Antenatal Stressful Life Events and Postpartum Depressive Symptoms in the United States: The Role of Women's Socioeconomic Status Indices at the State Level

Background: Approximately 10%-20% of women suffer from postpartum depression (PPD), important predictors of which are antenatal stressful life event (SLE) experiences. The association between women's state-level socioeconomic status (SES) and PPD has not been explored. This study aimed to examine whether the association between antenatal SLE and PPD symptoms was moderated by women's state-level SES. Methods: Data from the 2009-2011 Pregnancy Risk Assessment Monitoring System (PRAMS) were used. State-level women's employment/earnings and social/economic autonomy indices were computed from indicators published by the Institute of Women's Policy Research (IWPR). Multilevel multivariable logistic regression analyses were performed. Results: Among 91,253 women with valid responses, 11.3% had PPD symptoms, prevalence ranging from 7.1% in Illinois to 17.1% in Arkansas. Women who experienced all four stressor categories, including partner related, traumatic, emotional, and financial, had the highest odds (adjusted odds ratio [aOR]: 5.43; 95% confidence interval [CI]: 5.36-5.51) of PPD symptoms. The odds of experiencing PPD symptoms decreased with an increase in the state-level social/economic autonomy index (aOR: 0.75; 95% CI: 0.64-0.88). There was significant cross-level interaction between number of stressor categories experienced and state-level index. Conclusions: Screening for antenatal SLEs can help identify women at risk for PPD symptoms. That the odds of having PPD symptoms decreased with increasing state-level social/economic autonomy and women residing in states with lower indices were more vulnerable to the impacts of antenatal stressors, could have policy implications related to improving the SES of women in these states.