Risk factors for postpartum depression among abused and nonabused women

The Social Context of Pregnancy, Respectful Maternity Care, Biomarkers of Weathering, and Postpartum Mental Health Inequities: A Scoping Review

Background: Mental health disorders are the number one cause of maternal mortality and a significant maternal morbidity. This scoping review sought to understand the associations between social context and experiences during pregnancy and birth, biological indicators of stress and weathering, and perinatal mood and anxiety disorders (PMADs). Methods: A scoping review was performed using PRISMA-ScR guidance and JBI scoping review methodology. The search was conducted in OVID Medline and Embase. Results: This review identified 74 eligible English-language peer-reviewed original research articles. A majority of studies reported significant associations between social context, negative and stressful experiences in the prenatal period, and a higher incidence of diagnosis and symptoms of PMADs. Included studies reported significant associations between postpartum depression and prenatal stressors (n = 17), socioeconomic disadvantage (n = 14), negative birth experiences (n = 9), obstetric violence (n = 3), and mistreatment by maternity care providers (n = 3). Birth-related post-traumatic stress disorder (PTSD) was positively associated with negative birth experiences (n = 11), obstetric violence (n = 1), mistreatment by the maternity care team (n = 1), socioeconomic disadvantage (n = 2), and prenatal stress (n = 1); and inverse association with supportiveness of the maternity care team (n = 5) and presence of a birth companion or doula (n = 4). Postpartum anxiety was significantly associated with negative birth experiences (n = 2) and prenatal stress (n = 3). Findings related to associations between biomarkers of stress and weathering, perinatal exposures, and PMADs (n = 14) had mixed significance. Conclusions: Postpartum mental health outcomes are linked with the prenatal social context and interactions with the maternity care team during pregnancy and birth. Respectful maternity care has the potential to reduce adverse postpartum mental health outcomes, especially for persons affected by systemic oppression.

Antenatal depression across trimesters as a risk for postpartum depression and estimation of the fraction of postpartum depression attributable to antenatal depression: A systematic review and meta-analysis of cohort studies

OBJECTIVE

This meta-analysis aimed at estimating the prevalence of postpartum depression (PPD) at different postpartum timepoints in women with antenatal depression (AD) in the three trimesters. We also examined the association between AD and PPD, and estimated the population attributable fraction of PPD to AD.

METHODS

This systematic review and meta-analysis identified cohort studies that determined the prevalence of PPD in women who had AD, and those that examined the association between AD and PPD from PubMed, Embase, MEDLINE, CINAHL and PsycINFO. Articles were appraised using the modified Newcastle Ottawa Scale and data were analyzed using Comprehensive Meta-Analysis.

RESULTS

Eighty-eight (88) cohort studies with a combined sample size of 1,042,448 perinatal women contributed to the meta-analysis. About 37% pregnant women who had AD, later had PPD. Those with AD had four times higher odds of developing PPD (OR: 4.58; 95% CI = 3.52-5.96). The odds of having PPD were higher when AD was observed in the first or third trimester compared to the second trimester. About 12.8% of PPD cases were attributable to AD.

CONCLUSION

The findings should inform future clinical guidelines on the screening, the frequency of screening, and follow-up care in maternal-mental health.

Obstetric violence in southwestern Turkey: Risk factors and its relationship to postpartum depression

This study was conducted to determine the relationship between violence, risk factors, and depression at the end of pregnancy. The sample of this descriptive and cross-sectional study consisted of 426 women for normal postpartum monitoring during the six-month period and living in southwestern Turkey of the study. About 5.6% of the women who participated in the study were exposed to obstetric violence. 5.2% of them were intimate partner violence before pregnancy. 79.1% (n = 24), 29.1%, and 25% of them were subjected to physical, sexual, and economic violence, respectively. In addition, 7.5% of women were exposed to verbal obstetric violence. It was found that the postpartum depression scores of the women who had been subjected to violence from their husbands before pregnancy were high.

