thesis statement example for postpartum depression

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• Postpartum Depression Essays

Postpartum Depression Essays (Examples)

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Postpartum depression.

Postpartum Depression: The ole of Nurses Nursing oles and Postpartum Depression Postpartum Depression: The Preventive and Interventional oles of Nurses Postpartum depression is widely recognized as a significant health threat to the mother and the rest of the family, and thus to society, but the biggest threat is to the lifetime health prospects of the newborn infant. Given the health significance of postpartum depression, recent research about the risk factors for this condition, and recommendations for interventions, were examined. While a direct causal link between depression and child neglect does not appear to exist, or be statistically strong, there is a significant indirect causal link. The essential connection seems to be difficulty bonding and bonding is essential to the process of maternal-infant attachment. There also appears to be an inverse relationship between the strength of the attachment and the risk of postpartum depression, such that both mother and child benefit from a strong….

Choi, Hyungin, Yamashita, Tatsuhisa, Wada, Yoshihisa, Narumoto, Jin, Nanri, Hiromi, Fujimori, Akihito et al. (2010). Factors associated with postpartum depression and abusive behavior in mothers with infants. Psychiatry and Clinical Neurosciences, 64, 120-127.

Courey, Tamra J., Martsolf, Donna, Draucker, Claire B., and Strickland, Karen B. (2008). Hildegard Peplau's theory and the healthcare encounters of survivors of sexual violence. Journal of the American Psychiatric Nurses Association, 14(2), 136-143.

Grassley, Jane S. (2010). Adolescent mothers' breastfeeding social support needs. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 39, 713-722.

Humphries, Joan M. And McDonald, Carol. (2012). Unveiling new dimensions: A hermeneutic exploration of perinatal mood disorder and infant feeding. Issues in Mental Health Nursing, 33, 377-386.

Postpartum depression is a serious problem among women. Once thought of as a relatively minor phase within the postpartum cycle, it is now known that it can seriously impair the individual woman's ability to function under the stress of new parenthood and can seriously erode the family, at a point of foundational transition. Over the last twenty years doctors and the general public have demonstrated greater knowledge of the problem of postpartum depression through awareness and of coarse research. According to the British Columbia eproductive Mental Health Program the prevalence of postpartum depression is relatively high but has risk factors associated with age, social support level and prior history of either previous postpartum depression or other forms of clinical depression. The most vulnerable time for a woman to develop onset of mood disorders is during the postpartum period. Approximately 12- 16% of women experience depression during the postpartum period. Adolescent mothers will….

(1995). Depression A Multimedia Sourcebook. Westport, CT: Greenwood Press.

Dickstein, S., Seifer, R., Hayden, L.C., Schiller, M., Keitner, G., Miller, I., Matzko, M., Sameroff, A.J., Rasmussen, S., & Magee, K.D. (1998). Levels of Family Assessment: II. Impact of Maternal Psychopathology on Family Functioning. Journal of Family Psychology, 12(1), 23-40.

Goldstein, L.H., Diener, M.L., & Mangelsdorf, S.C. (1996). Maternal Characteristics and Social Support Across the Transition to Motherhood: Associations with Maternal Behavior. Journal of Family Psychology, 10(1), 60-71.

Howell, E. & Bayes, M. (Eds.). (1981). Women and Mental Health. New York: Basic Books.

Postpartum Depression Past and Current

If that is indeed the case, again her societal position afforded her this opportunity although it was in no way an intervention. She voiced some concern through tears in the quiet of the night. However, Scott points out that this submissive positioning exemplified in the story only served to support the diminished position of women during the time. Ecological adaptation equates to diminished female capacity for Scott and any reader who chooses to look past the flowery verbiage regarding the Yellow Wallpaper. Conclusion Postpartum depression is regarding by experts in the field as an environmental factor that is influential with the mother, child, and mother child dyad. When postpartum depression reaches a chronic state, less than ideal patterns of mother-infant interactions can develop. esultantly, secure attachment is delayed or hindered entirely, which serves to negatively effect social, emotional, cognitive, and neurological development. Empirical findings and the very nature of child development….

Besser, A., Priel, B., & Wiznitzer, A. Childbearing depressive symptomology in high risk pregnancies the roles of working models and social support. Personal Relationships 9 (2002): 395-413.

Cox, J., Holden, J., & Sagovsky, R. detection of postnatal depression: development of the 10 item Edinburgh Postnatal Depression Scale. British Journal of Psychotherapy, 150, (1987): 782-786.

Goodman, S. Depression in mothers. Annual Review of Clinical Psychology, 3, (2007): 107-135.

Kinnaman, G., & Jacobs, R. Seeing in the dark. Michigan: Baker Publishing Group, 2006.

Postpartum Depression Theory in Contemporary

, 2009, 239). When women begin to feel depressed, they often do not go find help or understand that this is an event that is more common than one would think. They tend to isolate their depression, which accelerates it even more. Advanced nurse practitioners and other nursing and clinical staff can help better provide for women by being accepting of their depression, rather than questioning it. Nursing staff can help ease some of the stress by not condemning the depressive feelings or symptoms, which typically make it worse. ather, nursing staff can help the women identify with others who have undergone similar depressive states, thus helping them understand they are not alone and reducing the pressure to put on a facade, which only increases mental stress and accelerates the condition overall. Unfortunately, there are gaps in the literature in regards to the potential risk factors of PPD, leading to the….

Maeve, M. Katherine. Postpartum depression theory. Chapter 34.

Oppo, a., Mauri, M., Ramacciotti, V., Camilleri, S., Banti, C., Rambellie, M.S., Montagnani, S., Cortopassi, a. Bettini, S., Ricciardulli, S. Montaresi, P., Rucci, Beck, C.T., Cassano, G.B. (2009). Risk factors for postpartum depression: The role of the Postpartum Depression Predictors Inventory-Revised (PDPI-R). Archive of Women's Mental Health, 12(2009), 239-249.

Postpartum Depression Is a Completely

It takes time, reading baby-care books, talks with the pediatrician, support groups with other mothers, and experience to know how to care for a child. And the maternally bonding feelings sometimes take weeks or months to develop. Perfect aby. The fantasy that your baby will be beautiful in every way, sleep through the night, and never cry is exactly that -- a fantasy. And the thoughts that all your friends new babies are perfect and yours isn't is also a fantasy. In 99 cases out of 100 that won't happen. ut these thoughts can contribute to PPD. Perfect Mother. eing the perfect mom will never happen -- either for you or your friends whom you perceive as perfect. You think you are not living up to the ideally perfect mother because you have trouble sometimes balancing the baby, other children, housework, a job, a spouse, and a myriad of other tasks.….

Bibliography

ACOG. (2009, January). Postpartum depression. Retrieved February 27, 2010, from the American Congress of Obstetricians and Gynecologists (ACOG):  http://www.acog.org/publications/patient_education/bp091.cfm  familydoctor.org staff. (2008, February). Postpartum depression and the baby blues. Retrieved February 28, 2010, from familydoctor.org:  http://familydoctor.org/online/famdocen/home/women/pregnancy/ppd/general/379.html 

Lane, B. (2007, January 21). Causes of postpartum depression. Retrieved February 28, 2010, from suite101.com: http://pregnancychildbirth.suite101.com/article.cfm/causes_of_postpartum_depression

Leopold, K., & Zoschnick, L. (n.d.). Postpartum depression. Retrieved March 1, 2010, from obgyn.net:  http://www.obgyn.net/femalepatient/femalepatient.asp?page=leopold 

Mayo Clinic Staff. (2009). Postpartum Depression. Retrieved February 27, 2010, from Mayoclinic.com:  http://www.mayoclinic.com/health/postpartum-depression/DS00546

Postpartum Depression or Postnatal Depression Is a

Postpartum depression or postnatal depression is a term that describes the occurrence of moderate to severe depression in a woman after she has given birth (although sometimes men are given this diagnosis when severe depression occurs after the birth of a child). This depression may occur soon after delivery and may linger up to a year or longer. In the majority of recognized cases the depression occurs within the first three months following the delivery of the child. The DSM-IV does not recognize postpartum depression as a distinct disorder. People who receive a diagnosis of postpartum depression must first meet the standard diagnostic criteria for a major depressive episode and then they must satisfy the additional specifier criteria for the postpartum onset (American Psychiatric Association [APA], 2000). This criterion states that the onset of the major depressive episode must occur within four weeks after delivery. Postpartum depression then should be responsive….

American Psychiatric Association. (2000). Diagnostic and statistical manualof mental disorders (4th Ed.-test revision). Washington D.C.: author.

Cohen, J. (1997). The earth is round (p < .05). The American Psychologist, 49 (12), 997-1003.

Daston, L. (2005). Scientific error and the ethos of belief. Social Research, 72 (1), 1-28.

Hageman, W.J., & Arrindell, W.A. (1999). Establishing clinically significant change: Increment of precision and the distinction between individual and group level of analysis. Behavior Research and Therapy, 37, 1169-1193.

Postpartum Depression According to the

The issue that is most often associated with the diagnosis of PPD is the time frame, however Records notes that there are major discrepancies between the maternity and psychiatric literature making a 2-12-month diagnosis difficult (Records pp). The subjects in Records's study described how their past abuse experiences affected their thoughts and view of their labor, delivery, and postpartum experiences (Records pp). Records revealed that "all of the subjects felt that the combined recall of trauma events and the labor and delivery experience provided the foundation for the PPD...perceived negative labor and delivery experience as the basis for their PPD" (Records pp). In the May 01, 2002 issue of OB GYN News, Erik L. Goldman cites Dr. Diana Dell's press briefing sponsored by the American College of Obstetricians and Gynecologists. According to Dell, women are under tremendous pressure to "make perfect babies and to be perfect mothers and perfect wives...and….

Works Cited

Cohen, Lee. "Treating postpartum depression." OB GYN News. February 02, 2002.

Retrieved October 29, 2005 from HighBeam Research Library Web site.

Epperson, C. Neill. "Postpartum Major Depression: Detection and Treatment."

American Family Physician. April 15, 1999. Retrieved October 29, 2005 from HighBeam Research Library Web site.

Postpartum Depression Screening Postpartum Depression Evaluation Plan

Postpartum Depression Screening Postpartum Depression Evaluation Plan for Postpartum Depression Screening Initiative Evaluation Plan for Postpartum Depression Screening Initiative Although a number of screening and treatment programs for postpartum depression have been implemented, many of these programs have not been studied to determine efficacy (reviewed by Yawn et al., 2012b). This lack of evidence has prevented a number of agencies and organizations from issuing recommendations, including the American College of Obstetrics and Gynecology and the U.S. Preventive Services Task Force. The Institute of Medicine's (2001) report, titled "Crossing the Quality Chasm: A New Health System for the 21st Century," proposed six aims to improve health care in America. These aims were providing safe, effective, patient-centered, timely, efficient, and equitable care. One of the rules outlined to help achieve these aims was to ensure that patients received care based on the best scientific evidence available. In keeping with this goal of providing evidence-based care, an….

Gilbody, Simon, Richards, David, Brealey, Stephen, and Hewitt, Catherine. (2007). Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): A diagnostic meta-analysis. Journal of General Internal Medicine, 22(11), 1596-1602.

Gilbody, Simon, Sheldon, Trevor, and House, Allan. (2008). Screening and case-finding instruments for depression: A meta-analysis. Canadian Medical Association Journal, 178(8), 997-1003.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. IOM.edu. Retrieved 20 Sep. 2012 from http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf.

Kozhimannil, Katy Backes, Adams, Alyce S., Soumerai, Alisa B. Busch, and Huskamp, Haiden A. (2011). New Jersey's efforts to improve postpartum depression care did not change treatment patterns for women on Medicaid. Health Affairs, 30(2), 293-301.

Postpartum Depression and Its Treatment

After controlling for initial depressive symptoms during pregnancy, optimism was associated with fewer depressive symptoms at three weeks postpartum" (Grote & Bledsoe, 2007). They found this in other areas of women's lives, as well, such as reaching menopause and other stressful events that can often lead to the development of depression. Thus, if a family member or loved one suspects a new mother may develop postpartum depression, they could give her support, understanding, and help her to become more optimistic in her outlook to help ward off or deal with the disorder. Support from family members is also an important element of care after the baby is born, and the lack of it can help lead to depression. In conclusion, postpartum depression is a common disorder, and it can hit just about any new mother. In some cases, the symptoms disappear by themselves, but in severe cases, the woman should….

Abrams, L.S., & Curran, L. (2007). Not just a middle-class affliction: Crafting a social work research agenda on postpartum depression. Health and Social Work, 32(4), 289+.

Editors. (2008). Depression during and after pregnancy. Retrieved 8 Dec. 2008 from the Women's Health.gov Web site:  

Postpartum Depression and Depression

Coping Skills: Postpartum Depression One of the most useful coping strategies for individuals suffering from depression is to take active steps to reduce the stressors responsible for triggering the depression in the first place (Orzechowska, Zajaczkowska, Talarowska, & Galecki 2013). For patients diagnosed with postpartum depression, this may include reducing the sleep deprivation and constant demands of caring for a newborn. Ensuring that the patient has support from her partner, relatives, and if possible from a hired nurse can reduce some of the factors which may exacerbate her negative mood. Another coping skill is that of reframing. Many women feel guilty that they do not have wholly positive feelings about their newborn and have ambivalent feelings about mothering in general. "Positive reinterpretation and growth (growing as a person as a result of the experience, seeing events in a positive light)" can encourage the woman to see her desire to maintain a….

