Maternal depressive symptoms, depression, and psychiatric medication use in relation to risk of preterm delivery

Maternal Depressive Symptomology and Small-for-Gestational-Age: Do Coping Efforts Moderate the Relationship?

INTRODUCTION

Evidence regarding the impact of prenatal depression and other psychosocial factors, such as coping, on perinatal outcomes is limited. We examined whether depressive symptoms during pregnancy were associated with the rate of having a small-for-gestational-age (SGA) infant and whether women's coping styles modified the relationship.

METHODS

Data were obtained from a cohort of 1410 Black/African American women in Metropolitan Detroit, MI, using a structured maternal interview and medical record abstraction. Depressive symptomology was measured using the Center for Epidemiologic Studies Depression (CES-D) Scale. Women's coping efforts (confronting, distancing, and internalizing) were assessed using the Ways of Coping (WOC) questionnaire. Modified-Poisson regression models assessed direct and moderated associations.

RESULTS

About 20% of women had severe depressive symptoms (CES-D > 23). Severe depressive symptoms were associated with having an SGA infant (adjusted PR [aPR] = 1.39, 95% CI = 1.02-1.89). Among women who frequently utilized confrontive coping efforts, severe depressive symptoms were marginally associated with SGA (PR = 1.43, 95% CI = 0.98-2.09), but not among women using confrontive coping less frequently. Regarding distance coping, severe depressive symptoms were not associated with SGA among women who frequently used distancing. However, severe depressive symptoms were associated with SGA (PR = 1.52, 95% CI = 1.03-2.24) among women who use distancing coping less frequently.

CONCLUSIONS

/Implications. Our findings suggest the use of confrontive and distancing coping moderates the relationship between depressive symptoms and SGA. In addition to screening for depressive symptomology during pregnancy, clinicians may want to assess coping styles as they drive women's response to stress and may be amenable to intervention.

Racialization processes and depressive symptoms among pregnant Mexican-origin immigrant women

This study examines how racialization processes (conceptualized as multilevel and dynamic processes) shape prenatal mental health by testing the association of discrimination and the John Henryism hypothesis on depressive symptoms for pregnant Mexican-origin immigrant women. We analyzed baseline data (n = 218) from a healthy lifestyle intervention for pregnant Latinas in Detroit, Michigan. Using separate multiple linear regression models, we examined the independent and joint associations of discrimination and John Henryism with depressive symptoms and effect modification by socioeconomic position. Discrimination was positively associated with depressive symptoms (β = 2.84; p < .001) when adjusting for covariates. This association did not vary by socioeconomic position. Women primarily attributed discrimination to language use, racial background, and nativity. We did not find support for the John Henryism hypothesis, meaning that the hypothesized association between John Henryism and depressive symptoms did not vary by socioeconomic position. Examinations of joint associations of discrimination and John Henryism on depressive symptoms indicate a positive association between discrimination and depressive symptoms (β = 2.81; p < .001) and no association of John Henryism and depressive symptoms (β = -0.83; p > .05). Results suggest complex pathways by which racialization processes affect health and highlight the importance of considering experiences of race, class, and gender within racialization processes.

Mental health concerns during pregnancy associated with the risk of preterm birth: A retrospective cohort study

BACKGROUNDS

There are multiple risk factors for preterm birth (PTB), one of the most important of which is mood disorders during pregnancy. We aimed to comprehensively investigate the association of both total mental health concerns and ten specific psychiatric symptoms with PTB risk.

METHODS

A cohort study was performed consisting of 25,175 pregnant women who participated in Women and Children's Hospital of Chongqing Medical University between 2020 and 2022. The Symptom Checklist 90 (SCL-90) was utilized to assess the psychiatric symptoms. Multivariable or multinomial logistic regression was applied to investigate mental health concerns associated with risk of PTB or its different clinical sub-categories, respectively. Sensitivity analyses were further performed to validate the results.

RESULTS

8336 women who met the inclusion criteria were included; of these, 547 (6.6 %) had preterm deliveries, and 2542 (30.5 %) had mental health concerns. Compared with women with healthy minds, women with total mental health concerns had a 29.0 % higher risk of overall PTB (OR = 1.28, 95%CI = 1.07-1.54), medical-induced PTB (OR = 1.49, 95%CI = 1.05-2.13) and spontaneous PTB with premature rupture of membranes (OR = 1.33, 95%CI = 1.01-1.74). As to the specific psychological symptoms, hostility pregnant women had a 55.0 % higher risk of PTB (OR = 1.55, 95%CI = 1.14-2.11). Similar results were observed in most of the sensitivity analyses.

LIMITATIONS

This is a single-center study, thus the extrapolation of the results may be limited.

CONCLUSIONS

Pregnant women with mental health symptoms, especially hostility, have an increased risk of PTB. The findings underscore that integrating mental health services into routine maternal care may be a strategy to prevent PTB.

Antenatal depressive symptoms and adverse birth outcomes in healthy start participants: The modifying role of utilization of mental health services

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.

Consensus Panel Recommendations for the Pharmacological Management of Pregnant Women with Depressive Disorders

INTRODUCTION

The initiative of a consensus on the topic of antidepressant and anxiolytic drug use in pregnancy is developing in an area of clinical uncertainty. Although many studies have been published in recent years, there is still a paucity of authoritative evidence-based indications useful for guiding the prescription of these drugs during pregnancy, and the data from the literature are complex and require expert judgment to draw clear conclusions.

METHODS

For the elaboration of the consensus, we have involved the scientific societies of the sector, namely, the Italian Society of Toxicology, the Italian Society of Neuropsychopharmacology, the Italian Society of Psychiatry, the Italian Society of Obstetrics and Gynecology, the Italian Society of Drug Addiction and the Italian Society of Addiction Pathology. An interdisciplinary team of experts from different medical specialties (toxicologists, pharmacologists, psychiatrists, gynecologists, neonatologists) was first established to identify the needs underlying the consensus. The team, in its definitive structure, includes all the representatives of the aforementioned scientific societies; the task of the team was the evaluation of the most accredited international literature as well as using the methodology of the "Nominal Group Technique" with the help of a systematic review of the literature and with various discussion meetings, to arrive at the drafting and final approval of the document.

RESULTS

The following five areas of investigation were identified: (1) The importance of management of anxiety and depressive disorders in pregnancy, identifying the risks associated with untreated maternal depression in pregnancy. (2) The assessment of the overall risk of malformations with the antidepressant and anxiolytic drugs used in pregnancy. (3) The evaluation of neonatal adaptation disorders in the offspring of pregnant antidepressant/anxiolytic-treated women. (4) The long-term outcome of infants' cognitive development or behavior after in utero exposure to antidepressant/anxiolytic medicines. (5) The evaluation of pharmacological treatment of opioid-abusing pregnant women with depressive disorders.

