Depressive symptoms during the perinatal period by disability status: Findings from the United States Pregnancy Risk Assessment Monitoring System

Abstract Aims The aim of the current study was to compare the prevalence of depressive symptoms during the perinatal period among respondents with a disability as compared to those without a disability. Design We conducted a secondary analysis of nationally representative data from the Pregnancy Risk Assessment Monitoring System data from 24 participating United States between 2018 and 2020. Methods A cross‐sectional sample of 37,989 respondents provided data on disability, including difficulty in vision, hearing, ambulation, cognition, communication and self‐care. The outcome of interest was perinatal depressive symptoms, defined as experiencing depressive symptoms during the antenatal period or postpartum period. Regression models were used to calculate odds of depressive symptoms during these two time periods by disability status while controlling for relevant sociodemographic characteristics and depressive symptoms prior to pregnancy. Results Respondents with disabilities experienced a higher prevalence of depressive symptoms in both the antenatal period and postpartum period as compared to those without disabilities. In fully adjusted models, respondents with disabilities had 2.4 times the odds of experiencing depressive symptoms during pregnancy and 2.1 times the odds of experiencing postpartum depressive symptoms as compared to respondents without disabilities. Conclusion Respondents with disabilities experience a higher prevalence of depressive symptoms throughout the perinatal period thereby increasing the risk for adverse maternal, neonatal and infant health outcomes. Impact Perinatal depression is a significant public health issue globally, and our findings suggest that persons with disability are at an increased risk for depressive symptoms both during pregnancy and in the postpartum period. Our findings represent a call to action to improve clinical and supportive services for women with disabilities during the perinatal period to improve their mental health and the consequent health of their offspring. Patient or Public Contribution We thank our Community Advisory Board members who have been instrumental in the conception of this study.


| INTRODUC TI ON
Perinatal depression, a highly prevalent and complex complication of pregnancy and childbirth, is associated with multiple adverse maternal and child outcomes (ACOG Committee Opinion No. 757, 2018).
Encompassing antenatal depression that occurs during pregnancy and postpartum depression occurring in the first 12 months following birth, perinatal depression is experienced by one in seven women (ACOG Committee Opinion No. 757, 2018). Although 11.5% have long been cited as the mean prevalence of perinatal depression , rates vary depending on the measurement method and the period on which prevalence is measured. For example, a 2005 systematic review  revealed estimates for antenatal depression ranging from 8.5% to 11.0% and 6.5% to 12.9% for postpartum depression. However, a 2016 literature review yielded an average prevalence of 17% for antenatal depression and 13% for postpartum depression (Underwood et al., 2016).
According to an analysis of 2018 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) administered in 31 states, the average prevalence of postpartum depression was 13.2%, ranging from 9.7% to 23.5%, depending on the state reporting (Bauman et al., 2020). That study also reported on the prevalence of women having been asked about depression by a provider during prenatal care (79.1%) and postpartum visits (87.4%).

