Skip to main content Accessibility help

The impact of education, country, race and ethnicity on the self-report of postpartum depression using the Edinburgh Postnatal Depression Scale

  • A. Di Florio (a1) (a2), K. Putnam (a1), M. Altemus (a3), G. Apter (a4), V. Bergink (a5) (a6), J. Bilszta (a7), R. Brock (a8), A. Buist (a7), K. M. Deligiannidis (a9), E. Devouche (a10), C. N. Epperson (a11), C. Guille (a12), D. Kim (a11), P. Lichtenstein (a13), P. K. E. Magnusson (a13), P. Martinez (a14), T. Munk-Olsen (a6), J. Newport (a15), J. Payne (a16), B. W. Penninx (a17), M. O'Hara (a8), E. Robertson-Blackmore (a18), S. J. Roza (a5), K. M. Sharkey (a19), S. Stuart (a8), H. Tiemeier (a5), A. Viktorin (a13), P. J. Schmidt (a14), P. F. Sullivan (a1), Z. N. Stowe (a20), K. L. Wisner (a21), I. Jones (a2), D. R. Rubinow (a1) and S. Meltzer-Brody (a1)...



Universal screening for postpartum depression is recommended in many countries. Knowledge of whether the disclosure of depressive symptoms in the postpartum period differs across cultures could improve detection and provide new insights into the pathogenesis. Moreover, it is a necessary step to evaluate the universal use of screening instruments in research and clinical practice. In the current study we sought to assess whether the Edinburgh Postnatal Depression Scale (EPDS), the most widely used screening tool for postpartum depression, measures the same underlying construct across cultural groups in a large international dataset.


Ordinal regression and measurement invariance were used to explore the association between culture, operationalized as education, ethnicity/race and continent, and endorsement of depressive symptoms using the EPDS on 8209 new mothers from Europe and the USA.


Education, but not ethnicity/race, influenced the reporting of postpartum depression [difference between robust comparative fit indexes (∆*CFI) < 0.01]. The structure of EPDS responses significantly differed between Europe and the USA (∆*CFI > 0.01), but not between European countries (∆*CFI < 0.01).


Investigators and clinicians should be aware of the potential differences in expression of phenotype of postpartum depression that women of different educational backgrounds may manifest. The increasing cultural heterogeneity of societies together with the tendency towards globalization requires a culturally sensitive approach to patients, research and policies, that takes into account, beyond rhetoric, the context of a person's experiences and the context in which the research is conducted.


Corresponding author

*Address for correspondence: S. Meltzer-Brody, Department of Psychiatry, University of North Carolina at Chapel Hill, Campus Box #7160, Chapel Hill, NC 27599, USA. (Email:


