Postpartum mood among universally screened high and low socioeconomic status patients during COVID-19 social restrictions in New York City

Postpartum depression (PPD) is a prevalent and serious public health concern, impacting maternal and child well-being. The COVID-19 pandemic added another layer of complexity, potentially exacerbating existing stressors. While several studies have examined the pandemic's impact on maternal mental health, few have considered the role of socioeconomic status (SES) and none have utilized universal screening within regular clinical care. This study aimed to investigate changes in postpartum mood symptomatology before and during the COVID-19 pandemic in New York City, and to explore whether these changes differed based on SES. The study is crucial because understanding the differential impacts of the pandemic on diverse populations is vital for developing targeted interventions and policies. Existing literature highlights the significant relationship between SES and mental health, with low SES women facing higher risks of postpartum mood disorders due to factors such as limited access to healthcare, inadequate childcare, and reduced social support. The COVID-19 pandemic and related restrictions presented a unique opportunity to assess how these factors interact and how they could be addressed to enhance postpartum mental health.

The existing literature extensively documents the high prevalence of postpartum depression and its detrimental effects on both mothers and their children. Studies consistently demonstrate that women of lower socioeconomic status are disproportionately affected by PPD due to a multitude of factors including financial strain, lack of social support, inadequate childcare, and limited access to mental healthcare. The income gradient in health outcomes, where lower income correlates with poorer health, is a significant concern. While the causal relationship between poverty and mental health remains debated (social selection vs. social causation), evidence largely supports the social causation hypothesis, suggesting that poverty itself contributes to mental illness. The COVID-19 pandemic introduced a novel stressor to the equation, with early studies reporting increased anxiety and depression among pregnant and postpartum individuals. However, these studies often suffered from methodological limitations such as biased sampling through self-selection recruitment methods.

This study employed a universal screening approach, utilizing the Edinburgh Postnatal Depression Scale (EPDS) to assess postpartum mood symptomatology. The sample consisted of 516 postpartum patients who received care at Mount Sinai Health System sites in New York City between January 2, 2020, and June 30, 2020. Patients were categorized into high and low SES groups based on the location of their clinical service, with Mount Sinai's community practices serving predominantly lower SES populations and Faculty Practices serving higher SES individuals. The EPDS, a validated 10-item self-report instrument, was administered either in person or virtually (telephone) during regular postpartum appointments. Data were collected from the electronic health record (EHR). The study employed Wilcoxon-Mann-Whitney tests to compare EPDS scores between groups, accounting for the ordinal nature of the EPDS data and the potential for outliers. The analysis examined changes in mood symptomatology (1) before and after the implementation of COVID-19 restrictions (March 13, 2020), and (2) between high and low SES groups, both before and after the restrictions. Ethical approval was obtained, and informed consent was waived due to the use of de-identified data from a clinical setting.

A total of 516 postpartum patients were screened; 418 (71.9%) reported some mood change (EPDS ≥1), 64 (12.4%) scored ≥9 (possible depression), and 33 (6.4%) scored ≥12 (probable depression). No significant difference in EPDS scores was observed between high and low SES groups before the implementation of COVID-19 restrictions. However, a statistically significant decrease in mood symptomatology was observed overall following the imposition of restrictions [U(Npre-restrictions=264, Npost-restrictions=252)=25,084.5, z=-4.90, p<0.001]. Notably, this decrease was significantly more pronounced among patients in the low SES group [U(Nlow-SES, pre-restrictions=147, Nlow-SES, post-restrictions=176)=9209.0, z=-4.56, p<0.001], while the high SES group showed no significant change [U(Nhigh-SES, pre-restrictions=117, Nhigh-SES, post-restrictions=76)=4045.5, z=-1.06, p=0.288]. The comparison between high and low SES groups after the restrictions also showed significant difference [U(Nlow-SES, post-restrictions=176, Nhigh-SES, post-restrictions=76)=4895.0, z=-3.48, p<0.001]. Table 1 in the original paper provides a detailed breakdown of descriptive statistics and EPDS scores across different time periods and SES groups.

The study's findings reveal a differentiated impact of COVID-19 restrictions on postpartum mood based on SES. The improved mood in lower SES women contrasts with previous research that often highlights the negative mental health impacts of such restrictions. This unexpected positive outcome suggests that the reduction in usual stressors related to childcare, work, and social pressures brought about by the lockdowns may have played a beneficial role for low-SES mothers. The alleviation of these burdens, which typically disproportionately affect low-SES women, offers a potential explanation for the observed improvement. This finding challenges the common narrative of solely negative pandemic effects and highlights a unique opportunity to understand and leverage these unexpected positive effects for policy development. The study emphasizes that targeted support, focusing on easing the work-family-childcare burden, may significantly improve maternal mental health outcomes among low-SES populations.

This study demonstrates that postpartum depression is a prevalent and serious condition with significant morbidity, and its manifestation differs across socioeconomic strata. The improved postpartum mood observed among lower SES women during COVID-19 restrictions in New York City underscores the importance of considering social and economic factors in maternal mental health care. Future health policies should focus on supporting the work-family-childcare balance for low-SES women, potentially disrupting the cycle of poverty and improving long-term outcomes for both mothers and their children. Further research should investigate these effects in different contexts and explore the long-term consequences of pandemic-related policies on maternal mental health.

This study, being a treatment-seeking sample from specific New York City healthcare centers, might not fully represent the diverse socioeconomic landscape of the city or the United States. The universal screening approach, while beneficial, only captures patients who sought care, which might exclude those with limited access due to various factors, particularly affecting lower SES populations. The study also lacked sufficient power to analyze demographic differences beyond SES. Finally, the long-term impact of COVID-19 restrictions and their eventual lifting on postpartum mood remains to be seen.