CONCLUSIONS

Considering the state of the art, it is therefore necessary in the first instance to frame the issue of pharmacological choices in pregnant women who need treatment with antidepressant and anxiolytic drugs on the basis of data currently available in the literature. Particular attention must be paid to the evaluation of the risk/benefit ratio, understood both in terms of therapeutic benefit with respect to the potential risks of the treatment on the pregnancy and on the fetal outcome, and of the comparative risk between the treatment and the absence of treatment; in the choice prescription, the specialist needs to be aware of both the potential risks of pharmacological treatment and the equally important risks of an untreated or undertreated disorder.

Paternal and maternal psychiatric history and risk of preterm and early term birth: A nationwide study using Swedish registers

BACKGROUND

Women with psychiatric diagnoses are at increased risk of preterm birth (PTB), with potential life-long impact on offspring health. Less is known about the risk of PTB in offspring of fathers with psychiatric diagnoses, and for couples where both parents were diagnosed. In a nationwide birth cohort, we examined the association between psychiatric history in fathers, mothers, and both parents and gestational age.

METHODS AND FINDINGS

We included all infants live-born to Nordic parents in 1997 to 2016 in Sweden. Psychiatric diagnoses were obtained from the National Patient Register. Data on gestational age were retrieved from the Medical Birth Register. Associations between parental psychiatric history and PTB were quantified by relative risk (RR) and two-sided 95% confidence intervals (CIs) from log-binomial regressions, by psychiatric disorders overall and by diagnostic categories. We extended the analysis beyond PTB by calculating risks over the whole distribution of gestational age, including "early term" (37 to 38 weeks). Among the 1,488,920 infants born throughout the study period, 1,268,507 were born to parents without a psychiatric diagnosis, of whom 73,094 (5.8%) were born preterm. 4,597 of 73,500 (6.3%) infants were born preterm to fathers with a psychiatric diagnosis, 8,917 of 122,611 (7.3%) infants were born preterm to mothers with a pscyhiatric diagnosis, and 2,026 of 24,302 (8.3%) infants were born preterm to both parents with a pscyhiatric diagnosis. We observed a shift towards earlier gestational age in offspring of parents with psychiatric history. The risks of PTB associated with paternal and maternal psychiatric diagnoses were similar for different psychiatric disorders. The risks for PTB were estimated at RR 1.12 (95% CI [1.08, 1.15] p < 0.001) for paternal diagnoses, at RR 1.31 (95% CI [1.28, 1.34] p < 0.001) for maternal diagnoses, and at RR 1.52 (95% CI [1.46, 1.59] p < 0.001) when both parents were diagnosed with any psychiatric disorder, compared to when neither parent had a psychiatric diagnosis. Stress-related disorders were associated with the highest risks of PTB with corresponding RRs estimated at 1.23 (95% CI [1.16, 1.31] p < 0.001) for a psychiatry history in fathers, at 1.47 (95% CI [1.42, 1.53] p < 0.001) for mothers, and at 1.90 (95% CI [1.64, 2.20] p < 0.001) for both parents. The risks for early term were similar to PTB. Co-occurring diagnoses from different diagnostic categories increased risk; for fathers: RR 1.10 (95% CI [1.07, 1.13] p < 0.001), 1.15 (95% CI [1.09, 1.21] p < 0.001), and 1.33 (95% CI [1.23, 1.43] p < 0.001), for diagnoses in 1, 2, and ≥3 categories; for mothers: RR 1.25 (95% CI [1.22, 1.28] p < 0.001), 1.39 (95% CI [1.34, 1.44] p < 0.001) and 1.65 (95% CI [1.56, 1.74] p < 0.001). Despite the large sample size, statistical precision was limited in subgroups, mainly where both parents had specific psychiatric subtypes. Pathophysiology and genetics underlying different psychiatric diagnoses can be heterogeneous.

CONCLUSIONS

Paternal and maternal psychiatric history were associated with a shift to earlier gestational age and increased risk of births before full term. The risk consistently increased when fathers had a positive history of different psychiatric disorders, increased further when mothers were diagnosed and was highest when both parents were diagnosed.

Prevalence and associated factors of perinatal depression among working pregnant women: a hospital-based cross-sectional study

Perinatal depression is a major public health problem having serious negative impacts on personal, family, and child developmental outcomes. This study aimed to determine the prevalence of major depressive disorder (MDD) and its associated factors in working pregnant women. This descriptive, cross-sectional study was performed on 389 working pregnant women enrolled from four Tunisian public maternity hospitals. Data collection tools were the sociodemographic, obstetric, family relationships, and work environment questionnaire, and the Center for Epidemiologic Studies Depression Scale (CES-D). The mean score of depression was 27.39 ± 6.97 and 76.1% of women had major depressive symptoms using cutoff points on the CES-D ≥ 23. Family income, diagnosis with a chronic illness, history of depression, and employment categories were associated with major depressive symptoms. In multivariate analyses, family income and work posture were significantly associated with MDD. These results suggest an increased burden of MDD during pregnancy in Tunisian women. Prevention, early detection, and interventions are needed to reduce the prevalence of perinatal depression.

Associations Between Maternal Depression, Antidepressant Use During Pregnancy, and Adverse Pregnancy Outcomes: An Individual Participant Data Meta-analysis

OBJECTIVE

To evaluate the associations of depressive symptoms and antidepressant use during pregnancy with the risks of preterm birth, low birth weight, small for gestational age (SGA), and low Apgar scores.

DATA SOURCES

MEDLINE, EMBASE, ClinicalTrials.gov, and PsycINFO up to June 2016.

METHODS OF STUDY SELECTION

Data were sought from studies examining associations of depression, depressive symptoms, or use of antidepressants during pregnancy with gestational age, birth weight, SGA, or Apgar scores. Authors shared the raw data of their studies for incorporation into this individual participant data meta-analysis.

TABULATION, INTEGRATION, AND RESULTS

We performed one-stage random-effects meta-analyses to estimate odds ratios (ORs) with 95% CIs. The 215 eligible articles resulted in 402,375 women derived from 27 study databases. Increased risks were observed for preterm birth among women with a clinical diagnosis of depression during pregnancy irrespective of antidepressant use (OR 1.6, 95% CI 1.2-2.1) and among women with depression who did not use antidepressants (OR 2.2, 95% CI 1.7-3.0), as well as for low Apgar scores in the former (OR 1.5, 95% CI 1.3-1.7), but not the latter group. Selective serotonin reuptake inhibitor (SSRI) use was associated with preterm birth among women who used antidepressants with or without restriction to women with depressive symptoms or a diagnosis of depression (OR 1.6, 95% CI 1.0-2.5 and OR 1.9, 95% CI 1.2-2.8, respectively), as well as with low Apgar scores among women in the latter group (OR 1.7, 95% CI 1.1-2.8).

CONCLUSION

Depressive symptoms or a clinical diagnosis of depression during pregnancy are associated with preterm birth and low Apgar scores, even without exposure to antidepressants. However, SSRIs may be independently associated with preterm birth and low Apgar scores.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42016035711.