Hide All
Alarcón, RD (2009). Culture, cultural factors and psychiatric diagnosis: review and projections. World Psychiatry 8, 131139.
Alonso, J, Buron, A, Bruffaerts, R, He, Y, Posada-Villa, J, Lepine, J-P, Angermeyer, MC, Levinson, D, de Girolamo, G, Tachimori, H, Mneimneh, ZN, Medina-Mora, ME, Ormel, J, Scott, KM, Gureje, O, Haro, JM, Gluzman, S, Lee, S, Vilagut, G, Kessler, RC, Von Korff, M; World Mental Health Consortium (2008). Association of perceived stigma and mood and anxiety disorders: results from the World Mental Health Surveys. Acta Psychiatrica Scandinavica 118, 305314.
Bauer, A, Parsonage, M, Knapp, M, Iemmi, V, Adelaja, B (2014). Costs of Perinatal Mental Health Problems. London School of Economics and the Centre for Mental Health: London.
Boots Family Trust (2013). Boots Family Trust Perinatal Mental Health Report (
Brown, TA (2015). Confirmatory Factor Analysis for Applied Research, 2nd edn. The Guilford Press: New York and London.
Cantwell, R, Clutton-Brock, T, Cooper, G, Dawson, A, Drife, J, Garrod, D, Harper, A, Hulbert, D, Lucas, S, McClure, J, Millward-Sadler, H, Neilson, J, Nelson-Piercy, C, Norman, J, O'Herlihy, C, Oates, M, Shakespeare, J, de Swiet, M, Williamson, C, Beale, V, Knight, M, Lennox, C, Miller, A, Parmar, D, Rogers, J, Springett, A (2011). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG: An International Journal of Obstetrics and Gynaecology 118 (Suppl. 1), 1203.
Chatterji, P, Markowitz, S (2012). Family leave after childbirth and the mental health of new mothers. Journal of Mental Health Policy and Economics 15, 6176.
Chentsova-Dutton, YE, Ryder, AG, Tsai, J (2014). Understanding depression across cultural contexts. In Handbook of Depression, 3rd edn. (ed. Gotlib, IH and Hammen, CL), pp. 337354. Guilford: New York.
Comstock, GW, Helsing, KJ (1976). Symptoms of depression in two communities. Psychological Medicine 6, 551563.
Cook, TM, Wang, J (2010). Descriptive epidemiology of stigma against depression in a general population sample in Alberta. BMC Psychiatry 10, 29.
Cooper, WO, Willy, ME, Pont, SJ, Ray, WA (2007). Increasing use of antidepressants in pregnancy. American Journal of Obstetrics and Gynecology 196, 544.e1544.e5.
Cox, J, Holden, J, Henshaw, C (2014). Perinatal Mental Health: The Edinburgh Postnatal Depression Scale (EPDS) Manual, 2nd revised edn. RCPsych Publications: London.
Cox, JL (1988). Childbirth as a life event: sociocultural aspects of postnatal depression. Acta Psychiatrica Scandinavica. Supplementum 344, 7583.
Cox, JL, Holden, JM, Sagovsky, R (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry: The Journal of Mental Science 150, 782786.
Cunningham, NK, Brown, PM, Page, AC (2014). Does the Edinburgh Postnatal Depression Scale measure the same constructs across time? Archives of Women's Mental Health 18, 793804.
Dagher, RK, McGovern, PM, Dowd, BE (2014). Maternity leave duration and postpartum mental and physical health: implications for leave policies. Journal of Health Politics, Policy and Law 39, 369416.
Dagher, RK, McGovern, PM, Dowd, BE, Lundberg, U (2011). Postpartum depressive symptoms and the combined load of paid and unpaid work: a longitudinal analysis. International Archives of Occupational and Environmental Health 84, 735743.
Dolbier, CL, Rush, TE, Sahadeo, LS, Shaffer, ML, Thorp, J; Community Child Health Network Investigators (2013). Relationships of race and socioeconomic status to postpartum depressive symptoms in rural African American and non-Hispanic white women. Maternal and Child Health Journal 17, 12771287.
Eberhard-Gran, M, Eskild, A, Tambs, K, Opjordsmoen, S, Ove Samuelsen, S (2001). Review of validation studies of the Edinburgh Postnatal Depression Scale. Acta Psychiatrica Scandinavica 104, 243249.
Edge, D, Rogers, A (2005). Dealing with it: black Caribbean women's response to adversity and psychological distress associated with pregnancy, childbirth, and early motherhood. Social Science and Medicine (1982) 61, 1525.
Gan, Z, Li, Y, Xie, D, Shao, C, Yang, F, Shen, Y, Zhang, N, Zhang, G, Tian, T, Yin, A, Chen, C, Liu, J, Tang, C, Zhang, Z, Liu, J, Sang, W, Wang, X, Liu, T, Wei, Q, Xu, Y, Sun, L, Wang, S, Li, C, Hu, C, Cui, Y, Liu, Y, Li, Y, Zhao, X, Zhang, L, Sun, L, Chen, Y, Zhang, Y, Ning, Y, Shi, S, Chen, Y, Kendler, KS, Flint, J, Zhang, J (2012). The impact of educational status on the clinical features of major depressive disorder among Chinese women. Journal of Affective Disorders 136, 988992.
Gibson, J, McKenzie-McHarg, K, Shakespeare, J, Price, J, Gray, R (2009). A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women. Acta Psychiatrica Scandinavica 119, 350364.
Gregorich, SE (2006). Do self-report instruments allow meaningful comparisons across diverse population groups? Testing measurement invariance using the confirmatory factor analysis framework. Medical Care 44, S78S94.