| BACKG ROU N D
The aetiology of perinatal depression is complex involving sociodemographic, psychosocial and biological risk factors (Dagher et al., 2021). Prominent documented risks for both antenatal and postpartum depression include low socioeconomic status, single marital status, prior or current intimate partner violence, history of depression and/or anxiety, adverse life events, history of adverse childhood experiences, poor social support, unintended pregnancy, gestational diabetes and racial/ethnic minority status (Dagher et al., 2021;Liu et al., 2013;Mukherjee et al., 2016;Wilson et al., 2020). Risks identified for depression during pregnancy include pregnancy complications, poor relationship quality and receipt of public health insurance (Dagher et al., 2021). Risk factors specific for postpartum depression include prenatal and antenatal depression and anxiety, low self-esteem, childcare stress, obstetric complications, postpartum blues, difficult infant temperament, sudden change in reproductive hormones following birth and genetic variations (Dagher et al., 2021;Guintivano et al., 2018). The literature is mixed regarding maternal age, with some research suggesting the risk for postpartum depression is greater under age 24, decreases between ages 24 and 35, but increases with advanced maternal age (Guintivano et al., 2018).
When untreated, perinatal depression can contribute to multiple negative maternal and child consequences. Depression during pregnancy and postpartum is associated with maternal suicidal ideation, breastfeeding difficulties, paternal depression and child behavioural and mental health problems (Alhusen et al., 2013;Dagher et al., 2021;Field, 2017;Letourneau et al., 2012;Slomian et al., 2019).
Postpartum depression is associated with maternal and infant health problems; relationship, family functioning and parenting difficulties; maternal substance misuse; poor maternal attachment and developmental problems in the child (Alhusen et al., 2021;Dagher et al., 2021;Goodman, 2019;Slomian et al., 2019). When severe, postpartum depression can be associated with suicidal ideation, thoughts of infant harm and in rare cases, infanticide (Van Niel & Payne, 2020).
Perinatal depression may be particularly salient for the approximate 12% of U.S. women of childbearing age who have a disability (Courtney-Long et al., 2015). Women with disabilities are increasingly choosing to become pregnant and give birth, with pregnancy occurrence similar to women without disabilities (10.8% vs. 12.3%) (Horner-Johnson et al., 2016). Although many women with disabilities experience successful pregnancies, growing evidence links maternal disability with a risk for adverse maternal and neonatal outcomes such as a greater risk of pregnancy complications and perinatal depression (Gleason et al., 2021;Mitra, Parish, et al., 2015;Signore et al., 2011).
Depression and other psychological distress are disproportionally prevalent in people with disabilities (Cree et al., 2020). Women with disabilities are at a greater risk for depression than women without disabilities, men with disabilities, and the general population (Chevarley et al., 2006). Multiple studies based largely on convenience samples demonstrate that women with disabilities are at an elevated risk for perinatal depression (Brown et al., 2016(Brown et al., , 2017Krysko et al., 2022;Pohl et al., 2020), a risk confirmed by populationbased research in Norway, Canada and the United States (Brown et al., 2019;Eid et al., 2021;Mitra, Parish, et al., 2015).
Analysing data from the Rhode Island PRAMS, Mitra and colleagues reported higher rates of postpartum depression in mothers Patient or Public Contribution: We thank our Community Advisory Board members who have been instrumental in the conception of this study.

K E Y W O R D S
antepartum depression, disability, nurses, postpartum depression, pregnancy with disabilities (28.9%) than those without disabilities (10%) (Mitra, Parish, et al., 2015). This disparity was observed after accounting for sociodemographic variables, other maternal characteristics linked with postpartum depression, prenatal and antenatal depression and seeing a provider for mental health issues. Although greater antenatal depression was observed in women with versus without disabilities (25.2% and 7.6% respectively), it was only marginally associated with postpartum depression in women with disabilities. Women with disabilities' risk factors for postpartum depression included medical problems or intimate partner violence during pregnancy. When compared to other mothers, those with disabilities were more likely to disclose perinatal depression symptoms to their healthcare provider.
Although representing the first population-based investigation of postpartum depression in women with disabilities, it was limited to data collected in only one state. No known research has used representative data from multiple states to estimate the prevalence of perinatal depression in women with disabilities.

| Aims
The purpose of the current study was to examine the prevalence of antenatal and postpartum depression among women with and without disabilities who have given birth through the analysis of a PRAMS dataset which recently incorporated a disability questionnaire supplement (Svestkova, O., 2008).

| Design and setting
For the current analyses, we analysed data from CDC's PRAMS, a surveillance system that collects data from the time before, during and shortly after pregnancy among persons who have recently given birth. The goal of the PRAMS project is to improve the health of mothers and infants by reducing adverse outcomes. As such, PRAMS collects information on maternal attitudes and experiences throughout the perinatal period including attitudes and feelings about the most recent pregnancy, preconception care, breastfeeding intention and duration, cigarette smoking and alcohol use, abuse during the perinatal period, mental health, infant health care and contraceptive use. Potential respondents are contacted between 2 and 6 months postpartum by mail through a pre-letter that introduces PRAMS to the respondent and informs her that a questionnaire will soon arrive.
This packet is sent to all sampled respondents 3-7 days after the preletter. Additionally, a tickler note is sent with up to two additional questionnaire packets sent for respondents who do not respond to initial mailings. If no response by mail, they are contacted by telephone. Per CDC guidelines, data are available for states meeting a minimum response rate of greater than or equal to 55%. On average, 75% of states have met or exceeded the threshold since 2007.
Survey responses are linked to birth certificate data for analyses. We used data from 2018 to 2020, the most recent data available at the time of data analysis.