Maternal obesity and depression reported at the first antenatal visit

Background

Maternal obesity and depression are common and both have been associated with adverse pregnancy outcomes.

Aims

The aim of this observational study was to examine the relationship between maternal body mass index (BMI) category and self-reported depression at the first antenatal visit.

Methods

Women who delivered a baby weighing ≥ 500 g over nine years 2009–2017 were included. Self-reported sociodemographic and clinical details were computerised at the first antenatal visit by a trained midwife, and maternal BMI was calculated after standardised measurement of weight and height.

Results

Of 73,266 women, 12,304 (16.7%) had obesity, 1.6% (n = 1126) reported current depression and 7.5% (n = 3277) multiparas reported a history of postnatal depression. The prevalence of self-reported maternal depression was higher in women who had obesity, > 35 years old, were socially disadvantaged, smokers, had an unplanned pregnancy and used illicit drugs. After adjustment for confounding variables, obesity was associated with an increased odds ratio (aOR) for current depression in both nulliparas (aOR 1.7, 95% CI 1.3–2.3, p < 0.001) and multiparas (aOR 1.8, 95% CI 1.5–2.1, p < 0.001) and postnatal depression in multiparas (aOR 1.4, 95% CI 1.3–1.5, p < 0.001). The prevalence of current depression was higher in women with moderate/severe obesity than in women with mild obesity (both p < 0.001).

Conclusions

We found that self-reported maternal depression in early pregnancy was independently associated with obesity. The prevalence of depression increased with the severity of obesity. Our findings highlight the need for implementation of strategies and provision of services for the prevention and treatment of both obesity and depression.

Supplementary information

The online version contains supplementary material available at 10.1007/s11845-021-02665-5.

Perceived stress may mediate the relationship between antenatal depressive symptoms and preterm birth: A pilot observational cohort study

Background

Screening for changes in pregnancy-related anxiety and depressive symptoms during pregnancy may further our understanding of the relationship between these two variables and preterm birth.

Objectives

To determine whether changes in pregnancy-related anxiety and depressive symptoms during pregnancy influence the risk of preterm birth among Pakistani women; explore whether perceived stress moderates or mediates this relationship, and examine the relationship between the various components of pregnancy-related anxiety and preterm birth.

Methods

A prospective cohort study design was used to recruit a diverse sample of 300 low-risk pregnant women from four centers of Aga Khan Hospital for Women and Children in Karachi, Pakistan. Changes in pregnancy-related anxiety and depressive symptoms during pregnancy were tested. Multiple logistic regression analysis was used to determine a predictive model for preterm birth. We then determined if the influence of perceived stress could moderate or mediate the effect of depressive symptoms on preterm birth.

Results

Changes in pregnancy-related anxiety (OR = 1.1, CI 0.97–1.17, p = 0.167) and depressive symptoms (OR = 0.9, CI 0.85–1.03, p = 0.179) were insignificant as predictors of preterm birth after adjusting for the effects of maternal education and family type. When perceived stress was added into the model, we found that changes in depressive symptoms became marginally significant after adjusting for covariates (OR = 0.9, CI 0.82–1.01, p = 0.082). After adjusting for the mediation effect of change in perceived stress, the effect of change in depressive symptoms on preterm birth were marginally significant after adjusting for covariates. Among six different dimensions of pregnancy-related anxiety, mother’s concerns about fetal health showed a trend towards being predictive of preterm birth (OR = 1.3, CI 0.97–1.72, p = 0.078).

Conclusions

There may be a relationship between perceived stress and antenatal depressive symptoms and preterm birth. This is the first study of its kind to be conducted in Pakistan. Further research is required to validate these results.

Does maternal race or ethnicity modify the association between maternal psychiatric disorders and preterm birth?

PURPOSE

Preterm birth risk has been linked to maternal racial and ethnic background, particularly African American heritage; however, the association of maternal race and ethnicity with psychiatric disorders and preterm birth has received relatively limited attention.

METHODS

The Consortium on Safe Labor (2002-2008) is a nationwide U.S. cohort study with 223,394 singleton pregnancies. Clinical data were obtained from electronic medical records, including maternal diagnoses of psychiatric disorders. Relative risk (RR) and 95% confidence intervals (CI) were estimated for the association between maternal psychiatric disorders and preterm birth (<37 completed weeks) using log-binomial regression with generalized estimating equations. The interaction effect of maternal psychiatric disorders with race and ethnicity was also evaluated.

RESULTS

Non-Hispanic White (RR, 1.42; 95% CI, 1.35-1.49), Hispanic (RR, 1.44; 95% CI, 1.29-1.60), and non-Hispanic Black (RR, 1.21, 95% CI, 1.13-1.29) women with any psychiatric disorder were at increased risk for delivering preterm infants, compared with women without any psychiatric disorder. However, non-Hispanic Black women with any psychiatric disorder, depression, bipolar disorder, and schizophrenia had a significantly lower increase in preterm birth risk than non-Hispanic White women.

CONCLUSIONS

Despite the significant association between maternal psychiatric disorders and preterm birth risk, psychiatric disorders did not appear to contribute to racial and ethnic disparities in preterm birth.

Racial Differences in the Association Between Maternal Antenatal Depression and Preterm Birth Risk: A Prospective Cohort Study

BACKGROUND

In the United States, racial/ethnic disparities in preterm birth (PTB) are well documented, but explanations for why the disparity persists remain to be fully explored. We examined racial/ethnic differences in the association of maternal antenatal depression with PTB (<37 completed weeks of gestation) risk.

METHODS

In a prospective cohort study, participants (n = 2073) included non-Hispanic (NH) black, NH white, Asian, and Hispanic women who received prenatal care at a university obstetric clinic January 2004-March 2010, and delivered at the university's hospital. We obtained data from self-reported questionnaires and electronic medical records. We assessed antenatal depression using the Patient Health Questionnaire-9 and self-reported antenatal antidepressant medication use. Poisson regression models were used to estimate the association between antenatal depression and PTB risk, within strata of race/ethnicity.

RESULTS

NH black (risk ratio [RR] = 1.89; 95% confidence interval [CI]: 0.94, 3.80), NH white (RR = 1.58, 95% CI: 1.04, 2.39), and Asian (RR = 2.06; 95% CI: 0.69, 6.13) women with antenatal depression were at increased risk for delivering preterm infants, compared with women without antenatal depression, although the associations were statistically significant only among NH white women. There was no evidence of an association between antenatal depression and risk of PTB among Hispanic women (RR = 0.96; 95% CI: 0.28, 3.25); p-value for interaction = 0.81.

CONCLUSION

Our findings suggest race-specific associations of antenatal depression with an increased risk of delivering a preterm infant, supporting the importance of considering race/ethnicity when examining risk factors for health outcomes.