Guedeney, N, Fermanian, J (1998). Validation study of the French version of the Edinburgh Postnatal Depression Scale (EPDS): new results about use and psychometric properties. European Psychiatry: The Journal of the Association of European Psychiatrists 13, 8389.
Hirschfeld, G, von Brachel, R (2014). Multiple-group confirmatory factor analysis in R – a tutorial in measurement invariance with continuous and ordinal indicators. Practical Assessment, Research & Evaluation 19, 112 (
Keller, MC, Neale, MC, Kendler, KS (2007). Association of different adverse life events with distinct patterns of depressive symptoms. American Journal of Psychiatry 164, 15211529; quiz 1622.
Kendler, KS, Aggen, SH, Li, Y, Lewis, CM, Breen, G, Boomsma, DI, Bot, M, Penninx, BWJH, Flint, J (2015). The similarity of the structure of DSM-IV criteria for major depression in depressed women from China, the United States and Europe. Psychological Medicine 45, 19451954.
Kozhimannil, KB, Kim, H (2014). Maternal mental illness. Science 345, 755755.
Kroeber, AL, Kluckhohn, C (1952). Culture: a critical review of concepts and definitions. Papers of the Peabody Museum of American Archeology and Ethnology 47, 223.
Kumar, R (1994). Postnatal mental illness: a transcultural perspective. Social Psychiatry and Psychiatric Epidemiology 29, 250264.
Lara-Cinisomo, S, Wisner, KL, Meltzer-Brody, S (2015). Advances in science and biomedical research on postpartum depression do not include meaningful numbers of Latinas. Journal of Immigrant and Minority Health/Center for Minority Public Health 17, 15931596.
Meltzer-Brody, S (2011). New insights into perinatal depression: pathogenesis and treatment during pregnancy and postpartum. Dialogues in Clinical Neuroscience 13, 89100.
Meltzer-Brody, S, Boschloo, L, Jones, I, Sullivan, PF, Penninx, BW (2013). The EPDS-Lifetime: assessment of lifetime prevalence and risk factors for perinatal depression in a large cohort of depressed women. Archives of Women's Mental Health 16, 465473.
Millsap, RE (2011). Statistical Approaches to Measurement Invariance. Routledge: New York.
Munk-Olsen, T, Gasse, C, Laursen, TM (2012). Prevalence of antidepressant use and contacts with psychiatrists and psychologists in pregnant and postpartum women. Acta Psychiatrica Scandinavica 125, 318324.
Munk-Olsen, T, Laursen, TM, Pedersen, CB, Mors, O, Mortensen, PB (2006). New parents and mental disorders. JAMA 296, 25822589.
O'Connor, E, Rossom, RC, Henninger, M, Groom, HC, Burda, BU (2016). Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force. JAMA 315, 388406.
Paykel, ES (2008). Basic concepts of depression. Dialogues in Clinical Neuroscience 10, 279289.
Pop, VJ, Komproe, IH, van Son, MJ (1992). Characteristics of the Edinburgh Post Natal Depression Scale in the Netherlands. Journal of Affective Disorders 26, 105110.
Postpartum Depression: Action Towards Causes and Treatment (PACT) Consortium (2015). Heterogeneity of postpartum depression: a latent class analysis. Lancet Psychiatry 2, 5967.
Ray, R, Gornick, JC, Schmitt, J (2010). Who cares? Assessing generosity and gender equality in parental leave policy designs in 21 countries. Journal of European Social Policy 20, 196216.
Schomerus, G, Matschinger, H, Baumeister, SE, Mojtabai, R, Angermeyer, MC (2014). Public attitudes towards psychiatric medication: a comparison between United States and Germany. World Psychiatry 13, 320321.
Shonkoff, JP, Boyce, W, McEwen, BS (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. JAMA 301, 22522259.
Teng, L, Robertson Blackmore, E, Stewart, DE (2007). Healthcare worker's perceptions of barriers to care by immigrant women with postpartum depression: an exploratory qualitative study. Archives of Women's Mental Health 10, 93101.
Tolstoy, L (1878 [1939]). Anna Karenina. Oxford University Press/Humphrey Milford: Oxford.
Venables, WN, Ripley, BD (2003). Modern Applied Statistics with S, 4th edn. Springer: New York.
Wisner, KL, Sit, DKY, McShea, MC, Rizzo, DM, Zoretich, RA, Hughes, CL, Eng, HF, Luther, JF, Wisniewski, SR, Costantino, ML, Confer, AL, Moses-Kolko, EL, Famy, CS, Hanusa, BH (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry 70, 490498.


Related content

Powered by UNSILO

The impact of education, country, race and ethnicity on the self-report of postpartum depression using the Edinburgh Postnatal Depression Scale

  • A. Di Florio (a1) (a2), K. Putnam (a1), M. Altemus (a3), G. Apter (a4), V. Bergink (a5) (a6), J. Bilszta (a7), R. Brock (a8), A. Buist (a7), K. M. Deligiannidis (a9), E. Devouche (a10), C. N. Epperson (a11), C. Guille (a12), D. Kim (a11), P. Lichtenstein (a13), P. K. E. Magnusson (a13), P. Martinez (a14), T. Munk-Olsen (a6), J. Newport (a15), J. Payne (a16), B. W. Penninx (a17), M. O'Hara (a8), E. Robertson-Blackmore (a18), S. J. Roza (a5), K. M. Sharkey (a19), S. Stuart (a8), H. Tiemeier (a5), A. Viktorin (a13), P. J. Schmidt (a14), P. F. Sullivan (a1), Z. N. Stowe (a20), K. L. Wisner (a21), I. Jones (a2), D. R. Rubinow (a1) and S. Meltzer-Brody (a1)...


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed.