Perinatal mood and anxiety disorders (PMADs)—depression, anxiety, and bipolar disorders—can present a serious risk for both the mother and child. Its prevalence in pregnant mothers has increased in recent years.1
Moreover, according to the investigators of a newly published study on differences in detection and treatment of PMADs between rural and urban residence, the health inequity and treatment gaps faced by communities of color and low-income expectant mothers could be putting more families at risk than previously known.1 The coauthors note that much research has reflected this health disparity, including one study that reported a significantly higher prevalence of postpartum depression in Medicaid recipients, registering at >30%, well above the national estimate that is between 8% to 11%;1,2 another study revealed White Medicaid recipients were twice as likely as Black recipients to seek and receive mental health services throughout pregnancy and postpartum.3
Although other investigational efforts have shown similar results in other race-stratified population samples, there is little data that further dissects the role that both race and local residency could have on PMAD diagnoses and subsequent treatments.1
To help fill the knowledge gap, Eric C. Nacev, MD, MPH, from the department of Obstetrics and Gynecology at Oregon Health and Science University in Portland, Oregan, and colleagues sought to document and highlight the impact both race and rurality could have on expectant mothers’ mental health outcomes. This study used Medicaid data and birth certificates from Oregon and South Carolina, 2 states that have large rural populations and urban centers, from 2016 to 2020. The researchers specifically looked at singleton births among Medicaid recipients aged 12 to 44 years, with 22 to 44 weeks of gestational period.1
Medicaid claims data included clinical diagnostic codes as well as treatments received, where if at least 1 pharmacotherapy prescription or 1 session of talk therapy were listed, a participant was considered to have received treatment. Other extracted Medicaid data included maternal residence (where rurality can be categorized through the Rural-Urban Area Codes zip code classification), modes of delivery, and pregnancy-related clinical complications such as gestational diabetes and hypertensive disorders, resulting in a large cohort of 185,809 participants.1
PMAD diagnoses were more prevalent in urban residents than in rural residents, but over half of diagnosed individuals received no mental health treatments.
Among all the qualifying registered births, 27% (n=50,820) occurred in rural areas, compared to 73% (n=134,989) in urban areas; South Carolina registered a higher proportion of births in rural areas than Oregon (29.8% and 24.3%, respectively). Births to Black residents were more prevalent in rural areas (31.5%) than in urban areas (25.8%), while births to White residents in rural and urban areas were comparable (55.6% and 56.2%, respectively).1
According to Medicaid claims data, PMAD diagnosis rates were higher in urban residents (19.5%) than in rural residents (18.1%, P<.001), with a large majority of the diagnoses occurring during pregnancy (70.6%), and a smaller proportion of diagnoses made postpartum or within 60 days after birth (29.4%, P=.514). However, despite almost a quarter of expectant or new mothers receiving any PMAD diagnoses, 58.4% did not receive any treatment. Of those who did receive treatment, 20% received at least 1 talk therapy session and 21% received at least 1 pharmacotherapy prescription, and no statistical difference in type of treatment was seen between urban and rural residency (P=.079).1
Although rurality affects Black residents’ likelihood of receiving any PMAD diagnoses, it has little effects on White residents.
The researchers performed logistic regression analyses on these data to compare residency effects as well as racial differences in receiving PMAD diagnosis and treatments while also considering relevant factors that could impact mental health, such as pregnancy complications, adequacy of prenatal care, and neonatal intensive care unit admission, resulting in adjusted odds ratio (OR) values. After accounting for these factors, urban residents were more likely to have a PMAD diagnosis compared to rural residents (OR, 1.059; 95% CI, 1.059-1.059; P<.001), and when the data were race-stratified, Black mothers were more likely to have a PMAD diagnosis as an urban resident than as a rural resident (OR, 1.188; 95% CI, 1.188-1.188; P<.001). This difference was not as prominent for White mothers regardless of rurality (OR, 1.027; 95% CI, 0.843-1.252; P<.101).1
Overall, the data suggested a strong interaction between rurality and race, but low treatment rates among all surveyed groups.
According to the authors, the results of this analyses suggest that Black residents in urban areas are especially vulnerable to PMADs compared to White residents in general. Unlike other studies, which have suggested that rural women are at higher risk of mental health conditions, this study, which included a considerably more significant proportion of people of color, showed that effects on mental health may be more intricately connected to race than a simplistic urban versus rural divide, further highlighting the historic lack of diversity and inclusion in investigational studies.1
The researchers hypothesized that social factors could contribute to the race-rurality disparities. “Some rural Black residents, particularly in the South, may have resources, community, and coping mechanisms that may not be as available to their urban counterparts, such as high rates of religious participation,” they wrote. These mechanisms, they said, could partially counterbalance mental health effects from systemic racism, which have historically been shown to impact PMAD rates.1
While mental health providers in rural areas are more scarce compared to urban areas, considering population density with its significantly higher demands may also create an effective scarcity in urban zip codes. The health disparity highlighted by this latest study underscores a pressing need for increased mental health accessibility in the United States. And, the authors note the data could have been limited or incomplete, due to gaps in screening and low rates of attendance at post-natal visits. This suggests perhaps an even greater population with PMAD than noted in this study who could benefit from assistance.1
Overall, this study could guide health practitioners to improve screening and interventions for more marginalized groups, which could alleviate morbidity associated with PMADs in the future.1
Published:
Christella Gordon-Kim is a medicinal chemist working to target proteins relevant to Alzheimer’s Disease. She earned her PhD in biomolecular chemistry at Emory University.
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