Stressors Across the Life-Course and Preterm Delivery: Evidence From a Pregnancy Cohort

Objectives Growing evidence suggests that pre-conception stressors are associated with increased risk of preterm delivery (PTD). Our study assesses stressors in multiple domains at multiple points in the life course (i.e., childhood, adulthood, within 6 months of pregnancy) and their relation to PTD. We also examine heterogeneity of associations by race/ethnicity, PTD timing, and PTD clinical circumstance. Methods We assessed stressors retrospectively via mid-pregnancy questionnaires in the Pregnancy Outcomes and Community Health Study (1998-2004), a Michigan pregnancy cohort (n = 2559). Stressor domains included abuse/witnessing violence (hereafter "abuse"), loss, economic stress, and substance use. We used logistic and multinomial regression for the following outcomes: PTD (<37 weeks' gestation), PTD by timing (≤34 weeks, 35-36 weeks) and PTD by clinical circumstance (medically indicated, spontaneous). Covariates included race/ethnicity, education, parity, and marital status. Results Stressors in the previous 6 months were not associated with PTD. Experiencing abuse during both childhood and adulthood increased adjusted odds of PTD among women of white or other race/ethnicity only (aOR 1.6, 95 % CI 1.1, 2.5). Among all women, abuse in childhood increased odds of late PTD (aOR 1.5, 95 % CI 1.0, 2.2) while abuse in both childhood and adulthood non-significantly increased odds of early PTD (aOR 1.6, 95 % CI 0.9, 2.7). Sexual, but not physical, abuse in both childhood and adulthood increased odds of PTD (aOR 1.9, 95 % CI 1.0, 3.5). Conclusions Experiences of abuse-particularly sexual abuse-across the life-course may be important considerations when assessing PTD risk. Our results motivate future studies of pathways linking abuse and PTD.

The Impact of Antenatal Psychological Group Interventions on Psychological Well-Being: A Systematic Review of the Qualitative and Quantitative Evidence

Depression, anxiety and stress in the perinatal period can have serious, long-term consequences for women, their babies and their families. Over the last two decades, an increasing number of group interventions with a psychological approach have been developed to improve the psychological well-being of pregnant women. This systematic review examines interventions targeting women with elevated symptoms of, or at risk of developing, perinatal mental health problems, with the aim of understanding the successful and unsuccessful features of these interventions. We systematically searched online databases to retrieve qualitative and quantitative studies on psychological antenatal group interventions. A total number of 19 papers describing 15 studies were identified; these included interventions based on cognitive behavioural therapy, interpersonal therapy and mindfulness. Quantitative findings suggested beneficial effects in some studies, particularly for women with high baseline symptoms. However, overall there is insufficient quantitative evidence to make a general recommendation for antenatal group interventions. Qualitative findings suggest that women and their partners experience these interventions positively in terms of psychological wellbeing and providing reassurance of their 'normality'. This review suggests that there are some benefits to attending group interventions, but further research is required to fully understand their successful and unsuccessful features.

Prenatal depression and adverse birth outcomes: an updated systematic review

Complications related to preterm birth (PTB) and low birth weight (LBW) are leading causes of infant morbidity and mortality. Prenatal depression is a hypothesized psychosocial risk factor for both birth outcomes. The purpose of this systematic review was to examine evidence published between 1977 and 2013 on prenatal depression and risks of these primary adverse birth outcomes. A systematic search of the PUBMED and PsycINFO databases was conducted to identify studies testing the associations between prenatal depressive symptoms, or diagnoses of depression, and risk of PTB or LBW. We systematically selected 50 published reports on PTB and length of gestation, and 33 reports on LBW and BW. Results were reviewed by two independent reviewers and we evaluated the quality of the evidence with an established systematic review method, the Newcastle Ottawa Scale. We then undertook a narrative synthesis of the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Less than a quarter of 50 published reports found that prenatal depression was significantly associated with PTB or gestational age. In contrast, slightly more than half of the 33 reports found that prenatal depression was associated with LBW or BW. When weighing methodological features, we determined that the effects of prenatal depression on LBW are more consistent than effects on length of gestation or PTB. Although the evidence may not be strong enough to support routine depression screening for risk of adverse outcomes, screening to enable detection and timely treatment to reduce risk of postpartum depression is warranted. Further rigorous research on prenatal depression and adverse birth outcomes is needed.

Maternal bereavement and the risk of preterm delivery: the importance of gestational age and of the precursor of preterm birth

BACKGROUND

Maternal stress during pregnancy may increase the risk of preterm delivery (PD), but the associations between stress and subtypes of PD are not clear. We investigated maternal loss of a close relative and risks of very and moderately PD (<32 and 32-36 weeks, respectively) and spontaneous and medically indicated PD.

METHOD

We studied 4 940 764 live singleton births in Denmark (1978-2008) and Sweden (1973-2006). We retrieved information on death of women's family members (children, partner, siblings, parents), birth outcomes and maternal characteristics from nationwide registries.

RESULTS

Overall, the death of a close family member the year before pregnancy or in the first 36 weeks of pregnancy was associated with a 7% increased risk of PD [95% confidence interval (CI) 1.04-1.10]. The highest hazard ratios (HR) for PD were found for death of an older child [HR (95% CI) 1.20 (1.10-1.31)] and for death of a partner [HR (95% CI) 1.31 (1.03-1.66)]. These losses were associated with higher risks of very preterm [HR (95% CI) 1.61 (1.29-2.01) and 2.07 (1.15-3.74), respectively] than of moderately preterm [HR (95% CI) 1.14 (1.03-1.26) and 1.22 (0.94-1.58), respectively] delivery. There were no substantial differences in the association between death of a child or partner and the risk of spontaneous v. medically indicated PD.

CONCLUSIONS

Death of a close family member the year before or during pregnancy was associated with an increased risk of PD, especially very PD. Possible mechanisms include both spontaneous and medically indicated preterm birth.

Movin' on Up: Socioeconomic Mobility and the Risk of Delivering a Small-for-Gestational Age Infant

OBJECTIVE

Poor fetal growth is associated with increased rates of adverse health outcomes in children and adults. The social determinants of poor fetal growth are not well understood. Using multiple socioeconomic indicators measured at the individual level, this study examined changes in maternal socioeconomic position (SEP) from childhood to adulthood (socioeconomic mobility) in relation to poor fetal growth in offspring.

METHODS

Data were from the Pregnancy Outcomes and Community Health Study (September 1998-June 2004) that enrolled women in mid-pregnancy from 52 clinics in five Michigan communities (2463 women: 1824 non-Hispanic White, 639 non-Hispanic Black). Fetal growth was defined by birthweight-for-gestational age percentiles; infants with birthweight-for-gestational age <10th percentile were referred to as small-for-gestational age (SGA). In logistic regression models, mothers whose SEP changed from childhood to adulthood were compared to two reference groups, the socioeconomic group they left and the group they joined.

