Trauma, Psychiatric Disorders, and Treatment History among Pregnant African American Women

Abstract

Objective:

Pregnant African American women living in low-income urban communities have high rates of trauma exposure and elevated risk for the development of trauma-related disorders, including posttraumatic stress disorder (PTSD) and depression. Yet, engagement in behavioral health services is lower for African American women than Caucasian women. Limited attention has been given to identifying trauma exposure and PTSD, especially within at-risk communities. The present study examined rates of trauma exposure, PTSD, depression, and behavioral health treatment engagement in an OB/GYN clinic within an urban hospital.

Method:

The study included 633 pregnant African American women screened within the OB/GYN clinic waiting room; 55 of the women also participated in a subsequent detailed clinical assessment based on eligibility for a separate study of intergenerational risk for trauma and PTSD in African American mother-child dyads.

Results:

Overall, 98% reported trauma exposure, approximately one-third met criteria for probable current PTSD and one-third endorsed moderate-or-severe depression based on self-report measures. Similar levels were found based on clinical assessments in the subsample. While 18% endorsed depression treatment, only 6% received treatment for PTSD. In a subsample of women with whom chart reviews were conducted (n=358), 15% endorsed a past psychiatric diagnosis but none shared their PTSD diagnosis with their OB/GYN provider.

Conclusion:

Results of the current study highlight elevated levels of trauma exposure, PTSD, and depression in low-income, African American pregnant women served by this urban clinic, and demonstrate the need for better identification of trauma-related disorders and appropriate linkage to culturally-responsive care especially for PTSD.

More than 70% of individuals in the United States experience at least one traumatic event in their lifetime (Breslau, 2009). However, individuals living in low income urban environments are at greater risk for exposure to multiple traumatic events, often chronic and interpersonal in nature, resulting in elevated risk for trauma-related behavioral health conditions like posttraumatic stress disorder (PTSD; Goldmann et al., 2011; Seng, Kohn-Wood, McPherson, & Sperlich, 2011). In the general population, the lifetime prevalence of PTSD has been estimated to be 6.4% (Pietrzak, Goldstein, Southwick, & Grant, 2011), but rates as high as 30–50% are observed among African Americans living in areas with high violence (Gillespie et al., 2009).

Depression is another common reaction to trauma and can develop even in the absence of PTSD following exposure to traumatic events, with higher rates found in African Americans than Caucasians (Alim et al., 2006; Bernet & Stein, 1999; Wang et al., 2010). For rates of major depressive disorder (MDD) in the general population, the lifetime prevalence is estimated to be 16.2% (Kessler, Berglund, Demler, & et al., 2003). Regarding MDD, lifetime rates closer to 40% have been found in urban communities with high rates of trauma exposure and violence (>90% African American; Gillespie et al., 2009). Importantly, there is significant overlap between PTSD and depression and these disorders often co-occur. In fact, recent changes to the PTSD diagnostic criteria in the DSM-5 (American Psychiatric Association, 2013) now include a symptom cluster of “negative cognitions and mood” which includes many symptoms consistent with an MDD diagnosis (e.g., anhedonia). Therefore, in examining the impact of trauma on psychiatric outcomes, both PTSD and depression are important and relevant.