Fitelson, E., Kim, S. Baker, A., & Leight, L. (2011). Treatment of postpartum depression:

clinical, psychological and pharmacological options. International Journal of Women's Health, 3: 1 -- 14. Retrieved from:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3039003/ 

Leandro, P. & Castillo, M. (2010). Coping with stress and its relationship with personality dimensions, anxiety, and depression. Procedia, 5: 1562-1573. Retrieved from:  http://www.sciencedirect.com/science/article/pii/S1877042810017003 

Orzechowska, A. Zajaczkowska, M., Talarowska, M. & Galecki, P. (2013). Depression and ways of coping with stress: A preliminary study. Medical Science Monitor, 19: 1050 -- 1056. Retrieved from:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3852369/

Postpartum Depression in New Moms

Cognitive Behavioral Therapy and Postpartum Depression Introduction Becoming a new mother can be a very overwhelming experience for some women and the symptoms of postpartum depression that follow birth can confuse and deject them. It is important that women receive the therapeutic help they need in these situations. This paper will discuss the symptoms and causes of postpartum depression, how a counselor can develop strategies to work with clients experiencing postpartum depression, how a counselor can build rapport, barriers to care, and psychological interventions the counselor can use to treat the client. Symptoms and Causes Symptoms of postpartum depression for new mothers include a range of signs that can go from mild to extreme. On the mild end of the scale one may experience mood swings, anxiety, sadness, irritability, feelings of being overwhelmed, crying, inability to concentrate, loss of appetite and trouble sleeping (Mayo Clinic, 2020). These symptoms can last anywhere from a few….

Post-Partum Depression

birth of a child is often a time of anxiety for both parents and a source of physical, emotional, and mental strain for the soon to be mother. Within a short amount of time however, family members usually become accustomed to new sleeping schedules, different routines, and even occasional moments of mild depression or mood swings. Their lives quickly return to normal, and their emotions become stable, which allows them to experience the joy of having a newborn child. For nearly ten percent of new mothers and over thirty percent of all mothers, however, the feelings of mild depression and periods of mood swings do not disappear (Verkerk, 2005). This lingering sense of depression and anguish is known as postpartum depression, and is an extremely misunderstood, misdiagnosed mental illness that plagues thousands of women each year. Untreated, postpartum depression can become a nightmare for the women who experience it, and….

Ainsworth, P. (2000). Understanding depression. Jackson, MS: University Press of Mississippi.

British Columbia Reproductive Mental Health Program. (2000). Psychosis. Reproductive Mental Health. Retrieved from BCRMHP. Web site: http://www.bcrmh.com/disorders/psychosis.htm.

Canadian Mental Health Association. (2004). Postpartum depression. Reach Out. Retrieved from the Canadian Mental Health Association. Web site:  http://www.cmha.ca/bins/content_page.asp?cid=3-86-87-88 .

Meinrad, P., & Reicherts, M. Depressed people coping with aversive situations. In P. Meinrad (Ed.), Stress, coping, and health: A situation-behavior approach (pp. 103-105). Seattle, WA: Hogrefe and Huber.

postpartum depression and gilman yellow wallpaper

Long before the term postpartum depression became part of the vernacular, Charlotte Perkins Gilman deftly and sensitively describes the complex condition in her short story “The Yellow Wallpaper.” The story describes the prevailing attitudes towards women and their narrowly defined roles in society. White, upper middle class women like the narrator of “The Yellow Wallpaper” could not easily express discontent with their position as wife and mother. The narrator’s husband—a physician—believes there is “nothing the matter” with his wife except “temporary nervous depression” and “a slight hysterical tendency,” (Gilman 648). Noting her brother is also a physician, the narrator exclaims, “But what is one to do,” when one is just a woman, and therefore a subordinate whose total financial and social dependency on their male counterparts precludes their self-determination (Gilman 649). To address her “hysteria,” the narrator’s husband and brother confine her to a pleasant enough country home, but restrict….

Postpartum Depression and Nursing

nursing because a solution to it directly impacts the level of quality care that staff can provide to patients. The research is quantitative. The underlying purpose of the study is to test whether providing information from assessments about patient-caregiver hospice dyads to interdisciplinary teams is effective in improving hospice outcomes. The purpose does correspond to an EBP focus -- namely, therapy/treatment. Greater awareness leads to a greater ability to provide care. This study could have been undertaken as a qualitative study by conducting interviews with caregivers and/or patients to assess personal reactions to the issue at hand. Example 2: Qualitative Research The research problem is very relevant to the actual practice of nursing because it regards how patients deal with suffering, self-blame, guilt, etc., all of which nurses will encounter when treating them. The research is qualitative. The underlying purpose of the study is to provide description of a situation. The purpose does correspond to an EBP….

How women can mitigate the impacts of postpartum depression

Background of postpartum depressionDepression has quickly become a major public health concern for those in the United States. COVID-19 and its resulting health consequences have exacerbated many of the impacts of depression on women within developed worlds. The pandemic for example, caused massive and unexpected job loss of millions of families. Many of those impacted such as travel, tourism, and retail are still reeling from the economic consequences of the virus. These elements can combine to severely impact the psychological wherewithal of individuals in society, particularly women. Child bearing is one of the most powerful and stressful events a woman can experience. If unprepared financially, or healthcare wise, this stress can result in depression. For once Women are nearly twice as likely to experience depression during their childbearing years as compared to men. Postpartum depression is defined by academics as an episode of non-psychotic depression according to standardized diagnostic criteria….

References 1. Beck, C. T. (1995). The effects of postpartum depression on maternal-infant interaction: a meta-analysis. Nursing Research, 44, 298-304.2. Cooper, P. J. & Murray, L. (1997). The impact of psychological treatments of postpartum depression on maternal mood and infant development. In L.Murray & P. J. Cooper (Eds.), Postpartum depression and child development (pp. 201-220). New York: Guilford Press.3. Jacobsen, T. (1999). Effects of postpartum disorders on parenting and on offspring. In L.J.Miller (Ed.), Postpartum Mood Disorders (pp. 119-139). Washington, DC.: American Psychiatric Press4. Milgrom, J. (1994). Mother-infant interactions in postpartum depression: an early intervention program. Australian Journal of Advanced Nursing, 11, 29-38.

Can you provide guidance on how to outline an essay focusing on Should men get more paternity leave?

Outline for an Essay on Should Men Get More Paternity Leave? I. Introduction Hook: Begin with a compelling statistic or anecdote that highlights the importance of paternity leave. Thesis statement: State the main argument that men should be entitled to more paternity leave. II. Section 1: Importance of Paternity Leave for Fathers Discuss the benefits of paternity leave for fathers: Improved bonding with the newborn Reduced stress and anxiety Increased involvement in childcare Provide evidence from research and studies to support these claims. III. Section 2: Benefits of Paternity Leave for Families Highlight the positive impact paternity leave has on families: Enhanced child....

Unsure if my postpartum depression thesis statement is focused enough. Would you give feedback?

Thesis statement: Despite advancements in medical and societal understanding, postpartum depression remains a substantial mental health concern, and addressing it requires not only better screening and treatment options, but also increased awareness and support for affected mothers. Your thesis statement provides a clear focus on the ongoing significance of postpartum depression as a mental health issue. However, consider adding more specific details or examples that support the need for better screening, treatment options, awareness, and support for affected mothers. Including statistics or research findings on the prevalence and impact of postpartum depression could strengthen your thesis statement. Additionally, you may want....

Original Thesis Statement: Postpartum depression is a serious mental health condition that significantly impacts the physical, emotional, and social well-being of mothers. Feedback: The original thesis statement is comprehensive and accurately describes the significance of postpartum depression. However, it is somewhat broad and does not provide a specific focus for the thesis. A more focused thesis statement would help to guide the research and argumentation in the paper. Revised Thesis Statement: Postpartum depression is a prevalent mental health condition that manifests in diverse ways and requires tailored treatment approaches to improve maternal outcomes. Explanation: The revised thesis statement is more focused in several ways: 1. It identifies a....

Can you provide an outline of the potential risks and challenges associated with teenage pregnancy?

I. Introduction A. Background information on teenage pregnancy B. Thesis statement II. Causes of Teenage Pregnancy A. Lack of sex education 1. Insufficient knowledge about contraception methods 2. Misinformation about pregnancy prevention B. Peer pressure 1. Influence from friends and social groups 2. Desire for acceptance and popularity C. Absence of parental guidance 1. Lack of communication within the family 2. Deterioration of family values and morals III. Consequences of Teenage Pregnancy A. Health risks for the mother and child 1. Increased likelihood of complications during pregnancy and childbirth 2. Higher rates of preterm birth and low birth weight babies B. Education....

Research Paper

Postpartum Depression: The ole of Nurses Nursing oles and Postpartum Depression Postpartum Depression: The Preventive and Interventional oles of Nurses Postpartum depression is widely recognized as a significant health threat to the…

Postpartum depression is a serious problem among women. Once thought of as a relatively minor phase within the postpartum cycle, it is now known that it can seriously impair…

If that is indeed the case, again her societal position afforded her this opportunity although it was in no way an intervention. She voiced some concern through tears…

, 2009, 239). When women begin to feel depressed, they often do not go find help or understand that this is an event that is more common than one…

Research Proposal

It takes time, reading baby-care books, talks with the pediatrician, support groups with other mothers, and experience to know how to care for a child. And the maternally…

Postpartum depression or postnatal depression is a term that describes the occurrence of moderate to severe depression in a woman after she has given birth (although sometimes men are…

The issue that is most often associated with the diagnosis of PPD is the time frame, however Records notes that there are major discrepancies between the maternity and…

Postpartum Depression Screening Postpartum Depression Evaluation Plan for Postpartum Depression Screening Initiative Evaluation Plan for Postpartum Depression Screening Initiative Although a number of screening and treatment programs for postpartum depression have been…

After controlling for initial depressive symptoms during pregnancy, optimism was associated with fewer depressive symptoms at three weeks postpartum" (Grote & Bledsoe, 2007). They found this in other…

Psychology - Abnormal

Coping Skills: Postpartum Depression One of the most useful coping strategies for individuals suffering from depression is to take active steps to reduce the stressors responsible for triggering the depression…

Cognitive Behavioral Therapy and Postpartum Depression Introduction Becoming a new mother can be a very overwhelming experience for some women and the symptoms of postpartum depression that follow birth can confuse…

birth of a child is often a time of anxiety for both parents and a source of physical, emotional, and mental strain for the soon to be mother.…

Long before the term postpartum depression became part of the vernacular, Charlotte Perkins Gilman deftly and sensitively describes the complex condition in her short story “The Yellow Wallpaper.” The…

nursing because a solution to it directly impacts the level of quality care that staff can provide to patients. The research is quantitative. The underlying purpose of the study is…

Background of postpartum depressionDepression has quickly become a major public health concern for those in the United States. COVID-19 and its resulting health consequences have exacerbated many of the…

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Postpartum Depression: Treatment and Therapy Essay

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Introduction

Postpartum depression.

Although for many people the birth of a child is an exciting part of life, for some it may cause adverse health outcomes. One of them is postpartum depression that can be characterized by mood swings, sleep deprivation, and anxiety. This paper discusses a patient that presented in the clinic with these symptoms. It outlines the possible treatment and therapy methods, as well as the implications of the condition.

A 28-year-old patient presented in the office three weeks after giving birth to her first son with the symptoms of postpartum depression. The woman was a single mother; she did not have a strong support system as her former partner refused to help her and her family lived in a different state. She noted that she was sleep-deprived, she felt apathetic, sad, experienced anxiety, and had a decreased appetite.

The patient reported that she was diagnosed with depression seven years ago but underwent treatment and had not had the symptoms for a long time. The woman noted that her mother also had signs of a mental disorder but never sought professional help. The patient cried while talking to me; her emotional state was poor. In addition, the woman admitted that she had thought of harming her newborn son because she felt that she was tired of taking care of him.

The typical signs of postpartum depression include the presence of sleep disorder, fatigue, crying, anxiety, changes in appetite, and feelings of inadequacy (Tharpe, Farley, & Jordan, 2017). The patient has these symptoms, which allowed for establishing the diagnosis. Drug therapy included the prescription of tricyclic antidepressants, as they do not pose risks to infants during breastfeeding (Anxiety and Depression Association of America, 2018). Additional therapies included adequate nutrition with the exclusion of caffeine and herbal remedies, such as 2 cups of lemon balm tea daily (Tharpe et al., 2017).

Moreover, I advised the woman to participate in support groups’ meetings and have a scheduled time for personal care, hobbies, and favorite activities, as well as sleep. In addition, I asked the patient to try to have some time away from her child as it could improve her mental state as well. As for follow-up care measures, I suggested that the woman could document her thoughts and feelings and update me on the changes in her condition by visiting my office in two weeks. Moreover, I invited the patient to participate in an educational session on the aspects of postpartum depression.

The primary implication of the woman’s condition is that it is vital to educate individuals on its symptoms and assure them that this experience is common. Moreover, it is necessary to continue establishing support groups and psychotherapy sessions aimed to eliminate this issue. Postpartum depression may affect not only this woman but her entire family unit as the individuals close to the patient can also start experiencing emotional distress and other related symptoms. In the case of my patient, the condition may affect her relationships with her child, potentially causing a poor emotional bond and behavioral problems in the infant.