Interpersonal Violence Around Pregnancy Experienced by Rural and Urban Canadian Women: Correlates and Selected Health Outcomes

Interpersonal violence around pregnancy is of increasing global public health concern affecting both women themselves and their children. The primary aim of this study is to explore and identify potential correlates of such violence and to examine maternal and birth outcomes subsequent to that violence in a nationally representative sample of urban and rural women in Canada. The data are from the Maternity Experiences Survey (MES), a Canadian population-based postcensus survey administered to 6,421 Canadian mothers in 2006. Survey participants were 15 years and older and had given birth to a singleton and continued to live with their infant at the time of the survey. The survey response rate was 78%. Multivariable logistic regression analyses were used in the analysis with adjustments made for confounding variables. The study findings indicated that living in an urban environment was associated with an increased risk of interpersonal violence experience around the time of pregnancy (OR = 1.31, 95% CI: 1.03-1.66). In addition, being aboriginal, young, unmarried, economically disadvantaged, a nonimmigrant, and having more than four pregnancies, as well as cigarette smoking, alcohol drinking and drug use before the pregnancy were correlated with interpersonal violence around pregnancy. Maternal interpersonal violence experiences were also associated with postnatal depression and stressful life events among both urban and rural mothers. However, maternal interpersonal violence experiences were only associated with preterm birth among rural mothers but not among urban mothers. The present study highlights the need to implement effective interventions for women experiencing interpersonal violence around pregnancy due to its potential impact on maternal and newborn's physical and mental health. Screening and intervention should be targeted high-risk women particularly those who are indigenous, young, unmarried, nonimmigrants, of lower socioeconomic status, and manifesting high risk health behaviors.

Screening for intimate partner violence in the early postpartum period: Maternal and child health and social outcomes from birth to 5-years post-delivery

BACKGROUND

Intimate partner violence (IPV) during pregnancy is a substantial public health concern, yet little is known about the developmental trajectory of these women and their children after birth.

OBJECTIVE

The objective was to examine maternal and child health as well as social outcomes from birth to 5-years post-delivery associated with a positive (vs. negative) maternal IPV screen around the time of delivery.

PARTICIPANTS AND SETTING

Manitoban women giving birth to a live singleton infant from January 1, 2003 to December 31, 2006 were followed from birth to 5-years post-delivery (analytic sample: N = 40,051).

METHODS

Administrative databases from the Manitoba Centre for Health Policy provided data for the study. Descriptive statistics and logistic regression were used to examine relationships between IPV screen response around the time of birth (i.e., current, or history of, violence between parenting partners) with maternal and child health as well as social outcomes.

RESULTS

Women screening positive for IPV had increased odds of diagnosed mood/anxiety disorders, personality disorders, substance use disorders, diabetes, respiratory morbidity, and intentional/non-intentional injury hospitalizations (adjusted odds ratio [AOR] range 1.81-5.59, p < .01). Children of women screening positive for IPV had increased odds of diagnosed attention deficit-hyperactivity disorder, lower respiratory infections, and injury hospitalizations (AOR range 1.53-2.00, p < .01), child welfare organization contact (AOR = 8.84, p <  .01), and of being more developmentally vulnerable at kindergarten across domains of functioning (AOR range 1.69-1.93, p <  .01) than children of mothers screening negative for IPV.

CONCLUSION

A positive IPV screen was associated with poorer maternal and child health, increased child and family services contact, and children being more developmentally vulnerable in the 5-years after delivery.

Maternal violence experiences and risk of postpartum depression: A meta-analysis of cohort studies

BACKGROUND

Most of original studies indicated maternal violence experiences is associated with adverse obstetric outcomes, to date, but it is not clear that the association of maternal violence experiences and the risk of postpartum depression (PPD). We aimed to assess the association between maternal violence experiences and risk of developing PPD by performing a meta-analysis of cohort studies.

METHODS

PubMed, Google Scholar, Cochrane Libraries and Chinese databases were searched through December 2017 to identify studies that assessed the association between violence and PPD. Meta-analysis was conducted by the RevMan software and Stata software. Potential heterogeneity source was explored by subgroup analysis and potential publication bias was assessed by Begg's funnel plots and Egger's linear regression test.