One group at particular risk in regard to negative outcomes associated with trauma exposure is pregnant African American women living in low-income communities. Studies have found high rates of cumulative trauma exposure and PTSD among pregnant African American women (Dailey, Humphreys, Rankin, & Lee, 2011; Seng et al., 2011; Seng, Low, Sperlich, Ronis, & Liberzon, 2009). In addition, rates of perinatal depression (i.e., depression that occurs during pregnancy or in the first year following delivery) are higher for women with a history of trauma versus those without such a history (Alvarez-Segura et al., 2014; Meltzer-Brody et al., 2013; Seng, D’Andrea, & Ford, 2014), for African American women versus non-minority women (Melville, Gavin, Guo, Fan, & Katon, 2010), as well as for economically disadvantaged women versus non-economically disadvantaged women (Goyal, Gay, & Lee, 2010). Estimates of perinatal depression in low-income ethnic minority samples have found rates of current depression ranging from 19–28% (Melville et al., 2010). To our knowledge, however, there have been no studies estimating rates of PTSD among low-income ethnic minority women within obstetrics/gynecology (OB/GYN) clinics. Furthermore, evidence suggests that African Americans in particular may be at greater risk for the development of PTSD than other non-white minorities (Alegría et al., 2013; Roberts, Gilman, Breslau, Breslau, & Koenen, 2011). Identification of trauma-related psychiatric symptoms and appropriate linkages to care is critical during the prenatal period because of the potential risk for adverse birth outcomes (Yonkers et al., 2014), particularly in African American women (Sealy-Jefferson, Giurgescu, Slaughter-Acey, Caldwell, & Misra, 2016) and the potential transmission of intergenerational risk of trauma and related disorders from mothers to their children (Sack, Clarke, & Seeley, 1995). Therefore, it is critical to understand rates of trauma exposure, psychiatric disorders, and treatment engagement among pregnant African American women in high risk, low-income communities.

A substantial number of women treated in OB/GYN clinics have unrecognized and untreated psychiatric disorders (Seng et al., 2011; Tandon, Cluxton-Keller, Leis, Le, & Perry, 2012). Historically, misdiagnosis and underdiagnosis of psychiatric disorders has been a common problem for African Americans (Bell, Jackson, & Bell, 2015; Roberts et al., 2011) and this can lead to less access to or engagement in behavioral health care services. While numerous studies exist demonstrating rates of depression and subsequent access to behavioral health care in OB/GYN settings, to our knowledge, only three studies have examined PTSD prevalence, detection by healthcare providers, and/or behavioral health treatment engagement (Seng et al., 2011; Seng et al., 2009; Smith et al., 2004) and none have focused on a low-income African American sample.

Despite the evidence for trauma and psychiatric risk for pregnant women in low-income urban environments, there remain substantial challenges with adequate identification and diagnosis of trauma-related psychiatric disorders, access to behavioral health treatment, and treatment engagement in this population (Davis, Ressler, Schwartz, Stephens, & Bradley, 2008; Fiscella, Franks, Gold, & Clancy, 2000). In order to fill gaps in research on PTSD prevalence and treatment engagement within at risk, low-income African American communities, the goal of the current paper is to provide detailed characteristics of trauma exposure and psychiatric disorders in a sample of African American women who are pregnant and are seeking medical treatment in an urban hospital setting serving a primarily low-income minority population (>90% African American). We will describe our sample’s sociodemographic characteristics, trauma histories, and PTSD and depression rates. This will enable us to build upon what we know about prenatal depression, and expand to address previous or concurrent trauma exposure, PTSD, and the comorbidity of PTSD and depression. We will further contribute to the literature by examining behavioral health treatment engagement and detection of psychiatric disorders by medical providers in the sample. Associations between socioeconomic status (SES) and rates of trauma, PTSD, depression, and treatment engagement will also be examined to better understand how SES may play a role in risk within these communities. To reduce the intergenerational transmission of risk for trauma and trauma-related conditions (Sack et al., 1995), it is critical to better understand the prevalence of psychiatric conditions and disparities in behavioral health care access among pregnant women experiencing disproportionate levels of trauma and adversity so that improved assessments and linkages to care can be achieved.

Methods

Recruitment Procedures

The current study focuses on a secondary analysis of data collected from January 2011 through May 2015 for a broader project, the Grady Trauma Project, which was initiated as an NIH-funded study (MH071537) examining genetic and trauma-related risk factors for the development of PTSD among non-psychiatric treatment seeking individuals within an urban hospital setting. The details of the original study and recruitment procedures still used now have been described elsewhere (Gillespie et al., 2009). Briefly, all study participants for the present analyses were women recruited from the outpatient OB/GYN clinic at Grady Memorial Hospital in Atlanta, GA, which services a primarily low SES, inner city and racial minority population (>90% African American). Women were approached from waiting rooms in the OB/GYN clinic by a member of the research team and asked to participate in a study examining the psychological and health impacts of trauma exposure. To be eligible for participation, participants had to be at least 18 years old, not actively psychotic, and able to give informed consent. It was not a requirement to have experienced trauma to participate. After signing the informed consent approved by the Emory Institutional Review Board and the Grady Hospital Research Oversight Committee, an initial interview was administered with questionnaires regarding trauma history, PTSD and depression symptoms, and psychological variables. Trained research assistants administered this interview, which took 45–75 minutes to complete (duration largely dependent on participant’s trauma history and symptoms). All self-report measures are read out loud to participants to reduce potential challenges with understanding or low literacy. Only African American women who were recruited out of OB/GYN clinic and endorsed being pregnant were included in study analyses; we chose to include African Americans only because our sample was >95% African American and we were specifically interested in understanding trauma and psychiatric disorder rates in pregnant African American women. Women were included at any stage of pregnancy; stage of pregnancy was not systematically assessed and so data on pregnancy stage was not collected for all participants. The recruitment strategy for the broader Grady Trauma Project was focused on identifying a general representative sample of individuals seeking treatment in the medical clinics at Grady Hospital and understand rates of trauma exposure, psychiatric symptoms, and risk and protective factors related to trauma; since the goal of this study is to examine rates of trauma exposure, psychiatric symptoms, and treatment engagement in pregnant African American women, the use of this sample for secondary analysis to meet this goal is warranted.

A subset of the pregnant African American women recruited in the study were also invited to participate in a secondary phase of the study based on eligibility for another study going at the time. Specifically, this was an NICHD funded study examining intergenerational trauma and PTSD risk in African American mothers and their children (HD071982; see Cao, Powers, Cross, Bradley, & Jovanovic, 2017) for a description of study methods)). Inclusion criteria was as follows: at least 18 years old, not actively psychotic, able to give informed consent, self-identified as African American, child in the age range of 8 – 12. These women were administered structural clinical interviews at a later scheduled visit (approximately 1–2 weeks following initial screening assessment) conducted by research staff that were trained and supervised by a licensed clinical psychologist.

Participants

The sample consisted of 633 pregnant African American women (mean age = 25.79, SD = 5.74). Demographic details of the study sample are listed in Table 1. Additional pregnancy information was only available on a subset of women with whom chart review data was abstracted at a later time for a separate project; out of the chart review sample of 358 women, range of gravidity was 0 to 10 (mean = 3.33, SD = 2.18) and range of parity was 0 to 5 (mean = 1.42, SD = 1.41). Twenty percent of these women endorsed a history of preterm birth. Fifty-five women also returned for the clinical assessment portion of the study; demographics of this subsample are also depicted in Table 1.

Table 1.

Demographic Characteristics for Overall Sample and Subsample

Factor	Total sample	Subsample
	N	N
	633	55
Demographic Characteristics	%	%
Race
African American	100.0	100.0
Ethnicity
Hispanic	2.1	0.0
Employed	36.7	41.8
Household monthly income <$2,000	80.3	75.9
Education
Less than high school degree	22.6	29.1
Graduated high school or GED	45.3	32.7
Some college or college degree	31.2	34.5
Graduate school	0.9	3.6
Marital status
Single or never married	82.3	69.1
Married	6.3	5.5
Divorced	3.5	7.3
Separated	1.6	1.8
Widowed	0.3	0.0
Domestic partner	6.0	16.4

Note: The total sample reflects women identified and interviewed in the OB/GYN clinic and the subsample reflects the women that engaged in a follow-up clinical assessment following eligibility for a separate study of intergenerational risk for trauma and PTSD in African American mothers and their children.

