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Karim S, Cai B, Merchant AT, Wilcox S, Zhao X, Alston K, Liu J. Antenatal depressive symptoms and adverse birth outcomes in healthy start participants: The modifying role of utilization of mental health services. Midwifery 2024; 132:103985. [PMID: 38581969 DOI: 10.1016/j.midw.2024.103985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE We examined the association between antenatal depressive symptoms and adverse birth outcomes in Midland Healthy Start (MHS) participants and determined whether receiving mental health services reduced the odds of adverse outcomes among those with elevated antenatal depressive symptoms. METHOD Data from a retrospective cohort of participants (N = 1,733) served by the MHS in South Carolina (2010-2019) were linked with their birth certificates. A score of ≥16 on the Center for Epidemiologic Studies Depression Scale was defined as elevated antenatal depressive symptoms. Services provided by MHS were categorized into: (1) receiving mental health services, (2) receiving other services, and (3) not receiving any services. Adverse birth outcomes included preterm birth, low birth weight, and small for gestational age. RESULTS Around 31 % had elevated antenatal depressive symptoms. The prevalences of preterm birth, low birthweight, and small for gestational age were 9.5 %, 9.1 %, and 14.6 %, respectively. No significant associations were observed between elevated depressive symptoms and adverse outcomes. Among women with elevated antenatal depressive symptoms, the odds for small for gestational age were lower in those who received mental health services (AOR 0.33, 95 % CI 0.15-0.72) or other services (AOR 0.34, 95 % CI 0.16-0.74) compared to those who did not receive any services. The odds for low birth weight (AOR 0.34, 95 % CI 0.13-0.93) were also lower in those who received mental health services. CONCLUSIONS Receiving screening and referral services for antenatal depression reduced the risks of having small for gestational age or low birth weight babies among MHS participants.
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Affiliation(s)
- Sabrina Karim
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Discovery I, Columbia, SC, 29208, USA
| | - Bo Cai
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Discovery I, Columbia, SC, 29208, USA
| | - Anwar T Merchant
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Discovery I, Columbia, SC, 29208, USA
| | - Sara Wilcox
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, 921 Assembly St, Columbia, SC 29208, USA
| | - Xingpei Zhao
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Discovery I, Columbia, SC, 29208, USA
| | | | - Jihong Liu
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene Street, Discovery I, Columbia, SC, 29208, USA.
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2
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M Hamid G, Maldonado L, Moriarty H, Deatrick JA. Social Determinants of Health in the Lives of Urban-Dwelling, Pregnant Puerto Rican Women and Families: Nursing Implications From a Secondary Narrative Analysis. JOURNAL OF FAMILY NURSING 2023; 29:59-73. [PMID: 36129198 DOI: 10.1177/10748407221121826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Urban-dwelling childbearing Puerto Rican women and families on the U.S. mainland face a myriad of social determinants that affect pregnancy and overall health outcomes. Historically, Puerto Ricans have poorest pregnancy outcomes of all Hispanic women. Acknowledgment of the cyclic, structural barriers faced by this patient population is essential to providing wholistic care. Here, we discuss family nursing implications derived from narrative analysis of a parent study that investigated ecological systems affecting 21 pregnant Puerto Rican women residing in an impoverished and crime-ridden neighborhood in Philadelphia. Content analysis of interviews revealed interwoven social determinants of health embedded in participant narratives. Furthermore, we present case vignettes based on integration of participant interviews that encapsulate the everyday experiences of these women and their families and provide clinicians with guidance and strategies for interacting with and advocating for this population.
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3
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Moore Simas TA, Leung K, Nuss E, Marieni M, Marcus B, Rosal MC, Chasan-Taber L. Factors Associated with Risk of Perinatal Depressive Symptoms Among Puerto Rican Women with Hyperglycemia. Matern Child Health J 2022; 26:1741-1751. [PMID: 35386031 DOI: 10.1007/s10995-022-03429-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Rates of perinatal depression and pregnancy hyperglycemia are higher in Hispanic women as compared to non-Hispanic white women. In turn, depressive symptoms may reduce a woman's ability to engage in lifestyle changes that could reduce their subsequent diabetes risk. METHODS We conducted a secondary analysis using data from Estudio Parto to evaluate sociodemographic, behavioral, psychosocial, and medical factors associated with perinatal depressive symptoms. Estudio Parto was a randomized controlled trial conducted in Western Massachusetts from 2013 to 17. Eligible participants had pregnancy hyperglycemia. The Edinburgh Postnatal Depression Scale (EPDS) was administered at 24-28 weeks gestation and at 6 weeks, 6 months, and 12 months postpartum. An EPDS cutpoint of 10 or greater defined the presence of depressive symptoms. RESULTS In this sample of Puerto Rican women with pregnancy hyperglycemia, 32% and 27% showed prenatal and postpartum depressive symptoms, respectively. Among participants, 35.5% were diagnosed with GDM, 44.3% with isolated hyperglycemia, and 20.2% with impaired glucose tolerance. In multivariable models, being unmarried (OR 3.87; 95% CI 1.51-9.94), prenatal substance use (smoking or alcohol consumption; OR 2.96; 95% CI 1.41-6.18), and maternal age (1.11 for each year; 95% CI 1.04-1.18) were associated with higher odds of prenatal depressive symptoms. None of the risk factors were associated with subsequent postpartum depression in adjusted analyses. CONCLUSIONS Identifying factors associated with prenatal and postpartum depression in Puerto Rican women with pregnancy hyperglycemia can inform targeted lifestyle interventions in this at-risk group, increase the likely adoption of healthy lifestyle behaviors, and thereby work to address health disparities. CLINICALTRIALS gov NCT01679210; date of registration 08/07/2012.
