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OBJECTIVE

To examine the trajectory and risk factors of depression symptoms among parents from NICU admission to 30 days postdischarge. We hypothesized depression symptom scores would decrease from admission and then increase from discharge to 30 days.

METHODS

Prospective longitudinal cohort study of premature infants in NICU. Parents completed the validated Edinburgh Postnatal Depression Scale (EPDS) at 4 time points: NICU admission, discharge, and 14 days and 30 days postdischarge. EPDS score change across time and probability of a positive screen (EPDS ≥10) were by assessed using mixed effect regression models.

RESULTS

Of 431 parents enrolled (mothers, n = 230 [53%]), 33% of mothers (n = 57) and 17% of fathers (n = 21) had a positive EPDS screening. Score change was 1.9 points different between mothers and fathers (confidence interval [CI]: 1.3–2.6; P < .0001), with mothers decreasing 2.9 points (CI: 2.1–3.7; P < .0001) and fathers decreasing 1.0 points (CI: 0.1–2.0; P = .04). Over time, mothers decreased 10.96 times (CI: 2.99–38.20; P = .0003); fathers decreased at a nonsignificant rate. Admission or discharge screening improved 30-day depressive symptom prediction (AUC 0.66 baseline demographics only versus 0.84+initial [P < .0001], and versus 0.80+discharge screening [P < .001]).

CONCLUSIONS

Mothers and fathers experience different depressive symptom trajectories from NICU to home. Screening parents for postpartum depression during the NICU stay is likely to result in improved identification of parents at risk for postpartum depression after discharge. Focused attention on fathers appears warranted.

What’s Known on This Subject:

Parents with premature infants face an increased risk of poor emotional functioning, anxiety, and mood disorders, which can alter parenting and child outcomes. The trajectory of maternal and paternal depressive symptoms from NICU to home is not well understood.

In this prospective longitudinal cohort study of 431 mothers and fathers, 33% of mothers and 17% of fathers screened positive for depressive symptoms initially. The probability of reporting depressive symptoms decreased significantly for mothers but not for fathers once home.

The NICU can be challenging for parents to navigate with their medically vulnerable infants. Parents of NICU infants may be predisposed to poor emotional functioning, anxiety, and mood disorders.1  “Pervasive uncertainty” was the phrase researchers of 1 qualitative study used to describe parents’ feelings from NICU discharge from the hospital.2  Whereas postpartum depression (PPD) is one of the most common complications of childbirth among mothers in general,3,4  parents in the NICU may have higher risks related to their infants’ medical vulnerability or the stress of a NICU stay.5  Mothers of premature infants PPD risk (28% to 40%)6  is nearly double that of mothers of term infants, with rates typically decreasing over time yet remaining higher in the infant’s first year.79  Paternal PPD has received less attention10,11  despite a prevalence of 5% to 13% among fathers of term infants.9,1214  Paternal PPD among fathers with premature infants is less studied,15  with researchers in recent literature concluding that paternal PPD among the premature population is 2% to 19% higher than the rate among fathers of term infants in immediate postnatal period.9  Stress, self-reported and measured physiologically via salivary cortisol, is noted to increase as fathers transition with their infants from the NICU to home and may become a risk for increased depression.16,17  Although this research provides insight into the time-dependent risk of parental PPD, researchers in few studies have examined the trajectory of depression among large numbers of both parents through key clinical transition periods such as NICU admission, discharge, and at home.

The importance of examining parental mental health is highlighted by its connection to childhood developmental outcomes. A 2019 American Academy of Pediatrics technical report conveyed the extensive evidence that adverse childhood experiences, such as parental depression, may have long-lasting impacts on a child’s development and general health.3  In fact, maternal PPD and psychological distress is likely to increase a child’s risk for delayed or impaired cognitive, emotional, and linguistic development as well as subsequent behavioral problems.4,18  More recent research reveals that paternal PPD detrimentally influences parenting and positive enrichment activities such as reading and telling stories.19,20  Paternal PPD has also been associated with subsequent child behavioral and emotional problems,21  with authors in 1 study reporting depressed fathers are more likely to spank their 1-year-old children.20  Even while evidence supports the linkage between parental mental health, childhood development, and the emotionally taxing NICU environment, the trajectory of maternal and paternal depression symptoms from NICU admissions through the transition home is not well understood.

