Social support during pregnancy: effects on maternal depressive symptoms, smoking and pregnancy outcome

Paternal support and preterm birth, and the moderation of effects of chronic stress: a study in Los Angeles county mothers

Maternal psychosocial stress is an important risk factor for preterm birth, but support interventions have largely been unsuccessful. The objective of this study is to assess how support during pregnancy influences preterm birth risk and possibly ameliorates the effects of chronic stress, life event stress, or pregnancy anxiety in pregnant women. We examined 1,027 singleton preterm births and 1,282 full-term normal weight controls from a population-based retrospective case-control study of Los Angeles County, California women giving birth in 2003, a mostly Latina population (both US-born and immigrant). We used logistic regression to assess whether support from the baby's father during pregnancy influences birth outcomes and effects of chronic stress, pregnancy anxiety, and life event stress. Adjusted odds of preterm birth decreased with better support (OR 0.73 [95%CI 0.52, 1.01]). Chronic stress (OR 1.46 [95%CI 1.11, 1.92]), low confidence of a normal birth (OR 1.57 [95% CI 1.17, 2.12]), and fearing for the baby's health (OR 1.67 [95%CI 1.30, 2.14]) increased preterm birth risk, but life events showed no association. Our data also suggested that paternal support may modify the effect of chronic stress on the risk of preterm birth, such that among mothers lacking support, those with moderate-to-high stress were at increased odds of delivering preterm (OR 2.15 [95%CI 0.92, 5.03]), but women with greater support had no increased risk with moderate-to-high chronic stress (OR 1.13 [95%CI 0.94, 1.35]). Paternal support may moderate the effects of chronic stress on the risk of preterm delivery.

Depression during pregnancy in women with a medical disorder: risk factors and perinatal outcomes

BACKGROUND

Approximately one-fifth of women present depression during pregnancy and puerperium, and almost 13% of pregnant women experience a major depressive disorder.

OBJECTIVE

The aim of this study was to identify risk factors for depression among pregnant women with a medical disorder and to evaluate the influence of depression on perinatal outcomes.

METHODS

Three hundred and twenty-six pregnant women with a medical disorder were interviewed. A semistructured interview was conducted for each participant using a questionnaire that had been developed previously. Major depression was diagnosed using the Portuguese version of the Primary Care Evaluation of Mental Disorders (PRIME-MD). The medical records of the participants were thoroughly reviewed to evaluate the perinatal results.

RESULTS

Major depressive disorder was diagnosed in 29 cases (9.0%). The prevalence of major depression was as follows: 7.1% for preeclampsia or chronic hypertension, 12.1% for cardiac disorder, 7.1% for diabetes mellitus, 6.3% for maternal anemia, 8.3% for collagenosis and 12.5% for a high risk of premature delivery. An univariate analysis showed a significant positive correlation between an average household income below minimum wage and a PRIME-MD diagnosis of major depression. A multiple regression analysis identified unplanned pregnancy as an independent predictor of major depression (86.2% in the group with a diagnosis of major depression by PRIME-MD vs. 68.4% in the group without major depression). A comparison between women who presented major depression and those who did not revealed no significant differences in the perinatal results (i.e., preterm delivery, birth weight and low Apgar scores).

CONCLUSION

In the present study, unplanned pregnancy in women with a medical disorder was identified as a risk factor for major depression during gestation. Major depression during pregnancy in women with a medical disorder should be routinely investigated using specific methods.

Risk factors for depressive symptoms during pregnancy: a systematic review

The purpose of this study was to evaluate risk factors for antepartum depressive symptoms that can be assessed in routine obstetric care. We evaluated articles in the English-language literature from 1980 through 2008. Studies were selected if they evaluated the association between antepartum depressive symptoms and > or =1 risk factors. For each risk factor, 2 blinded, independent reviewers evaluated the overall trend of evidence. In total, 57 studies met eligibility criteria. Maternal anxiety, life stress, history of depression, lack of social support, unintended pregnancy, Medicaid insurance, domestic violence, lower income, lower education, smoking, single status, and poor relationship quality were associated with a greater likelihood of antepartum depressive symptoms in bivariate analyses. Life stress, lack of social support, and domestic violence continued to demonstrate a significant association in multivariate analyses. Our results demonstrate several correlates that are consistently related to an increased risk of depressive symptoms during pregnancy.

Maternal social support and neighborhood income inequality as predictors of low birth weight and preterm birth outcome disparities: analysis of South Carolina Pregnancy Risk Assessment and Monitoring System survey, 2000-2003

Effects of income inequality on health and other social systems have been a subject of considerable debate, but only a few studies have used multilevel models to evaluate these relationships. The main objectives of the study were to (1) Evaluate the relationships among neighborhood income inequality, social support and birth outcomes (low birth weight, and preterm delivery) and (2) Assess variations in racial disparities in birth outcomes across neighborhood contexts of income distribution and maternal social support. We evaluated these relationships by using South Carolina Pregnancy Risk Assessment and Monitoring System (PRAMS) survey for 2000-2003 geocoded to 2000 US Census data for South Carolina. Multilevel analysis was used to simultaneously evaluate the association between income inequality (measured as Gini), maternal social relationships and birth outcomes (low birth weight and preterm delivery). The results showed residence in neighborhoods with medium levels of income inequality was independently associated with low birth weight (OR: 2.00; 95% CI 1.14-3.26), but not preterm birth; low social support was an independent risk for low birth weight or preterm births. The evidence suggests that non-Hispanic black mothers were at increased risks of low birth weight or preterm birth primarily due to greater exposures of neighborhood deprivations associated with low income and reduced social support and modified by unequal income distribution.