Measures

The Traumatic Events Inventory (TEI; Gillespie et al., 2009) is a self-report measure of lifetime history of traumatic events and details type of trauma(s) experienced or witnessed. Total level of trauma exposure was measured by a sum score reflecting the total number of different types of trauma (e.g., car accident, sexual assault, and natural disaster) to which a participant had been exposed in their lifetime. For this study, the TEI was used to measure overall trauma load for events witnessed or experienced (i.e., TEI total score). See Table 2 for a list of percentages of types of traumas witnessed or experienced by participants.

Table 2.

Descriptive Details on Trauma and Psychiatric Symptoms for Overall Sample and Subsample

Factor	Total sample			Subsample
		N			N
		633			55
Trauma and Psychiatric Symptoms	Mean	SD	Range	Mean	SD	Range
TEI Total Score	3.97	2.98	0–17	4.85	3.37	0–11
mPSS	12.50	11.48	0–50	16.49	12.51	0–47
BDI-II	14.77	10.97	0–57	17.12	13.96	0–57
Trauma Exposure by Type		%			%
Exposure to ≥1 trauma (TEI)		98.4			100.0
Natural Disaster		16.5			27.3
Serious Accident/Injury		40.0			56.4
Sudden Life-threatening Illness		11.1			16.4
Military Combat		0.5			0.0
Witnessed Close Friend/Family Member Murdered		10.4			7.3
Attacked with a Weapon by SO		14.4			23.6
Attacked w/out a Weapon by SO		32.8			43.6
Attacked with a Weapon by non-SO		18.7			21.8
Attacked w/out a Weapon by non-SO		23.8			21.8
Witnessed Family Member Attacked with Weapon		25.4			32.7
Witnessed Non-family Member Attacked with Weapon		24.6			16.4
Witnessed Family Member Attacked w/out Weapon		31.3			30.9
Witnessed Non-family Member Attacked w/out a Weapon		29.1			30.9
Witnessed Violence between Caregivers		29.9			41.8
Physical Abuse		15.7			20.0
Emotional Abuse		27.5			30.9
Sexual Abuse < age 18		32.2			36.4
Sexual Assault (age 18+)†		7.6			10.9

Note: TEI=Traumatic Events Inventory; CTQ=Childhood Trauma Questionnaire; mPSS=modified PTSD Symptom Scale; BDI-II=Beck Depression Inventory, II; SO=significant other.

^†with physical force

The Modified Posttraumatic Stress Disorder Symptom Scale (mPSS; Coffey, Dansky, Falsetti, Saladin, & Brady, 1998) is a reliable and well-validated 18-item self-report measure, that was used to assess PTSD symptoms based on DSM-IV-TR (American Psychiatric Association, 2000) criteria. Internal consistency of this measure in the current study was high, α = 0.91. The presence/absence of a probable PTSD diagnosis was determined based on if participants met for at least 1 re-experiencing symptom, 3 avoidance and/or numbing symptoms, 2 hyperarousal symptoms, and if the duration of symptoms was greater than one month.

The Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) is a reliable and well validated 21-item self-report measure used to assess depressive symptoms. Internal consistency of this measure in the current study was high, α = 0.92. Depression severity scores were coded as follows: none or minimal depression = 0–13, mild depression = 14–19, moderate depression = 20–28, and severe depression = 29–63 based on previously identified cutoffs (Beck et al., 1996). In the present study, presence/absence of probable depression included moderate-or-severe levels of depressive symptoms.

As part of the Demographics Questionnaire, participants also were asked yes/no questions regarding if they had ever been in treatment for 1) PTSD or 2) depression.