Although experiences from NICU admission through discharge can adversely impact the emotional health of parents, the NICU is one of the few health care environments where integrated care is possible.22  Awareness in the NICU could provide better preventive management for families and a springboard from which primary care physicians can further assess emotional risk factors during follow-up visits. Fundamental to this heightened understanding is knowing when to screen NICU families and what other social and clinical factors to consider when evaluating parents’ likelihood of developing depression symptoms.

Therefore, our purpose with this study is to examine the trajectory of depression symptoms among mothers and fathers at several time points from NICU admission to 30 days after NICU discharge using the validated Edinburgh Postnatal Depression Scale (EPDS). We hypothesized that from birth to discharge, depression symptom scores would decrease as the infant stabilized in the NICU and subsequently increase from discharge to 30 days at home for mothers and fathers, perhaps in response to the stress and additional responsibility parents take on as they assume full care for their infants once home. Furthermore, we examined the association of key social and clinical factors with depression scores up to 30 days postdischarge to assess the role these factors have in the predictability of being at risk for depression symptoms.

This prospective longitudinal cohort study analysis collected data from April 2019 through February 2020 in a quasi-experimental control-intervention smartphone application trial designed to support parents of NICU infants. Because no relevant sociodemographic or outcome differences as a function of the study design were found, intervention and control parents are combined in the current study. Additionally, intervention status was included as a covariate in all analyses to account for potential variance in outcome due to intervention; none were noted. The research protocol was approved by Northwestern University’s Institutional Review Board and registered at Clinical Trials as https://clinicaltrials.gov/ct2/show/NCT03505424 .

Fathers and mothers of premature infants (<37 weeks’ gestational age [GA]) admitted to the NICU (NICU parents) at Prentice Woman’s Hospital, Chicago, Illinois, were eligible for participation in this study (separately or together, regardless of marital status) if they were legal adults, English-speaking, and expected to stay a minimum of a week and if the medical team did not identify causes for exclusion (eg eminent death, child protective services involvement). Parents were excluded from analysis if they did not complete at least 1 parental depression questionnaire across the 4 study time points. Parents lacking an initial or discharge depression questionnaire score and a depression questionnaire score at 30 days postdischarge were excluded from the prediction analyses.

After written informed consent was obtained on NICU admission, parent and infant demographics were collected by chart review and parental survey. Approximately 1 week after admissions, a standardized parental depression symptom questionnaire was given to parents (initial assessment). The same measure was administered at 3 additional time points: at NICU discharge (mean within 2 days of discharge [SD = 6]), 2 weeks after NICU discharge, and 30 days after discharge. All questionnaires were requested to be completed independently by each parent.

Depression symptoms were measured by using the EPDS.23  The EPDS is a self-report questionnaire designed to screen for depression among women during the postnatal period. The scale has also been used reliably with fathers24  and parents of preterm infants25  in the postpartum. Although a cutoff score of ≥13 has been used to dichotomously signify a positive screen for major depression, research has validated that a score of 10 or higher has better sensitivity for major or minor depression23,26  and is useful for screening. Thus, a cutoff score of 10 was considered a positive EPDS screening result.