RESULTS

Approximately, 8.2 % of women (non-Hispanic White: 6.3 %, non-Hispanic Black: 13.9 %) delivered an SGA infant. Upward mobility was associated with decreased risk of delivering an SGA infant. Overall, the SGA adjusted-odds ratio was 0.34 [95 % confidence interval (CI) 0.17-0.69] for women who moved from lower to middle/upper versus static lower class, and 0.44 (CI 0.28-1.04) for women who moved from middle to upper versus static middle class. There were no significant differences in SGA risk when women were compared to the SEP group they joined.

CONCLUSIONS

Our findings support a link between mother's socioeconomic mobility and SGA offspring. Policies that allow for the redistribution or reinvestment of resources may reduce disparities in rates of SGA births.

Gestational Age at Term, Delivery Circumstance, and Their Association with Childhood Attention Deficit Hyperactivity Disorder Symptoms

BACKGROUND

Perinatal characteristics may identify subgroups of term-born children at risk for academic and behavioural difficulties. Using follow-up data from the Pregnancy Outcomes and Community Health Study, we subdivided term births according to two potential markers of perinatal risk (gestational age, delivery circumstance) and evaluated their association with attention deficit hyperactivity disorder (ADHD) symptoms.

METHODS

We included children born at term whose mothers completed the Conners' Parent Rating Scales-Revised-Short Form (CPRS-R-S) (n = 610; ages: 3-9 years). The CPRS-R-S yields age and sex-referenced T-scores for the two primary dimensions of ADHD (inattention, hyperactivity) and an ADHD Index that reflects both dimensions. Using general linear models, we evaluated whether: (1) term delivery defined by gestational week (reference: 39-40 weeks), or (2) term delivery circumstance defined by labour onset type and mode of delivery (reference: spontaneous labour, vaginal delivery) was associated with these problems.

RESULTS

Following adjustment for parity, sociodemographics, and maternal mental health both during pregnancy and at the child follow-up survey, the induced labour plus caesarean group exhibited higher inattention and ADHD Index scores relative to the spontaneous labour, vaginal delivery group (inattention: mean difference = 5.1, 95% CI 0.6, 9.7; ADHD Index: mean difference = 4.1, 95% CI 0.5, 7.8). Findings were primarily driven by male children.

CONCLUSIONS

Among term-born children, only those whose mothers experienced induction of labour that culminated in caesarean delivery exhibited higher levels of ADHD symptoms. Prenatal, antepartum, and/or postnatal factors associated with this delivery profile may reflect increased risk for such problems.

Obesity and mental disorders during pregnancy and postpartum: a systematic review and meta-analysis

OBJECTIVE

To evaluate the prevalence and risk of antenatal and postpartum mental disorders among obese and overweight women.

DATA SOURCES

Seven databases (including MEDLINE and ClinicalTrials.gov) were searched from inception to January 7, 2013, in addition to citation tracking, hand searches, and expert recommendations.

METHODS OF STUDY SELECTION

Studies were eligible if antenatal or postpartum mental disorders were assessed with diagnostic or screening tools among women who were obese or overweight at the start of pregnancy. Of the 4,687 screened articles, 62 met the inclusion criteria for the review. The selected studies included a total of 540,373 women.

TABULATION, INTEGRATION, AND RESULTS

Unadjusted odds ratios were pooled using random-effects meta-analysis for antenatal depression (n=29), postpartum depression (n=16), and antenatal anxiety (n=10). Obese and overweight women had significantly higher odds of elevated depression symptoms than normal-weight women and higher median prevalence estimates. This was found both during pregnancy (obese odds ratio [OR] 1.43, 95% confidence interval [CI] 1.27-1.61, overweight OR 1.19, 95% CI 1.09-1.31, median prevalence: obese 33.0%, overweight 28.6%, normal-weight 22.6%) and postpartum (obese OR 1.30, 95% CI 1.20-1.42, overweight OR 1.09, 95% CI 1.05-1.13, median prevalence: obese 13.0%, overweight 11.8%, normal-weight 9.9%). Obese women also had higher odds of antenatal anxiety (OR 1.41, 95% CI 1.10-1.80). The few studies identified for postpartum anxiety (n=3), eating disorders (n=2), or serious mental illness (n=2) also suggested increased risk among obese women.

CONCLUSION

Health care providers should be aware that women who are obese when they become pregnant are more likely to experience elevated antenatal and postpartum depression symptoms than normal-weight women, with intermediate risks for overweight women.

Preterm birth and antidepressant medication use during pregnancy: a systematic review and meta-analysis

INTRODUCTION

Preterm birth is a major contributor to neonatal morbidity and mortality and its rate has been increasing over the past two decades. Antidepressant medication use during pregnancy has also been rising, with rates up to 7.5% in the US. The objective was to systematically review the literature to determine the strength of the available evidence relating to a possible association between antidepressant use during pregnancy and preterm birth.

METHODS

We conducted a computerized search in PUBMED, MEDLINE and PsycINFO through September 2012, supplemented with a manual search of reference lists, to identify original published research on preterm birth rates in women taking antidepressants during pregnancy. Data were independently extracted by two reviewers, and absolute and relative risks abstracted or calculated. Our a priori design was to group studies by level of confounding adjustment and by timing of antidepressant use during pregnancy; we used random-effects models to calculate summary measures of effect.

RESULTS

Forty-one studies met inclusion criteria. Pooled adjusted odds ratios (95% CI) were 1.53 (1.40-1.66) for antidepressant use at any time and 1.96 (1.62-2.38) for 3rd trimester use. Controlling for a diagnosis of depression did not eliminate the effect. There was no increased risk [1.16 (0.92-1.45)] in studies that identified patients based on 1st trimester exposure. Sensitivity analyses demonstrated unmeasured confounding would have to be strong to account for the observed association.

DISCUSSION

Published evidence is consistent with an increased risk of preterm birth in women taking antidepressants during the 2nd and 3rd trimesters, although the possibility of residual confounding cannot be completely ruled out.

A systematic review and quantitative assessment of sleep-disordered breathing during pregnancy and perinatal outcomes

PURPOSE

Previous investigations have suggested a strong association between sleep-disordered breathing (SDB) during pregnancy and perinatal outcomes. However, the results of the following replication studies were not always concordant. Therefore, this meta-analysis was conducted to evaluate the more reliable estimate.

METHODS

A systematic literature search was performed on PubMed, Springer Link, and EMBASE to identify all eligible studies published before August 2013. Summary odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using fixed or random effects model.

RESULTS

A total of 24 publications met the inclusion criteria and were included in this meta-analysis. Findings demonstrated that moderate-to-severe SDB during pregnancy was associated with gestational diabetes mellitus (OR=1.78; 95% CI, 1.29 to 2.46), pregnancy-related hypertension (OR=2.38; 95% CI, 1.63 to 3.47), preeclampsia (OR=2.19; 95% CI, 1.71 to 2.80), preterm delivery (OR=1.98; 95% CI, 1.59 to 2.48), low birth weight (OR=1.75; 95% CI, 1.33 to 2.32), neonatal intensive care unit (NICU) admission (OR=2.43; 95% CI, 1.61 to 3.68), intrauterine growth restriction (OR=1.44; 95% CI, 1.22 to 1.71), and Apgar score of <7 at 1 min (OR=1.78; 95% CI, 1.10 to 2.91) based on all studies but not gestational age and birth weight.