Postpartum depression is a severe condition that may affect a patient’s life significantly. It can cause individuals to feel anxious, experience mood swings and changes in appetite, and have thoughts of harming their newborn children. The management strategy for this illness can include drug therapy along with alternative remedies. It is vital to establish support groups and educational training for people having postpartum depression to decrease its incidence.

Anxiety and Depression Association of America. (2018). Postpartum depression . Web.

Tharpe, N. L., Farley, C., & Jordan, R. G. (2017). Clinical practice guidelines for midwifery & women’s health (5th ed.). Burlington, MA: Jones & Bartlett Publishers.

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IvyPanda. (2021, July 9). Postpartum Depression: Treatment and Therapy. https://ivypanda.com/essays/postpartum-depression-discussion/

"Postpartum Depression: Treatment and Therapy." IvyPanda , 9 July 2021, ivypanda.com/essays/postpartum-depression-discussion/.

IvyPanda . (2021) 'Postpartum Depression: Treatment and Therapy'. 9 July.

IvyPanda . 2021. "Postpartum Depression: Treatment and Therapy." July 9, 2021. https://ivypanda.com/essays/postpartum-depression-discussion/.

1. IvyPanda . "Postpartum Depression: Treatment and Therapy." July 9, 2021. https://ivypanda.com/essays/postpartum-depression-discussion/.

Bibliography

IvyPanda . "Postpartum Depression: Treatment and Therapy." July 9, 2021. https://ivypanda.com/essays/postpartum-depression-discussion/.

• Patient Care & Health Information
• Diseases & Conditions
• Postpartum depression

The birth of a baby can start a variety of powerful emotions, from excitement and joy to fear and anxiety. But it can also result in something you might not expect — depression.

Most new moms experience postpartum "baby blues" after childbirth, which commonly include mood swings, crying spells, anxiety and difficulty sleeping. Baby blues usually begin within the first 2 to 3 days after delivery and may last for up to two weeks.

But some new moms experience a more severe, long-lasting form of depression known as postpartum depression. Sometimes it's called peripartum depression because it can start during pregnancy and continue after childbirth. Rarely, an extreme mood disorder called postpartum psychosis also may develop after childbirth.

Postpartum depression is not a character flaw or a weakness. Sometimes it's simply a complication of giving birth. If you have postpartum depression, prompt treatment can help you manage your symptoms and help you bond with your baby.

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Symptoms of depression after childbirth vary, and they can range from mild to severe.

Baby blues symptoms

Symptoms of baby blues — which last only a few days to a week or two after your baby is born — may include:

• Mood swings
• Irritability
• Feeling overwhelmed
• Reduced concentration
• Appetite problems
• Trouble sleeping

Postpartum depression symptoms

Postpartum depression may be mistaken for baby blues at first — but the symptoms are more intense and last longer. These may eventually interfere with your ability to care for your baby and handle other daily tasks. Symptoms usually develop within the first few weeks after giving birth. But they may begin earlier — during pregnancy — or later — up to a year after birth.

Postpartum depression symptoms may include:

• Depressed mood or severe mood swings
• Crying too much
• Difficulty bonding with your baby
• Withdrawing from family and friends
• Loss of appetite or eating much more than usual
• Inability to sleep, called insomnia, or sleeping too much
• Overwhelming tiredness or loss of energy
• Less interest and pleasure in activities you used to enjoy
• Intense irritability and anger
• Fear that you're not a good mother
• Hopelessness
• Feelings of worthlessness, shame, guilt or inadequacy
• Reduced ability to think clearly, concentrate or make decisions
• Restlessness
• Severe anxiety and panic attacks
• Thoughts of harming yourself or your baby
• Recurring thoughts of death or suicide

Untreated, postpartum depression may last for many months or longer.

Postpartum psychosis

With postpartum psychosis — a rare condition that usually develops within the first week after delivery — the symptoms are severe. Symptoms may include:

• Feeling confused and lost
• Having obsessive thoughts about your baby
• Hallucinating and having delusions
• Having sleep problems
• Having too much energy and feeling upset
• Feeling paranoid
• Making attempts to harm yourself or your baby

Postpartum psychosis may lead to life-threatening thoughts or behaviors and requires immediate treatment.

Postpartum depression in the other parent

Studies show that new fathers can experience postpartum depression, too. They may feel sad, tired, overwhelmed, anxious, or have changes in their usual eating and sleeping patterns. These are the same symptoms that mothers with postpartum depression experience.

Fathers who are young, have a history of depression, experience relationship problems or are struggling financially are most at risk of postpartum depression. Postpartum depression in fathers — sometimes called paternal postpartum depression — can have the same negative effect on partner relationships and child development as postpartum depression in mothers can.

If you're a partner of a new mother and are having symptoms of depression or anxiety during your partner's pregnancy or after your child's birth, talk to your health care provider. Similar treatments and supports provided to mothers with postpartum depression can help treat postpartum depression in the other parent.

When to see a doctor

If you're feeling depressed after your baby's birth, you may be reluctant or embarrassed to admit it. But if you experience any symptoms of postpartum baby blues or postpartum depression, call your primary health care provider or your obstetrician or gynecologist and schedule an appointment. If you have symptoms that suggest you may have postpartum psychosis, get help immediately.

It's important to call your provider as soon as possible if the symptoms of depression have any of these features:

• Don't fade after two weeks.
• Are getting worse.
• Make it hard for you to care for your baby.
• Make it hard to complete everyday tasks.
• Include thoughts of harming yourself or your baby.

If you have suicidal thoughts

If at any point you have thoughts of harming yourself or your baby, immediately seek help from your partner or loved ones in taking care of your baby. Call 911 or your local emergency assistance number to get help.

Also consider these options if you're having suicidal thoughts:

• Seek help from a health care provider.
• Call a mental health provider.
• Contact a suicide hotline. In the U.S., call or text 988 to reach the 988 Suicide & Crisis Lifeline , available 24 hours a day, seven days a week. Or use the Lifeline Chat . Services are free and confidential. The Suicide & Crisis Lifeline in the U.S. has a Spanish language phone line at 1-888-628-9454 (toll-free).
• Reach out to a close friend or loved one.
• Contact a minister, spiritual leader or someone else in your faith community.

Helping a friend or loved one

People with depression may not recognize or admit that they're depressed. They may not be aware of signs and symptoms of depression. If you suspect that a friend or loved one has postpartum depression or is developing postpartum psychosis, help them seek medical attention immediately. Don't wait and hope for improvement.

There is a problem with information submitted for this request. Review/update the information highlighted below and resubmit the form.

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There is no single cause of postpartum depression, but genetics, physical changes and emotional issues may play a role.

• Genetics. Studies show that having a family history of postpartum depression — especially if it was major — increases the risk of experiencing postpartum depression.
• Physical changes. After childbirth, a dramatic drop in the hormones estrogen and progesterone in your body may contribute to postpartum depression. Other hormones produced by your thyroid gland also may drop sharply — which can leave you feeling tired, sluggish and depressed.
• Emotional issues. When you're sleep deprived and overwhelmed, you may have trouble handling even minor problems. You may be anxious about your ability to care for a newborn. You may feel less attractive, struggle with your sense of identity or feel that you've lost control over your life. Any of these issues can contribute to postpartum depression.

Risk factors

Any new mom can experience postpartum depression and it can develop after the birth of any child, not just the first. However, your risk increases if:

• You have a history of depression, either during pregnancy or at other times.
• You have bipolar disorder.
• You had postpartum depression after a previous pregnancy.
• You have family members who've had depression or other mood disorders.
• You've experienced stressful events during the past year, such as pregnancy complications, illness or job loss.
• Your baby has health problems or other special needs.
• You have twins, triplets or other multiple births.
• You have difficulty breastfeeding.
• You're having problems in your relationship with your spouse or partner.
• You have a weak support system.
• You have financial problems.
• The pregnancy was unplanned or unwanted.

Complications

Left untreated, postpartum depression can interfere with mother-child bonding and cause family problems.

• For mothers. Untreated postpartum depression can last for months or longer, sometimes becoming an ongoing depressive disorder. Mothers may stop breastfeeding, have problems bonding with and caring for their infants, and be at increased risk of suicide. Even when treated, postpartum depression increases a woman's risk of future episodes of major depression.
• For the other parent. Postpartum depression can have a ripple effect, causing emotional strain for everyone close to a new baby. When a new mother is depressed, the risk of depression in the baby's other parent may also increase. And these other parents may already have an increased risk of depression, whether or not their partner is affected.
• For children. Children of mothers who have untreated postpartum depression are more likely to have emotional and behavioral problems, such as sleeping and eating difficulties, crying too much, and delays in language development.

If you have a history of depression — especially postpartum depression — tell your health care provider if you're planning on becoming pregnant or as soon as you find out you're pregnant.

• During pregnancy, your provider can monitor you closely for symptoms of depression. You may complete a depression-screening questionnaire during your pregnancy and after delivery. Sometimes mild depression can be managed with support groups, counseling or other therapies. In other cases, antidepressants may be recommended — even during pregnancy.
• After your baby is born, your provider may recommend an early postpartum checkup to screen for symptoms of postpartum depression. The earlier it's found, the earlier treatment can begin. If you have a history of postpartum depression, your provider may recommend antidepressant treatment or talk therapy immediately after delivery. Most antidepressants are safe to take while breastfeeding.
• Depressive disorders. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision DSM-5-TR. American Psychiatric Association; 2022. https://dsm.psychiatryonline.org. Accessed May 9, 2022.
• Postpartum depression. Office on Women's Health. https://www.womenshealth.gov/mental-health/mental-health-conditions/postpartum-depression. Accessed May 5, 2022.
• Depression among women. Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/depression/index.htm. Accessed May 5, 2022.
• What is peripartum depression (formerly postpartum)? American Psychiatric Association. https://www.psychiatry.org/patients-families/postpartum-depression/what-is-postpartum-depression. Accessed Nov. 18, 2022.
• Viguera A. Postpartum unipolar depression: Epidemiology, clinical features, assessment, and diagnosis. https://www.uptodate.com/contents/search. Accessed Nov. 18, 2022.
• Viguera A. Mild to moderate postpartum unipolar major depression: Treatment. https://www.uptodate.com/contents/search. Accessed May 6, 2022.
• Viguera A. Severe postpartum unipolar major depression: Choosing treatment. https://www.uptodate.com/contents/search. Accessed May 6, 2022.
• Faden J, et al. Intravenous brexanolone for postpartum depression: What it is, how well does it work, and will it be used? Therapeutic Advances in Psychopharmacology. 2020; doi:10.1177/2045125320968658.
• FAQs. Postpartum depression. American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/postpartum-depression. Accessed May 6, 2022.
• Suicide prevention. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/suicide-prevention. Accessed May 6, 2022.
• Postpartum depression. Merck Manual Professional Version. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/postpartum-care-and-associated-disorders/postpartum-depression#. Accessed May 6, 2022.
• AskMayoExpert. Depression in pregnancy and postpartum. Mayo Clinic; 2022.
• American Academy of Pediatrics. Postpartum care of the mother. In: Guidelines for Perinatal Care. 8th ed. American Academy of Pediatrics; American College of Obstetricians and Gynecologists; 2017.
• Kumar SV, et al. Promoting postpartum mental health in fathers: Recommendations for nurse practitioners. American Journal of Men's Health. 2018; doi:10.1177/1557988317744712.
• Scarff JR. Postpartum depression in men. Innovations in Clinical Neuroscience. 2019;16:11.
• Bergink V, et al. Postpartum psychosis: Madness, mania, and melancholia in motherhood. American Journal of Psychiatry. 2016; doi:10.1176/appi.ajp.2016.16040454.
• Yogman M, et al. Fathers' roles in the care and development of their children: The role of pediatricians. Pediatrics. 2016; doi:10.1542/peds.2016-1128.
• FDA approves first treatment for post-partum depression. U.S. Food and Drug Administration. https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-post-partum-depression. Accessed May 6, 2022.
• Deligiannidis KM, et al. Effect of zuranolone vs placebo in postpartum depression: A randomized clinical trial. JAMA Psychiatry. 2021; doi:10.1001/jamapsychiatry.2021.1559.
• Betcher KM (expert opinion). Mayo Clinic. May 10, 2022.
• 988 Suicide & Crisis Lifeline. https://988lifeline.org/. Accessed Nov. 18, 2022.

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• v.13(1); 2022 Jan

Design and Evaluation of a Postpartum Depression Ontology

Rebecca b. morse.

1 Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States

Abigail C. Bretzin

Silvia p. canelón, bernadette a. d'alonzo, andrea l. c. schneider.

2 Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States

Mary R. Boland

Associated data.

Objective  Postpartum depression (PPD) remains an understudied research area despite its high prevalence. The goal of this study is to develop an ontology to aid in the identification of patients with PPD and to enable future analyses with electronic health record (EHR) data.

Methods  We used Protégé-OWL to construct a postpartum depression ontology (PDO) of relevant comorbidities, symptoms, treatments, and other items pertinent to the study and treatment of PPD.