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Affiliation(s)
- Tiffany A Moore Simas
- Departments of Obstetrics & Gynecology, Pediatrics, Psychiatry and Population & Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Katherine Leung
- Department of Obstetrics & Gynecology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Emily Nuss
- Departments of Obstetrics & Gynecology, Pediatrics, Psychiatry and Population & Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Michelle Marieni
- Departments of Obstetrics & Gynecology, Pediatrics, Psychiatry and Population & Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Bess Marcus
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Milagros C Rosal
- Division of Preventive and Behavioral Medicine, Department of Population & Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Lisa Chasan-Taber
- Department of Biostatistics & Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, 401 Arnold House, 715 North Pleasant Street, Amherst, MA, 01003-9304, USA.
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4
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Simonovich SD, Nidey NL, Gavin AR, Piñeros-Leaño M, Hsieh WJ, Sbrilli MD, Ables-Torres LA, Huang H, Ryckman K, Tabb KM. Meta-Analysis Of Antenatal Depression And Adverse Birth Outcomes In US Populations, 2010-20. Health Aff (Millwood) 2021; 40:1560-1565. [PMID: 34606360 DOI: 10.1377/hlthaff.2021.00801] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Untreated depression presents a distinct set of risks for pregnancy complications. Past studies have connected antenatal depression with adverse birth outcomes. The purpose of this study was to conduct an updated systematic review and meta-analysis examining the relationship between depression during pregnancy and associated adverse birth outcomes in US populations during the period 2010-20. As a trend, disparities in adverse pregnancy outcomes and maternal morbidities for Black pregnant people compared with those for White pregnant people continue to rise. Addressing mental health conditions during pregnancy has the potential to ameliorate a large and excessive burden on adverse birth outcomes among childbearing people and their offspring. Policy solutions to encourage, mandate, and reimburse universal depression screening during pregnancy are warranted.
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Affiliation(s)
- Shannon D Simonovich
- Shannon D. Simonovich is an assistant professor in the School of Nursing, College of Science and Health, DePaul University, in Chicago, Illinois
| | - Nichole L Nidey
- Nichole L. Nidey is an assistant professor in the Division of Biostatistics and Epidemiology at Cincinnati Children's Hospital and the Department of Pediatrics, University of Cincinnati College of Medicine, in Cincinnati, Ohio
| | - Amelia R Gavin
- Amelia R. Gavin is an associate professor in the School of Social Work, University of Washington, in Seattle, Washington
| | - María Piñeros-Leaño
- María Piñeros-Leaño is an assistant professor in the School of Social Work, Boston College, in Boston, Massachusetts
| | - Wan-Jung Hsieh
- Wan-Jung Hsieh is a PhD student in the School of Social Work, University of Illinois at Urbana-Champaign, in Urbana, Illinois
| | - Marissa D Sbrilli
- Marissa D. Sbrilli is a PhD student in the Department of Psychology, University of Illinois at Urbana-Champaign
| | - Lauren A Ables-Torres
- Lauren A. Ables-Torres is an undergraduate student in the College of Science and Health, DePaul University
| | - Hsiang Huang
- Hsiang Huang is an assistant professor in the Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, in Cambridge, Massachusetts
| | - Kelli Ryckman
- Kelli Ryckman is a professor in the Department of Epidemiology, College of Public Health, University of Iowa, in Iowa City, Iowa
| | - Karen M Tabb
- Karen M. Tabb is an associate professor in the School of Social Work, University of Illinois at Urbana-Champaign
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Jahan N, Went TR, Sultan W, Sapkota A, Khurshid H, Qureshi IA, Alfonso M. Untreated Depression During Pregnancy and Its Effect on Pregnancy Outcomes: A Systematic Review. Cureus 2021; 13:e17251. [PMID: 34540477 PMCID: PMC8448270 DOI: 10.7759/cureus.17251] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 08/17/2021] [Indexed: 11/23/2022] Open
Abstract
Depression is characterized by sad, irritated, or empty moods, as well as somatic and cognitive changes such as loss of concentration, anhedonia, hopelessness, loss of appetite, sleep disturbances, and suicidal ideation, all of which have a negative impact on an individual's ability to function. Depression that occurs during pregnancy is known as antenatal depression. The occurrence of depression during pregnancy and afterward is quite high. Women having a history of depression before pregnancy have a high probability of getting depression during pregnancy again. The purpose of the study is to review the effect of untreated depression during pregnancy on maternal and neonatal outcomes. The primary outcomes of this review were the identification of studies showing the relationship between untreated depression during the pregnancy indicated by depression measures and any associated adverse birth outcomes; specifically, low birth weight, small for gestational age, preterm birth, postpartum depression, and infant neurodevelopmental outcome. We reviewed 20 population-based contemporary cohort studies with a range of populations from 54 to 194,494, all of them representing the population of gestational age located in multiple jurisdictions. It was found that maternal depression during pregnancy has a positive association with preterm birth, small for gestational age, stillbirth, low birth weight, and maternal morbidity including perinatal complications, increased operative delivery, and postpartum depression. To prevent these adverse outcomes, depression should be screened, monitored, and managed appropriately keeping risk-benefit in consideration.