CONCLUSIONS

This meta-analysis revealed that moderate-to-severe SDB during pregnancy may be associated with most of adverse perinatal outcomes. Further well-designed studies are warranted to confirm our findings.

Depression during pregnancy: a risk factor for adverse neonatal outcomes? A critical review of the literature

OBJECTIVE

We reviewed studies of maternal depression and preterm birth (PTB), low birthweight (LBW) and small-for-gestational-age (SGA) in the context of methodological differences between studies and potential limitations.

METHODS

We conducted a literature search of PubMed (1996-2011) for English-language studies of maternal depression and (1) PTB and gestational age (GA), (2) LBW and birthweight (BW) and (3) SGA. Thirty-six studies met eligibility criteria.

RESULTS

Elevated depression levels, particularly in early- to mid-pregnancy, appear to increase risk of PTB and SGA. Findings suggest an increased risk for LBW, but were less consistent. Methodological differences and limitations likely contributed to conflicting findings. A wide range of depression measures were used with the majority of studies utilizing measures not designed, or validated, for pregnant women. Studies failed to assess depression at multiple pregnancy time points, thus constraining the ability to assess the impact of duration and pattern of exposure to depression. Antidepressant use and co-morbid psychosocial factors were rarely considered as potential confounders or effect modifiers.

CONCLUSIONS

Studies suggest that depression during pregnancy may be an important risk factor for PTB and SGA, and possibly LBW. Improved study methodology is needed to elucidate the consequence of maternal depression on adverse birth outcomes.

The social determinants of infant mortality and birth outcomes in Western developed nations: a cross-country systematic review

Infant mortality (IM) and birth outcomes, key population health indicators, have lifelong implications for individuals, and are unequally distributed globally. Even among western industrialized nations, striking cross-country and within-country patterns are evident. We sought to better understand these variations across and within the United States of America (USA) and Western Europe (WE), by conceptualizing a social determinants of IM/birth outcomes framework, and systematically reviewing the empirical literature on hypothesized social determinants (e.g., social policies, neighbourhood deprivation, individual socioeconomic status (SES)) and intermediary determinants (e.g., health behaviours). To date, the evidence suggests that income inequality and social policies (e.g., maternal leave policies) may help to explain cross-country variations in IM/birth outcomes. Within countries, the evidence also supports neighbourhood SES (USA, WE) and income inequality (USA) as social determinants. By contrast, within-country social cohesion/social capital has been underexplored. At the individual level, mixed associations have been found between individual SES, race/ethnicity, and selected intermediary factors (e.g., psychosocial factors) with IM/birth outcomes. Meanwhile, this review identifies several methodological gaps, including the underuse of prospective designs and the presence of residual confounding in a number of studies. Ultimately, addressing such gaps including through novel approaches to strengthen causal inference and implementing both health and non-health policies may reduce inequities in IM/birth outcomes across the western developed world.

Effect of the healthy MOMs lifestyle intervention on reducing depressive symptoms among pregnant Latinas

Depression during the prenatal and postpartum periods is associated with poor maternal, perinatal and child outcomes. This study examines the effectiveness of a culturally and linguistically tailored, social support-based, healthy lifestyle intervention led by trained community health workers in reducing depressive symptoms among pregnant and early postpartum Latinas. A sample of 275 pregnant Latinas was randomized to the Healthy MOMs Healthy Lifestyle Intervention (MOMs) or the Healthy Pregnancy Education (control) group. More than one-third of participants were at risk for depression at baseline. MOMs participants were less likely than control group participants to be at risk for depression at follow-up. Between baseline and 6 weeks postpartum, MOMs participants experienced a significant decline in depressive symptoms; control participants experienced a marginally significant decline. For MOMs participants, most of this decline occurred during the pregnancy intervention period, a time when no change occurred for control participants. The change in depressive symptoms during this period was greater among MOMs than control participants ("intervention effect"). From baseline to postpartum, there was a significant intervention effect among non-English-speaking women only. These findings provide evidence that a community-planned, culturally tailored healthy lifestyle intervention led by community health workers can reduce depressive symptoms among pregnant, Spanish-speaking Latinas.

Depression and serotonin reuptake inhibitor treatment as risk factors for preterm birth

BACKGROUND

Major depressive disorder and the use of serotonin reuptake inhibitors (SRIs) in pregnancy have been associated with preterm birth. Studies that have attempted to separate effects of illness from treatment have been inconclusive. We sought to explore the separate effects of SRI use and major depressive episodes in pregnancy on risk of preterm birth.

METHODS

We conducted a prospective cohort study of 2793 pregnant women, oversampled for a recent episode of major depression or use of an SRI. We extracted data on birth outcomes from hospital charts and used binary logistic regression to model preterm birth (<37 weeks' gestation). We used ordered logistic regression to model early (<34 weeks' gestation) or late (34-36 weeks) preterm birth, and we used nominal logistic regression to model preterm birth antecedents (spontaneous preterm labor/preterm premature rupture of membranes/preterm for medical indications/term).

RESULTS

Use of an SRI, both with (odds ratio = 2.1 [95% confidence interval = 1.0-4.6]) and without (1.6 [1.0-2.5]) a major depressive episode, was associated with preterm birth. A major depressive episode without SRI use (1.2 [0.68-2.1]) had no clear effect on preterm birth risk. None of these exposures was associated with early preterm birth. Use of SRIs in pregnancy was associated with increases in spontaneous but not medically indicated preterm birth.

CONCLUSIONS

SRI use increased risk of preterm birth. Although the effect of a major depressive episode alone was unclear, symptomatic women undergoing antidepressant treatment had elevated risk.

Depression in pregnancy, infant birth weight and DNA methylation of imprint regulatory elements

Depressed mood in pregnancy has been linked to low birth weight (LBW, < 2,500 g), a risk factor for adult-onset chronic diseases in offspring. We examined maternal depressed mood in relation to birth weight and evaluated the role of DNA methylation at regulatory sequences of imprinted genes in this association. We measured depressed mood among 922 pregnant women using the CES-D scale and obtained birth weight data from hospital records. Using bisulfite pyrosequencing of cord blood DNA from 508 infants, we measured methylation at differentially methylated regions (DMRs) regulating imprinted genes IGF2/H19, DLK1/MEG3, MEST, PEG3, PEG10/SGCE, NNAT and PLAGL1. Multiple regression models were used to examine the relationship between depressed mood, birth weight and DMR methylation levels. Depressed mood was associated with a more that 3-fold higher risk of LBW, after adjusting for delivery mode, parity, education, cigarette smoking, folic acid use and preterm birth. The association may be more pronounced in offspring of black women and female infants. Compared with infants of women without depressed mood, infants born to women with severe depressed mood had a 2.4% higher methylation at the MEG3 DMR. Whereas LBW infants had 1.6% lower methylation at the IGF2 DMR, high birth weight (> 4,500 g) infants had 5.9% higher methylation at the PLAGL1 DMR compared with normal birth weight infants. Our findings confirm that severe maternal depressed mood in pregnancy is associated with LBW, and that MEG3 and IGF2 plasticity may play important roles.