| Respondents
The population of interest for each PRAMS state is resident women who recently gave birth within their state to a live-born infant during the surveillance year. Annual sample sizes per state range from 1000 to 3000 respondents. Sample sizes are determined according to stratification plan, number of births and available budgets. A state's birth certificate file serves as the sampling frame for identifying new mothers. To ensure that women with multiple births are sampled at the same rate as those with singleton births, only one infant from a multiple gestation is randomly selected to be included in the sampling frame. The PRAMS sample is stratified so that subpopulations of particular public health importance can be oversampled, including mothers of low birthweight infants, those living in high-risk geographic locations, and racial and ethnic minority groups. Individual states and territories choose a stratification plan based on their public health priorities.
The sample for this analysis included respondents who had a live birth from 2018 to 2020 and were asked the Washington Group Short Set of Questions on Disability (WG-SS) disability questions (unweighted n = 45,561). The WG-SS questions were asked in 24 states, with some states discontinuing (Maine, New York, Rhode Island, West Virginia) and other states (Tennessee, New Hampshire) incorporating WG-SS disability questions during the study period.
We carefully analysed the WG-SS responses by state, by year and by 'batch' for completion; our sample included only responses from batches in which the WG-SS questions were asked. Participants who were not asked the WG-SS questions were excluded from our sample, and participants who were not asked about depressive symptoms were excluded from our sample.
Overall, 24 states were included in our sample. Regarding missing data, 781 participants (1.7%) had missing responses for depressive symptoms during pregnancy, and 989 participants (2.2%) had missing responses for depressive symptoms during the postpartum period.
Other covariates were between 0% and 8.5% missing (see Figure 1), thus we performed complete case analysis. This resulted in 37,715 complete cases for depressive symptoms during pregnancy and 37,762 complete cases for depressive symptoms in the postpartum period.

| Data collection
In 2018, a series of questions related to disability were added as an optional questionnaire for participating states and territories.
The disability questionnaire supplement consists of the WG-SS that has been used within other federal and global surveys. These questions are based on the World Health Organization's International Classification of Functioning, Disability and Health and provide standardized language as well as a framework for operationalizing disability (Svestkova, O., 2008). Respondents are asked five disability questions including if they have difficulty seeing, even when wearing glasses or contact lenses; difficulty hearing, even if using a hearing aid(s); difficulty walking or climbing steps; difficulty remembering or concentrating; difficulty with self-care, such as washing or dressing and difficulty communicating, understanding or being understood in their usual language. Response options include no difficulty, some difficulty, a lot of difficulty and cannot do this at all. Aligned with recommendations of subject matter experts at the National Institutes of Health and CDC, and in consultation with the CDC PRAMS teams, we coded a response of 'no difficulty' or 'some difficulty' as 'no disability' while responses of 'a lot of difficulty' or 'I cannot do this at all' were coded as 'yes disability'. Respondents who answer 'no' to some disability questions and leave one or more of the other disability questions blank are considered missing data. The disability questions were first asked in 2018 in 22 states, but not in all 'batches' or months of PRAMS administration.

| Ethical considerations
Prior approval for this study was obtained from the institutional review board of the study team's institution. As analyses included

| Data analysis
The outcomes of interest included depression during pregnancy and in the postpartum period. Depression during pregnancy was assessed using the question 'During your most recent pregnancy, did you have any of the following conditions? …Depression' (yes or no).
Respondents self-report 'yes' or 'no' and this is not corroborated Respondents who responded 'always' or 'often' to either question were classified as experiencing postpartum depression.
Covariates of interest were selected as potential confounders of the association of disability and depression based on the literature (Cree et al., 2020;Nosek et al., 2008

| Validity, reliability and rigour
The PRAMS is one of the largest state-based surveillance systems that include women with live births, including their experiences over the perinatal period. Data obtained from PRAMS are linked to birth certificate information. Because PRAMS data are self-reported, the reliability and validity with other population-based data collection systems, such as the birth certificate, have been confirmed in multiple studies (Ahluwalia et al., 2013;Gayle et al., 1988;Hosler et al., 2010). PRAMS incorporates a number of quality control measures. Data entry verification is required for a minimum of 10% of mail surveys received and many states perform 100% verification.
Supervisors are required to monitor 10% of all telephone interviews to assure proper survey administration and recording of responses.
Nonresponse rates are low (1% to 2% for most questions) with the exception of response rates to the question on household income (averages 6% nonresponse rate). No imputation procedures are used for item nonresponse.