Results  The PDO identifies and visualizes the risk factor status of variables for PPD, including comorbidities, confounders, symptoms, and treatments. The PDO includes 734 classes, 13 object properties, and 4,844 individuals. We also linked known and potential risk factors to their respective codes in the International Classification of Diseases versions 9 and 10 that would be useful in structured EHR data analyses. The representation and usefulness of the PDO was assessed using a task-based patient case study approach, involving 10 PPD case studies. Final evaluation of the ontology yielded 86.4% coverage of PPD symptoms, treatments, and risk factors. This demonstrates strong coverage of the PDO for the PPD domain.

Conclusion  The PDO will enable future researchers to study PPD using EHR data as it contains important information with regard to structured (e.g., billing codes) and unstructured data (e.g., synonyms of symptoms not coded in EHRs). The PDO is publicly available through the National Center for Biomedical Ontology (NCBO) BioPortal ( https://bioportal.bioontology.org/ontologies/PARTUMDO ) which will enable other informaticists to utilize the PDO to study PPD in other populations.

Background and Significance

Importance and prevalence of postpartum depression.

While approximately 15 to 85% of women experience the “baby blues” or some form of sadness in the 2 weeks following delivery, 1 postpartum depression (PPD) is a more severe and longer lasting mental illness that is detrimental to both the mother and newborn. PPD is classified as an episode of major depressive disorder (MDD) that can occur up to 12 months after childbirth, 2 and it affects approximately 10 to 20% of mothers. 3 4 While unexplained crying and general sadness are common symptoms, PPD can produce more severe consequences such as feelings of hopelessness, intense anxiety, 5 suicidal ideation, thoughts about harming the baby, 6 and mother–infant bonding challenges that can affect the child's future development. 5

Need for Increased Research on Risk Factors Underlying Postpartum Depression

The PPD field includes a considerable amount of risk factor research, with the strongest identified factors being a history of depression, anxiety during pregnancy, and depression during pregnancy; 7 however, due to the large number of variables involved in pregnancy and birth, numerous factors are understudied or not researched at all. Many risk factors, such as preeclampsia 7 8 9 10 and Cesarean section, 7 8 9 10 11 lack a consensus, with separate studies reporting mixed levels of significance. Additionally, several studies 12 13 14 do not adjust for important confounding variables, such as a history of psychiatric illness, and therefore reduce the generalizability and usefulness of the results. Furthermore, due to the stigma associated with mental illness disclosure, studies may also suffer from recruitment or follow-up difficulties. 15 Despite electronic health record (EHR) research promoting investigation of a variety of confounding variables, assembly of large cohorts, assessment of associations among risk factor subgroups (e.g., types of Cesarean sections), and avoidance of challenges in study recruitment and follow-up, 15 very few PPD papers have utilized EHRs. Thus, it is necessary to improve PPD risk factor research by expanding the use of EHRs.

Ontologies Are Useful for Large-Research Consortiums

Large research consortiums exist, including the Observational Health Data Sciences and Informatics consortium (OHDSI; https://www.ohdsi.org/ ) along with several recent novel coronavirus disease 2019 (COVID-19)-specific consortiums such as N3C ( https://ncats.nih.gov/n3c ). While a separate initiative, N3C utilizes the same Common Data Model that OHDSI utilizes in their consortium. These consortiums are great in providing standard methods to translate individual hospital record systems into a shareable and easily computable framework that enables queries and more complex scripts to run across multiple sites simultaneously. However, these consortiums do not provide disease-specific ontology information or methods for extracting relevant patients for particular diseases, they merely provide concept sets. These concept sets include information that is largely derived from the Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT) ontology framework. They do not contain links to relevant comorbidities or diseases often confused with the disease of interest. However, a well-defined ontology would provide not only the disease codes and concepts needed to extract relevant patients but also the links and relationships between these concepts. Ideally, it would also contain relevant risk factors specific to the disease of interest.

Purpose of This Study

To support clinicians in screening for and treating patients with PPD, we aim to characterize the important clinical facets of PPD by demonstrating the relationships among confirmed (known) and potential risk factors, symptoms, comorbidities, and treatments in an ontology. We also link relevant International Classification of Diseases (ICD) code sets corresponding to the PPD risk factors to enable researchers to easily identify them in their EHR cohorts. We use a task-based approach to validate our ontology by considering whether it can identify the PPD risk factors, symptoms, and treatments present in 10 case studies of PPD patients derived from web sites, 16 17 magazines, 18 and blogs. 19 20 21 22 23 However, we are not limited to just code sets. We also include noncore information, such as age, parity, and other relevant nondiagnostic code comorbidities, and risk factors that should be included in any PPD study.

The methods for this ontology include four parts as follows: (1) determination of the ontology's scope and survey of the literature, (2) review of existing ontologies related to PPD and evaluation of their usability in the ontology, (3) representation of the PPD knowledge base, and (4) evaluation of the ontology for correctness and usefulness. The target population for this postpartum depression ontology (PDO) includes researchers interested in using EHRs to investigate maternal mental health and medical professionals hoping to improve PPD screening and diagnosis.

Ontology Scope and Survey of the Literature

To determine the scope of the PDO, we conducted a survey of the PPD literature based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines 24 using PubMed and Google Scholar ( Fig. 1 ). Although the PRISMA format is used, numbers are not included in Fig. 1 because the total number of reviewed papers varied by each risk factor investigated; moreover, this was not a comprehensive systematic review or meta-analysis, but a survey of the literature for the purposes of constructing our ontology. We screened titles and abstracts of studies for conditions and their relationship to PPD or depression, then assessed each condition against the criteria for determining confirmed versus potential PPD risk factors which are delineated in Fig. 2 . Eligibility for consideration as a confirmed PPD risk factor was determined by adjustment for important confounders; when the study was not a meta-analysis, systematic review or literature review, papers had to adjust for a history or experience during pregnancy of psychiatric illness, either prior to or during pregnancy. Confirmed risk factor papers were further required to find a statistically significant increased risk of PPD at p  < 0.05 and/or an effect size that was moderate (>0.30) 25 postadjustment, include a comparison group, and have a general consensus in the field regarding the condition's relationship with PPD. In contrast, eligibility for consideration as a potential PPD risk factor from the literature survey required a statistically significant association between the condition and either PPD or depression. We noted that postnatal surveys were often given to women which introduced the potential for recall bias; however, their reported symptoms and risk factors were corroborated in other papers and case studies, leading to their inclusion in risk factor determination. Following initial review, full-text retrieval and an additional round of review followed. Studies were then synthesized to classify the risk factors.

Flow diagram of paper selection process for papers involved in postpartum depression (PPD). There were many risk factors for PPD and therefore each risk factor (i.e., labeled as [Condition] in Fig. 1 ) was searched to identify further information with regards to PPD risk factor status. This step was conducted primarily because research of certain PPD risk factors is scant and the field can change over time; therefore, we wanted the most up-to-date and relevant information with regards to PPD risk factor status. We have not included numbers in Fig. 1 because the total number of reviewed papers varies by each confirmed and potential risk factor that we investigated. The criteria for delineating confirmed versus potential PPD risk factors is further described in Fig. 2 with paper count cutoffs.

Criteria used to determine postpartum depression (PPD) risk factor status. In Fig. 2 , the eligibility criteria for a condition's consideration as a confirmed or potential PPD risk factor is shown. All confirmed risk factor papers had to adjust for psychiatric illness, either prior to or during pregnancy, excluding meta-analyses, systematic reviews and literature reviews. In determining whether to include these latter studies, three considerations were made: (1) at least one other source had to adjust for a history or experience during pregnancy of psychiatric illness, (2) these studies had a level of influence in their field as determined by citations numbering above and often beyond 200, and (3) the first authors were influential in their field with h-indexes above 40.

After identifying confirmed and potential PPD risk factors, we categorized them into four different types as follows: (1) mental condition related, (2) pregnancy or birth related, (3) instability mediated by outside factor related, and/or (4) other body condition related. Mental condition–related risk factors included mental illness diagnoses, as well as perceptions of self or others. Pregnancy- or birth-related risk factors included any complications or difficulties related to the pregnancy and delivery, while instability mediated by outside factor–related risk factors included conditions at least partially outside the mother's control such as socioeconomic status and abuse. Finally, unclassifiable risk factors were categorized as other body condition-related which included nonpregnancy issues such as asthma. Polyhierarchical modeling was used to create the ontology, allowing risk factors to be categorized as multiple risk types.

Review of Existing Ontologies in the Postpartum Depression Domain

A useful ontology must be accessible for different groups and applications, 26 so we first reviewed existing ontologies for reuse. We used the National Center for Biomedical Ontology (NCBO) BioPortal ( https://bioportal.bioontology.org/ ), Ontobee ( http://www.ontobee.org/ ), Open Biological and Biomedical Ontology Service ( http://www.obofoundry.org/ ), AberOWL ( http://aber-owl.net/#/ ), Ontology Search ( https://www.ebi.ac.uk/ols/index ), and Protégé Ontology Library ( https://protegewiki.stanford.edu/wiki/Protege_Ontology_Library ) to examine ontologies and ontology classes related to PPD. We evaluated these ontologies for their coverage of the PPD domain, as well as their ability to characterize PPD risk factors and symptoms.

More than 110 vocabulary resources were found that included depression-related classes but were not specific to PPD at the ontology level. We included information from the five most relevant sources in the PPD domain in Table 1 . Of the vocabulary resources identified, few included PPD entries, and most entries lacked detail, further demonstrating the need to develop a PDO.

Abbreviations: APA, American Psychological Association; MDD, major depressive disorder; PDO, postpartum depression ontology; PPD, postpartum depression.

Given the lack of focus on PPD in these resources and our specific target population of EHR researchers and medical professionals, we created an ontology separate from other existing resources to best fit researchers' and medical professionals' needs. The five most relevant sources in Table 1 were used to organize the ontology and will help to standardize future versions through mappings to established ontologies such as SNOMED CT ( https://www.nlm.nih.gov/healthit/snomedct/index.html ), a source commonly used in constructing ontologies representative of EHR data. 27

Protégé-OWL Representation of the Postpartum Depression Knowledge Base

The PDO was written in the Web Ontology Language (OWL) using the application Protégé-OWL v.5.5.0. 28 The initial ontology was built considering pregnancy- and mental health–related ICD codes, as well as ICD codes for PPD risk factors. Symptoms of PPD included in the initial ontology were obtained from the literature review by Stewart et al. 29 Updated versions of the ontology postevaluation included treatments and other PPD-related variables.

Supplementary Table S1 (available in the online version) includes the descriptions of the PDO's three main superclasses, as well as examples of important pregnancy, and mental health subclasses in each hierarchy. In the PDO, each class that was a confirmed or potential risk factor included the relevant ICD-9 and -10 codes as individuals. Although the ICD-10-clinical modification (CM) clinical terminology defined ICD codes as classes, they had only one logical parent class, whereas ICD codes in the PDO had relationships with multiple parent classes and therefore necessitated multiple inheritance; thus, ICD codes were designated as individuals in this ontology.

Evaluation of the Ontology for Correctness and Usefulness

The ontology was evaluated for correctness of ontology form, domain knowledge, and usability. Ontology form was evaluated using the Pellet reasoner in Protégé-OWL, while domain knowledge and usability were assessed through case review by two domain experts (R.B.M. and M.R.B.). Ten patient case studies from eight online sources were compiled, 16 17 18 19 20 21 22 23 describing women presenting with various PPD phenotypes. These online sources were chosen to provide a representative set of experiences including various risk factors and symptoms that may not always be recorded in clinical notes, as well as to allow widespread sharing of results without Health Insurance Portability and Accountability Act (HIPAA) concerns. Recent work by Borland et al 30 has also demonstrated the importance of considering patient experiences in building accurate ontologies about specific conditions in addition to the traditional encyclopedic knowledge included. The two domain experts independently reviewed the first five cases to determine missing risk factors, as well as PPD symptoms and treatments. During case review, terms, and phrases (“chunks”) relevant to the mother and PPD were highlighted, then compiled and categorized by their relevant features. For example, the chunk “down feelings” was categorized by the relevant feature “symptoms of depression: depressed mood.” The chunks chosen by the domain experts were compared to compile a list of all relevant features identified. Then, duplicates were removed, and the unique relevant features were labeled as symptoms, risk factors, treatments, or other. Finally, the PDO was evaluated for its inclusion of the unique relevant features, so that necessary changes and additions to the domain knowledge could be made. A second pass using five more cases was then conducted to evaluate the updated ontology. Fig. 3 illustrates an overview of the evaluation process, including the specific process of determining the number of unique relevant features to be analyzed against the existing ontology in each evaluation.

Evaluation schema. Two postpartum depression (PPD) case study evaluations for the postpartum depression ontology (PDO) were conducted. Both evaluations consisted of extracting relevant terms and phrases from the case studies by two evaluators, comparing relevant terms, and excluding features that were not PPD symptoms, risk factors, or treatments. In Fig. 3 , the assessment of the PDO against these relevant features is shown.

Postpartum Depression Ontology

The PDO was designed to formalize the PPD knowledge base in terms of ICD codes and clinical notes, including its risk factors, symptoms, treatments, comorbidities, and other related pregnancy or mental illness conditions. The ontology includes 734 classes, 13 object properties, and 4,844 individuals. The ontology has been made available on the NCBO BioPortal at https://bioportal.bioontology.org/ontologies/PARTUMDO for researchers to utilize and incorporate into their future work.