RESULTS

Overall, women experiencing any violence events compared with the reference group were at a higher risk of developing PPD (odds ratio [OR] = 2.04; 95% confidence interval [CI]: 1.72-2.41). Additionally, different types of violence events such as sexual (OR = 1.56; 95%CI: 1.35-1.81), emotional (OR = 1.75; 95%CI: 1.61-1.89), and physical violence (OR = 1.90; 95%CI: 1.36-2.67), as well as domestic (OR = 2.05; 95%CI: 1.50-2.80) or childhood violence (OR = 1.59; 95%CI: 1.34-1.88) also increased the risk of developing PPD. Relevant heterogeneity moderators have been identified by subgroup analysis. Sensitivity analysis yielded consistent results.

CONCLUSIONS

Maternal violence experiences are significantly associated with risk of developing PPD. These finding highlight the necessary to protect women from any types of violence and formulate preventive strategies to promote the maternal mental health.

Luteinizing hormone-follicle stimulating hormone ratio as biological predictor of post-partum depression

BACKGROUND

Post-partum depression (PPD) is the common adverse outcome of child bearing which affects the wellbeing of both mother and newborn and has long-term effects. Hence, reliable potential biological tests for early detection of PPD are essential. Follicle stimulating hormone (FSH) and luteinizing hormone (LH) were associated with depressive disorders and the present study estimated the levels of serum FSH, LH in postpartum depression and explored them as predictive biomarkers in the development of PPD.

METHODS

In this nested case control study done at a tertiary care hospital in South India, 450 postpartum women were screened at 6th week post-delivery for PPD. Socio-demographic and clinical data were recorded and depressive symptoms were assessed using Edinburgh Postnatal Depression Scale (EPDS). Out of 450 subjects screened, 100 women with depressive symptoms were categorized as cases and 100 controls were selected from the remaining subjects matching for age and BMI with cases. Serum levels of FSH and LH were measured using direct competitive immunoassay by chemiluminescene technology.

RESULTS

Serum LH/FSH ratio was found to be significantly (p=0.02) low in PPD women when compared to normal postpartum subjects. We also found a significant negative correlation between LH/FSH ratio and EPDS scores. Based on the receiver operating characteristic curve, the optimal cut-off value for serum of LH/FSH levels in predicting postpartum depression was estimated to be 0.22mlU/mL with an AUC of 0.598 (95%CI, 0.291-0.859).

CONCLUSION

Our study demonstrated that low LH/FSH ratio after delivery was associated with increased risk for the development of PPD. Low LH/FSH ratio at six-week post delivery can be used as a robust biochemical predictor of post-partum depression.

Elevated levels of Hs-CRP and IL-6 after delivery are associated with depression during the 6 months post partum

The objective of this study is to determine whether inflammatory markers (high-sensitivity C-reactive protein (Hs-CRP) and interleukin (IL)-6) early in the postpartum period contribute to the development of postpartum depression (PPD). From 4 May 2014 to 30 June 2014, all eligible women not on medication for depression giving birth at the Beijing Chao-Yang hospital were consecutively recruited and followed up for 6 months. Depression symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS), and inflammatory biomarkers (Hs-CRP and IL-6) were tested. During the study period, 296 women were enrolled and completed follow-up. In these women, 45 (15.2%) were considered as meeting the criteria for PPD. Serum levels of Hs-CRP and IL-6 in women with PPD were significantly higher than those without PPD (all P<0.0001). Receiver operating characteristics to predict PPD demonstrated areas under the curve of IL-6 of 0.861 (95% confidence interval (CI), 0.801-0.922), which was superior to Hs-CRP (0.837 (95% CI, 0.781-0.894), P<0.01). In multivariate logistic regression analysis, IL-6 and Hs-CRP were independent predictors of PPD. The present study demonstrates a strong relationship between elevated serum Hs-CRP and IL-6 levels at admission and the development of PPD within 6 months.

