Services Task Force (USPSTF) recommends depression screening in the general adult population, including pregnant and postpartum women,¹⁰ the American College of Obstetricians and Gynecologists (ACOG) recommends depression screening at least once during the perinatal period and during comprehensive postpartum checkups,¹¹ and the American Academy of Pediatrics (AAP) recommends maternal depression screening at the 1-, 2-, 4-, and 6-month well-child visits.¹²

Nationally, ~90% of women attend their postpartum checkup.¹³ ACOG recommends an initial assessment within the first 3 weeks postpartum, ongoing care as needed, and a checkup no later than 12 weeks postpartum.¹⁴ Attendance at the postpartum checkup varies by maternal and infant characteristics,¹⁵ and women with antenatal depressive symptoms may be less likely to attend.¹⁶ A national survey found that less than half of women who attended a postpartum checkup felt that they received adequate information about postpartum depression.¹⁷ In a 2017 survey of obstetrician-gynecologists, 82.3% reported often or always screening postpartum patients for depression.¹⁸ Thus, not all providers are screening at the postpartum checkup, and even if universal screening was implemented, screening women for PDS only at postpartum checkups may miss women who cannot attend or whose depressive episode occurs at a different time. Although the majority of women report stable or slightly decreasing PDS over time, 2%–10% report a significant increase beyond 6 months postpartum.^3,19

The AAP advises infant attendance at nine well-child visits with a health care provider or pediatrician from 2 weeks after birth through 24 months of age.²⁰ Nationally, ~92.7% of children aged 2 years have had at least one well-child visit, but, on average, they attend only six of the nine visits recommended by the AAP.²¹ In 2013, less than half of pediatricians screened mothers for depression.²² Since then, AAP has recommended that pediatricians screen mothers for depression at the 1-, 2-, 4-, and 6-month well-child visits.¹²

Programs that offer home visits are another aspect of postpartum health care, but eligibility varies. Federally funded home visiting is traditionally geared toward low-income families, but some parts of the United States offer coverage for universal home visiting.^23,24 These visits provide families with assistance and information about breastfeeding, child development, parenting techniques, employment, and child care.²⁵ Although most home visitors cannot treat depression, they may be able to screen and refer to care.²⁶ Federally funded home visiting programs are mandated to screen for depression; in 2019, approximately 82% of caregivers were screened for depression by a home visitor.²⁷

Given the frequency of well-child visits and postpartum home visits, they may be opportunities to screen for PDS and refer to services, if needed. ACOG recommends that programs not only reduce barriers to attendance at postpartum checkups but also incorporate psychological well-being assessment into additional encounters like well-child visits and postpartum home visits.^11,14 Screening at multiple encounters provides more opportunities for women to be screened by health care professionals with longer term interactions with mothers and infants.^12,28 We evaluated women’s encounters with postpartum health care to identify screening opportunities for PDS. We aimed to do so by assessing the (1) prevalence of maternal characteristics by PDS, (2) prevalence of postpartum checkups, well-child visits, and postpartum home visitation by PDS, and (3) independent association between attendance at health care encounters and PDS, controlling for maternal characteristics.

Data on infant attendance at well-child visits were available for 27,602 women during 2012–2015. Of those, we excluded 3,612 (12.3%) respondents missing information on whether the infant was alive at survey completion, PDS, postpartum checkup, postpartum home visitation, and covariates included in adjusted models. The final analytic sample included 23,990 women (weighted n = 1,939,865). Compared to women excluded from the analytic sample, women included in our analysis were more likely to be non-Hispanic white, have >12 years of education, have private insurance, and not have an infant in the NICU (p’s <0.05; Supplementary Table S1).

The prevalence of PDS among women in our sample was 10.6% (95% CI: 10.0–11.2; Table 1). The distribution of maternal age, race/ethnicity, marital status, education, insurance during pregnancy, quantity of stressors in the year before delivery, and whether the baby stayed in the NICU significantly differed by PDS status (p’s < 0.001). Those with PDS were more likely than their counterparts to be <24, non-Hispanic black or other race, unmarried, or educated ≤12 years; have Medicaid; report a higher number of stressors in the year before delivery; and have a baby in NICU ( p’s ≤ 0.001).

