By Anthony J. Hill, Ph.D., and Crystal Regina Hettinger, B.A.
Postpartum Depression (PPD) is a pervasive public health concern. Furthermore, PPD disproportionately affects African American women than other groups. Financial stress is a key predictor for developing PPD. Financial stress is mostly associated with poverty in the literature. The authors argue that financial stress needs to encompass the full range of financial realities that African American women face due to discrimination, oppression, and structural racism to comprehend the scope and reach of PPD fully. The authors also offer strategies for mediating the effects of financial stress on overall well-being and implications for practice.
A Healthy People 2020 objective is to decrease the number of women delivering a live birth who experience postpartum depressive symptoms (PDS). To establish a baseline for this objective, the Centers for Disease Control and Prevention (CDC) sought to describe self-reported PDS overall by three years of data (2004, 2008, and 2012) from 27 states using the Pregnancy Risk Assessment Monitoring System (PRAMS). In 2012, the overall PDS prevalence was 11.5% for 27 states and ranged from 8.0% to 20.1% (Ko, Rockhill, Tong, Morrow, & Farr, 2017). Mood swings after the birth of a child are not uncommon. Following delivery, mothers often experience a period of “emotional lability” characterized by spells of crying, which usually peaks around five days postpartum and then subside (Albright, 1993, p. 316). The term “baby blues” describes this period. On the postpartum mental health continuum, the baby blues is on the less severe end with postpartum depression representing the most serve end of the continuum. Each year, “more women will suffer from postpartum depression and other mood disorders than the combined number of new cases of men and women with tuberculosis, leukemia, multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, and epilepsy” (Fazlagić, 2011). Postpartum depression (PPD) is a pervasive health concern.
Low-socioeconomic status (SES) is a key predictor of developing PPD (Abrams & Curran, 2007; Horwitz, Briggs-Gowan, Storfer-Isser, & Carter, 2007; Mundorf et al., 2018). Moreover, African American mothers disproportionally experience PPD more than their white counterparts (Barakat, Martinez, Thomas, & Handley, 2014; Doe et al., 2017; Horwitz, Briggs- Gowan, Storfer-Isser, & Carter, 2007). This paper expands the conversation about the intersectionality of race, postpartum depression, and financial stress. The author argues that consideration for financial stress must tap into a full range of financial stressors that African American women face daily beyond the confines of poverty or low socioeconomic status. Such a conversation is needed to understand the scope and reach of postpartum depression fully.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) Fifth Edition does not recognize PPD as a separate diagnosis; rather, mothers must meet the criteria for a major depressive episode and the criteria for the peripartum-onset specifier. The definition is, therefore, a major depressive episode with onset in pregnancy or within four weeks of delivery (American Psychiatric Association, 2013). The DSM-IV characterizes PPD by depressed mood, anhedonia, agitation or movement retardation, feelings of worthlessness or inappropriate guilt, and thoughts of suicide or death (Clay & Seehusen, 2004). Symptoms of PPD also include extreme mood swings, excessive sleeping or insomnia, changes in appetite, chronic exhaustion or hyperactivity, feeling unable to cope with everyday problems, irritability, difficulty with memory and concentration, fear of contact with other people, and a lack of love for the child or family (Fazlagić, 2011). Also, mothers who experience PPP are likely to have co-occurring somatic complaints, including breast infections, headaches, fatigue, and body aches (Hung & Chung, 2001).
Certain psychosocial factors are key predictors of a mother developing PPD. The predictors include low socioeconomic status (Kim et al., 2011), inadequate social resources (Albright, 1993; Mundorf et al., 2018; Oddy, Rowe, & Fisher, 2009), and limited access to therapeutic services (Kothari et al., 2016). Lack of partner support is also a key predictor of PPD (Fazlagić, 2011). Previous postpartum depression; a history of depression, anxiety, or stress; stressful life events; and childhood trauma can be predisposing factors for PPD (De Venter et al., 2016). Also, minority mothers, especially African Americans, are particularly prone to PPD (Abrams & Curran, 2007; Barakat, Martinez, Thomas, &
Handley, 2014; Guintivano et al., 2018; Horwitz, et al., 2007; Kim et al., 2012; Mukherjee, Fennie, Coxe, Madhivanan, & Trepks, 2018).