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Affiliation(s)
- Nasrin Jahan
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Terry R Went
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Waleed Sultan
- Medicine, Beni Suef University Faculty of Medicine, Beni Suef, EGY.,Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Surgery, Halifax Health Medical Center, Daytona Beach, USA
| | - Alisha Sapkota
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Hajra Khurshid
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Israa A Qureshi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Michael Alfonso
- School of Medicine, Universidad del Rosario, Bogota, COL.,Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Pampaka D, Papatheodorou SI, AlSeaidan M, Al Wotayan R, Wright RJ, Buring JE, Dockery DW, Christophi CA. Antenatal depressive symptoms and adverse perinatal outcomes. BMC Pregnancy Childbirth 2021; 21:313. [PMID: 33879069 PMCID: PMC8059279 DOI: 10.1186/s12884-021-03783-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 04/08/2021] [Indexed: 11/22/2022] Open
Abstract
Background The association of antenatal depression with adverse pregnancy, birth, and postnatal outcomes has been an item of scientific interest over the last decades. However, the evidence that exists is controversial or limited. We previously found that one in five women in Kuwait experience antenatal depressive symptoms. Therefore, the aim of this study was to examine whether antenatal depressive symptoms are associated with preterm birth (PTB), small for gestational age (SGA), or large for gestational age (LGA) babies in this population. Methods This was a secondary analysis based on data collected in the Transgenerational Assessment of Children’s Environmental Risk (TRACER) Study that was conducted in Kuwait. Logistic regression analysis was used to examine whether antenatal depressive symptoms assessed using the Edinburgh Depression Scale (EDS) were associated with preterm birth, small for gestational age, and large for gestational age babies. Results A total of 1694 women had complete information about the outcomes of interest. Women with depressive symptoms in pregnancy had increased, albeit non-significant, odds of having PTB (OR = 1.41; 95%CI: 0.81, 2.45), SGA babies (OR = 1.26; 0.80, 1.98), or LGA babies (OR = 1.27; 0.90, 1.79). Antenatal depressive symptoms had similar increased odds for the three outcomes even after adjusting for several covariates though none of these reached statistical significance. Conclusions In the present study, the depressive symptoms in pregnancy did not predict adverse birth outcomes, such as PTB, SGA, and LGA, which adds to the currently non-conclusive literature. However, further research is needed to examine these associations, as the available evidence is quite limited.
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Affiliation(s)
- Despina Pampaka
- Cyprus International Institute for Environmental and Public Health, Cyprus University of Technology, 95 Eirinis Street, 3041, Limassol, Cyprus
| | | | | | | | - Rosalind J Wright
- Department of Pediatrics & Institute for Exposomic Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Julie E Buring
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Douglas W Dockery
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Costas A Christophi
- Cyprus International Institute for Environmental and Public Health, Cyprus University of Technology, 95 Eirinis Street, 3041, Limassol, Cyprus. .,Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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7
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Ecological Systems Affecting Urban Childbearing Puerto Rican Women in the City of Philadelphia. Matern Child Health J 2021; 25:929-937. [PMID: 33759042 DOI: 10.1007/s10995-021-03121-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The purpose of this study was to explore socio-ecological influences affecting the daily lives of urban, pregnant Puerto Rican women and factors negatively influencing their health seeking behaviors related to prenatal care. METHODS Qualitative, descriptive methods were used including individual interviews and focus groups to obtain maximum understanding of the women's lives. The interviews and focus groups were conducted using a semi-structured interview guide based on various components of the study's conceptual framework. Content analytic strategies included rigorous and systematic processes to increase trustworthiness: training, supervision, audits, electronic technologies, and ongoing input of the research team. RESULTS Factors on all levels of the study's conceptual framework compound the effects of stressors and restrictions on the lives of urban, childbearing Puerto Rican woman. The intersectionality of issues for Puerto Rican women can either mitigate or heighten the pressure on their daily lives. CONCLUSIONS This initial research sets the groundwork for further studies, such as narrative analysis, to better understand how to build appropriate and relevant interventions. Uncovering the women's stories gives them the opportunity to be a critical part of cross-sector partnerships towards the development of sustainable interventions.