The Clinician-Administered PTSD Scale (CAPS; Blake et al., 1995) is an interviewer-administered psychometrically validated diagnostic instrument used to determine the presence/absence of a current PTSD diagnosis based on DSM criteria. Both CAPS for DSM-IVTR (American Psychiatric Association, 2000; CAPS-IV) and DSM-5 (American Psychiatric Association, 2013; CAPS-5) were used in the present study due to switching when CAPS-5 was released; twenty percent (n=11) received the CAPS for DSM-IV-TR. Interrater reliability (IRR) within this sample has been examined previously and showed good IRR for current diagnosis of PTSD (k = 0.83) (Powers, Fani, Carter, Cross, & Bradley, 2017).

The MINI International Neuropsychiatric Interview (MINI; Sheehan et al., 1998) is a reliable and well-validated structured diagnostic interview that assesses mood, anxiety, substance use, and psychotic disorders based on DSM-IV-TR criteria. The MINI was used in the present study to determine the presence/absence of current and lifetime major depressive disorder (MDD) and the presence of lifetime PTSD. Specific reliability data on the MINI in this sample is not available. As part of the MINI, qualitative data regarding medical and psychiatric diagnoses given by physicians, medication use, and treatment history were obtained.

Data Analysis

All statistical analyses were conducted using SPSS Version 24.0 (Armonk, NY: IBM Corp.). First, descriptive statistics on all variables of interest were run and are included in Table 2. Prevalence rates of PTSD and depression were determined across each sample. Then, rates of behavioral health service utilization were analyzed in the overall sample and by relevant diagnosis. Data previously extracted from the medical chart on a subsample of study participants also were examined to determine percentage of participants identified by providers as having psychiatric disorders (n=358). Differences in rates of trauma, PTSD, depression, and treatment engagement by measures of SES (i.e., monthly household income, education) were also examined using Analysis of Variance (ANOVA) and Chi-Square Tests.

Results

Prevalence of trauma exposure, PTSD, and depression

Overall sample.

The current sample of women was highly traumatized, with 98% reporting exposure to at least one type of traumatic event; the average number of types of traumas reported was four. The most common types of traumas included experiencing a serious accident/injury, intimate partner violence with or without a weapon, and sexual violence. See Table 2 for full descriptive information on traumas and percentages of all trauma types queried.

As shown in Table 3, approximately 30% of the women met DSM-IV-TR criteria for a probable diagnosis of current PTSD based on the mPSS. Additionally, almost 30% met criteria for moderate or severe depression based on the BDI-II; that percentage jumped to 45% if including individuals with mild levels of depression. Seventeen percent met criteria for both a probable diagnosis of current PTSD and moderate or severe depression.

Table 3.

Psychiatric Diagnoses and Behavioral Health Service Utilization Percentages

Factor	Total sample	Chart Review	Subsample
	N	N	N
	633	358	55
Treatment	%	%	%
Any behavioral health treatment	19.4	15.4	29.1
Depression treatment	17.9	14.5	29.1
PTSD treatment	6.2	4.7	12.7
Psychiatric Diagnosis
Psychiatric disorder identified in medical chart during OB visit	-	15.4	-
Current PTSD (mPSS/CAPS)	29.5	28.2	32.7
Lifetime PTSD (MINI)	-	-	56.4
Current MDD (BDI-II/MINI)	27.8	26.5	27.3
Lifetime MDD (MINI)	-	-	50.9

Note: The total sample reflects women identified and interviewed in the OB/GYN clinic and the subsample reflects the women that engaged in a follow-up clinical assessment following eligibility for a separate study of intergenerational risk for trauma and PTSD in African American mothers and their children. CAPS = Clinical Administered PTSD Scale; mPSS = modified PTSD Symptom Scale; MINI = Mini International Neuropsychiatric Inventory; BDI-II = Beck Depression Inventory, II (BDI-II percentage includes moderate or severe depression symptoms).