Maternal PPD could affect a child’s emotional development, increasing later manifestations of psychological problems. For example, researchers found children of mothers who had PPD at any point in time developed mental health problems at greater rates than those whose mothers did not have PPD (Closa-Monasterolo et al., 2017). Researchers also found a correlation between social problems, attention problems, rule-breaking behavior, aggression, anxiety, and depression in children whose mothers experienced PPD (Closa-Monasterolo et al., 2017). Moreover, PPD can negatively impact cognitive skills and language skills (van der Zee-van den Berg et al., 2017), ability to pay attention, conduct, and social skills infants and toddlers of mothers who experience PPD.
Also, husbands or partners are more likely to develop depression in the postpartum period if the mother develops PPD (Clay & Seehusen, 2004). Poor infant-attachment and bonding (Wisner, Parry, & Piontek, 2002) and increased risk of child abuse and neglect are possible consequences of maternal PPD. Stigma is also associated with PPD. Furthermore, researchers found African American mother who experiences PPD are less like to accept prescription medication and mental health services than their white counterparts. But, African American mothers are more likely to accept spiritual counseling, while white women are more likely to accept herbal treatment (Bodnar-Deren, Been, Balbierz, & Howell, 2017).
Race And Financial Stress
The Financial Health Institute (n.d.) considers financial stress as a condition that is the result of financial and economic events that create anxiety, worry, or a sense of scarcity and is accompanied by a physiological stress response. In 2014, the American Psychological Association (APA) reported nearly three-quarters (72%) of adults report feeling stressed about money at least some of the time and nearly one-quarter say that they experience extreme stress about money (22% rate their stress about money during the past month as an 8, 9, or 10 on a 10-point Likert scale). People who experience severe financial stress are at risk of exposure to the legal system. A report from the Bureau of Justice Statistics elucidates the connection between household poverty and nonfatal violent victimization between 2008-2012. For example, poor households at or below the poverty rate hand more than double the rate of violent victimization as persons in high-income households. The same report reveals that poorer households had higher rates of violence involving a firearm than households above the poverty level. In addition, poor urban African Americans had rates of violence similar to poor urban whites (Harrell, Langton, Berzofsky, Couzens, & Smiley- McDonald, 2014).
African American households especially feel the impact of financial stress due to discrimination, oppression, and structural racism, which has created greater disparities in wealth and debt (Plyes, 2018). According to the Economic Policy Institute, the median and average wealth of white families is 12 times the wealth of their African American counterparts (de Costa, 2019). Because wealth is a primary indicator of financial well-being, wealth disparity is particularly troubling for African American families. Wealth enables families to transfer income earned in the past to meet spending demands in the future (de Costa, 2019).
The link between wealth and homeownership is important for the majority of American families. They can leverage home equity to pay for college and other major expenses. Homeownership among African American families is alarmingly low. According to the National Association of Real Estate Brokers (NARER), for African Americans, the homeownership rate is 30.5 percentage points lower than non-Hispanic whites (72.2 percent) and 22 percentage points lower than the national homeownership rate of 63.7% (2019). A lack of homeownership greatly hinders the ability of African American families to build wealth, which can later be used to pay for college or other major expenses. Housing disparity has deep roots in the economic history of America.
Before the Fair Housing Act of 1968, federal housing policy prevented African American families from buying homes in the suburbs in the 1940s, ’50s, and even into the 1960s. Government surveyors graded neighborhoods using a color-coding scheme. Green represented the best neighborhoods. Neighborhoods designated with the color blue were considered desirable. Yellow neighborhoods were considered to be declining, and those neighborhoods labeled as red were considered hazardous. The redlined neighborhoods were the ones that lenders considered as credit risks, in large part, because of the residents’ racial and ethnic demographics. The impact of this racist policy has prevented large numbers of African American families from building wealth through homeownership. Consequently, African American families were not able to transfer wealth from one generation to the next.
The lack of homeownership prevents African American families from building wealth. Other obstacles also prevent many African Americans from achieving financial security. For example, a report commissioned by the National Association for the Advancement of Colored People (NAACP) titled “The Challenge of Credit Card for the African American Middle Class” shed light on the financial realities of a vast number of African American families (Ruelschlin & Asante-Muhammad, 2013). The following are highlights from that report:
The African American Middle Class Is Paying Down Debt But Still Relies On Credit Cards to Make Ends Meet.