Postpartum Depression Risk Factor Identification

In total, 78 risk factors were identified, with 8 labeled as confirmed risk factors and 70 as potential risk factors. The first PPD ontology was constructed with 7 confirmed risk factors and 55 potential risk factors; however, after the initial evaluation, one confirmed risk factor was identified by the first case study evaluation and added. Furthermore, 11 potential risk factors were added, with 7 identified by the first case study evaluation and 4 by clinical expertise. The final evaluation of case studies revealed three more potential risk factors, and one potential risk factor was identified by additional clinical expertise.

Table 2 includes all confirmed risk factors and eight selected potential risk factors. Confirmed risk factors were strongly supported in the literature with at least two independent groups finding a statistically significant increased risk of PPD and many citations; citations for the literature supporting the eight confirmed risk factors ranged from 47 to 2,492 citations as of April 12, 2021, with each risk factor supported by at least one paper with 245 or more citations ( Table 2 ). In contrast, conditions that were classified as potential risk factors often failed to include some known confounding variables, had a potentially bidirectional relationship with PPD, 31 or lacked extensive research in the field, with few papers on the subject or an established association with depression but not PPD. Supplementary Table S2 (available in the online version) includes a complete list of the 70 potential risk factors identified from the literature, case studies, and clinical expertise. Since these additional risk factors are only “potential” due to the existence of some disagreement in the literature with regard to their role in PPD, we include them as a supplement if researchers are interested.

Abbreviation: PPD, postpartum depression.

All 4,844 individuals in the ontology were subclasses of one or more of the 8 confirmed risk factor classes, or subclasses of the 47 potential risk factors for which ICD codes existed. For history of depression, anxiety, and PPD, as well as lack of support postpregnancy, there were no ICD codes with the “history of” or “post pregnancy” temporal designations. A star (*) in Table 2 indicates the ontology class under which the ICD codes (individuals) for these conditions are located; however, the temporal relationship would need to be determined by a researcher or medical professional. For example, a patient with a history of PPD would be diagnosed with one of the ICD codes that was an individual of the Postpartum_Depression class. Researchers could then specify a time range when pulling patient codes from EHRs to determine whether patients had a history of PPD or current PPD. Furthermore, there were 23 potential risk factors for which there existed no ICD codes; thus, these risk factors are designated by a double star (**).

Postpartum Depression Ontology Object Properties

The object properties within the PDO are included in Table 3 . Object properties were critical for demonstrating the relationships of risk factors with PPD, as well as detailing injury relationships for the investigation of traumatic brain injury (TBI) as a potential risk factor. There were 13 object properties in total with seven classified as pregnancy- or mental health–related and two specifically showing the relationships among PPD and its risk factors. There were nine object properties with the general domain class OWL: Thing due to the domain spanning the entire ontology; for example, there were risk factors in all three superclasses of the PDO.

Abbreviations: ICD, International Classification of Diseases; PPD, postpartum depression.

Pregnancy- and Mental Health–Related Object Properties

The PPD risk factors spanned the ontology and were categorized as several distinct types, leading to general owl:Thing domain classes for both PPD-related object properties. To differentiate among the types of risk factors, the object property has_PPD_risk_type was created with a range of Postpartum_Depression_Risk_Type. This class was further subdivided into the four risk factor type classes. To demonstrate whether the literature supported classes as confirmed or potential risk factors, the object property has_PPD_risk_factor_status was formed with a range of Postpartum_Depression_Risk_Status. This class included three subclasses identifying variables as confirmed, potential or not risk factors; this latter categorization included the class Mistaken_for_PPD which contained conditions with symptoms similar to those of PPD that could lead to an incorrect diagnosis.

The object property has_PPD_risk_factor_status required the use of the conjunction ‘only’ to relate it to a class and exclude the possibility of a confirmed risk factor also being a potential risk factor or not a risk factor. For example, Abuse_Violence_Type—the class representing all forms of abuse—had the object property relationship has_PPD_risk_factor_status ‘only’ Confirmed_PPD_Risk_Factor. In contrast, the object property has_PPD_risk_type allowed the conjunctions ‘only’ and ‘some’ to relate classes due to the polyhierarchical structure of the PDO. Abuse_Violence_Type had the object property relationship has_PPD_risk_type ‘only’ Instability_Mediated_by_Outside_Factor_Related_PPD_Risk_Type because it could not be classified as one of the other three types. However, History_of_Postpartum_Depression used the conjunction ‘some’ because it could be considered both a mental condition and pregnancy- or birth-related risk type, and ‘some’ specifies an “at least one” relationship. 32 Fig. 4 shows an example of the relationships and individuals for the confirmed risk factor abuse and, more specifically, sexual abuse.

Individuals and the has_PPD_risk_factor_status object property showing abuse as an example. In Fig. 4 , blue arrows show a has subclass relationship, the yellow arrow shows a has_PPD_risk_factor_status only relationship with the Confirmed_PPD_Risk_Factor class, and the purple arrows signify a has individual relationship. ICD codes for sexual abuse are shown here, with two overlapping the Physical_Abuse class. ICD, International Classification of Disease; PPD, postpartum depression.

Three more pregnancy- or mental health–related object properties were particularly important in the ontology. The object property has_ICD_version was used among the 4,844 individuals of the PPD risk factors to show whether the codes were from version ICD-9 or -10; no specified conjunction was necessary because the object property connected individuals. Fig. 5 represents the other object property illustrating the variety of PPD symptoms included in the final version of the PDO. The is_symptom_of object property had a range of Postpartum_Depression, and the conjunction ‘some’ was used because these symptoms are at least related to Postpartum_Depression, yet they could also be related to other conditions. Any symptoms and signs with synonymous or similar descriptions were included using the rdfs:label annotation.

Symptoms of PPD as shown in the PDO. In Fig. 5 , a representation of several PPD symptoms is visualized, in which the blue arrows show a has subclass relationship and the orange arrows signify an is_symptom_of some relationship with the Postpartum_Depression class. The yellow boxes show clustering of synonyms and similar terms under the rdfs:label annotation. PDO, postpartum depression ontology; PPD, postpartum depression.

Other Object Properties

There were six object properties classified as “Other.” Due to the relationship among traumatic injury, TBI, physical abuse, and depression, 33 34 35 a clinical expert (M.R.B.) recommended that we include TBI in the ontology as a potential PPD risk factor. Thus, the injury class required three object properties to relate five important subclasses of the injury superclass: Injury_Type, Injury_Area, Injury_Depth, Injury_Trauma, and TBI_Related_Injury. The class Injury_Type was related to the classes Injury_Depth and Injury_Trauma by the object properties has_injury_depth and has_injury_trauma_type , respectively, while TBI_Related_Injury was related to Injury_Area by the object property has_injury_area. All used the conjunction ‘only’ to exclude false injury descriptions; for example, the class Traumatic_Brain_Injury used the conjunction ‘only’ to provide closure to the object property has_injury_trauma_type ‘only’ Traumatic_Injury such that a nontraumatic cause of a brain injury was excluded.

Of the remaining three object properties classified as “Other,” the is_during object property was particularly important. Since the ontology was created to represent the PPD knowledge base, time was defined relative to pregnancy and delivery. The is_during object property was used to form many complex class expressions which have more than one conjunction. For example, the class Gestational_Diabetes was equivalent to Diabetes ‘and’ is_during ‘only’ Time_During_Pregnancy. In other words, gestational diabetes is a type of diabetes that only occurs during pregnancy. In another example, the object property defined the meaning of a very preterm baby, which is a baby born between 28 weeks of gestation up to 31 weeks 6 days gestation. 36 In this case, the object property would be used as follows: Very_Preterm is_during ‘only’ (28_Weeks_Gestation ‘or’ 29_Weeks_Gestation ‘or’ 30_Weeks_Gestation ‘or’ 31_Weeks_Gestation).

Evaluation Results

Case study evaluation results.

The case study evaluation was performed in two rounds of five case studies by R.B.M. and M.R.B ( Supplementary Table S3 , available in the online version). In the first set of 158 sentence chunks ( Fig. 3 ), 60 chunks (38%) were identified as relevant features by the two evaluators, and all 60 were annotated similarly. The remaining 98 chunks (62%) were only identified by one evaluator due to varying expertise; these were discussed to reach a consensus opinion for all. This process was repeated for the second set of case studies with 214 sentence chunks ( Fig. 3 ). Of these,106 chunks (49.5%) were identified as relevant features by both evaluators with 96 annotated similarly and 10 without consensus. This lack of consensus was due to differing interpretations of the sentence chunks. For example, “I wasn't eating or drinking enough water, which meant my body wasn't making breastmilk” was interpreted by R.B.M. as “breastfeeding difficulties,” whereas M.R.B. interpreted this as “nutrition issues.” For these 10 chunks and 108 (50.5%) identified by only one evaluator, a second discussion led to a consensus on classification of relevant features.

Table 4 shows the results of the analysis comparing the unique relevant features identified through case studies to the PDO in both rounds of evaluation. During the initial evaluation, 79 unique relevant features were analyzed. In total, 30.4% of all unique relevant features were explicitly included in the first PPD ontology; when similar classes for unique relevant features without an explicit class in the ontology were considered, 45.6% of the unique relevant features were covered. All 14 PPD treatments in the initial evaluation were not encapsulated, so they were added to a new class of features called PPD_Treatment. Furthermore, of the 11 PPD risk factors that were not already included, 10 were potential risk factors and one—History_of_Anxiety—was identified as a confirmed risk factor. A subsequent survey of the literature on History_of_Anxiety was performed to fulfill the criteria required in Fig. 2 .

Abbreviations: PDO, postpartum depression ontology; PPD, postpartum depression.

The final evaluation involved 88 unique relevant features of which 77.3% were already explicitly included in the second PPD ontology and 86.4% were covered when similar classes were evaluated. Interestingly, only three new potential risk factors were identified out of the 30 risk factor chunks, demonstrating a 90.0% accuracy in the ontology's goal of characterizing PPD risk factors. Most treatments were already included (83.3%), whereas several new symptoms were identified.

The Pellet Reasoner Evaluation Results

We used the Pellet reasoner to evaluate the final ontology and 154 inconsistencies were found. All inconsistencies resulted from multiple inheritance of ICD code individuals under the three disjoint superclasses: Condition, Maternal_Descriptor, and Medical_Procedure_Encounter_or_Treatment ( Supplementary Table S1 , available in the online version).

One major source of inconsistencies were ICD codes describing high-risk pregnancies which are classified as a descriptor of pregnancy risk in the ontology. For example, ICD-10 code O09.811, which is defined as “Supervision of pregnancy resulting from assisted reproductive technology, first trimester,” is an individual of the High_Risk and Assisted_Reproductive_Technology_Cycle classes. However, these are located under the Maternal_Descriptor and Medical_Procedure_Encounter_or_Treatment superclasses, respectively. ICD codes classified as multiple gestations also exhibited many inconsistencies. The ICD-9 code V27.3, which is defined as “Outcome of delivery, twins, one liveborn and one stillborn,” exhibited multiple inheritance of the classes Infant_Stillbirth (Condition) and Multiple_Gestation (Maternal_Descriptor).

The inconsistencies identified by the Pellet reasoner demonstrated that the three superclasses of the PDO should not be disjoint; some ICD codes are both descriptive in nature, as well as indicate a condition or procedure. All inconsistencies were deemed to be valid from a logical and clinical perspective, and we modified the ontology accordingly. The finalized ontology available on NCBO reflects the latest and most correct and updated version of the ontology. If any changes are made postpublication of this manuscript, those will also be shared with the community via the NCBO BioPortal at: https://bioportal.bioontology.org/ontologies/PARTUMDO . For an overview of the entire ontology's hierarchy please see Fig. 6 .

A graphical overview of the Postpartum Depression Ontology Superclasses and Direct Subclasses of the Ontology.

As the first PPD-specific ontology to our knowledge, the PDO was built inclusive of ICD codes to represent the PPD knowledge domain in an EHR-accessible format for researchers and medical professionals. After a literature search and two rounds of evaluation, the ontology encompasses treatments, symptoms, risk factors, and other related conditions, as well as personal descriptors and procedures. Most importantly, the PDO compiles 78 known and potential PPD risk factors that were identified through the literature, case studies, and clinical expertise. To date, no studies have considered all of these factors together, yet understanding the totality of risk factors is critical given the high prevalence of PPD 3 4 and its serious consequences. 5 6 The PDO developed here designates eight variables as confirmed risk factors and 70 as potential risk factors in an effort to inform not only diagnoses but also to identify and improve prevention strategies.

The literature search revealed many risk factors, yet very few had sufficient evidence to support a causal relationship with PPD. Despite agreement among most papers reviewed that a history of mental illness was one of the strongest risk factors for PPD development, 7 8 9 25 37 38 39 other variables investigated often had contradictory significance levels, indicating the possibility of a bidirectional relationship or an absence of sufficient evidence. Given the importance of understanding risk factors and the lack of agreement in the field, we designed this ontology as a resource to discover which areas in the field required further research. Thus, the object property and class combination of “ has_PPD_risk_factor_status ‘only’ Potential_PPD_Risk_Factor” directs researchers to identify conditions that have not been adequately studied and promotes investigation of these conditions to add to the field through the inclusion of the relevant ICD codes.

The confirmed risk factor section of the ontology promotes adjustment for factors as confounding variables in future risk factor studies, as well as helps medical professionals to identify patients at risk. Since ICD codes were included in the ontology for each of the confirmed PPD risk factors, medical professionals may offer more individualized care by using these codes to supplement screening tools such as the PPD-specific Edinburgh Postnatal Depression Scale (EPDS), 40 the Center for Epidemiologic Studies Depression (CES-D) scale, 41 the Beck Depression Inventory, 42 and the Patient Health Questionnaire-9 (PHQ-9). 43 Additionally, researchers can now more easily identify larger cohorts of women at risk for PPD by using the ICD codes included in EHRs; this population is a critical target for future intervention studies.

While the PDO incorporates ICD codes for EHR analyses, it was important to include information beyond its coverage of medical diagnoses and the information typically included in EHRs such as age and weight. Specifically, we added classes characterizing the mother's intentions and perceptions of support, self, and the pregnancy that may only be present in clinical notes or not at all. This type of information is rarely—if ever—included in ontologies with mental health sections, yet negative perceptions of reality and illusions often influence mental health unfavorably. 44 Furthermore, outcomes that differ from the mother's expectations, such as intent to breastfeed but inability to do so, have been linked to an increased risk of PPD; 45 thus, this type of information is crucial to include. While perceptions of reality may be difficult to diagnose, this PDO can improve the current self-assessment screening tools 40 41 42 43 that may suffer from self-reporting bias, 46 as well as suggest topics about intentions and perceptions to discuss with patients such as expecting to lose pregnancy weight quickly.

In addition to classes that were added to characterize intentions, perceptions, and other variables missing from ICD codes, the use of polyhierarchical modeling and multiple inheritance was crucial in building the PDO. The polyhierarchy was particularly important for risk factor classification; simply creating a list of risk factors would have been insufficient, as this would not allow the categorization of risk factors into multiple risk types. In addition, multiple inheritance was critical for ICD codes which often had more than one parent class. For example, the ICD-10 code T74.11XA, which is defined as “Adult physical abuse, confirmed, initial encounter,” had the parent classes Abuse_Violence_Type, Adult_Victim, Confirmed_Abuse, and Physical_Abuse. It was necessary to identify each aspect of the code—confirmed abuse, abuse type, and victim age—because these variables could play a role in risk factor research, such as determining age of sustained abuse or type of sustained abuse as carrying a greater risk of developing PPD. Thus, the development of the PDO through these modeling choices allowed the characterization of the PPD knowledge domain's complexity.

During the evaluation of the PDO, clinical case studies provided a unique focus on PPD treatments and symptoms that were often absent from the literature and ICD codes. None of the treatments identified from the first set of case studies were included in the ontology which partially accounts for the low total percent coverage (30.4%); when treatments were removed from analysis, there was a small increase to 36.9% coverage. Further, comprehensive coverage of PPD symptoms was difficult because many of the symptom names used in the case studies were similar to other symptoms described by different women. Even though the coverage of symptoms doubled between evaluations, there was only 67.4% coverage in the final evaluation, suggesting the need to continue updating the ontology with more symptoms and to increase the use of the rdfs:label annotation. Moreover, despite their absence from ICD codes, which limits EHR research, these symptoms may be included in clinical notes or screening results that could aid in the development of better screening tools or in the choice of treatments by medical professionals.

To date, this PDO evaluation is limited by the relatively low number of case studies reviewed and the use of two evaluators. Another limitation is that one of the evaluators (R.B.M.) was the developer of the ontology; however, the second evaluator (M.R.B) produced similar results in the evaluation and a consensus opinion with regard to correctness was derived from comparison of the evaluations, demonstrating the usability and reliability of the ontology independent of the developer. Future work will involve a secondary evaluation with additional case studies and new evaluators to assess the strength of the ontology in its inclusion of all information relevant to a PPD diagnosis. Newly constructed ontologies will be assessed for relevance to the PDO and new terms will be included; one such example is the semantic-based verbal autopsy framework for maternal death 47 which includes many pregnancy complications that could increase the risk of PPD in cases of maternal survival. Additionally, further refinement of PPD symptoms and treatments is required, as the number of relevant features in those categories added after the two rounds of evaluation suggest that there are more PPD features. However, we are confident that most treatments, symptoms, and risk factors are included either explicitly or through a similar feature in the ontology due to the final evaluation yielding 86.4% coverage. In fact, the inclusion of 90.0% of risk factors—which is the most important category for the PDO's target population—demonstrates that these are sufficiently characterized.

Beyond a deeper exploration and evaluation of the current PDO, our future work will involve incorporating more relevant ICD codes into the PDO. Currently, the ICD-9 and -10 codes included as individuals in the ontology are categorized under the eight confirmed PPD risk factors and the 47 potential PPD risk factors for which there are relevant ICD codes. As the literature expands, future iterations of the ontology will be updated with additional risk factors and their ICD codes, 48 as well as include codes from ICD version 11. ICD-11 will be available to Member States in 2022 to replace earlier versions; 49 thus, the relevant ICD codes from all versions must be included as individuals, so that researchers can identify the most up-to-date codes to use in EHR studies. Finally, the terms in the PDO will be mapped to SNOMED CT, ICD-9-CM, and ICD-10-CM to improve accessibility and standardization of resources.

The PDO is a comprehensive ontology of the PPD knowledge base designed to include information needed for a PPD diagnosis. We made our ontology readily accessible via the NCBO BioPortal (available at: https://bioportal.bioontology.org/ontologies/PARTUMDO ) for researchers to utilize and incorporate into their future work. Our evaluation focused on the use of case studies to demonstrate its coverage and usefulness. Interestingly, the PDO adds a new dimension to the knowledge base by compiling researched risk factors and designating them as confirmed (known) or potential PPD risk factors, with ICD codes used in EHRs included for these risk factors. The PDO can therefore illuminate areas of PPD that require further investigation, as well as supplement the current PPD screening techniques employed, promoting more clarity in the field for researchers and potentially improving the standard of care provided by medical professionals. As an ontology, the PDO provides much more detail than would typically be available in disease concept sets because it provides relationships between concepts and other useful information for conducting research studies on PPD.

Clinical Relevance Statement

Postpartum pepression (PPD) remains an understudied research area despite its high prevalence. This study contributes an ontology to aid in the identification of patients with PPD and to enable future analyses with electronic health record (EHR) data. In addition to PPD, relevant comorbidities that have been reported in the literature that are related to PPD are included. The ontology is freely available on the NCBO BioPortal web site and was constructed using Protégé-OWL. Our ontology will enable future researchers to study PPD using EHR data as it contains important information with regards to structured (e.g., billing codes) and unstructured data (e.g., synonyms of symptoms not coded in EHRs) and also the connections between diseases and comorbidities. The PDO is publicly available through the National Center for Biomedical Ontology (NCBO) BioPortal ( https://bioportal.bioontology.org/ontologies/PARTUMDO ) which will enable other informaticists to utilize the PDO to study PPD in other populations.

Multiple Choice Questions

• NCBO BioPortal
• PubMed Central

Correct Answer: The correct answer is option a. Our ontology is made freely available on the NCBO BioPortal web site. The NCBO was founded as one of the National Centers for Biomedical Computing supported by the NHGRI, NHLBI, and the NIH Common Fund.

• ICD-9 and ICD-10

Correct Answer: The correct answer is option d. Our ontology includes diagnostic codes for both ICD-9 and ICD-10 for researchers using those terminologies. These can be easily mapped to SNOMED-CT using existing OHDSI Common Data Model mappings.

• ICD-9, ICD-10
• ICD-10, ICD-11

Correct Answer: The correct answer is option d. While ICD-9 has diagnosis codes for depression, there is no explicit code for “postpartum depression.” However, in ICD-10, an explicit code for postpartum depression appears, and ICD-11 also contains specific codes.

Funding Statement

Funding We thank the University of Pennsylvania for generous funds to support this project (R.B.M., S.P.C., and M.R.B.). Support also provided by the Penn Injury Science Center (B.A.D'A., S.P.C., and M.R.B.) which is an Injury Control Research Center funded by the Centers for Disease Control and Prevention (CDC; grant no.: R49CE003083). Support also provided by the NIH NINDS brain injury training grant (grant no.: T32 NS 043126) supporting A.C.B. with mentors M.R.B. and A.L.C.S.

Conflict of Interest None declared.

Protection of Human and Animal Subjects

This research did not involve human subjects.

Author Contribution

Conceived study design: R.B.M. and M.R.B. Developed methodology: R.B.M., B.A.D'A., and M.R.B. Provided clinical advice pertinent to study problem: A.L.C.S. and A.C.B. Wrote paper: R.B.M. and M.R.B. Reviewed, edited, and approved final manuscript: R.B.M., A.C.B., B.A.D'A., S.P.C., A.L.C.S., and M.R.B.

Supplementary Material

Postpartum Depression

The lies i told myself with postpartum depression, 6 steps to rediscovering yourself when dealing with postpartum depression..

Posted July 16, 2024 | Reviewed by Michelle Quirk

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• One in five new moms will get postpartum depression and anxiety during the first 12 months after childbirth.
• Reframing negative thoughts and realigning motherhood expectations are helpful daily practices.
• You can ask for help, improve sleep, practice self-care, connect with others, meditate, and grieve changes.

Let’s be honest, early motherhood, starting from pregnancy all the way through the toddler years, is extremely hard. As a new mom, we struggle with minimal sleep, painful physical recovery, extreme hormonal fluctuations, and often profound identity changes, all while caring for our new child around the clock.

But if your experience of motherhood changes from being hard into feelings of despair, helplessness, or overwhelming anxiety , please know that you are not alone. One in five new moms will experience postpartum depression and anxiety, which can start unexpectedly any time during the first year after childbirth.

While postpartum depression and anxiety are the most common complications of childbirth , many new moms are never taught the symptoms, how to support themselves and their families, or even how to find help. As a result, many of us struggle alone for far too long.

T he Onset of My Postpartum Depression Lies

After having my child, I felt OK at first—I was struggling with sleep deprivation, breastfeeding challenges, and physical recovery from childbirth, but mentally I was still holding on and felt like myself. Then week six came and my world turned upside down—suddenly I couldn’t sleep at all, and I fell down a mental black hole where I felt completely alone, helpless, and overwhelmed with anxiety and despair.

All I could think about, day in and day out, were these three, simple statements:

• I am a terrible mom.
• This despair and worry will never end.
• I will never feel like myself again.

These statements were lies—negative thoughts that clouded every minute of every day.

The joy, love, and happiness I believed a new mom should feel were vastly different than my reality during those first 18 months of my child’s life. Society, social media , and even Hollywood had taught me that this was supposed to be one of the happiest times of my life; but, instead, it was filled with darkness, shame , and a complete loss of who I was.

Finding Help

I had no idea what was happening to me. As a first-time mom, I spent months during my pregnancy planning to care for my child in every imaginable scenario, but I never thought about or prepared to care for my own mental health.

After I hit my lowest point when intrusive thoughts kicked in, I realized I needed help—and with medication from my health care provider and regular appointments with a maternal mental health therapist, I started to slowly but surely find myself again.

During this process, I learned that those three negative statements I told myself constantly truly were lies caused by postpartum depression. I have rephrased those lies to be the truth:

• I am not a terrible mom—I am a great mom who loves her child and simply struggled with the most common childbirth complication.
• This despair and worry will end—postpartum depression and anxiety are treatable.
• I will feel like myself again—you will.

6 Steps to Rediscovering Myself (That Can Help You, Too!)

If you tell yourself similar lies or are struggling postpartum, these six key actions helped me heal and find myself again:

• Ask for help: Talk to your health care provider and/or a maternal mental health therapist that you trust to learn more about treatment options, including medication, traditional therapy , and group support. You are the best advocate for yourself, so reach out for support as soon as you realize you are struggling.
• Improve your sleep: Getting more sleep might seem impossible as a new mom, but adequate sleep is crucial for your mental well-being. Sleep deprivation can both cause and increase postpartum depression symptoms so create a sleep plan each week. Look at ways to prioritize your sleep over other activities, ask for support to give you more uninterrupted sleep, and make sure your sleep environment is set up adequately to help you rest.
• Practice self-care: Focus on supporting yourself physically and emotionally each day, even if you only have a few free moments to find a glimmer (small moments that bring you joy, such as listening to your favorite podcast or eating your favorite snack). Self-care is essential for the well-being of new moms.
• Connect with others: "Find your village" is something new moms are often told for good reason; social support and having a sense of community can help those struggling with postpartum depression and anxiety and reduce the feelings of isolation. Look for postpartum depression support groups in your local area or virtually.
• Practice mindful meditation : Focusing on the present moment and calming your mind through mindful meditation can reduce postpartum depression symptoms as well. Try to spend a few moments each day focusing on the present moment or doing a short meditation practice.
• Grieve your identity change: Becoming a mom changes who you are as a person and how you see yourself—and this shift in your self-identity can be both positive and negative. Write down any areas of yourself that you miss and need to grieve (such as having alone time, spontaneity, and privacy) as well as new parts of yourself that you have gained and want to celebrate (such as increased patience, new love for your child, and your strength). You are always changing, so take time to process and honor who you are in this moment.