Late-preterm birth by delivery circumstance and its association with parent-reported attention problems in childhood

OBJECTIVE

Late-preterm birth (LPB, 34-36 wk) has been associated with an increased risk of attention problems in childhood relative to full-term birth (FTB, ≥37 wk), but little is known about factors contributing to this risk. The authors investigated the contributions of clinical circumstances surrounding delivery using follow-up data from the Pregnancy Outcomes and Community Health (POUCH) Study.

METHODS

Women who delivered late preterm or full term and completed the sex- and age-referenced Conners' Parent Rating Scales-Short Form: Revised were included in the present analysis (N = 762; children's age, 3-9 y). The Conners' Parent Rating Scales-Short Form: Revised measures dimensions of behavior linked to attention problems, including oppositionality, inattention, hyperactivity, and a global attention problem index. Using general linear models, the authors evaluated whether LPB subtype (medically indicated [MI] or spontaneous) was associated with these dimensions relative to FTB.

RESULTS

After adjustment for parity, sociodemographics, child age, and maternal symptoms of depression and serious mental illness during pregnancy and at the child survey, only MI LPB was associated with higher hyperactivity and global index scores (mean difference from FTB = 3.8 [95% confidence interval {CI}: 0.5, 7.0] and 3.1 [95% CI 0.0, 6.2]). These findings were largely driven by children between 6 and 9 years. Removal of women with hypertensive disorders during pregnancy (N = 85) or placental findings related to hypertensive conditions (obstruction, decreased maternal spiral artery conversion; N = 134) reduced the differences below significance thresholds.

CONCLUSIONS

Among LPBs, only MI LPB was associated with higher levels of parent-reported childhood attention problems, suggesting that complications motivating medical intervention during the late-preterm period mark increased risk for such problems. Hypertensive disorders seem to play a role in these associations.

The use of psychosocial stress scales in preterm birth research

Psychosocial stress has been identified as a potential risk factor for preterm birth. However, an association has not been found consistently, and a consensus on the extent to which stress and preterm birth are linked is still lacking. A literature search was performed with a combination of keywords and MeSH terms to detect studies of psychosocial stress and preterm birth. Studies were included in the review if psychosocial stress was measured with a standardized, validated instrument and if the outcomes included either preterm birth or low birthweight. Within the 138 studies that met inclusion criteria, 85 different instruments were used. Measures that had been designed specifically for pregnancy were used infrequently, although scales were sometimes modified for the pregnant population. The many different measures that have been used may be a factor that accounts for the inconsistent associations that have been observed.

Association between maternal comorbidity and preterm birth by severity and clinical subtype: retrospective cohort study

Background

Preterm birth (PTB) is a major cause of infant morbidity and mortality, but the relationship between comorbidity and PTB by clinical subtype and severity of gestational age remains poorly understood. We evaluated associations between maternal comorbidities and PTB by clinical subtype and gestational age.

Methods

We conducted a retrospective cohort study of 1,329,737 singleton births delivered in hospitals in the province of Québec, Canada, 1989-2006. PTB was classified by clinical subtype (medically indicated, preterm premature rupture of membranes (PPROM), spontaneous preterm labour) and gestational age (< 28, 28-31, 32-36 completed weeks). Odds ratios (OR) of PTB by clinical subtype for systemic and localized maternal comorbidities were estimated using polytomous logistic regression, adjusting for maternal age, grand multiparity, and period. Attributable fractions were calculated.

Results

PTB rates were higher among mothers with comorbidity (10.9%) compared to those without comorbidity (4.7%). Several comorbidities were associated with greater odds of medically indicated PTB compared with no comorbidity, but only comorbidities localized to the reproductive system were associated with spontaneous PTB. Drug dependence and mental disorders were strongly associated with PPROM and spontaneous PTBs across all gestational ages (OR > 2.0). At the population level, several major comorbidities (placental abruption, chorioamnionitis, oliogohydramnios, structural abnormality, cervical incompetence) were key contributors to all clinical subtypes of PTB, especially at < 32 weeks. Major systemic comorbidities (preeclampsia, anemia) were key contributors to PPROM and medically indicated PTBs.

Conclusions

The relationship between comorbidity and clinical subtypes of PTB depends on gestational age. Prevention of PPROM and spontaneous PTB may benefit from greater attention to preeclampsia, anemia and comorbidities localized to the reproductive system.

Risk of placental abruption in relation to maternal depressive, anxiety and stress symptoms

BACKGROUND

Little is known about the influence of psychiatric factors on the etiology of placental abruption (PA), an obstetrical condition that complicates 1-2% of pregnancies. We examined the risk of PA in relation to maternal psychiatric symptoms during pregnancy.

METHODS

This case-control study included 373 PA cases and 368 controls delivered at five medical centers in Lima, Peru. Depressive, anxiety and stress symptoms were assessed using the Patient Health Questionnaire (PHQ-9) and the Depression Anxiety Stress Scales (DASS-21). Multivariable logistic regression models were fit to calculate odds ratios (aOR) and 95% confidence intervals (CI) adjusted for confounders.

RESULTS

Depressive symptoms of increasing severity (using the DASS depression subscale) was associated with PA (p for trend=0.02). Compared with women with no depressive symptoms, the aOR (95%CI) for PA associated with each level of severity of depression symptoms based on the DASS assessment were as follows: mild 1.84 (0.91-3.74); moderate 1.25 (0.67-2.33); and severe 4.68 (0.98-22.4). The corresponding ORs for mild, moderate, and moderately severe depressive symptoms based on the PHQ assessment were 1.10 (0.79-1.54), 3.31 (1.45-7.57), and 5.01 (1.06-23.6), respectively. A positive gradient was observed for the odds of PA with severity of anxiety (p for trend=0.002) and stress symptoms (p for trend=0.002).

LIMITATIONS

These cross-sectionally collected data may be subject to recall bias.

CONCLUSIONS

Maternal psychiatric disorders may be associated with an increased occurrence of AP. Larger studies that allow for more precise evaluations of maternal psychiatric health in relation to PA risk are warranted.

Dispensing patterns and pregnancy outcomes for women dispensed selective serotonin reuptake inhibitors in pregnancy

BACKGROUND

The safety of selective serotonin reuptake inhibitors (SSRIs) during pregnancy remains uncertain. The purpose of this study was to investigate dispensing patterns and pregnancy outcomes for women dispensed an SSRI in pregnancy.