The large majority of women attended a postpartum checkup (90.7%; Fig. 1), but attendance was lower among women with PDS than among those without PDS (85.1% vs. 91.4%). The vast majority of women reported infant attendance at well-child visits (98.8%), but attendance was slightly lower among women with PDS than among those without PDS (97.3% vs. 98.9%). The prevalence of receiving postpartum home visitation was low (11.2%), but was higher in women with PDS than among those without PDS (13.7% vs. 10.9%). After adjusting for confounders, differences between women with and without PDS in engagement with postpartum checkups (aPR: 0.96; 95% CI: 0.93–0.99), well-child visits (aPR: 0.99; 95% CI: 0.98–1.00), and home visitation (aPR: 1.18; 95% CI: 1.02–1.35) were minimal. Maternal age, parity, and number of stressors before pregnancy were consistently independently associated with attendance for each of these visits ( p < 0.05).

In terms of combinations of visits, of all women, 8.9% missed their postpartum checkup but reported that their infant attended a well-child visit; 89.9% reported attendance at both (Fig. 2). Of women with PDS, 13.5% missed their postpartum checkup but reported that their infant attended a well-child visit; 83.9% reported attendance at both. Of all women, 0.9% missed their postpartum checkup but reported home visitation; 10.3% reported encounters with both (Fig. 3). Of women with PDS, 2.0% missed their postpartum checkup but received postpartum home visitation; 11.7% reported encounters with both. Of all women, 99.6%, 90.9%, and 10.1% reported at least 1, 2, or 3 health care encounters, respectively (Fig. 4). Of women with PDS, 98.8%, 86.1%, and 11.2% reported at least 1, 2, or 3 health care encounters, respectively.

In this population-based sample of postpartum women, 1 in 11 women did not attend a postpartum checkup and may have missed an opportunity to be screened for PDS. Of women with PDS, 13.5% missed their postpartum checkup but reported infant attendance at a well-child visit; 2% missed their postpartum checkup, but received a home visitor. Weighted, these two groups represent at least 26,000 women with PDS in our sample who could have been screened for depression if offered routinely during these encounters. If depression screening was offered routinely at all three types of visit, our analysis shows that over 98% of women with PDS would have been screened for depression at least once, while ~86% would have been screened at least twice and ~11% would have been screened at least thrice. After controlling for covariates, women with PDS were about as likely as those without PDS to attend their postpartum checkup, report infant attendance at well-child visits, and receive home visitors.

Many,^33–36 but not all,³⁷ studies have found that mothers reporting antenatal or postpartum depression were no less likely to have their infants attend age-appropriate, well-child visits. Although a retrospective cohort study at an Illinois care center found an association between depression and postpartum checkup nonattendance,¹⁶ the authors only considered antenatal depressive symptomology, not postpartum depressive symptomology, which may explain the difference in findings. In contrast, another population-based study using New Jersey data found that women with a positive depression screen at delivery or postpartum had similar attendance at postpartum checkups as women with negative depression screens.³⁶

Our study found that infant attendance at well-child visits occurs more commonly than mother attendance at postpartum checkups. Although well-child visits are intended to provide immunizations, track infant growth and development, and discuss concerns,²⁰ AAP recommends maternal depression screening at these checkups because of the potential effect of maternal depression on parenting and child health outcomes.¹² Specifically, PDS can increase the likelihood of parental abuse or neglect, missed health care visits, failed immunization uptake, reduced breastfeeding, and low car seat adherence.^37–39 Well-child visits may be opportunities for maternal depression screening because mothers often attend these checkups.⁴⁰ Pediatricians may also be the only health professional that the family continuously interacts with, particularly for mothers who are covered by Medicaid during pregnancy but lose coverage 60 days postpartum.¹² A 2013 survey of AAP members found that only 44% of pediatricians screened mothers for depression.²² Estimates of depression screening by pediatricians have not been documented since the introduction of the AAP guidelines, but low screening percentages may be due to ethical and legal questions regarding pediatricians’ responsibility and liability for the quality of screening, referral, and follow-up, as well as time constraints during visits.⁴¹ Several state Medicaid programs have recognized the importance of maternal depression screening and now allow pediatricians to bill for this screening as part of well-child visits.⁴² The 21st Century Cures Act of 2016 also authorized the Health Resources and Services Administration to fund states to implement the Screening and Treating for Maternal Depression and Related Behavioral Disorders Program. This program gives pediatricians (and other providers) access to training or psychiatric consultation on maternal depression screening, treatment, and follow-up services and links to community-based resources.⁴³