^*n=358; - indicates no data available within the sample

Next, potential differences in rates of trauma exposure, PTSD, or depression based on SES were examined. There was a significant association between trauma exposure and education level (p<.001), such that individuals with greater than high school level education had the highest level of trauma exposure. There was also a significant association between moderate or severe depression and both education and income (p’s<.05), such that a greater percentage of individuals with less education and income endorsed depression. Additionally, there was a significant association between probable PTSD diagnosis and income (p<.01), such that a greater percentage of individuals with less income endorsed PTSD (see Supplemental Table 1).

Subsample with clinical assessment data.

Table 2 also shows descriptive information on traumas and self-reported PTSD and depressive symptoms in the subsample of women that completed a clinical assessment (n=55). Mean levels of overall trauma exposure and self-reported PTSD symptoms were significantly higher (p = 0.038 and p = 0.014, respectively) among these women in comparison to the overall sample. Self-reported depression levels were not significantly different between groups (p = 0.137). Rates of diagnosed psychiatric disorders were similar to that found with the overall sample; approximately one-third of the sample met criteria for current PTSD based on the CAPS and one-third met criteria for current MDD based on the MINI. As shown in Table 3, more than half of these women met criteria for lifetime PTSD and for lifetime MDD based on the MINI. Regarding comorbidity between PTSD and MDD, 16.4% met criteria for both current PTSD and current MDD; 43.6% met criteria for both lifetime PTSD and lifetime MDD.

Behavioral health treatment engagement

Overall sample.

Rates of behavioral health treatment engagement are shown in Table 3. Across all participants, treatment engagement for depression was endorsed at a higher rate than for PTSD (17.9% versus 6.2%). Of the women with a probable diagnosis of current PTSD, only 12.8% reported receiving treatment for PTSD. Of the women with moderate or severe levels of depression, 34.1% reported receiving treatment for depression.

Based on medical records in a subsample of these participants (n=358), 15% endorsed a past psychiatric diagnosis (prior to pregnancy) to the provider. Eighty-one percent of the women reported a depression diagnosis, 18% indicated a bipolar disorder diagnosis, and 2% indicated a schizoaffective disorder diagnosis. None of these women indicated a previous or current PTSD diagnosis based on the questions asked during their medical visit.

Associations between PTSD/depression treatment engagement and SES were also examined; no significant associations were found (see Supplemental Table 1).

Subsample with clinical assessment data.

During a detailed history of medical and psychiatric treatment at the follow up clinical visit for the 55 women that completed the clinical assessment, only one woman out of the 18 (5.5%) with current PTSD endorsed a medical diagnosis of PTSD and she was also the only woman who endorsed active engagement in psychiatric treatment at the time of the interview; 14.2% reported taking medication for comorbid depression (see below). Only four out of the 16 (25.0%) women with current MDD endorsed a medical diagnosis of MDD, 18.8% reported actively taking medication to treat depression and 18.8% reported current psychiatric treatment of some form.

Discussion

The current study advances our understanding of trauma exposure, psychiatric symptoms, and treatment utilization and the links among these in pregnant women by focusing on a unique and high-risk population. Specifically, the current study is the first to examine prevalence rates of trauma exposure, PTSD, and depression along with rates of accessing behavioral health services in African American pregnant women seeking services from an OB/GYN medical clinic serving primarily urban, low-income, minority individuals. The findings underscore the presence of high rates of trauma exposure and psychiatric symptoms in this population and highlight the notion that these environmental and behavioral health outcomes may account for an important component of inequity in health services and outcomes in low SES, African American populations. Virtually all of the women (>98%) were exposed to at least one traumatic event in their lifetime and the majority of them experienced multiple different types of traumatic events. The types of traumas experienced by these women were often chronic and interpersonal in nature, with intimate partner violence, sexual violence, and child abuse being some of the most common types of traumas. We also found high rates of current and lifetime perinatal PTSD and depression across both self-report and clinician administered measures. In fact, in the subsample with clinical assessment data, the rates of PTSD and depression were similar to that of the self-reported rates in the overall sample despite having higher levels of trauma and PTSD symptoms, suggesting that the self-report measures function quite well in this type of population and may even underestimate current symptoms. Importantly, we also found low rates of behavioral health service utilization. This was particularly true for PTSD, where the absence of information on PTSD diagnoses within medical charts of these women was apparent. These results highlight the necessity of systematic screening for trauma exposure and psychiatric symptoms among OB/GYN patients in high risk communities and better understanding of barriers to behavioral health care engagement along with the importance of easy access to culturally-responsive behavioral health care services, preferably that are integrated.