African Americans carry a balance of $5,784 in credit card debt.
Forty-two percent of African Americans report using their credit cards for basic living expenses like rent, mortgage payments, groceries, utilities, or insurance because they do not have enough money in their checking or savings accounts. Whites and Latinos have similar credit card usage.
The African America Middle Class, Like the American Middle Class As a Whole, Uses Credit Cards to Make Critical Investments In Their Future, Including For Higher Education, Entrepreneurship, and Medical Expenses.
Fifty percent of indebted African American households report expenses related to sending a child to college contributed to their current credit card debt.
Forty-three percent of African Americans reported that out of pocket medical expenses contribute to their credit card debt. The findings are similar for whites and Latinos.
The African American Middle Class Reports Worse Credit Scores and Different Causes Of Poor Credit.
Sixty-six percent of African American households report having a credit score of 620 or above, compared with 85% of white households.
Only 42% of African American households reported having “good” or “excellent” credit, compared to 74% of white households.
African American households were more likely to report that late student loan payments or errors on their credit report contributed to their poor credit scores. White households were more likely to report that late mortgage payments and the use of nearly all existing lines of credit contributed to their poor credit scores.
Moderate-Income African Americans Have Similar Rates Of Default and Late Payments To Moderate-Income White Americans.
There were no significant differences in the frequency of African American and white households declaring bankruptcy, being evicted, or having property repossessed.
There were no significant differences in the number of times African Americans and whites were late on credit card payments.
African Americans Are More Likely To BE Called By Bill Collectors And Have Seen Credit Tighten.
As a result of debt, bill collectors called 71% of African American middle-income households, compared to 50% of white middle-income households.
Just over half of African American middle-income households reported seeing their credit limit reduced, having a credit card canceled, or being denied for a credit card in the three years following the recession.
Further, the unemployment rate for African Americans is twice as high as white unemployment at the national level. According to Economic Policy Institute, African American workers had the highest unemployment rate nationally at 6.3%, followed by Hispanic workers at 4.5%, white workers at 3.2% and Asian workers at 3.0% during the third quarter of 2018 (Jones, 2018). Household debt and financial insecurity have a negative impact on health and mental health outcomes (Berger, Collins, & Cuesta, 2016). Limiting the conversation about financial stress to poverty does not adequately capture the scope of financial realities that African American women face daily.
Research documents well the correlation between race (Barakat, Martinez, Thomas, & Handley, 2014) and financial stress, usually poverty, (Kothari et al., 2016) as a predictor for PPD. For a more robust conversation about the intersectionality of race, financial stress, and PPD, we need to expand our thinking of financial stress beyond a one-dimensional attribute of poverty to a multi-dimensional construct which addresses a multitude of financial stressors. Financial stress encompasses a range of financial realities that African Americans face, from poverty to stifling consumer debt and a plethora of financial stressors along the continuum. Such a conversation is needed to elucidate the fact that because of a history of structural oppression and discrimination, African Americans face a bevy of barriers that prevent many from achieving financial stability, thereby increasing the likelihood of African American mothers experiencing PPD, not those who experience poverty. Middle- and upper-class African American mothers also experience financial stressors, which could contribute to the onset of PPD.
Not expanding current conceptualizations of financial stress beyond poverty to include the full range of financial stressors that African American mothers encounter may lure middle- and upper-class women into a false sense of security when it comes to developing PPD. They may see their privileged socioeconomic status (SES) as a buffer. However, the reality of financial stress can be pervasive and negatively impact health and mental health outcomes regardless of SES.
If an expectant mother is experiencing financial stress, it is important for healthcare professionals to connect her to resources (benefits eligibility, credit counseling, and mental health services) to mitigate the negative influence of financial stress on overall well-being and to help minimize the stigma and shame which often accompany financial stress. Because financial stress is a predictor for developing PPD, mothers must feel in control of or have a plan for improving their financial situation, thereby minimizing its impact on maternal health. Because African American women are at greater risk of developing PPD than their white counterparts, these and other strategies for improving challenging financial situations are essential for a sense of overall well-being. Research demonstrates that perceived financial well-being is a predictor of overall well-being (Netemeyer, Warmath, Fernandes, & Lynch, 2017) and may lessen the chances of a mother developing PPD.