Managing unipolar depression in pregnancy

PURPOSE OF REVIEW

The management of depression in pregnancy is complex, as it is based on balancing the risks with the benefits of treatment versus no treatment for both the mother and the fetus. The current literature in the field of reproductive psychiatry is difficult to navigate and at times contradictory. This article aims to review both nonpharmacological and pharmacological modalities in the treatment of perinatal depression. A literature review using PubMed and MEDLINE databases was used to collect literature from the past 2 years; however, given the relatively small amount of research in reproductive psychiatry, several salient articles from the past 5 years have also been included in this review.

RECENT FINDINGS

Recent US Food and Drug Administration and Health Canada warnings regarding poor neonatal adaptation and adverse perinatal outcomes associated with antidepressant use in pregnancy have changed patterns of practice for prescribing physicians. Many physicians are now left with a sense of indecisiveness regarding the safety of treating their depressed, pregnant patients. Similarly, these warnings have changed patients' attitudes and their willingness to consider pharmacological treatment for depression. Although these warnings demand attention and careful consideration, research has also shown that exposure to mental illness in pregnancy has deleterious short-term and long-term effects for the exposed mother and fetus.

SUMMARY

The field of reproductive psychiatry is rapidly evolving. Clinicians need to keep abreast of changes in the management of depression during pregnancy. Ongoing research in this field is important so that the most up-to-date recommendations may be provided to pregnant women.

Early risk factors for miscarriage: a prospective cohort study in pregnant women

Many pregnancies are lost during early gestation, but clinicians still lack tools to recognize risk factors for miscarriage. Thus, the identification of risk factors for miscarriage during the first trimester in women with no obvious risk for a pregnancy loss was the aim of this prospective cohort trial. A total of 1098 women between gestation weeks 4 and 12 in whom no apparent signs of a threatened pregnancy could be diagnosed were recruited. Demographic, anamnestic, psychometric and biological data were documented at recruitment and pregnancy outcomes were registered subsequently. Among the cases with sufficiently available data, 809 successfully progressing pregnancies and 55 subsequent miscarriages were reported. In this cohort, risk of miscarriage was significantly increased in women at higher age (>33 years), lower body mass index (< or =20 kg/ m(2)) and lower serum progesterone concentrations (< or =12 ng/ml) prior to the onset of the miscarriage. Women with subsequent miscarriage also perceived higher levels of stress/demands (supported by higher concentrations of corticotrophin-releasing hormone) and revealed reduced concentrations of progesterone-induced blocking factor. These risk factors were even more pronounced in the subcohort of women (n = 335) recruited between gestation weeks 4 and 7. The identification of these risk factors and development of an interaction model of these factors, as introduced in this article, will help clinicians to recognize pregnant women who require extra monitoring and who might benefit from therapeutic interventions such as progestogen supplementation, especially during the first weeks of pregnancy, to prevent a miscarriage.

Social support and resilience to stress across the life span: a neurobiologic framework

This review discusses selected neurobiologic and genetic factors-including noradrenergic and hypothalamic-pituitary-adrenal axis markers, oxytocin pathways, and serotonin transporter and brain-derived neurotrophic factor gene polymorphisms-in the context of resilience to stress, with an emphasis on social support. Social support's impact on medical and psychiatric health outcomes is reviewed, and putative mediators are discussed. The reviewed literature indicates that social support is exceptionally important to maintaining good physical and psychological health in the presence of genetic, developmental, and other environmental risks. Future studies should continue to explore the neurobiologic factors associated with social support's contribution to stress resilience.

Determinants of low birth weight in urban Pakistan

OBJECTIVE

To identify determinants of low birth weight (LBW) in Karachi, Pakistan, including environmental exposures and nutritional status of the mother during pregnancy.

DESIGN

Cross-sectional study.ParticipantsFive hundred and forty mother-infant pairs. We interviewed mothers about obstetric history, diet and exposure to Pb. We measured birth weight and blood lead level (BLL). We performed multiple log binomial regression analysis to identify factors related to LBW.

RESULTS

Of 540 infants, 100 (18.5 %) weighed <or=2.5 kg. Umbilical cord BLL was not significantly associated with LBW. Maternal poor self-rated health (adjusted prevalence ratio (adjPR) = 1.83; 95 % CI 1.09, 3.07) and none or one prenatal visit (adjPR = 2.18; 95 % CI 1.39, 3.43) were associated with LBW. A statistically significant interaction between mothers' mid upper-arm circumference (MUAC) and dietary vitamin C intake was noted. Compared with mothers with MUAC above the median and dietary vitamin C intake above the 3rd quartile (>208.7 mg/d), infants of mothers with MUAC less than or equal to the median and dietary vitamin C intake >208.7 mg/d (adjPR = 10.80; 95 % CI 1.46, 79.76), mothers with MUAC above the median and vitamin C intake <or=208.7 mg/d (adjPR = 10.67; 95 % CI 1.50, 76.02) and mothers with MUAC less than or equal to the median and vitamin C intake <or=208.7 mg/d (adjPR = 13.19; 95 % CI 1.85, 93.79) more likely to give birth to an LBW infant.

