Associations between state-level abortion restrictions and postpartum depression symptoms from a United States nationwide cohort.

Background: U.S. maternal mortality rates have more than doubled over the last two decades, with maternal mental health conditions being significant contributors. Concurrently, the adoption of U.S. state-level restrictions on abortion access have also increased. We aimed to examine the association between the number of state-level abortion restrictions and postpartum depression symptoms in a U.S. nationwide cohort. Methods: This retrospective cohort study compared state-level abortion restriction policy data from the Guttmacher Institute from each preceding year (2016-2021) to rates of postpartum depression symptoms collected from the nationally representative Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 8 (2017-2022) dataset. PRAMS participants were randomly selected from 41 participating states' birth registries, representing 30·4% of U.S. live births. The primary outcome was postpartum depression symptoms, assessed using validated screening questions. Secondary outcomes included demographic and clinical predictors of postpartum depression. Variables found to be significant on bivariate analysis were included in the logistic multivariable model. People with lived experience were involved in the design, analysis, and interpretation of this study. Findings: The sample included 201,770 respondents, weighted to represent 5·65 million individuals. The mean age was 29·7 years, with 72·6% identifying as White and 57·9% having private insurance. Higher numbers of state-level abortion restrictions were associated with increased odds of postpartum depression symptoms (OR = 1·02, 95% CI [1·01, 1·03], p = 0·001), particularly among those relying on public insurance (OR = 1·02, 95% CI [1·01-1·04], p = 0·002). This association was particularly pronounced among racial and ethnic minorities, individuals with a history of depression, and those with lower levels of education or income who gave birth in high-restriction states. Interpretation: The adoption of more abortion restrictions is linked to higher prevalence of postpartum depression symptoms, especially for those with public insurance. These findings show that restricted abortion has detrimental effects on perinatal mental health, highlighting the need for policy reforms. Funding: No funding was provided for this study, funding from Brigham and Women's Hospital, Mary Horrigan Connors Center for Women's Health Research was provided for journal editorial processing fees.