In addition to standard demographic variables, social (ie marital status, education, employment status, and income) and clinical (ie infant GA, length of stay [LOS], and birth weight) variables were also collected. Race was categorized as white, Black, Hispanic, or other; marital status was dichotomized as “married” and “not married”; education was dichotomized as “less than college” or “college degree and higher”; household income was dichotomized at $100 000 annually. GA was categorized into 3 groups: <28 weeks’, 28.0 to 32.6 weeks’, and >32 weeks’ GA. Demographic characteristics of the sample were summarized by using means (SDs) or medians (ranges) for continuous variables and frequencies (percentages) for categorical variables. Mean EPDS score and frequency of positive EPDS screen was summarized across all time points for the sample as a whole and individually by sex. The percentage of patients with continuing depression was calculated for the sample as a whole and separately by parent sex. We used a series of mixed effects liner regression models to assess the change in EPDS score across time. A random family effect was included in the model to account for covariance in mother’s and father’s responses. To determine if trends in EPDS scores across time differed by parent sex and GA, we included the effect of parent sex, GA, the interactions of time × parent sex and time × GA, and the 3-way interaction of time × parent sex × GA. Final models were adjusted for additional covariates believed to be associated with the outcome (parent age, race, marital status, education, employment status, household income, and LOS). Additionally, intervention status was included as a covariate in all analyses to adjust for any variation in outcome caused by the intervention. Model results are reported as β estimates of the effect of each factor on the outcome of EPDS score, independent of each other factor, and model-based estimates of EPDS score at each time point were calculated for graphical display. To assess change in probability of a positive EPDS screening across time, we repeated the above analyses using a series of mixed effect logistic regression models, including a random effect for family, the above listed interactions, and fully adjusting for covariates. Model results are reported as odds ratio of the effect of each factor on the dichotomous EPDS outcome, and estimates at each time point were calculated and transformed into odds of a positive screen to be displayed graphically. Results reported are from the fully adjusted models. To assess the ability of depression screening while in the NICU to predict a positive screen at 30 days after discharge, we completed 3 simple logistic regression models: model 1 modeled the effect of baseline demographic characteristics (parent age, sex, race, marital status, education, employment status, household income, and GA) on the dichotomous outcome of positive EPDS screening (ie, EPDS ≥ 10) at 30 days after discharge; model 2 added the effect of the initial EPDS screening to model 1; and model 3 added the effect of screening at discharge to model 1. Each subject’s predicted outcome based on each model was compared with the subject’s actual outcome. Receiver operating characteristic curves (ROCs) were generated, and area under the curve (AUC) was calculated. AUC comparisons of models including previous EPDS score (models 2 and 3) were compared with those of the original model (model 1) by using χ2 tests.27 These analyses were repeated, stratifying by sex, to determine if classification differed between mothers and fathers. A total of 431 parents were enrolled at baseline (mothers, n = 230 [53%]; fathers, n = 201 [47%]). Of these parents, 75% of mothers (n = 171) and 57% of fathers (n = 113) completed their discharge + 30 days follow-up EPDS screening; Table 1 reveals sample demographic characteristics. Of note, average infant GA was 31.5 weeks with median LOS 26 days (range: 4–144 days). At the initial EPDS assessment shortly after NICU admission, 33% of mothers (n = 57) and 17% of fathers (n = 21) had a positive EPDS screening result, with average scores of 8 for mothers and 6 for fathers (range: 0–21). TABLE 1 Demographic Characteristics of Families and Infants CharacteristicOverall (n = 431)aFemale (n = 230)aMale (n = 201)a Family Married, No. (%) 348 (82) 179 (79) 169 (86) College degree, No. (%) 319 (75) 172 (76) 147 (74) Household income of$100 000 or more, No. (%) 305 (73) 152 (68) 153 (78)
Parent age, mean (SD), y 34.0 (5.6) 33.0 (5.1) 35.1 (5.9)
Employment, No. (%)
Full-time 337 (80) 154 (68) 183 (94)
Not full-time 82 (20) 71 (32) 11 (6)
Race, No. (%)
White 251 (59) 123 (54) 128 (64)
Black 72 (17) 40 (18) 32 (16)
Hispanic 54 (13) 37 (16) 17 (9)
Other 49 (12) 27 (12) 22 (11)
Infant 336a — —
GA, mean (SD), w 31.5 (4.5) — —