Some interesting patterns emerged when we examined the associations between trauma, PTSD, depression, and behavioral health care engagement with indicators of SES. Higher levels of trauma exposure was not specifically related to lower SES among these women; in fact, women with higher education had the highest number of traumas. However, SES was related to higher levels of PTSD and depression symptoms in this sample, which is consistent with research showing higher levels of depression in low SES women (Goyal, Gay, & Lee, 2010) and further highlights the increased risk for trauma-related psychiatric conditions in low SES African American women. We did not find an association between SES and reported engagement in behavioral health care suggesting that there may be additional barriers present for women with low SES in these settings despite greater levels of psychiatric symptoms.

Great strides have been made to bring awareness to perinatal depression and the benefits of universal screening and linkage to care across the United States (O’connor, Rossom, Henninger, Groom, & Burda, 2016; Wilkes, 2015). In fact, the American College of Obstetricians and Gynecologists recommends at least one screening for depression during the perinatal period for all women (ACOG Committee Opinion, 2018). Yet, African American women experience disparities in depression screening rates and linkage to care (Kato, Borsky, Zuvekas, Soni, & Ngo-Metzger, 2018), and this screening often occurs during the six week postpartum visit which may be an important missed opportunity to screen and link women to behavioral health care earlier (Bhat, Reed, & Unützer, 2017). Furthermore, despite these strides with perinatal depression generally, awareness of its relationship to prior trauma exposure, and the prevalence of trauma exposure and PTSD in pregnant women, particularly in at-risk minority populations, remains limited. The high rates of PTSD observed in this sample fit with previous work by our team showing that PTSD is underdiagnosed in the broader population of women and men and served by this urban hospital (Gillespie et al., 2009; Schwartz, Bradley, Sexton, Sherry, & Ressler, 2005). However, none of these diagnoses were noted by providers among the 358 women whose medical charts we reviewed suggesting a clear disconnect between medical record data and our observed screening rates. Additionally, the low rates of service utilization parallel other research demonstrating similar patterns in general (Tandon et al., 2012) and for PTSD (Seng et al., 2009) in OB/GYN patients.

Beyond potential challenges with screening for trauma and psychiatric symptoms in OB/GYN clinics, it is important to note the many barriers that exist in accessing care among women in at risk communities even when psychiatric symptoms are identified (Bhat et al., 2018). Some major barriers include lack of available behavioral health resources, stigma around seeking help, and lack of cultural consideration in care offered (Goodman, Dimidjian, & Williams, 2013; Kato et al., 2018; Lara-Cinisomo, Clark, & Wood, 2018). Additionally, many of these women are navigating the demands of pregnancy while confronting other chronic stressors, such as dangerous neighborhoods, lack of adequate and accessible transportation services or child care, poverty, as well as the historical context of racial discrimination and disadvantage (Thornton et al., 2016). Clearly identifying relevant barriers and findings ways to reduce such barriers in these at risk communities is essential as we move forward in trying to improve care for women.