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8
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Vanderkruik R, Gonsalves L, Kapustianyk G, Allen T, Say L. Mental health of adolescents associated with sexual and reproductive outcomes: a systematic review. Bull World Health Organ 2021; 99:359-373K. [PMID: 33958824 PMCID: PMC8061667 DOI: 10.2471/blt.20.254144] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 12/03/2020] [Accepted: 12/06/2020] [Indexed: 11/27/2022] Open
Abstract
Objective To systematically review the literature on the mental health of adolescents associated with sexual and reproductive outcomes, and compare the mental health outcomes with that of other age groups. Methods We searched seven databases for relevant peer-reviewed articles published between 1 January 2010 and 25 April 2019. Our inclusion criteria required that the study included age-disaggregated data on adolescents, and focused and assessed mental health outcomes associated with pregnancy or sexually transmitted infections. We extracted data on the specific health event, the mental health outcome and the method of measuring this, and comparisons with other age groups. Findings After initially screening 10 818 articles by title and abstract, we included 96 articles in our review. We observed that a wide-ranging prevalence of mental ill-health has been reported for adolescents. However, most studies of mental health during pregnancy did not identify an increased risk of depression or other mental disorders among adolescents compared with other age groups. In contrast, the majority of studies conducted during the postpartum period identified an increased risk of depression in adolescents compared with other age groups. Three studies reported on mental health outcomes following abortion, with varying results. We found no studies of the effect of sexually transmitted infections on mental health among adolescents. Conclusion We recommend that sexual and reproductive health services should be accessible to adolescents to address their needs and help to prevent any adverse mental health outcomes.
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Affiliation(s)
- Rachel Vanderkruik
- Massachusetts General Hospital, 185 Cambridge Street, Boston, MA 02114, United States of America
| | - Lianne Gonsalves
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Tomas Allen
- Department of Quality, Norms and Standards, World Health Organization, Geneva, Switzerland
| | - Lale Say
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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9
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Shenassa ED, Widemann LG, Hunt CD. Antepartum Depression and Preterm Birth: Pathophysiology, Epidemiology, and Disparities due to structural racism. Curr Psychiatry Rep 2021; 23:14. [PMID: 33630175 DOI: 10.1007/s11920-021-01223-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Informed by the evidence of links between physiology of stress and parturition, we review recent epidemiologic evidence (2015-2020) of antenatal depression as a risk factor for preterm birth (PTB). We also explain racial/ethnic disparities in depression and preterm birth as a consequence of structural racism. RECENT FINDINGS Epidemiologic evidence is consistent in linking antepartum depression with an elevated risk of PTB. Antidepressant usage has been linked with an elevated risk of PTB. However, recent evidence suggests that severity of depression is the underlying driver of the elevated risk attributed to antidepressant usage. The number of depressive symptoms, as a proxy for severity of maternal stress, may be a more informative predictor of PTB than criterion based predictors. Across various study designs, measurement modalities, and populations, antenatal depression predicts an elevated risk of delivering preterm. The physiology of stress provides a plausible explanation for this observation. Excessive stress-induced elevations in maternal and then fetal HPA hormones can alter maternal and fetal homeostasis and hasten the timing of parturition. Antenatal depression and exposure to structural racism are two stressors that can trigger the maternal stress response. Chronically elevated levels of stress hormones among women of color in the USA provide a likely physiologic explanation for Black-White disparities in the risk of PTB. Focusing on the number of depressive symptoms as the more informative predictor of PTB raises several questions. We consider these questions as well as directions for future research in the context of recent advances in the field.
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Affiliation(s)
- Edmond D Shenassa
- Maternal & Child Health Program, Department of Family Science; and Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland, College Park, MD, USA. .,Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA. .,Department of Epidemiology & Biostatistics, School of Medicine, University of Maryland, Baltimore, MD, USA.
| | - Lea G Widemann
- Maternal & Child Health Program, Department of Family Science; and Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland, College Park, MD, USA
| | - Cole D Hunt
- Maternal & Child Health Program, Department of Family Science; and Department of Epidemiology and Biostatistics, School of Public Health, University of Maryland, College Park, MD, USA
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10
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Montagnoli C, Zanconato G, Cinelli G, Tozzi AE, Bovo C, Bortolus R, Ruggeri S. Maternal mental health and reproductive outcomes: a scoping review of the current literature. Arch Gynecol Obstet 2020; 302:801-819. [PMID: 32671543 DOI: 10.1007/s00404-020-05685-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/04/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Current data show that maternal mental conditions affect about 10% of pregnant women worldwide. Assessing timing and patterns of mental health illness, therefore, is critical to ensure the wellbeing of the mother, the new-born and the whole family. The aim of this review is to summarize the latest evidence linking maternal mental disorders and adverse reproductive outcomes. METHODS Following the PRISMA guidelines for systematic reviews, a literature search was conducted to ascertain the possible impact of mental health conditions on reproductive outcomes before and during pregnancy. The comprehensive strategy included cohort studies, randomised controlled trials and literature reviews on women with Primary Maternal Mental Illness (PMMI) and Secondary Maternal Mental Illness (SMMI) considering periconceptional, obstetric and foetal-neonatal outcomes. PubMed, WoS, CINAHL and Google scholar were used for the search. Cross-referencing in bibliographies of the selected papers ensured wider study capture. RESULTS Evidence linking depressive disorders and infertility among PMMI is weak. Given this, women with prior mental conditions experience additional distress when undergoing fertility treatments. Primary mental disorders may also increase the risk of miscarriage and other pregnancy complications (e.g., gestational diabetes). For SMMI, there is more robust evidence correlating Preterm Birth (PTB) and Low Birth Weight (LBW) with common mental disorders which develop during pregnancy. CONCLUSION Prevention and management of maternal mental health diseases and minor mental conditions within the first 1000 days' timeframe, should have a place in the holistic approach to women going through reproductive decisions, infertility treatment and pregnancy.
