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Postpartum Stressful Life Events and Intimate Partner Violence as Risk Factors for Self Reported Postpartum Depression among American Indian / Alaska Native Mothers. Maria N. Ness, M.P.H Kenneth D. Rosenberg, M.D., M.P.H. Office of Family Health, Oregon Public Health Division, Portland, OR

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Postpartum Stressful Life Events and Intimate Partner Violence as Risk Factors for Self Reported Postpartum Depression among American Indian / Alaska Native Mothers

Maria N. Ness, M.P.H

Kenneth D. Rosenberg, M.D., M.P.H.

Office of Family Health, Oregon Public Health Division, Portland, OR

Victoria Warren-Mears, Ph.D., R.D., L.D.

Thomas M. Weiser, M.D., M.P.H.

Northwest Portland Area Indian Health Board, Portland, OR

Council of State and Territorial Epidemiologists Annual Conference

June 14, 2011


Background postpartum depression ppd
Background: Postpartum Depression (PPD) Violence as Risk Factors for Self Reported Postpartum Depression among American Indian / Alaska Native Mothers

  • Maternal depressive disorder occurring after pregnancy

  • Very common, estimated that 10% to 15% of women in developed countries experience PPD

  • Period of increased risk from birth of child to two years postpartum

  • Other than direct effects on the mother, PPD impairs maternal role function, which can adversely affect the child, short or long term


Background ppd among american indian alaska native ai an women
Background: PPD among American Indian/Alaska Native (AI/AN) Women

  • Very little research examining PPD in AI/AN communities

  • Prevalence of PPD higher among AI/AN mothers than among general population

  • Studies have found prevalence of PPD as high as 23% among populations with a high proportion of AI/AN women


Research question
Research Question Women

  • Developed in conjunction with the Northwest Portland Area Indian Health Board

  • Triggered by reports of high prevalence of SLEs and IPV among AI/AN mothers

  • Research Question: Are postpartum stressful life events (SLEs) and intimate partner violence (IPV) risk factors for postpartum depression among AI/AN mothers in Oregon?


Data source prams 2
Data Source: PRAMS-2 Women

  • Oregon’s Pregnancy Risk Assessment Monitoring System (PRAMS) follow-back survey

  • Conducted when index child is two years old

  • Data collected in 2006 and 2007

  • N = 1,911 women of all race/ethnicities

  • n = 226 AI/AN women


Self reported ppd in prams 2
Self Reported PPD in PRAMS-2 Women

  • Self reported depressive symptoms 13 to 24 months postpartum examined using a two part question:

    In the past 12 months, has there been a period of 2 or more weeks when almost every day you:

    a) Felt sad, blue, or depressed for most of the day (Y/N)

    b) Lost pleasure or interest in most things you usually cared about or enjoyed (Y/N)

  • Mothers who answered yes to either part of this question were considered to be experiencing PPD*

*Prevalence of self-reported postpartum depressive symptoms--17 states, 2004-2005. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2008 Apr 11;57(14):361-6.


Categorization of sles
Categorization of SLEs Women

  • PRAMS-2 asks mothers to report SLEs experienced 13 to 24 months postpartum

  • SLEs from PRAMS categorized in previous studies, these were adapted to SLEs reported in PRAMS-2

  • Four categories of SLEs used, adapted from categories used by Ahluwalia et al, 2001*:

    • Partner related

    • Traumatic

    • Financial

    • Emotional

*Ahluwalia, Indu B., et al (2001) “Multiple Lifestyle and Psychosocial Risks and Delivery of Small for Gestational Age Infants”, Obstetrics & Gynecology, Vol 97, No. 5, Part 1, pg. 649-656


Categorization of sles cont
Categorization of SLEs, cont. Women

Table 1: Specific events included in each SLE category


Presence of ipv
Presence of IPV Women

  • PRAMS-2 asks mothers to report IPV experienced 13 to 24 months postpartum

  • Five part question, which examines:

    • Verbal abuse (Y/N)