Several study limitations are worth noting. First, pregnancy status of the women was based on self-report and it is possible that there were women included in the studies that misreported pregnancy. Additionally, given the cross-sectional nature of this study, we cannot determine how pregnancy status or stage of pregnancy status may have influenced active symptoms of PTSD and depression among these women. We limited the scope of our study to only include PTSD and depression, although other trauma-related disorder like substance use disorders may also be important to screen for and treat within this population. The subsample of women selected for clinical assessments was not representative of all pregnant woman in this population since the women had to have a child in the age range of 8–12 to participate in the subsequent study; this could have biased the results of our clinical findings in this subset, although it is important to note that the rates across the full sample and subsample were similar and no major differences in demographics between the groups were identified. Finally, while we were able to evaluate medical chart data on a subgroup of women enrolled in the study, much of our data on behavioral health service utilization is based on self-report and does not include detail regarding the type of behavioral health treatment received. Interestingly, reported rates of engagement in behavioral health services differed depending on the way the questions were asked (self-report yes/no questions versus open ended) and yes/no questions appeared to bring higher positive responses than open ended questions; for example, although some women endorsed prior treatment for depression or PTSD on a yes/no question, in follow-up open ended questions, some would elaborate that they had not been diagnosed with MDD or PTSD making it hard to determine the nature of treatment. These differences and the limitations of self-report of service utilization highlight the need to carefully consider how one is screening for previous linkage to care as we move forward in our efforts to improve identification, reduce barriers, and increase access to behavioral health care.

Despite the aforementioned limitations, it is evident from our findings that there is a need for screening of trauma and PTSD, greater awareness of the role trauma may have in perinatal depression, and linkage to trauma-informed care among pregnant women in at risk communities. This is especially true given that pregnancy influences the presentation of PTSD symptoms and related fear psychophysiology (Michopoulos et al., 2015; Seng et al., 2010) and stress exposure during gestation increases risk for adverse birth outcomes (e.g., preterm delivery) (Kertes et al., 2016; Koen et al., 2016; Seckl, 2004). African American women are at greater risk for preterm delivery (Sealy-Jefferson et al., 2016) and identifying and addressing potential contributing factors, such as trauma and psychiatric symptoms is vital. The devastating effects of PTSD on women and the potential intergenerational transmission of risk to their children makes screening for trauma and perinatal PTSD and depression an essential component of standard care for OB/GYN clinics in these settings moving forward. Further, while there is mounting evidence in support of the value of integrated care in primary care settings (Coventry et al., 2015; Machtinger, Cuca, Khanna, Rose, & Kimberg, 2015; Organization, 2008), this has not been as much of a focus in OB/GYN settings. Evidence supports integrating behavioral health care into OB/GYN settings for treating depression (Bhat et al., 2018; LaRocco-Cockburn et al., 2013; Poleshuck & Woods, 2014; Terrazas, Segre, & Wolfe, 2018), and using this approach to also integrate trauma-informed behavioral health care interventions into OB/GYN clinics serving at risk communities for trauma exposure, depression, and PTSD could be essential in closing the gaps in linkage to trauma-informed care among these women.

Clinical Impact Statement.

The current study highlights the high rates of chronic trauma exposure, PTSD, and depression based on self-report measures among pregnant African American women served in an OB/GYN clinic within a public urban hospital. Identification of PTSD in particular among providers and engagement in care among these women was limited and demonstrates the need for improved screening for trauma and PTSD, more accessible culturally-responsive trauma-informed care, and better identification of potential barriers to such care for pregnant women within these at risk communities.

Appendix. Data Transparency Narrative Description

The data reported in this manuscript were collected as part of a larger data collection. The specifics of this dataset including only pregnant women recruited from the OB/GYN clinics at an urban hospital have been previously published by colleagues (MS1); this manuscript focused on psychophysiological profiles of pregnant women with and without PTSD and compared PTSD symptom profiles (based on self-report) in pregnant and non-pregnant women recruited from the OB/GYN clinic. The present submitted manuscript focuses on overall rates of trauma, PTSD, depression, and treatment utilization across both self-report and clinician-administered measures and only includes pregnant women. The present submitted manuscript also includes a chart review of a subsample of the pregnant women and their indication of prior treatment for a psychiatric disorder.