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Affiliation(s)
- Caterina Montagnoli
- Department of the Hospital Management, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giovanni Zanconato
- Department of Surgery, Odonto-Stomatology and Maternal and Child Health, University of Verona, Verona, Italy
| | - Giulia Cinelli
- Predictive and Preventive Medicine Research Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
- School of Specialization in Food Science, University of Rome Tor Vergata, Rome, Italy
| | - Alberto Eugenio Tozzi
- Predictive and Preventive Medicine Research Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Chiara Bovo
- Department of the Hospital Management, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Renata Bortolus
- Directorate General for Preventive Health - Office 9, Ministry of Health, Rome, Italy
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11
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Backley S, Knee A, Pekow P, Markenson G, White KO, Schoen C, Chasan-Taber L. Prenatal Depression and Risk of Short Interpregnancy Interval in a Predominantly Puerto Rican Population. J Womens Health (Larchmt) 2020; 29:1410-1418. [PMID: 32471325 DOI: 10.1089/jwh.2019.8201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Background: Short interpregnancy interval (IPI) is associated with risk of adverse pregnancy outcomes; however, few studies have evaluated the role of depression as a risk factor for short IPI. Puerto Rican women in the United States experience disparities in adverse birth outcomes and have the highest birth rates. Methods: We analyzed the association between prenatal depressive symptoms and IPI in Proyecto Buena Salud, a prospective cohort of predominantly Puerto Rican women in Western Massachusetts (2006-2011). Depression was measured using the Edinburgh Postnatal Depression Scale (EPDS) in early, mid, and late pregnancy. We calculated follow-up time as the difference between the date of delivery of the index pregnancy and the last menstrual period of the subsequent pregnancy using medical records and billing data. We defined short IPI as ≤18 months. Results: Of 1262 eligible women, 35% (n = 440) had at least probable minor depression (EPDS scores ≥13) and 25% (n = 315) had probable major depression (EPDS scores ≥15). Participants were followed for a median of 3.7 years (interquartile range = 1.4-6.0 years) and 240 (20.6%) participants experienced a short IPI. After adjusting for risk factors, women with probable minor depression (adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] = 1.02-1.88) and probable major depression (aOR = 1.42, 95% CI = 1.02-1.97) during pregnancy had increased odds of short IPI. Conclusions: Prenatal depressive symptoms were common in this Puerto Rican population and were associated with a modest increase in odds of short IPI. Further examination of the pathways through which mental health may affect IPI in vulnerable populations is warranted.
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Affiliation(s)
- Sami Backley
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - Alex Knee
- Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - Penelope Pekow
- Department of Biostatistics and Epidemiology, School of Public Health & Health Sciences, University of Massachusetts, Amherst, Massachusetts, USA
| | - Glenn Markenson
- Department of Maternal-Fetal Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Katharine O White
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, Massachusetts, USA
| | - Corina Schoen
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts, USA
| | - Lisa Chasan-Taber
- Department of Biostatistics and Epidemiology, School of Public Health & Health Sciences, University of Massachusetts, Amherst, Massachusetts, USA
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12
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Fekadu Dadi A, Miller ER, Mwanri L. Antenatal depression and its association with adverse birth outcomes in low and middle-income countries: A systematic review and meta-analysis. PLoS One 2020; 15:e0227323. [PMID: 31923245 PMCID: PMC6953869 DOI: 10.1371/journal.pone.0227323] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/12/2019] [Indexed: 01/01/2023] Open
Abstract
Background Depression in pregnancy (antenatal depression) in many low and middle-income countries is not well documented and has not been given priority for intervention due to competing urgencies and the belief that it does not immediately cause fatalities, which mainly emanated from lack of comprehensive research on the area. To fill this research gap, this systematic review was conducted to investigate the burden of antenatal depression and its consequences on birth outcomes in low- and middle-income countries. Methods We systematically searched the databases: CINHAL, MEDLINE, EMCare, PubMed, PSyc Info, Psychiatry online, and Scopus for studies conducted in low and middle-income countries about antenatal depression and its association with adverse birth outcomes. We have included observational studies (case control, cross-sectional and cohort studies), written