CONCLUSIONS

In Pakistan, poor nutritional status and inadequate prenatal care were major determinants of LBW in this setting. Environmental factors including umbilical cord BLL were not significantly associated with LBW.

Reduced infant birthweight consequent upon maternal exposure to severe life events

OBJECTIVE

To investigate the association between maternal exposure to severe life events and fetal growth (birthweight and small for gestational age). Stress has been associated with adverse pregnancy outcome.

METHODS

Mothers of 1.38 million singleton live births in Denmark between January 1, 1979 and December 31, 2002 were linked to information on their spouses, parents, siblings, and older children. Exposure was defined as death or serious illness in a relative during pregnancy or in the 6 months before conception. Linear regression was used to examine the effect of exposure on birthweight. Log-linear binomial regression was used to assess the effect of exposure on small for gestational age.

RESULTS

Death of a relative during pregnancy or in the 6 months before conception reduced birthweight by 27 g (adjusted estimate -27 g, 95% Confidence Interval (CI) = -33, -22). There was a significant association between maternal exposure to death of a relative and risk of a baby weighing below the 10th percentile (adjusted relative risk (RR) = 1.17, 95% CI = 1.13, 1.22) and 5th percentile (adjusted RR = 1.22, 95% CI = 1.15, 1.29).

CONCLUSIONS

Mothers exposed to severe life events before conception or during pregnancy have babies with significantly lower birthweight. If this association is causal, the potential mechanisms of stress-related effects on birthweight include changes in lifestyle due to the exposure and stress-related dysregulation of the hypothalamic-pituitary-adrenal axis during pregnancy.

If nicotine is a developmental neurotoxicant in animal studies, dare we recommend nicotine replacement therapy in pregnant women and adolescents?

Tobacco use in pregnancy is a leading cause of perinatal morbidity and contributes in major ways to attention deficit hyperactivity disorder, conduct disorders and learning disabilities that emerge in childhood and adolescence. Over the past two decades, animal models of prenatal nicotine exposure have demonstrated that nicotine is a neurobehavioral teratogen that disrupts brain development by preempting the natural, neurotrophic roles of acetylcholine. Through its actions on nicotinic cholinergic receptors, nicotine elicits abnormalities of neural cell proliferation and differentiation, promotes apoptosis and produces deficits in the number of neural cells and in synaptic function. The effects eventually compromise multiple neurotransmitter systems because of the widespread regulatory role of cholinergic neurotransmission. Importantly, the long-term alterations include effects on reward systems that reinforce the subsequent susceptibility to nicotine addiction in later life. These considerations strongly question the appropriateness of nicotine replacement therapy (NRT) for smoking cessation in pregnant women, especially as the pharmacokinetics of the transdermal patch may actually enhance fetal nicotine exposure. Further, because brain maturation continues into adolescence, the period when smoking typically commences, adolescence is also a vulnerable period in which nicotine can change the trajectory of neurodevelopment. There are also serious questions as to whether NRT is actually effective as an aid to smoking cessation in pregnant women and adolescents. This review considers the ramifications of the basic science findings of nicotine's effects on brain development for NRT in these populations.

Stress and reproductive failure: past notions, present insights and future directions

PROBLEM

Maternal stress perception is frequently alleged as a cause of infertility, miscarriages, late pregnancy complications or impaired fetal development. The purpose of the present review is to critically assess the biological and epidemiological evidence that considers the plausibility of a stress link to human reproductive failure.

METHODS

All epidemiological studies published between 1980 and 2007 that tested the link between stress exposure and impaired reproductive success in humans were identified. Study outcomes were evaluated on the basis of how associations were predicted, tested and integrated with theories of etiology arising from recent scientific developments in the basic sciences. Further, published evidence arising from basic science research has been assessed in order to provide a mechanistic concept and biological evidence for the link between stress perception and reproductive success.

RESULTS

Biological evidence points to an immune-endocrine disequilibrium in response to stress and describes a hierarchy of biological mediators involved in a stress trigger to reproductive failure. Epidemiological evidence presents positive correlations between various pregnancy failure outcomes with pre-conception negative life events and elevated daily urinary cortisol. Strikingly, a relatively new conceptual approach integrating the two strands of evidence suggests the programming of stress susceptibility in mother and fetus via a so-called pregnancy stress syndrome.

CONCLUSIONS

An increasing specificity of knowledge is available about the types and impact of biological and social pathways involved in maternal stress responses. The present evidence is sufficient to warrant a reconsideration of conventional views on the etiology of reproductive failure. Physicians and patients will benefit from the adaptation of this integrated evidence to daily clinical practice.