If you are struggling with postpartum depression and anxiety, the negative thoughts you tell yourself about motherhood are likely lies.

Medication, therapy , and self-help strategies can help support your recovery, so don’t suffer in silence. There is help. And, remember, you are a great mom, this will end, and you will feel like yourself again.

Kelly Siebold is a postpartum depression and anxiety survivor, Founder and CEO of Thrive Postpartum, and podcast host who helps moms struggling with maternal mental health issues after experiencing them herself.

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• Introduction
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• Article Information

Outcomes are not contingent on having a primary care visit. Error bars indicate 95% CI.

Study Protocol

eFigure. Examples of Study Messages and Reminders

eTable 1. Outcome Definition Table

eTable 2. Comparison of the Intervention Components Between Groups

eTable 3. Reasons the Primary Care Appointment Could Not Be Scheduled

eTable 4. Secondary Outcomes by Health Condition Subgroups

eTable 5. Primary Outcome by Population Subgroups (Heterogeneity Analysis)

Data Sharing Statement

• Default Scheduling of Pregnancy-to-Primary Care Appointments JAMA Network Open Invited Commentary July 16, 2024 Meghan Bellerose, MPH

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Clapp MA , Ray A , Liang P , James KE , Ganguli I , Cohen JL. Postpartum Primary Care Engagement Using Default Scheduling and Tailored Messaging : A Randomized Clinical Trial . JAMA Netw Open. 2024;7(7):e2422500. doi:10.1001/jamanetworkopen.2024.22500

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Postpartum Primary Care Engagement Using Default Scheduling and Tailored Messaging : A Randomized Clinical Trial

• 1 Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
• 2 Harvard Medical School, Boston, Massachusetts
• 3 Department of Medicine, Massachusetts General Hospital, Boston
• 4 Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
• 5 Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
• Invited Commentary Default Scheduling of Pregnancy-to-Primary Care Appointments Meghan Bellerose, MPH JAMA Network Open

Question   What is the impact of a behavioral economic intervention designed to reduce patient administrative burden and information gaps on primary care practitioner (PCP) visit completion in the postpartum period?

Findings   In this randomized clinical trial of 360 patients with or at risk for a chronic condition, default PCP scheduling, tailored messages, and reminders increased postpartum PCP visit rates by 19 percentage points. The intervention also resulted in more individuals receiving important screening tests and services provided by their PCP.

Meaning   The findings of this trial suggest that a multifaceted and relatively low-resource behavioral economic intervention may improve postpartum health and well-being.

Importance   More than 30% of pregnant people have at least 1 chronic medical condition, and nearly 20% develop gestational diabetes or pregnancy-related hypertension, increasing the risk of future chronic disease. While these individuals are often monitored closely during pregnancy, they face major barriers when transitioning to primary care following delivery, due in part to a lack of health care support for this transition.

Objective   To evaluate the impact of an intervention designed to improve postpartum primary care engagement by reducing patient administrative burden and information gaps.

Design, Setting, and Participants   An individual-level randomized clinical trial was conducted from November 3, 2022, to October 11, 2023, at 1 hospital-based and 5 community-based outpatient obstetric clinics affiliated with a large academic medical center. Participants included English- and Spanish-speaking pregnant or recently postpartum adults with obesity, anxiety, depression, diabetes, chronic hypertension, gestational diabetes, or pregnancy-related hypertension and a primary care practitioner (PCP) listed in their electronic health record.

Intervention   A behavioral economics–informed intervention bundle, including default scheduling of postpartum PCP appointments and tailored messages.

Main Outcome and Measures   Completion of a PCP visit for routine or chronic condition care within 4 months of delivery was the primary outcome, ascertained directly by reviewing the patient’s electronic health record approximately 5 months after their estimated due date. Intention-to-treat analysis was conducted.

Results   A total of 360 patients were randomized (control, 176; intervention, 184). Individuals had a mean (SD) age of 34.1 (4.9) years and median gestational age of 36.3 (IQR, 34.0-38.6) weeks at enrollment. The distribution of self-reported race and ethnicity was 6.8% Asian, 7.4% Black, 68.6% White, and 15.0% multiple races or other. Most participants (75.4%) had anxiety or depression, 16.1% had a chronic or pregnancy-related hypertensive disorder, 19.5% had preexisting or gestational diabetes, and 40.8% had a prepregnancy body mass index of 30 or greater. Medicaid was the primary payer for 21.2% of patients. Primary care practitioner visit completion within 4 months occurred in 22.0% (95% CI, 6.4%-28.8%) of individuals in the control group and 40.0% (95% CI, 33.1%-47.4%) in the intervention group. In regression models accounting for randomization strata, the intervention increased PCP visit completion by 18.7 percentage points (95% CI, 9.1-28.2 percentage points). Intervention participants also had fewer postpartum readmissions (1.7% vs 5.8%) and increased receipt of the following services by a PCP: blood pressure screening (42.8% vs 28.3%), weight assessment (42.8% vs 27.7%), and depression screening (32.8% vs 16.8%).

Conclusions and Relevance   The findings of this randomized clinical trial suggest that the current lack of support for postpartum transitions to primary care is a missed opportunity to improve recently pregnant individual’s short- and long-term health. Reducing patient administrative burdens may represent relatively low-resource, high-impact approaches to improving postpartum health and well-being.

Trial Registration   ClinicalTrials.gov Identifier: NCT05543265

Although the chronic disease burden in pregnancy is high and increasing in the US, most people with chronic conditions do not successfully transition to primary care management following delivery. 1 - 9 More than 30% of pregnant people have diabetes, hypertension, or obesity, and 11% to 22% have anxiety or depression. 10 - 12 Furthermore, common pregnancy-related conditions (eg, gestational diabetes and pregnancy-related hypertension), which combined affect nearly 20% of pregnancies, confer an increased risk of developing chronic disease. 13 - 18 Strong evidence underpins the benefits of managing chronic conditions through primary care and of managing these conditions earlier in life. 19 - 22 However, while pregnant people with these conditions are often carefully monitored during pregnancy, many receive no routine care after their pregnancy, and nearly half of those with chronic conditions do not see their primary care practitioner (PCP) at all in the postpartum year. 23 The abrupt drop off from high health system engagement and motivation during pregnancy to limited or no health care encounters post partum has been termed a postpartum cliff. 24 Low rates of postpartum primary care engagement reflect a missed opportunity to improve the prevention and management of chronic disease.

Postpartum transitions from obstetric to primary care are encouraged by guidelines yet stymied by numerous barriers. Specifically, the American College of Obstetrics and Gynecology 25 recommends that all individuals have a comprehensive postpartum visit within 12 weeks of their delivery; at that time, obstetric care clinicians typically counsel patients on the importance of ongoing primary care follow-up. Yet, a range of systemic, financial, and behavioral barriers often prevents postpartum people from successfully transitioning to primary care. 26 - 30 Patient administrative burden (eg, appointment scheduling, information seeking, and insurance/billing issues) is increasingly recognized as a barrier to accessing care. 31 In a 2021 survey, 33% of patients reported that they delayed or did not seek health care because of the administrative burden. 31 The results of this burden may be amplified in the postpartum period when new parents are sleep deprived and face many competing demands, including caring for their newborn and family. This study aimed to increase patient engagement in primary care after the immediate postpartum period for pregnant individuals with conditions that convey a long-term health risk by reducing administrative burden and motivating continued health activation through an intervention based on insights from behavioral economics.

This study was an individual-level, 2-group, 1:1 stratified randomized clinical trial of the effectiveness of a behavioral economics–informed intervention to increase the rate of postpartum primary care visit completion. The study was conducted at 1-hospital based obstetric clinic and 5 community-based obstetric clinics from November 3, 2022, to October 11, 2023 (trial protocol and analysis plan included in Supplement 1 ). The Mass General Brigham Human Subjects Committee approved this study, and analyzed data were deidentified. Individuals provided verbal consent to participate and received financial compensation. The Consolidated Standards of Reporting Trials ( CONSORT ) reporting guideline was followed in reporting the study and its results.

Patients who had obesity (prepregnancy body mass index ≥30; calculated as weight in kilograms divided by height in meters squared), anxiety or depressive mood disorder, type 1 or 2 diabetes, chronic hypertension, gestational diabetes, or pregnancy-related hypertension listed in their electronic health record (EHR) were eligible to participate. Patients at high risk for hypertensive disorders of pregnancy, defined as those who would be recommended for low-dose aspirin by US Preventative Services Task Force guidelines, were eligible. Patients with these conditions were prioritized for inclusion in the study as they were more likely to have ongoing care needs after pregnancy. Also, this study was limited to patients who had a PCP listed or identified in their EHR, as the barriers and solutions to postdelivery primary care reengagement are different than establishing care with a new PCP; a preliminary analysis of patients receiving obstetric care at the study institution revealed that 90% had a PCP listed in the EHR. Other eligibility criteria included (1) pregnant or recently post partum (defined as up to 2 weeks after their estimated due date [EDD]), (2) receipt of prenatal care at the study institution or its affiliated clinics, (3) enrolled and elected to receive messages in the study institution’s EHR patient portal, (4) primary language of English or Spanish, (5) age 18 years or older at the time of enrollment, and (6) not actively undergoing a workup for or known to have fetal demise at the time of enrollment.

Eligible patients were approached in person and via telephone during the eligibility window (up to 2 weeks after their EDD). Those who consented to participate in the study were also asked to consent to receive text (SMS) messages separately. Individuals were randomized using a randomization table created by the statistician (K.E.J.) and uploaded directly into the REDCap randomization module, which was blinded to the primary investigators and study staff. The assignment sequence was stratified by 2 variables that were determined a priori to be important to ensure balance: visit with a PCP within 3 years before the EDD and site of prenatal care (hospital campus vs community-based obstetric clinic). Patients were randomized after they consented and completed a baseline survey.

The intervention was designed to increase the rate of postpartum primary care visit completion within 4 months after the patient’s EDD. The bundle included a targeted introduction message about the importance of seeing their PCP after delivery and informed them that, to support them in this, a study staff member would be making an appointment on their behalf; they were allowed to opt out or communicate about scheduling preferences. For those who did not opt out, the study staff called the PCP office and requested that a health care maintenance or annual visit be scheduled within the target 4-month window. If a patient had already seen their PCP for an annual visit within the year, they were scheduled for this visit when they were next eligible (ie, 1 year after their last annual examination), even if outside the 4-month study follow-up period. For those who had appointments scheduled, study-specific appointment reminders were sent approximately 1 month after the EDD and 1 week before the scheduled appointment via the EHR patient portal and SMS, and both used salient labeling to describe the visit; examples are shown in the eFigure in Supplement 2 . If the PCP worked in the same health system and an appointment was scheduled, an electronic message was sent to the PCP from the study staff about the appointment scheduled by the study staff. For those for whom an appointment could not be scheduled, similar reminders were sent on the importance of PCP follow-up and encouraged the patient to contact their PCP office directly to schedule. Reminders included best practice wording from behavioral economic nudge mega-studies, including that the appointment had been reserved for them. 32 Using salient labeling, the appointment was described as the postpartum-to–primary care transition appointment. Patients in the control group received 1 message within 2 weeks of the EDD with a generic recommendation for PCP follow-up after delivery.

The primary outcome was completing a primary care visit for routine or chronic condition care within 4 months of the patient’s EDD. Specifically, we considered the outcome to have occurred if the patient attended a health care maintenance (ie, annual examination) visit or a problem-based visit in which obesity, anxiety and/or depression, diabetes, or hypertension were addressed with a primary care clinician within 4 months after their EDD. This definition was chosen to include visits most likely to reflect primary care reengagement after delivery instead of a visit for an acute illness or issue. This time frame was selected for 2 reasons: to capitalize on the increased health activation and motivation that have been noted during pregnancy and because these patients were more likely to have conditions that required ongoing and active management outside of the traditional postpartum period (up to 12 weeks after delivery). We considered practitioners affiliated with internal medicine, family medicine, pediatric and adolescent medicine, and gynecology practices to provide primary care; however, we did not count designated postpartum visits to be primary care visits.

Alternative specifications for the primary outcome were compared in sensitivity analyses: (1) self-reported PCP visits within 4 months after the EDD, obtained from a survey sent approximately 5 months after the EDD; (2) primary outcome restricted to visits with the patient’s designated PCP; (3) primary outcome restricted to patients whose PCP was affiliated with the study institution’s health system; (4) primary outcome expanded to include any PCP visit (not only routine or chronic condition care) within 4 months after a patient’s EDD; and (5) primary outcome expanded to include any completed or scheduled PCP visit within 1 year of a patient’s EDD.

We examined secondary outcomes measuring unscheduled care: obstetric triage visit, emergency department or urgent care use, and readmission within 4 months after the delivery. We also measured the likelihood of a patient having a PCP visit that included specific primary care services within 4 months: weight screening, blood pressure screening, mood screening, plan for diabetes screening, plan for mental health care, and contraception planning. Content of care outcomes were also compared within population subgroups related to the eligibility health condition. All outcomes are defined in detail in eTable 1 in Supplement 2 .

The primary and most secondary outcomes were ascertained directly by reviewing the patient’s EHR approximately 5 months after their EDD. Study staff that performed the review were blinded to the group assignment. Secondary self-reported outcomes were obtained by an electronic survey sent to patients approximately 5 months after their EDD.