in English-language, scored in the range of “good quality” on the Newcastle Ottawa Scale (NOS), and were published between January 1, 2007 and December 31, 2017. Studies were excluded if a standardized approach was not used to measure main outcomes, they were conducted on restricted (high risk) populations, or had fair to poor quality score on NOS. We used Higgins and Egger’s to test for heterogeneity and publication bias. Primary estimates were pooled using a random effect meta-analysis. The study protocol was registered in PROSPERO with protocol number CRD42017082624. Result We included 64 studies (with 44, 035 women) on antenatal depression and nine studies (with 5,540 women) on adverse birth outcomes. Antenatal depression was higher in the lower-income countries (Pooled Prevalence (PP) = 34.0%; 95%CI: 33.1%-34.9%) compared to the middle-income countries (PP = 22.7%, 95%CI: 20.1%-25.2%) and increased over the three trimesters. Pregnant women with a history of economic difficulties, poor marital relationships, common mental disorders, poor social support, bad obstetric history, and exposure to violence were more likely to report antenatal depression. The risk of having preterm birth (2.41; 1.47–3.56) and low birth weight (1.66; 1.06–2.61) was higher in depressed mothers compared to mothers without depression. Conclusions Antenatal depression was higher in low-income countries than in middle-income countries and was found to be a risk factor for low birth weight and preterm births. The economic, maternal, and psychosocial risk factors were responsible for the occurrence of antenatal depression. While there could be competing priority agenda to juggle for health policymakers in low-income countries, interventions for antenatal depression should be reprioritized as vitally important in order to prevent the poor maternal and perinatal outcomes identified in this review.
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Affiliation(s)
- Abel Fekadu Dadi
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- College of Medicine and Public Health, Flinders University, Health Sciences Building, Adelaide, South Australia
- * E-mail:
| | - Emma R. Miller
- College of Medicine and Public Health, Flinders University, Health Sciences Building, Adelaide, South Australia
| | - Lillian Mwanri
- College of Medicine and Public Health, Flinders University, Health Sciences Building, Adelaide, South Australia
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Zilversmit Pao L, Harville EW, Wickliffe JK, Shankar A, Buekens P. The Cumulative Risk of Chemical and Nonchemical Exposures on Birth Outcomes in Healthy Women: The Fetal Growth Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E3700. [PMID: 31581440 PMCID: PMC6801557 DOI: 10.3390/ijerph16193700] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/23/2019] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
Abstract
Metals, stress, and sociodemographics are commonly studied separately for their effects on birth outcomes, yet often jointly contribute to adverse outcomes. This study analyzes two methods for measuring cumulative risk to understand how maternal chemical and nonchemical stressors may contribute to small for gestational age (SGA). SGA was calculated using sex-specific fetal growth curves for infants of pregnant mothers (n = 2562) enrolled in the National Institute of Child Health and Human Development (NICHD) Fetal Growth Study. The exposures (maternal lead, mercury, cadmium, Cohen's perceived stress, Edinburgh depression scores, race/ethnicity, income, and education) were grouped into three domains: metals, psychosocial stress, and sociodemographics. In Method 1 we created cumulative risk scores using tertiles. Method 2 employed weighted quantile sum (WQS) regression. For each method, logistic models were built with three exposure domains individually and race/ethnicity, adjusting for age, parity, pregnancy weight gain, and marital status. The adjusted effect of overall cumulative risk with three domains, was also modeled using each method. Sociodemographics was the only exposure associated with SGA in unadjusted models ((odds ratio) OR: 1.35, 95% (confidence interval) CI: 1.08, 1.68). The three cumulative variables in adjusted models were not significant individually, but the overall index was associated with SGA (OR: 1.17, 95% CI: 1.02, 1.35). In the WQS model, only the sociodemographics domain was significantly associated with SGA. Sociodemographics tended to be the strongest risk factor for SGA in both risk score and WQS models.
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Affiliation(s)
- Leah Zilversmit Pao
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA.
| | - Emily W Harville
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA.
| | - Jeffrey K Wickliffe
- Department of Global Environmental Health Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA.
| | - Arti Shankar
- Global Biostatistics and Data Science, Department of Global Environmental Health Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA.
| | - Pierre Buekens
- Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 70112, USA.