Dr. Anthony J. Hill is chair, graduate program director, and associate professor in the department of social work at Winthrop University in Rock Hill, South Carolina. He earned a Masters of Social Work (MSW) and a Ph.D. in Social Work from Howard University. He is a licensed clinical social worker, a member of the Academy of Certified Social Workers, a certified clinical trauma professional, and a certified financial social worker. Hill’s practice and research interests include mental health, psychological resilience, and financial social work.
Crystal Regina Hettinger, a Michigan native, is a Masters of Social Work (MSW) candidate at Winthrop University in Rock Hill, South Carolina. She holds a B.S. in Psychology from Ferris State University in Big Rapids, Michigan. She has an interest in mental health and plans to become a licensed clinical social worker.
- Abrams, L.S., & Curran, L. (2007). Not just a middle-class affliction: crafting a social work research agenda on postpartum. Health and Social Work, 32(4), 289-296.
- Albright, A. (1993). Postpartum depression: An Overview. Journal of Counseling & Development, 71(3), 316–320. https://doi.org/10.1002/j.1556-6676.1993.tb02219.x
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) Washington, DC: Author.
- American Psychological Association (2015). Stress in America: paying with our health. Retrieved from https://www.apa.org/news/press/releases/stress/2014/stress-report.pdf
- Barakat, S., Martinez, D., Thomas, M., & Handley, M. (2014). What do we know about gestational diabetes mellitus and risk for postpartum depression among ethnically diverse low-income women in the USA? Archives of Women’s Mental Health, 17(6), 587–592. https://doi.org/10.1007/s00737-014-0460-5
- Berger, M., Collins, J. M., & Cuesta, L. (2015). Household debt and adult depressive symptomsin the United States. Journal of Family Economic Issues, 37, 42-57.
- Bodnar-Deren, S., Benn, E., Balbierz, A., & Howell, E. (2017). Stigma and postpartum depression treatment acceptability among black and white women in the first six-months postpartum. Maternal & Child Health Journal, 21(7), 1457-1468.doi:10.1007/s10995-017-2263-6.
- Clay, E. C., & Seehusen, D. A. (2004). A review of postpartum depression for the primary care physician. Southern Medical Journal, 97(2), 157–161. https://doi.org/10.1097/01.SMJ.0000091029.34773.33
- Closa-Monasterolo, R., Gispert-Llaurado, M., Canals, J., Luque, V., Zaragoza-Jordana, M., Koletzko, B., … Escribano Subías, J. (2017). The effect of postpartum depression and current mental health problems of the mother on child behaviour at eight years. Maternal & Child Health Journal, 21(7), 1563–1572. https://doi.org/10.1007/s10995-017-2288-x
- de Costa, P. (2019, April 8). Housing discrimination underpins the staggering wealth gap between blacks and whites. Retrieved from https://www.epi.org/blog/housing-discrimination-underpins-the-staggering-wealth-gap-between-blacks-and-whites/
- Doe, S., LoBue, S., Hamaoui, A., Rezai, S., Henderson, C., & Mercado, R. (2017). Prevalence and predictors of positive screening for postpartum depression in minority parturients in the South Bronx. Archives of Women’s Mental Health, 20(2), 291–295. https://doi.org/10.1007/s00737-016-0695-4
- Fazlagić, A. (2011). Psychological correlates of postpartum depression. Acta Medica Medianae, 50(4), 62–68. https://doi.org/10.5633/amm.2011.0411
- Financial Health Institute (n.d.). Financial health & stress in human services. Retrieved from http://www.financialhealthinstitute.com/financial-health-financial-stress-in-human-services/
- Guintivano, J., Sullivan, P., Stuebe, A., Penders, T., Thorp, J., Putnam, K., … Meltzer-Brody, S. (2017). 893 – adverse life events, psychiatric comorbidity, and biological predictors of postpartum depression in an ethnically diverse sample of postpartum women. Biological Psychiatry, 81, S360–S361. https://doi.org/10.1016/j.biopsych.2017.02.618
- Harrell, E., Langton, L., Berzofsky, Couzens, & Smiley-McDonald, H. (2014). Household poverty and nonfatal violent victimization, 2008-2012. (NCJ 248384). Received from the Bureau of Justice Statistics website: https://www.bjs.gov/index.cfm?ty=pbdetail&iid=5137
- Hung, C.H., & Chung, H.H. (2001). The effects of postpartum stress and social support on postpartum women’s health status. Journal of Advanced Nursing, 36, pp. 676-684.