Our study also found that depression screening during postpartum home visitations may increase the proportion of women screened. Home visits aim to promote self-efficacy by providing support, helping reduce stress, and teaching problem-solving skills. They are most common among families with low income, low parental education, young age, or single parents.^25,44 Previous studies have shown that these same factors are associated with missing the postpartum checkup⁴⁵ and having postpartum depression.^46–48 Thus, incorporating depression screening into postpartum home visitation may help identify women with PDS and ensure referral to treatment. A survey of women eligible for home visitation found that 95% would be willing to complete a depression screening tool and 71% felt that the home, not clinics, was the most appropriate setting for screening.⁴⁹ For screening to succeed, home visitors would need training in screening and identification of depression, adequate time to conduct screening, and information on referrals to treatment.⁴⁴

It must be noted that many barriers to care exist, including stigma, financial constraints or lack of insurance coverage, and lack of coordination of services and integration in places where women normally seek care.⁵⁰ If screening was to occur universally at settings like postpartum checkups, well-child visits, and postpartum visitation, it would be important to establish and maintain coordinated care between the providers at these encounters. The Community Preventive Services Task Force recommends this collaborative care to manage depressive disorders on the basis of strong evidence of the effectiveness of this approach in improving symptoms and treatment adherence and response.⁵¹ In addition to coordinated care, systems must be in place to ensure that care is comprehensive and moves beyond screening.¹¹ A comprehensive care pathway would include assessment, triage and referral, treatment access, treatment initiation, symptom monitoring, and adaption of treatment based on symptoms.⁵² Many professional organizations, like the USPSTF, ACOG, and the AAP, recommend that clinicians be prepared to provide a patient with a high risk of perinatal depression or a positive screen with care or referral to care.^11,12,53 While this analysis provides insight into an initial step in this pathway, postpartum attendance at various health care encounters, future research regarding provider practices along this continuum would help to better understand if this comprehensive care is being implemented in an equitable manner.

This analysis is subject to at least five limitations. First, not all women with PDS have clinical depression, and the PHQ-2 may not identify all women with depression, since PRAMS is self-reported.³² Second, results may not be generalizable to jurisdictions or women excluded from this analysis (12.3%). The women excluded had more risk factors for PDS and nonattendance at health care encounters, so results depicting the number of women who could have been screened if it were offered at all encounters may be underestimated. Third, this analysis was cross-sectional, so we were unable to determine the chronologic order of events (e.g., if symptoms occurred before or after attendance). Fourth, information on infant attendance at well-child visits does not necessarily indicate mother attendance, but previous studies have found that mothers are the most likely family member to attend infant health care visits.⁴⁰ Finally, our analyses assumed that screening is being done universally at postpartum checkups now and that it would be done universally at well-child visits and postpartum home visits if it were added to these encounters.

In this analysis of eight PRAMS jurisdictions, we determined that, if depression screening were offered routinely at all postpartum checkups, well-child visits, and postpartum home visits, over 98% of women with PDS would be screened for depression at least once, while 86% would be screened at least twice and 11% would be screened at least thrice. Routine screening for postpartum depression at well-child visits and postpartum home visitations may improve identification of women with PDS and, if used in conjunction with accessible care options, increase access to treatment.