    • Limitation of contact with friends or family (Y/N)

    • Prevention of access to income (Y/N)

    • Physical Abuse (Y/N)

    • Sexual Abuse (Y/N)

  • Mothers who answered yes to any of these types of abuse were considered to be experiencing IPV


Additional covariates
Additional Covariates Women

  • Pregnancy intention

  • Maternal education

  • Maternal social support

  • Maternal race/ethnicity

  • Maternal age at birth

  • Maternal marital status

  • Urban or rural county of residence

  • Household’s income as percentage of the Federal Poverty Level


Statistical analysis methods
Statistical Analysis Methods Women

  • Prevalence of depression, SLEs, IPV and other risk factors examined among all racial groups

  • Bivariate logistic regression conducted to examine relationship between each risk factor and PPD among AI/AN women

  • Multivariable logistic regression conducted using step-wise backwards elimination to examine risk factors for PPD among AI/AN women


Descriptive results
Descriptive Results Women

Figure 1: Prevalence of PPD, SLEs and IPV occurring 13 – 24 months postpartum among mothers in Oregon, PRAMS-2 , 2006 & 2007


Bivariate results
Bivariate Results Women

Table 2: SLEs and IPV as risk factors for PPD 13 - 24 months postpartum among AI/AN mothers Oregon , PRAMS-2 , 2006 & 2007


Bivariate results cont
Bivariate Results, cont. Women

Table 2: SLEs and IPV as risk factors for PPD 13 - 24 months postpartum among AI/AN mothers Oregon , PRAMS-2 , 2006 & 2007


Multivariable results
Multivariable Results Women

  • Only partner-related SLEs and traumatic SLEs remained in the final multivariable logistic regression model

  • Partner-related SLEs increase the odds of

    PPD among AI/AN mothers 3.77 times (95% Confidence Interval = 1.88-7.50)

  • Traumatic SLEs increase the odds of

    PPD among AI/AN mothers 2.99 times (95% Confidence Interval = 1.44-5.85)


Discussion
Discussion Women

  • Discrepancy between strongest risk factors in bivariate analysis and significant risk factors in multivariable analysis:

    • Might be due to colinearity between partner-related SLEs and IPV

    • Might be due to small sample size of AI/AN women, combined with underreporting of IPV


Conclusions
Conclusions Women

  • Racial disparity in adverse life events among AI/AN women:

    • The prevalence of PPD is extremely high

    • AI/AN mothers experience higher rates of SLEs and IPV than any other racial/ethnic group

  • Partner-related and traumatic SLEs are statistically significant risk factors for PPD among AI/AN women


Strengths of analysis
Strengths of Analysis Women

  • Population based study

  • Minorities oversampled, including AI/AN

  • Data is weighted to exclude bias due to non-response

  • Survey is conducted during a unique time period, the second postpartum year, about which there is a scarcity of knowledge regarding PPD


Limitations of analysis
Limitations of Analysis Women

  • Findings are cross-sectional:

    • Limited information regarding temporality

    • Cannot infer causality

  • Several of the topics examined in this analysis, such as IPV, are very sensitive, which may lead to underreporting

  • Although AI/AN women are oversampled, the sample obtained is still small, which may lead to associations being too small to detect


Public health implications
Public Health Implications Women

  • Implement interventions to prevent partner-related or traumatic SLEs among AI/AN mothers, so that the odds of PPD are decreased

  • Increase screening for PPD among AI/AN mothers who have experienced partner-related or traumatic SLEs


Thank you
Thank you! Women

  • Acknowledgment: Kathleen A. Anger, Ph.D., Office of Family Health, Oregon Public Health Division, Portland, OR

  • Questions?

    Please contact Maria Ness:

    CDC/CSTE Applied Epidemiology FellowOregon Public Health DivisionOffice of Family Health800 NE Oregon Street, Suite 825Portland  OR  97232Phone: (971) 673 1564Fax: (971) 673 0240Email: [email protected]


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