Postpartum Depression: An Examination of the Referral Process for Low Income, Minority Women

Postpartum depression (PPD) is a serious and common psychiatric disorder that can have negative effects on women, their children, and families. Mothers living in poverty are more likely to be depressed (Hobfoll et al., 1995), and are likely to have greater barriers to accessing treatment (Song et al. 2004) than the general population. Mental health utilization has been shown to be particularly limited for women with PPD and low-income, ethnic minority women (Horowitz & Cousins, 2006). Although considerable emphasis has been placed on screening and identifying depression in women in prenatal and postpartum care, there is a need to address barriers from the point of identification of depression risk to actual initiation of treatment--the referral process--if these women are to receive adequate care for their depression. Enhanced referral strategies that make use of the social and cultural resources of the communities in which these women live may be the key to effective delivery of services to this vulnerable population. An existing university-community agency partnership decided to focus on the barriers and the facilitation of mental health utilization among low-income postpartum women in a large urban area.

A pilot investigation conducted in the community agency examined the current referral activities for women screened with high levels of postpartum depression symptoms in two ways: 1) focus groups were conducted with agency staff and 2) systemic data gathering of agency's current referral practices.

Three focus groups with 16 agency staff were conducted to examine practices, barriers and successes in mental health referrals for depressed women. The transcripts of the focus groups were analyzed through content analyses by three coders and the use of QSR NVivo 8. All coders coded each transcript independently and completed open coding of units of analysis, identified initial categories and engaged in comparative analysis.

The following themes emerged from the analysis: social support, life events, culture & language, continuity of care and mental health stigma. One important finding pertaining to social support is the suspicion with which many low income women view the mental health system and the time it takes to develop a trusting relationship. The postpartum women experience frequent life stressors and as a result the staff find it difficult to distinguish between a depressive disorder and a normal reaction to stress. In addition, these stressors make it harder to engage a postpartum mother into mental health treatment. Cultural taboos, translation of different languages and immigration issues all need to be navigated. Other findings, including facilitators of the referral process and implications of the findings for developing strategies for increasing referral completion will be discussed.

An examination of the referral process for PPD is critical to the field of social work as few women who need mental health treatment are following through on referrals. PPD affects not only women but their children, families and communities as well. Identifying barriers and facilitating factors to increase the likelihood of postpartum women seeking the treatment they need can impact long-term outcomes for both the women and their children.