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Mesner O, Davis A, Casman E, Simhan H, Shalizi C, Keenan-Devlin L, Borders A, Krishnamurti T. Using graph learning to understand adverse pregnancy outcomes and stress pathways. PLoS One 2019; 14:e0223319. [PMID: 31568495 PMCID: PMC6768465 DOI: 10.1371/journal.pone.0223319] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/18/2019] [Indexed: 12/31/2022] Open
Abstract
To identify pathways between stress indicators and adverse pregnancy outcomes, we applied a nonparametric graph-learning algorithm, PC-KCI, to data from an observational prospective cohort study. The Measurement of Maternal Stress study (MOMS) followed 744 women with a singleton intrauterine pregnancy recruited between June 2013 and May 2015. Infant adverse pregnancy outcomes were prematurity (<37 weeks' gestation), infant days spent in hospital after birth, and being small for gestational age (percentile gestational weight at birth). Maternal adverse pregnancy outcomes were pre-eclampsia, gestational diabetes, and gestational hypertension. PC-KCI replicated well-established pathways, such as the relationship between gestational weeks and preterm premature rupture of membranes. PC-KCI also identified previously unobserved pathways to adverse pregnancy outcomes, including 1) a link between hair cortisol levels (at 12–21 weeks of pregnancy) and pre-eclampsia; 2) two pathways to preterm birth depending on race, with one linking Hispanic race, pre-gestational diabetes and gestational weeks, and a second pathway linking black race, hair cortisol, preeclampsia, and gestational weeks; and 3) a relationship between maternal childhood trauma, perceived social stress in adulthood, and low weight for gestational age. Our approach confirmed previous findings and identified previously unobserved pathways to adverse pregnancy outcomes. It presents a method for a global assessment of a clinical problem for further study of possible causal pathways.
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MESH Headings
- Abortion, Spontaneous/diagnosis
- Abortion, Spontaneous/epidemiology
- Abortion, Spontaneous/metabolism
- Adult
- Algorithms
- Biomarkers/metabolism
- Delivery, Obstetric
- Diabetes, Gestational/diagnosis
- Diabetes, Gestational/epidemiology
- Diabetes, Gestational/metabolism
- Female
- Gestational Age
- Hair/chemistry
- Hair/metabolism
- Humans
- Hydrocortisone/metabolism
- Hypertension, Pregnancy-Induced/diagnosis
- Hypertension, Pregnancy-Induced/epidemiology
- Hypertension, Pregnancy-Induced/metabolism
- Infant, Low Birth Weight
- Infant, Newborn
- Infant, Premature
- Live Birth
- Pre-Eclampsia/diagnosis
- Pre-Eclampsia/epidemiology
- Pre-Eclampsia/metabolism
- Pregnancy
- Prospective Studies
- Statistics, Nonparametric
- Stillbirth
- Stress, Psychological/diagnosis
- Stress, Psychological/epidemiology
- Stress, Psychological/metabolism
- United States/epidemiology
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Affiliation(s)
- Octavio Mesner
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, United States of America
- Department of Statistics and Data Science, Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Alex Davis
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Elizabeth Casman
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Hyagriv Simhan
- Magee-Women’s Research Institute, Pittsburgh, PA, United States of America
| | - Cosma Shalizi
- Department of Statistics and Data Science, Carnegie Mellon University, Pittsburgh, PA, United States of America
| | - Lauren Keenan-Devlin
- Northshore University Health System, Evanston, Illinois, United States of America
| | - Ann Borders
- Northshore University Health System, Evanston, Illinois, United States of America
| | - Tamar Krishnamurti
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA, United States of America
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- * E-mail:
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Herbell K, Zauszniewski JA. Stress Experiences and Mental Health of Pregnant Women: The Mediating Role of Social Support. Issues Ment Health Nurs 2019; 40:613-620. [PMID: 31021665 DOI: 10.1080/01612840.2019.1565873] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Stress in pregnancy is an exceedingly common issue that impacts the mother's mental health and the health of her baby. Yet, women with a supportive network of friends and family may experience lower stress and improved mental health. Therefore, the aims of this secondary analysis were to (a) examine relationships between stress experiences (i.e. perceived stress, pregnancy-specific stress) and indicators of mental health (i.e. absence of depressive symptoms and resourcefulness), (b) determine the effects of social support on stress experiences and indicators of mental health, and (c) determine if social support mediates the relationship between stress experiences and indicators of mental health. A convenience sample of 82 women in their second and third trimester of pregnancy participated in the parent study. Findings indicate that stress experiences were moderately correlated with indicators of mental health and social support predicted stress experiences and indicators of mental health. All social support mediation models were not significant with the exception of social support mediating the relationship between pregnancy-specific stress and resourcefulness. This was the first study to investigate the mediating role of social support on the relationship between pregnancy-specific stress and resourcefulness. Pregnant women may benefit from social support interventions to meaningfully reduce their stress and promote mental health. Such interventions may be physical activity, group prenatal care, or even peripartum home visits.