GA category, No. (%), wk
<28 41 (10) — —
28–32.6 154 (36) — —
>32 236 (55) — —
Birth wt, mean (SD), g 1872 (788) — —
LOS, median (range), d 26 (4 to 144) — —
CharacteristicOverall (n = 431)aFemale (n = 230)aMale (n = 201)a
Family
Married, No. (%) 348 (82) 179 (79) 169 (86)
College degree, No. (%) 319 (75) 172 (76) 147 (74)
Household income of $100 000 or more, No. (%) 305 (73) 152 (68) 153 (78) Parent age, mean (SD), y 34.0 (5.6) 33.0 (5.1) 35.1 (5.9) Employment, No. (%) Full-time 337 (80) 154 (68) 183 (94) Not full-time 82 (20) 71 (32) 11 (6) Race, No. (%) White 251 (59) 123 (54) 128 (64) Black 72 (17) 40 (18) 32 (16) Hispanic 54 (13) 37 (16) 17 (9) Other 49 (12) 27 (12) 22 (11) Infant 336a — — GA, mean (SD), w 31.5 (4.5) — — GA category, No. (%), wk <28 41 (10) — — 28–32.6 154 (36) — — >32 236 (55) — — Birth wt, mean (SD), g 1872 (788) — — LOS, median (range), d 26 (4 to 144) — — —, not applicable. a Totals may not equal 100% because of missing data or rounding. Table 2 reveals the model-based estimates of effects on EPDS score, and Table 3 reveals the model-based odds ratios (that is, odds of a positive EPDS screen) for each effect. Figure 1 reveals the average EPDS score and the odds of a positive screen across all time points on the basis of these fully adjusted regression models. Change in score is represented by a solid line and change in odds by a dotted line for mothers (circles) and fathers (triangles). FIGURE 1 Total score and odds of a positive EPDS score over time. FIGURE 1 Total score and odds of a positive EPDS score over time. Close modal TABLE 2 Linear Regression Results for EPDS Score Model EffectEPDS Outcome Model Effect (β)95% CI Time −0.59*** (−0.89 to −0.30) Male sex −2.22*** (−3.31 to −1.12) GA (reference: 32+ wk) <28 wk 1.69 (−1.74 to 5.11) 28.0–32.6 wk 1.18 (−0.20 to 2.56) Time × sex interaction 0.49** (0.15 to 0.83) Time × GA interaction <28 wk −0.78* (−1.42 to −0.13) 28.0–32.6 wk −0.51** (−0.85 to −0.17) Time × sex × GA interaction <28 wk 0.25 (−0.62 to 1.12) 28.0–32.6 wk 0.43 (−0.03 to 0.89) Intervention group −1.19* (−2.33 to −0.04) Time × group interaction 0.02 (−0.27 to 0.32) Race (reference: white) Black −1.18 (−2.59 to 0.24) Hispanic −0.33 (−1.81 to 1.14) Other 0.91 (−0.41 to 2.23) Married −0.49 (−1.81 to 0.84) Greater than HS education 1.51* (0.20 to 2.81) Full−time employed 1.13 (−0.02 to 2.28) Household income >$100 000 −0.54 (−1.84 to 0.76)
LOS 0.01 (−0.02 to 0.05)
EffectEPDS Outcome Model
Effect (β)95% CI
Time −0.59*** (−0.89 to −0.30)
Male sex −2.22*** (−3.31 to −1.12)
GA (reference: 32+ wk)
<28 wk 1.69 (−1.74 to 5.11)
28.0–32.6 wk 1.18 (−0.20 to 2.56)
Time × sex interaction 0.49** (0.15 to 0.83)
Time × GA interaction
<28 wk −0.78* (−1.42 to −0.13)
28.0–32.6 wk −0.51** (−0.85 to −0.17)
Time × sex × GA interaction
<28 wk 0.25 (−0.62 to 1.12)
28.0–32.6 wk 0.43 (−0.03 to 0.89)
Intervention group −1.19* (−2.33 to −0.04)
Time × group interaction 0.02 (−0.27 to 0.32)
Race (reference: white)
Black −1.18 (−2.59 to 0.24)
Hispanic −0.33 (−1.81 to 1.14)
Other 0.91 (−0.41 to 2.23)
Married −0.49 (−1.81 to 0.84)
Greater than HS education 1.51* (0.20 to 2.81)
Full−time employed 1.13 (−0.02 to 2.28)
Household income >$100 000 −0.54 (−1.84 to 0.76) LOS 0.01 (−0.02 to 0.05) HS, high school. * P < .05. ** P < .005. *** P < .0001. TABLE 3 Logistic Regression Results for EPDS Dichotomous Outcome Model EffectsDichotomous Outcome Model Odds Ratio95% CI Time 0.67* (0.44–1.01) Male sex 0.09** (0.02–0.36) GA (reference: 32+ wk) <28 wk 13.20 (0.35 494.72) 28.0–32.6 wk 7.61* (1.52–37.83) Time × sex interaction 1.99* (1.2–3.3) Time × GA interaction <28 wk 0.41 (0.16–1.05) 28.0-32.6 wk 0.54* (0.32–0.9) Time × sex × GA interaction <28 wk 1.58 (0.55–4.6) 28.0-32.6 wk 1.28 (0.72–2.29) Intervention group 0.23* (0.06–0.91) Time × group interaction 1.13 (0.73–1.73) Race (reference: white) Black 0.44 (0.09–2.06) Hispanic 0.52 (0.11–2.49) Other 1.54 (0.4–5.85) Married 0.46 (0.1–2.09) Greater than HS education 3.32 (0.81–13.63) Full-time employed 3.32 (1.03–10.75) Household income >$100 000 0.73 (0.19–2.83)
LOS 1.01 (0.98–1.04)
EffectsDichotomous Outcome Model
Odds Ratio95% CI
Time 0.67* (0.44–1.01)
Male sex 0.09** (0.02–0.36)
GA (reference: 32+ wk)
<28 wk 13.20 (0.35 494.72)
28.0–32.6 wk 7.61* (1.52–37.83)
Time × sex interaction 1.99* (1.2–3.3)
Time × GA interaction
<28 wk 0.41 (0.16–1.05)
28.0-32.6 wk 0.54* (0.32–0.9)
Time × sex × GA interaction
<28 wk 1.58 (0.55–4.6)
28.0-32.6 wk 1.28 (0.72–2.29)
Intervention group 0.23* (0.06–0.91)
Time × group interaction 1.13 (0.73–1.73)
Race (reference: white)
Black 0.44 (0.09–2.06)
Hispanic 0.52 (0.11–2.49)
Other 1.54 (0.4–5.85)
Married 0.46 (0.1–2.09)
Greater than HS education 3.32 (0.81–13.63)
Full-time employed 3.32 (1.03–10.75)
Household income >\$100 000 0.73 (0.19–2.83)
LOS 1.01 (0.98–1.04)