Based on a historical cohort, we estimated that 33% of the targeted study population would have a PCP visit within 4 months of delivery. We estimated the intervention would increase the rate of PCP visit attendance by at least 15 percentage points (pp), a conservative estimate based on a prior study that examined default scheduling of postpartum obstetric care appointments (24-pp increase). 33 Assuming an α level of .05 and power of 80% and using a 2-sided z test, 334 patients were needed to detect a 15-pp difference. To account for individuals who may be lost to follow-up or withdraw, we planned to randomize 360 patients.

Patients were examined by intention-to-treat analysis. Patients who were lost to follow-up (ie, transferred obstetric care before delivery) or withdrew before the outcome assessment were excluded. Baseline patient characteristics and the percentage of patients who accessed the study messages in the EHR patient portal are reported. Primary and secondary outcomes were compared using χ 2 , t tests, and Fisher exact test, where appropriate. The pp difference in outcomes between the 2 groups was estimated using a linear probability regression model that included 2 indicator terms for the randomization strata, which were defined a priori.

A heterogeneity analysis was performed to understand the potential impact of the intervention among patient factors known or hypothesized to be disproportionately affected by administrative burdens. The primary outcome was compared among subgroups based on site of prenatal care (hospital- vs community-based clinic), chronic conditions (anxiety and/or depression, diabetes, hypertension, obesity, and multimorbidity, defined as >1 of the listed conditions), race (self-described Asian, Black, White, other [including American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander], or multiple) and ethnicity (self-described Hispanic or non-Hispanic), individual earnings/income (≤$30 000, $30 001-$75 000, or >$75 000), primary payer for delivery hospitalization (Medicaid or private/other), and self-reported physical and mental health status at the time of enrollment. 31 , 34 As known racial disparities exist in maternal health outcomes, including maternal morbidity and mortality, we examined the outcome by race to understand whether there was a differential impact among subgroups.

Stata, version 16.1 (StataCorp LLC) was used for the analysis. P values are reported for the primary outcome; P < .05 was considered statistically significant. As this project was not designed to have statistical power to detect the intervention’s impact on secondary outcomes or differences across subgroups, multiple hypothesis testing was not planned or prespecified. Results from secondary analyses are presented with 95% CIs that were not adjusted for multiple hypothesis testing. These secondary analyses should be considered exploratory, and results may not be reproducible.

Initially, 574 patients were identified as likely to be eligible based on predefined eligibility filters within the EHR ( Figure 1 ). Upon EHR review, 35 individuals were determined ineligible. Of those confirmed eligible, 77 could not be contacted and 102 declined. Thus, 360 patients were randomized: 176 to the control group and 184 to the intervention group. Six patients were excluded from the final analysis because they transferred their care to another institution before delivery (3 in each group). One patient in the intervention group withdrew from the study before the end of the follow-up period. The final number of patients analyzed in each group was 173 in the control group and 180 in the intervention group. Among study participants, 345 of 353 (97.7%) accessed study-related messages in the online patient portal. The proportion of patients in the intervention group who received each component of the intervention bundle is included in eTable 2 in Supplement 2 ; the study staff scheduled appointments for 137 participants (76.1%), of whom only 6 (4.4%) did not present and did not cancel their appointment. The most common reason the study staff did not schedule an appointment was that a PCP appointment was already scheduled (21 of 43 [48.8%]) (eTable 3 in Supplement 2 provides the full list). Of all participants, 61.8% completed the online electronic survey 5 months after the EDD.

The intervention and control groups were balanced in all baseline patient characteristics ( Table 1 ). Individuals included in the trial had a mean (SD) age of 34.1 (4.9) years and median gestational age of 36.3 (IQR, 34.0-38.6) weeks at enrollment. The distribution of self-reported race and ethnicity was 6.8% Asian, 7.4% Black, 68.6% White, and 15.0% multiple races or other; 2.3% declined to report their race. The distribution of self-reported ethnicities was 22.1% Hispanic and 75.4% non-Hispanic; 2.5% declined to report their ethnicity. Of the eligibility conditions, which were not mutually exclusive, 75.4% of all participants had anxiety or depression, 16.1% had a chronic or pregnancy-related hypertensive disorder, 19.5% had preexisting or gestational diabetes, and 40.8% had a prepregnancy body mass index of 30 or greater. Medicaid was the primary payer for the delivery encounter for 21.2% of patients. When surveyed, 11.6% reported their physical health and 19.6% reported their mental health as fair or poor. At enrollment, 34.3% of the participants had not seen any PCP within the previous 3 years and 29.2% were receiving obstetric care at one of the hospital’s satellite or affiliated health center clinics.

Table 2 reports the effects of the intervention on completion of a primary care visit for routine or chronic condition care within 4 months of the patient’s EDD. This primary outcome occurred in 40.0% (95% CI, 33.1%-47.4%) of the intervention group and 22.0% (95% CI, 6.4%-28.8%) of the control group ( P  < .001). When adjusted using linear probability regression models for prespecified randomization strata, the intervention increased the primary outcome by 18.7 (95% CI, 9.1-28.2) pp. The effects on the primary outcome were similar in the sensitivity analyses ( Table 3 ). There were no significant effects on obstetric triage visits or emergency department or urgent care use. However, the intervention group had fewer postpartum readmissions: 1.7% (95% CI, 0.5%-5.1%) vs 5.8% (95% CI, 3.1%-10.4%) ( Table 2 ).

Figure 2 compares the secondary outcomes related to the content or provision of care between the 2 groups. Intervention group participants had a higher likelihood of having a PCP visit with a weight screening (42.8%; 95% CI, 35.7%-50.1% vs 27.7%; 95% CI, 21.6%-34.9%), blood pressure screening (42.8%; 95% CI, 35.7%-50.1% vs 28.3%; 95% CI, 22.1%-35.1%), and mood screening (32.8%; 95% CI, 26.3%-40.0% vs 16.8%; 95% CI, 11.9%-23.1%). Intervention group participants were also more likely to have a PCP visit with a plan documented about their mental health (37.2%; 95% CI, 30.5%-44.5%) vs 23.1%; 95% CI, 17.4%-30.0%) and with a documented contraception plan (19.4%; 95% CI, 14.3%-25.9% vs 11.0%; 95% CI, 7.1%-16.6%). There was no significant difference in a documented plan for diabetes screening between the 2 groups. Comparisons of the secondary outcomes related to the content of care among subgroups of health conditions are reported in eTable 4 in Supplement 2 ; many comparisons were limited by small sample sizes.

There was treatment effect heterogeneity across health conditions, demographic characteristics, and baseline self-reported physical and mental health status (eTable 5 in Supplement 2 ). While the study was not powered to detect outcomes within subgroups, the intervention was associated with increases in PCP visits among nearly all subgroups examined.

Among pregnant people with common comorbidities, a behavioral economics–informed intervention bundle, including default appointment scheduling, tailored messaging, and nudge reminders, increased PCP visit completion within 4 months post partum by 18.7 pp, a nearly 2-fold increase. The primary finding was robust to multiple definitions or variations of the primary outcome, including self-reported PCP visit attendance. The effects on the primary outcome appeared largely consistent among population subgroups, although small sample sizes limited power in these comparisons. Not only did the intervention increase PCP visit completion, it also resulted in more individuals receiving important screening tests and services. There were no observed changes in emergent or urgent care visits between the 2 groups. However, any potential effects of facilitated primary care engagement on emergent care use are more likely to occur later in the postpartum year or beyond, and we intend to measure longer-term care use and outcomes in future studies.

Our results suggest that behavioral economic–informed interventions that reduce patient administrative burden have the potential to be relatively low-resource, high-impact approaches to increasing primary care use, a critical priority in the context of decreasing and inequitable primary care engagement in the US. 35 , 36 Behavioral economics research examines how people make predictable decision errors and tests interventions that leverage these insights to remove behavioral barriers (nudges). 37 - 47 These interventions often try to make it easier for people to make choices they already want to undertake but do not. In kind, the underlying hypothesis of the present study was that many postpartum individuals with or at high risk for chronic conditions who have a PCP assigned want to receive care by their PCP but face multiple barriers to primary care engagement in the postpartum period, including identifying who their PCP is and scheduling with them. Our study design was built to address 2 common behavioral barriers, namely, inattention and status quo bias, and demonstrated how default primary care appointment scheduling—a salient label for the appointment—and tailored SMS messages and appointment reminders can increase postpartum primary care engagement. Similar approaches have motivated other health behaviors, including in obstetric and postpartum care. 47 - 51

This study builds on prior efforts to improve postpartum health and well-being. 33 , 52 - 58 Our study is most closely aligned with the intervention research on postpartum care navigation in which patient navigators identify and holistically address patient-level barriers to care and assist with care coordination. 52 , 59 Although obstetric care navigators hold great promise for improving postpartum health care use, that level of intervention intensity and cost may not be necessary for most postpartum people needing primary care. Results from this study suggest that reducing some patient administrative barriers may be a relatively resource conscious but highly effective approach to encouraging postpartum primary care transitions. Specifically, we demonstrated this intervention could be delivered consistently, with the successful scheduling of an annual visit appointment for 76.1% of participants and a low no-show appointment rate of only 4.4%. Future work should focus on examining the health impacts and cost-effectiveness of the intervention.

The study had several limitations. First, the study tested a bundled intervention; we were unable to measure the effectiveness of the individual components for increasing PCP visits. Next, we observed health care encounters within a single health system, although the health system is large (>1300 PCPs). This study was conducted in Massachusetts, in which pregnancy-related Medicaid coverage extends for 12 months post partum and may impact the generalizability of our findings. We could not observe PCP visits for clinicians who do not use or are not affiliated with the health system’s common EHR. As an alternate measure, we examined self-reports of PCP visits, which was highly consistent with results using EHR data. However, the response rate of 61.8% (balanced across treatment and control groups) may also limit the generalizability of self-reported outcomes. This study focused on individuals who had an identified PCP at enrollment; given the limited availability of PCPs in certain areas, the effect of the intervention may be lessened for individuals seeking to establish care with a new PCP. In addition, the study was not powered to detect differences in many secondary outcomes related to the content of primary care within health conditions, and larger studies are needed to ascertain the impact of the intervention on the quality of primary care for specific conditions.

In this randomized clinical trial, a behavioral economics–informed intervention to improve postpartum transitions to primary care substantially increased postpartum primary care visit completion for patients with or at risk for common comorbidities. Targeting this population at a time of high health activation and motivation, this intervention represents a potentially scalable approach to increasing primary care engagement and ongoing health condition management in the postpartum months and beyond. Ongoing follow-up related to this study seeks to analyze condition-specific management (ie, the content and quality of care provided in the postpartum period) and long-term health outcomes. Similarly, as many individuals still did not attend a PCP appointment within 4 months even with the assistance of this intervention, additional investigations should focus on identifying and addressing remaining barriers to transitioning to primary care after pregnancy.

Accepted for Publication: May 2, 2024.

Published: July 16, 2024. doi:10.1001/jamanetworkopen.2024.22500

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Clapp MA et al. JAMA Network Open .

Corresponding Author: Mark A. Clapp, MD, MPH, Massachusetts General Hospital, 45 Fruit St, Boston, MA 02459 ( [email protected] ).

Author Contributions: Drs Clapp and Cohen had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Clapp, Ray, Cohen.

Acquisition, analysis, or interpretation of data: Clapp, Liang, James, Ganguli, Cohen.

Drafting of the manuscript: Clapp, Liang, Cohen.

Critical review of the manuscript for important intellectual content: Clapp, Ray, James, Ganguli, Cohen.

Statistical analysis: Clapp, Liang, James, Cohen.

Obtained funding: Clapp, Cohen.

Administrative, technical, or material support: Clapp, Ray, Liang.

Supervision: Clapp, Cohen.

Conflict of Interest Disclosures: Dr Clapp reported holding equity from the Delfina Care Scientific Advisory Board outside the submitted work. Dr Ganguli reported receiving grants from the National Institute on Aging, Commonwealth Fund, and Arnold Ventures, and personal fees from FPrime outside the submitted work. Dr Cohen reported receiving grants from the National Academy of Medicine and the National Academy on Aging during the conduct of the study. No other disclosures were reported.

Funding/Support: This study was funded by the National Institute on Aging via the Massachusetts Institute of Technology Roybal Center for Translational Research to Improve Health Care for the Aging (P30AG064190) and the National Bureau of Economic Research Roybal Center for Behavior Change in Health (P30AG034532). Additional support was provided by the National Academy of Medicine’s Health Catalyst Award.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Meeting Presentation: Initial results from this study were presented at the University of Pennsylvania Center for Health Incentives and Behavioral Economics Research Conference; October 30, 2023; Philadelphia, Pennsylvania; the 2023 Association for Public Policy Analysis and Management Fall Research Conference; November 10, 2023; Atlanta, Georgia; the American Economic Association Annual Meeting; January 7, 2024; San Antonio, Texas; and the 2024 American Society for Health Economists Conference; June 18, 2024; San Diego, California.

Data Sharing Statement: See Supplement 3 .

Additional Contributions: We thank Fowsia Warsame, BA, for serving as a paid clinical research coordinator for this trial; Hasan Quadri for serving as a paid data analyst; and Amanda Lee, MPP, and Fatima Vakil, BS, from the Jameel Poverty Action Lab for providing in-kind research management support.

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