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Affiliation(s)
- Kayla Herbell
- a aUniversity of Missouri Sinclair School of Nursing, S235 School of Nursing, University of Missouri , Columbia , Missouri , USA
| | - Jaclene A Zauszniewski
- a aUniversity of Missouri Sinclair School of Nursing, S235 School of Nursing, University of Missouri , Columbia , Missouri , USA.,b bFrances Payne Bolton School of Nursing, Case Western Reserve University , Cleveland , Ohio , USA
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16
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Ferguson KK, Rosario Z, McElrath TF, Vélez Vega C, Cordero JF, Alshawabkeh A, Meeker JD. Demographic risk factors for adverse birth outcomes in Puerto Rico in the PROTECT cohort. PLoS One 2019; 14:e0217770. [PMID: 31194765 PMCID: PMC6564423 DOI: 10.1371/journal.pone.0217770] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 05/17/2019] [Indexed: 11/24/2022] Open
Abstract
Preterm birth is a major public health problem, especially in Puerto Rico where the rates are among the highest observed worldwide, reaching 18% in 2011. The Puerto Rico Testsite for Exploring Contamination Threats (PROTECT) study is an ongoing investigation of environmental factors that contribute to this condition. In the present analysis, we sought to examine common risk factors for preterm birth and other adverse birth outcomes which have not been characterized previously in this unique population. Pregnant women from the PROTECT cohort are recruited from the heavily contaminated Northern coast of the island of Puerto Rico and are free of pre-existing conditions like diabetes. We examined associations between basic demographic, behavioral (e.g., tobacco and alcohol use), and pregnancy (e.g., season and year of delivery) characteristics as well as municipality of residence in relation to preterm birth (<37 weeks gestation), postterm birth (≥41 weeks gestation), and small and large for gestational age in univariate and multivariate logistic regression models. Between 2011 and 2017, 1028 live singleton births were delivered as part of the PROTECT cohort. Of these, 107 (10%) were preterm. Preterm birth rates were higher among women with low socioeconomic status, as indicated by education level and income, and among women with high pre-pregnancy body mass index (BMI). Odds ratios of small for gestational age delivery were higher for women who reported tobacco use in pregnancy and lower for women who delivered in the hurricane and dengue season (July-October). Overall, in pregnant women residing in Puerto Rico, socioeconomic status was associated with preterm birth but few other factors were associated with this or other adverse outcomes of pregnancy. Research to understand environmental factors that could be contributing to the preterm birth epidemic in Puerto Rico is necessary.
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Affiliation(s)
- Kelly K. Ferguson
- Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, United States of America
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
| | - Zaira Rosario
- University of Puerto Rico Graduate School of Public Health, San Juan, Puerto Rico
| | - Thomas F. McElrath
- Division of Maternal-Fetal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Carmen Vélez Vega
- University of Puerto Rico Graduate School of Public Health, San Juan, Puerto Rico
| | - José F. Cordero
- University of Puerto Rico Graduate School of Public Health, San Juan, Puerto Rico
- Epidemiology and Biostatistics Department, College of Public Health, University of Georgia, Athens, Georgia, United States of America
| | - Akram Alshawabkeh
- College of Engineering, Northeastern University, Boston, Massachusetts, United States of America
| | - John D. Meeker
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, United States of America
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18
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Pampaka D, Papatheodorou SI, AlSeaidan M, Al Wotayan R, Wright RJ, Buring JE, Dockery DW, Christophi CA. Postnatal depressive symptoms in women with and without antenatal depressive symptoms: results from a prospective cohort study. Arch Womens Ment Health 2019; 22:93-103. [PMID: 29971553 DOI: 10.1007/s00737-018-0880-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 06/22/2018] [Indexed: 01/01/2023]
Abstract
Evidence exists that the risk factors for depression in the antenatal and postnatal period may differ, but only a handful of studies looked at depression longitudinally. The aims of this study were (1) to estimate the prevalence of postnatal depressive symptoms in Kuwait where data about postnatal depression are scarce and identify its determinants and (2) to compare these risk factors between women who had experienced antenatal depressive symptoms and those that did not. Data collected in the TRansgenerational Assessment of Children's Environmental Risk (TRACER) Study in Kuwait were used in this analysis. The sample was restricted to the 1348 women who answered the Edinburgh Postnatal Depression Scale (EPDS) both antenatally and postnatally. The prevalence of postnatal depressive symptoms, defined by an EPDS score ≥ 10, was 11.7%. Overall, antenatal depressive symptoms were the strongest determinant of postnatal depressive symptoms. Multivariable logistic regression analysis showed that in women with depressive symptoms in pregnancy, having a lower household income was the most significant risk factor for postnatal depressive symptoms. Among women without antenatal depressive symptoms, those who had lower income, were Kuwaitis, experienced other problems in pregnancy such as perceived stress, PTSD symptoms and social isolation, and those who delivered a boy had higher odds of postnatal depressive symptoms. Antenatal depressive symptoms and other psychosocial characteristics can predict postnatal depressive symptoms. Therefore, maternal mental health issues should be detected during the antenatal period and support should be provided in order to lower the risk of postnatal depression and its sequelae.
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Affiliation(s)
- Despina Pampaka
- Cyprus International Institute for Environmental and Public Health, Cyprus University of Technology, 95 Eirinis Street, 3041, Limassol, Cyprus.
| | - Stefania I Papatheodorou
- Cyprus International Institute for Environmental and Public Health, Cyprus University of Technology, 95 Eirinis Street, 3041, Limassol, Cyprus
| | | | | | - Rosalind J Wright
- Department of Pediatrics and Institute for Exposomic Research, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Julie E Buring
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Douglas W Dockery
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Costas A Christophi
- Cyprus International Institute for Environmental and Public Health, Cyprus University of Technology, 95 Eirinis Street, 3041, Limassol, Cyprus.,Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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