HS, high school.

*

P < .05.

**

P < .005.

In the model of EPDS score across time, the interaction of time × sex and time × GA were both significant (P < .005 and P < .05, respectively), indicating that the trend across time differs by sex and GA (Table 2). Average change from the initial assessment to the final assessment (30 days after discharge) was significantly different between mothers and fathers, with mothers decreasing 2.9 points (confidence interval [CI]: 2.1–3.7; P < .0001) and fathers decreasing 1.0 points (CI: 0.1–2.0; P = .04). The 3-way interaction of time × sex × GA was not significant (P = .19).

Figure 1 also reveals the odds of a positive EPDS screen across time. At the initial assessment soon after NICU admission, mothers were 3.23 (CI: 0.65–16.03; P = .15) times more likely to have a positive screen than fathers, although this result was not statistically significant. The odds of reporting depressive symptoms at the initial assessment was 10.96 times higher (CI: 2.99–38.20; P = .0003) at the initial assessment compared with 30 days postdischarge for mothers; however, fathers’ odds did not change significantly during this time period (0.99 times [CI: 0.26–3.79], P = .9854). The trend across time is statistically significantly different between mothers and fathers (P = .0077), and this effect was not moderated by GA (P = .5548) (Table 3).

Figure 2 reveals the 3 ROC curves obtained from each of the models predicting positive depressive symptom screening at discharge + 30 for the full sample. The AUC for the demographics-only model (model 1) was 0.66 (CI: 0.57–0.74) (0.71 [CI: 0.58–0.82] for mothers, 0.61 [CI: 0.47–0.76] for fathers), suggesting demographic characteristics alone are poor predictors. However, with the addition of EPDS score at either the initial assessment (model 2) or discharge (model 3), the AUC increases to 0.84 (CI: 0.77–0.91, P < .0001) (0.84 [CI: 0.74–0.94], P = .004 for mothers; 0.82 [CI: 0.71–0.94], P = .0035 for fathers) and 0.80 (CI: 0.73–0.88, P = .0003) (0.80 [CI: 0.70–0.91], P = .0132 for mothers; 0.82 [CI: 0.71–0.93], P = .0165 for fathers), respectively. Together, these results indicate that screening at NICU admission or discharge can increase the likelihood of identifying positive depression symptom screening at 30 days postdischarge. Although the rate of depression differs across mothers and fathers, the ability to predict depression at 30-days postdischarge is still increased by screening during the NICU stay regardless of sex.

FIGURE 2

ROCs for models predicting depressive symptoms 30 days after NICU discharge.

FIGURE 2

ROCs for models predicting depressive symptoms 30 days after NICU discharge.

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In one of the largest clinical studies to date examining PPD among mothers and fathers of premature infants over the course of their NICU stay, transition home, and first 30 days at home, we found unanticipated differences by sex. In regards to our hypotheses, mothers indeed experience both a decrease in average depression symptom scores and probability of screening positive for depression. However, our hypothesis in regard to fathers was not supported. Rather, in this sample, although fathers did have a small and significant decrease in EPDS scores from initial assessment to 1 month after discharge, the probability of a positive depression screen remained the same across time. In other words, whereas mothers showed improvement over time in their EPDS scores, fathers essentially stayed the same.

In our analyses of potential social and demographic predictors of depression screening, few variables were associated with a positive depression screening at any one point. Although this may be due to sample homogeneity, our evidence supports the notion that screening for depression during the NICU stay has an improved predictive value based on ROC curve dynamics at 30 days postdischarge.