METHODS

Using data linkage of population-based health datasets from Western Australia and a national pharmaceutical claims dataset, our study included 123,405 pregnancies from 2002 to 2005. There were 3764 children born to 3703 women who were dispensed an SSRI during their pregnancy.

RESULTS

A total of 42.3% of the women were dispensed an SSRI in each trimester, and 97.6% of the women used the same SSRI throughout the first trimester without switching. The women who were dispensed an SSRI were more likely to give birth prematurely (adjusted odds ratio [aOR], 1.4; 95% confidence interval [CI], 1.2-1.7), to have smoked during the pregnancy (OR, 1.9; 95% CI, 1.8-2.1), and parity>1 (OR, 1.7; 95% CI, 1.5-1.8). The singletons were found to have a lower birth weight than expected when other factors were taken into account (OR, 1.2; 95% CI, 1.1-1.3). There was an increased risk of major cardiovascular defects (OR, 1.6; 95% CI, 1.1-2.3). The children of women dispensed citalopram during the first trimester had an increased risk of vesicoureteric reflux (OR, 3.1; 95% CI, 1.3-7.6). Children born to women dispensed sertraline had a higher mean birth weight than those born to women dispensed citalopram, paroxetine, or fluoxetine. This pattern was also seen in birth length.

CONCLUSIONS

Most women were dispensed the same SSRI throughout their pregnancy. We have confirmed previous findings with an increased risk of cardiovascular defects and preterm birth. New findings requiring confirmation include an increased risk of vesicoureteric reflux with the use of citalopram.

A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction

CONTEXT

Maternal depressive symptoms during pregnancy have been reported in some, but not all, studies to be associated with an increased risk of preterm birth (PTB), low birth weight (LBW), and intrauterine growth restriction (IUGR).

OBJECTIVE

To estimate the risk of PTB, LBW, and IUGR associated with antenatal depression.

DATA SOURCES AND STUDY SELECTION

We searched for English-language and non-English-language articles via the MEDLINE, PsycINFO, CINAHL, Social Work Abstracts, Social Services Abstracts, and Dissertation Abstracts International databases (January 1980 through December 2009). We aimed to include prospective studies reporting data on antenatal depression and at least 1 adverse birth outcome: PTB (<37 weeks' gestation), LBW (<2500 g), or IUGR (<10th percentile for gestational age). Of 862 reviewed studies, 29 US-published and non-US-published studies met the selection criteria.

DATA EXTRACTION

Information was extracted on study characteristics, antenatal depression measurement, and other biopsychosocial risk factors and was reviewed twice to minimize error.

DATA SYNTHESIS

Pooled relative risks (RRs) for the effect of antenatal depression on each birth outcome were calculated using random-effects methods. In studies of PTB, LBW, and IUGR that used a categorical depression measure, pooled effect sizes were significantly larger (pooled RR [95% confidence interval] = 1.39 [1.19-1.61], 1.49 [1.25-1.77], and 1.45 [1.05-2.02], respectively) compared with studies that used a continuous depression measure (1.03 [1.00-1.06], 1.04 [0.99-1.09], and 1.02 [1.00-1.04], respectively). The estimates of risk for categorically defined antenatal depression and PTB and LBW remained significant when the trim-and-fill procedure was used to correct for publication bias. The risk of LBW associated with antenatal depression was significantly larger in developing countries (RR = 2.05; 95% confidence interval, 1.43-2.93) compared with the United States (RR = 1.10; 95% confidence interval, 1.01-1.21) or European social democracies (RR = 1.16; 95% confidence interval, 0.92-1.47). Categorically defined antenatal depression tended to be associated with an increased risk of PTB among women of lower socioeconomic status in the United States.

CONCLUSIONS

Women with depression during pregnancy are at increased risk for PTB and LBW, although the magnitude of the effect varies as a function of depression measurement, country location, and US socioeconomic status. An important implication of these findings is that antenatal depression should be identified through universal screening and treated.

Levels of maternal serum corticotropin-releasing hormone (CRH) at midpregnancy in relation to maternal characteristics

BACKGROUND

Corticotropin-releasing hormone (CRH) in maternal blood originates primarily from gestational tissues and elevated levels in midpregnancy have been linked to adverse pregnancy outcomes. Investigators have hypothesized that high levels of maternal stress might lead to elevated CRH levels in pregnancy. Yet a few studies have measured maternal CRH levels among subgroups of women who experience disproportionate socioeconomic disadvantage, such as African-American and Hispanic women, and found that these groups have lower CRH levels in pregnancy. Our goal was to identify maternal characteristics related to CRH levels in midpregnancy and examine which if any of these factors help to explain race differences in CRH levels.

METHODS

The Pregnancy Outcomes and Community Health (POUCH) Study prospectively enrolled women at 15-27 weeks' gestation from 52 clinics in five Michigan communities (1998-2004). Data from the POUCH Study were used to examine maternal demographics, anthropometrics, health behaviors, and psychosocial factors (independent variables) in relation to midpregnancy blood CRH levels modeled as logCRHpg/ml (dependent variable). Analyses were conducted within a sub-cohort from the POUCH Study (671 non-Hispanic Whites, 545 African-Americans) and repeated in the sub-cohort subset with uncomplicated pregnancies (n=746). Blood levels of CRH and independent variables were ascertained at the time of enrollment. All regression models included week of enrollment as a covariate. In addition, final multivariate regression models alternately incorporated different psychosocial measures along with maternal demographics and weight. Psychosocial variables included measures of current depressive symptoms, perceived stress, coping style, hostility, mastery, anomie, and a chronic stressor (history of abuse as a child and adult).

RESULTS

In sub-cohort models, the adjusted mean log CRH level was significantly lower in African-Americans vs. non-Hispanic Whites; the difference was -0.48pg/ml (P<0.01). This difference was reduced by 21% (-0.38pg/ml, P<0.01) after inclusion of other relevant covariates. Adjusted mean log CRH levels were also lower among women with <12 years vs. >or=12 years of education (minimal difference=-0.19pg/ml, P<0.05), and among women with high levels of depressive symptoms who did not use antidepressants vs. women with lower levels of depressive symptoms and no antidepressant use (minimal difference=-0.13pg/ml, P<0.01). Log CRH levels were inversely associated with maternal weight (-0.03pg/ml per 10 pound increase, P<.05) but unrelated to smoking and all other psychosocial measures. Results were similar in the subset of women with uncomplicated pregnancies, except that lower CRH levels were also linked to higher perceived stress.

CONCLUSION

African-American women have lower blood CRH levels at midpregnancy and the race difference in CRH levels is reduced modestly after adjustment for other maternal characteristics. CRH levels were not elevated among women with high levels of perceived stress or more chronic stressors. The inverse association between CRH levels and maternal weight is likely due to a hemodilution effect. Relations among maternal CRH levels and maternal race, educational level, and depressive symptoms are difficult to explain and invite further investigation. Our results highlight a group of covariates that merit consideration in studies that address CRH in the context of pregnancy and/or post-partum complications.