Highlights
The 9% Increase
Individuals in the lowest socioeconomic status (SES) tercile residing in states with abortion trigger laws experienced a 9.0% relative increase in postpartum depression (PPD) diagnoses following the Dobbs decision compared to their counterparts in non-trigger states.
Socioeconomic Divergence
No significant association between abortion bans and PPD incidence was observed among individuals in middle or high SES groups, suggesting that financial and social resources may buffer the psychological impact of restricted reproductive access.
Demographic Disparities
States with trigger laws had higher concentrations of rural residents (22.3%) and low-SES populations (42.6%) compared to non-trigger states, creating a compounded vulnerability for maternal mental health.
Background: The Landscape of Reproductive Healthcare Post-Dobbs
The 2022 US Supreme Court decision in Dobbs v Jackson Women’s Health Organization fundamentally altered the landscape of reproductive healthcare in the United States. By overturning the federal right to abortion, the decision activated “trigger laws” or immediate bans in 22 states. While the legal and political debates have been exhaustive, the clinical community has remained deeply concerned about the secondary health consequences of these restrictions. Postpartum depression (PPD), a condition affecting approximately 1 in 8 women in the US, is a major contributor to maternal morbidity and mortality. Given that unplanned or unwanted pregnancies are known risk factors for PPD, the restriction of abortion access was hypothesized to exacerbate mental health risks, particularly for those with limited resources to navigate new legal barriers.
Study Design: A Difference-in-Differences Analysis of Medicaid Populations
To evaluate these impacts, researchers conducted a retrospective cohort study utilizing extensive Medicaid claims data from Kythera Labs, covering approximately 60% of the US Medicaid population. The study period spanned from January 2019 to December 2024, providing a robust window into both pre- and post-Dobbs environments. The study population included women and adolescents aged 12 to 55 years whose pregnancies resulted in live births or stillbirths. Participants were stratified into SES terciles based on zip code-level census data, allowing for a granular look at how financial stability influenced health outcomes. The primary exposure was residence in a state with an abortion trigger law enacted post-Dobbs. The researchers utilized a difference-in-differences (DD) methodological framework to isolate the effect of the legislative change from broader temporal trends in mental health diagnostics.
Key Findings: Divergent Mental Health Outcomes by Socioeconomic Status
The results of the study underscore a stark divide in how legislative changes affect different segments of the population. The cohort included 102,597 individuals in the pre-Dobbs era and 61,113 individuals post-Dobbs.
Statistical Significance in Low-SES Groups
Among the lowest SES group in trigger states, the data revealed a statistically significant increase in PPD diagnoses. The DD coefficient was 0.090 (95% CI, 0.035-0.146; P = .001), representing a 9% relative increase compared to low-SES women in states where abortion remained legal. This finding suggests that for those already facing economic hardship, the removal of reproductive autonomy serves as a potent stressor that manifests in clinical depression following delivery.
Stability in Middle and High SES Groups
In contrast, women in the middle and high SES terciles showed no significant change in PPD incidence post-Dobbs, regardless of whether they lived in a trigger state. This disparity suggests that individuals with more financial resources may be able to travel to other jurisdictions for care or have access to better social support systems that mitigate the psychological burden of restrictive laws.
Baseline State Disparities
Individuals in trigger states were found to be younger on average and more likely to reside in rural areas. Pre-Dobbs data showed that 42.57% of participants in trigger states were in the low-SES category, compared to only 24.91% in non-trigger states. Interestingly, women in trigger states were less likely to have documented obstetrical or maternal complications, yet they faced higher psychiatric risks post-delivery in the new legal environment.
The Socioeconomic Divide in Maternal Mental Health
From a clinical perspective, the 9% increase in PPD among low-SES populations is a critical signal. Low-SES individuals are more likely to rely on Medicaid, have less flexible employment, and lack the disposable income required for out-of-state travel. When an unintended pregnancy must be carried to term due to legal restrictions, the resulting economic and emotional strain is concentrated in these vulnerable households. The lack of a similar increase in higher SES groups reinforces the theory that the Dobbs decision did not impact all women equally, but rather intensified existing health inequities.
Expert Commentary: Clinical and Policy Implications
Medical experts and public health advocates suggest that these findings necessitate a shift in how postpartum care is delivered in restrictive states. Clinical practice must adapt by implementing more rigorous and frequent mental health screenings for Medicaid recipients. Policy interventions, such as the expansion of the postpartum Medicaid coverage period to 12 months, become even more vital in states where abortion is banned. Furthermore, the findings highlight the need for targeted funding for community-based mental health resources in rural and low-income zip codes.
Study Limitations
While the study is robust, limitations include the reliance on claims data, which only captures PPD cases that were officially diagnosed and billed. It is possible that the actual incidence of PPD is higher, as many low-SES individuals face barriers to accessing mental health care. Additionally, the study does not account for the availability of telehealth services or informal support networks that may vary by region.
Conclusion: Addressing the Vulnerability Gap
This cohort study provides compelling evidence that state-level abortion bans following the Dobbs decision are associated with a disproportionate increase in postpartum depression among the most economically vulnerable populations. As legislative landscapes continue to shift, the medical community must prioritize the mental health of those who bear the heaviest burden of these policies. Targeted support, improved access to psychiatric care, and comprehensive social services are essential to prevent a further widening of the maternal health gap in the United States.
References
1. Baser O, Sepulveda F, Lu Y, Endrizal A. Socioeconomic Status and Postpartum Depression Risk After the Dobbs v Jackson Women’s Health Organization Decision, Based on State Trigger Laws. JAMA Netw Open. 2026;9(2):e2557337.
2. American College of Obstetricians and Gynecologists (ACOG). Postpartum Mental Health Awareness and Access to Care. Clinical Practice Guideline No. 825.
3. Guyer B, et al. The Role of Medicaid in Maternal and Child Health. Annual Review of Public Health. 2024;45:321-340.