- Jones, J. (2018, October 30). Black unemployment is at least twice as high as white unemployment at the national level and in 12 states. Retrieved from https://www.epi.org/publication/2018q3_unemployment_state_race_ethnicity/
- Kim, H., Geppert, J., Quan, T., Bracha, Y., Lupo, V., & Cutts, D. (2012). Screening for postpartum depression among low-income mothers using an interactive voice response system. Maternal & Child Health Journal, 16(4), 921–928. https://doi.org/10.1007/s10995-011-0817-6
- Ko, J. Y., Rockhill, K. M., Tong, V. T., Morrow, B., & Farr, S. L. (2017). Trends in postpartum depressive symptoms – 27 States, 2004, 2008, and 2012. MMWR: Morbidity & Mortality Weekly Report, 66(6), 153–158. https://doi.org/10.15585/mmwr.mm6606a1
- Kothari, C., Liepman, M., Shama Tareen, R., Florian, P., Charoth, R., Haas, S., … Curtis, A. (2016). Intimate partner violence associated with postpartum depression, regardless of socioeconomic status. Maternal & Child Health Journal, 20(6), 1237–1246. https://doi.org/10.1007/s10995-016-1925-0
- McCue Horwitz, S., Briggs-Gowan, M. J., Storfer-Isser, A., & Carter, A. S. (2007). Prevalence, correlates, and persistence of maternal depression. Journal of Women’s Health, 16(5), 678–691. https://doi.org/10.1089/jwh.2006.0185
- Mukherjee, S., Fennie, K., Coxe, S., Madhivanan, P., & Trepka, M. J. (2018). Racial and ethnic differences in the relationship between antenatal stressful life events and postpartum depression among women in the United States: does provider communication on perinatal depression minimize the risk? Ethnicity & Health, 23(5), 542–565. https://doi.org/10.1080/13557858.2017.1280137
- Mundorf, C., Shankar, A., Moran, T., Heller, S., Hassan, A., Harville, E., & Lichtveld, M. (2018). Reducing the risk of postpartum depression in a low-income community through a community health worker intervention. Maternal & Child Health Journal, 22(4), 520–528. https://doi.org/10.1007/s10995-017-2419-4
- National Association of Real Estate Brokers (n.d.) African American homeownership falls to 50-year low. Retrieved from: http://www.nareb.com/african-american-homeownership-falls-50-year-low/
- Netemeyer, R. G., Warmath, D., Fernandes, D., & Lynch, J. G. (2017). How am I doing? Perceived financial well-being, its potential antecedents, and its relation to overall well-being. Journal of Consumer Research, (45), 68-89.
- Oddy, B., Rowe, H., & Fisher, J. (2009). Consumers’ views on the use of diagnostic labels to describe psychological distress in the postpartum: implications for health care. Australian Journal of Primary Health, 15(1), 9–16. https://doi.org/10.1071/PY08061
- Pyles, S. (2018, February 5). Smart money moves for black Americans in financial distress. Retrieved from https://www.nerdwallet.com/blog/finance/how-black-americans-can-move-past-financial-distress/
- Ruetschlin, C., & Asante-Muhammad, D. (2015). The challenge of credit card debt for the African American middle class. Retrieved from https://www.naacp.org/the-challenge-of-credit-card-debt-for-the-african-american-middle-class/
- Venter, M., Smets, J., Raes, F., Wouters, K., Franck, E., Hanssens, M., … Eede, F. (2016). Impact of childhood trauma on postpartum depression: a prospective study. Archives of Women’s Mental Health, 19(2), 337–342. https://doi.org/10.1007/s00737-015-0550-z
- Wisner, K. L., Parry, B. L., & Piontek, C. M. (2002). Postpartum depression. New England Journal of Medicine, 347(3), 194–199. https://doi.org/10.1056/NEJMcp011542
- Zee-van den Berg, A., Boere-Boonekamp, M., IJzerman, M., Haasnoot-Smallegange, R., & Reijneveld, S. (2017). Screening for postpartum depression in well-baby care settings: A systematic review. Maternal & Child Health Journal, 21(1), 9–20. https://doi.org/10.1007/s10995-016-2088-8