The increased depression symptom scores reported by mothers early in the NICU admissions period is similar to other research measuring mothers of preterm infants’ depression symptoms shortly after birth6,9  and consistent with higher reports of maternal depression screening symptoms compared with fathers.9  Of note, authors of a metanalysis of 23 longitudinal studies reported a decrease in the severity of depression symptoms among all mothers, not just mothers of medically vulnerable infants, over time.28  Although the trajectory of depression screening symptoms among mothers in our study reveals lower reported average depression symptoms as time proceeds, other researchers show that the pattern of maternal PPD is not homogenous.28,29

Our study includes a large sample of NICU fathers during 2 key life course transitions: the transition into fathering a new child and the transition from NICU to home with that child. Previous researchers have found that the transition to fatherhood can be associated with as much as a 68% increase in depression screening symptoms (prematurity unspecified).30  Despite this, fathers in this study reported lower average depression symptom scores at 30 days postdischarge compared with the early NICU period, consistent with other research.9  However, similar to 1 study with a 2-month follow-up,31  the probability of a positive score remained comparable across the study period, and when compared with mothers, fathers showed less improvement over time. Other researchers examining rates of stress disorders among parents of NICU infants found that fathers meet the diagnostic criteria of the examined disorders at rates higher than mothers 4 months after their infants’ births,17  further highlighting the importance of closely examining post-NICU psychological pathologies among fathers.

Identifying NICU parents at risk for PPD remains a challenge in pediatrics despite recommendations from national organizations for screening of mothers and fathers.32,33  With the growing understanding of the importance of parental mental health on family and infant wellbeing, universal screening of parents along with training of NICU bedside staff to help communicate and potentially identify parents who are struggling is needed. Resources made available to those parents at any point during the NICU or home time frame can take the form of trained social work or mental health professionals embedded in the NICU to begin making referrals more available for outpatient support once the infant is discharged.

An important aspect of understanding the development of PPD among NICU mothers and fathers is understanding what clinical and social factors are predictive of later depression. Notably, previous researchers have found that elevated depression symptoms in fathers was associated with adverse social and relationship factors.34  Furthermore, an array of different biological and behavioral expressions of depression have been reported between men and women.35,36  Despite these sex differences, the demographic characteristics we included were not associated with a positive depression screening result at 30 days postdischarge; screening at admission or discharge was associated, emphasizing the need for screening.

A number of limitations are present in this study. Depression screening questionnaires were used without diagnostic interviews. However, EPDS has reasonable sensitivity and clinical applicability for identifying PPD. Furthermore, we are unable to predict how unpartnered parents may be impacted. Although LOS or GA were used as model proxies for the severity of infant’s clinical condition, the direct effect of infant condition on outcomes may be unaccounted for. Models were also not adjusted for known depression risk factors among parents like past mental health diagnosis, substance abuse, or other trauma because these data were not collected. Finally, this study period lasted until 30 days postdischarge; symptoms may vary after this time period.

Insight into when and which parents of NICU infants experience depression symptoms and what predictive factors of positive depression screening results allows clinicians and families to better anticipate parental mental health needs after NICU discharge. Clinicians must understand how different populations are at risk for PPD37  to ensure optimal child outcomes. Screening parents for PPD while their infant is in the NICU may be a key first step toward assisting both parents and, in the case of fathers in particular, becoming aware of potential postdischarge needs.

The authors acknowledge Friends of Prentice for a generous grant to conduct this research. The funders did not influence in any way the outcomes or reporting of the findings in this study.

Dr Garfield conceptualized and designed the study, coordinated and supervised data analysis, drafted the initial manuscript, reviewed and critically revised the manuscript, and approved the final manuscript as submitted; Dr Lee conceptualized and designed the study, conducted the initial analyses, reviewed and critically revised the manuscript, and approved the final manuscript as submitted; Mr Warner-Shifflett conducted the initial analyses, designed the data collection, reviewed and critically revised the manuscript, and approved the final manuscript as submitted; Ms Jackson coordinated and supervised data analysis, reviewed and critically revised the manuscript, and approved the final manuscript as submitted; Ms Christie made substantial contributions to conception and design, coordinated and supervised data analysis, reviewed and critically revised the manuscript, and approved the final manuscript as submitted; Dr Miller made substantial contributions to conception and design, reviewed and critically revised the manuscript, and approved the final manuscript as submitted; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

This trial has been registered at www.clinicaltrials.gov (identifier: NCT03505424)

FUNDING: All phases of this study were supported by Friends of Prentice. The funders did not influence in any way the outcomes or reporting of the findings in this study.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-051136.

AUC

area under the curve

EPDS

Edinburgh Postnatal Depression Scale

GA

gestational age

LA

length of stay

PPD

postpartum depression

ROC

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## Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.