| RE SULTS
The sample included n = 35,404 respondents (unweighted) who did not report a disability and n = 2585 respondents who reported at least one disability; full characteristics are displayed in Table 1. The groups differed significantly with respect to age, education, race, income, relationship status and insurance provider.
Respondents with disabilities were more likely to report obtaining a high school education or less and were significantly more likely to be non-white. The majority (51%) of respondents with a disability reported a household income below the federal poverty level (FPL) as compared to 27% of respondents who did not report a disability.  (Field, 2017;Lancaster et al., 2010).
Regarding depressive symptoms in the postpartum period, respondents with at least one disability had an aOR of 2.14 (95% CI 1.80, 2.54), indicating they had more than twice the odds of postpartum depressive symptoms compared to those reporting no disabilities (Table 4). Other covariates associated with depressive symptoms in the postpartum period were maternal age, education, race, income, having Medicaid insurance and having a history of depression.

| DISCUSS ION
The results of this U.S. population-based analysis reveal that women with disabilities were nearly over twice as likely to experience depressive symptoms during pregnancy and in the postpartum period as compared to those without a disability. These significant differences were noted after controlling for relevant sociodemographic characteristics as well as depression prior to pregnancy. The prevalence of postpartum depressive symptoms in women with disabilities (33.6%) was lower than noted in a recent analysis of Massachusetts PRAMS data (2012-2017) in which 37.4% of women with disabilities reported postpartum depressive symptoms. Yet, the prevalence of postpartum depressive symptoms in women without disabilities was higher in our sample (12.1%) as compared to that noted in Massachusetts PRAMS (8.8%) (Booth et al., 2021). Across both time points, our prevalence was higher than findings of an analysis of Rhode Island PRAMS data (2009)(2010)(2011) in which approximately 30% of women with disabilities versus 10% of women without disabilities reported depressive symptoms in the postpartum period (Mitra, Iezzoni, et al., 2015).
Yet, in a recent analysis of women with multiple sclerosis receiving care at an academic health centre, the prevalence of postpartum depressive symptoms was significantly lower (13%) (Krysko et al., 2022).   . They also express unique concerns about pregnancy and motherhood which may increase their vulnerability to perinatal depression. For example, women with disabilities may have well-grounded apprehension that caesarean section decisions will be made based on the presence of disability and in the absence of medical necessity (Gleason et al., 2021). They may also be discouraged from becoming pregnant due to health concerns, and experience stigmatizing societal reactions about their pregnancy (Alhusen et al., 2020;Iezzoni et al., 2015).
Women with disabilities also face multiple unremitting barriers to receiving equitable care including physical or health system barriers such as inaccessible medical facilities and equipment, lack of interpreter services and other communication barriers, financial limitations and widespread discriminatory attitudes and biases of providers who question their ability for pregnancy, childbirth and parenting (Saeed et al., 2022;Tarasoff, 2017 (Roll et al., 2013). Finally, our analysis was limited to respondents who gave birth in the United States. Perinatal depression is a global public health issue , and these relationships should be examined in all contexts with the goal of improving mental health and pregnancy outcomes of child-bearing age women with disabilities. Bold values are statistically significant.

| CON CLUS ION
Our study suggests that women with disabilities are at an increased risk of experiencing depressive symptoms during the perinatal period compared to women without disabilities. Our findings represent a call to action to improve clinical and supportive services for women with disabilities during the perinatal period and to conduct research designed to explore factors contributing to perinatal depression disparities in women with disabilities. Providing focused support around the time of pregnancy and increasing disabilitysensitive training for clinicians will have the potential to enhance the perinatal health and health care of women with disabilities.

ACK N OWLED G EM ENTS
We acknowledge the Pregnancy Risk Assessment Monitoring System (PRAMS) working group and the Centers for Disease Control and Prevention for providing access to the PRAMS dataset for this analysis. We also acknowledge our Community Advisory Board for their expertise and steadfast commitment to reducing inequities in the Disability community.

FU N D I N G I N FO R M ATI O N
This research was funded by an R01 (R01HD102927) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

CO N FLI C T O F I NTE R E S T
The authors have no conflicts of interest to disclose.

PE E R R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15482.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are openly available via a data application to PRAMS at https://www.cdc.gov/prams/ prams -data/resea rchers.htm.