High-frequency intimate partner violence during pregnancy, postnatal depression and suicidal tendencies in Harare, Zimbabwe

INTRODUCTION

Intimate partner violence (IPV) is a common form of violence experienced by pregnant women and is believed to have adverse mental health effects postnatally. This study investigated the association of postnatal depression (PND) and suicidal ideation with emotional, physical and sexual IPV experienced by women during pregnancy.

METHODS

Data were collected from 842 women interviewed postnatally in six postnatal clinics in Harare, Zimbabwe. We used the World Health Organization versions of IPV and Centre for Epidemiological Studies - Depression Scale measures to assess IPV and PND respectively. We derived a violence severity variable and combined forms of IPV variables from IPV questions. Logistic regression was used to analyse data whilst controlling for past mental health and IPV experiences.

RESULTS

One in five women [21.4% (95% CI 18.6-24.2)] met the diagnostic criteria for PND symptomatology whilst 21.6% (95% CI 18.8-24.4) reported postpartum suicide thoughts and 4% (95% CI 2.7-5.4) reported suicide attempts. Two thirds (65.4%) reported any form of IPV. Although individual forms of severe IPV were associated with PND, stronger associations were found between PND and severe emotional IPV or severe combined forms of IPV. Suicidal ideation was associated with emotional IPV. Other forms of IPV, except when combined with emotional IPV, were not individually associated with suicidal ideation.

CONCLUSION

Emotional IPV during pregnancy negatively affects women's mental health in the postnatal period. Clinicians and researchers should include it in their conceptualisation of violence and health. Further research must look at possible indirect relationships between sexual and physical IPV on mental health.

Intimate partner violence and psychosocial health, a cross-sectional study in a pregnant population

BACKGROUND

The objective of this paper is to explore whether IPV 12 months before and/or during pregnancy is associated with poor psychosocial health.

METHODS

From June 2010 to October 2012, a cross-sectional study was conducted in 11 antenatal care clinics in Belgium. Consenting pregnant women were asked to complete a questionnaire on socio-demographics, psychosocial health and violence in a separate room. Overall, 2586 women were invited to participate and we were able to use data from 1894 women (73.2%) for analysis. Ethical clearance was obtained in all participating hospitals.

RESULTS

We found a significant correlation between IPV and poor psychosocial health: within the group of women who reported IPV, 53.2% (n = 118) had poor psychosocial health, as compared to 21% (n = 286) in the group of women who did not report IPV (P < 0.001). Lower psychosocial health scores were associated with increased odds of reporting IPV (aOR 1.55; 95% CI 1.39-1.72), with adjustments made for the language in which the questionnaire was filled out, civil/marital status, education and age. In other words, a decrease of 10 points on the psychosocial health scale (total of 140) increased the odds of reporting IPV by 55 %. When accounting for the 6 psychosocial health subscales, the analysis revealed that all subscales (depression, anxiety, self-esteem, mastery, worry and stress) are strongly correlated to reporting IPV. However, when accounting for all subscales simultaneously in a logistic regression model, only depression (aOR 0.87; 95 % CI 0.84-0.91) and stress (aOR 0.85; 95 % CI 0.77-095) remained significantly associated with IPV. The association between overall psychosocial health and IPV remained significant after adjusting for socio-demographic status.

CONCLUSION

Our research corroborated that IPV and psychosocial health are strongly associated. Due to the limitations of our study design, we believe that future research is needed to deepen understanding of the multitude of factors involved in the complex interactions between IPV and psychosocial health.

Association between serum 25-hydroxyvitamin D levels measured 24 hours after delivery and postpartum depression

OBJECTIVE

To assess the possible relationship between serum levels of 25[OH]D (25-hydroxyvitamin D) collected 24 hours after delivery and postpartum depression in a Chinese cohort sample.

DESIGN

Cohort study.

SETTING

One city hospital in Beijing, China.

POPULATION

Women delivering a full-term, singleton, live-born infant at one city hospital in Beijing between August 2013 and November 2013.

METHODS

Women were enrolled immediately postpartum. A blood sample was obtained 24-48 hours after childbirth to test serum levels of 25[OH]D. Participation consisted of a visit to an obstetric unit 3 months after delivery.

MAIN OUTCOME MEASURE

At 3 months' postpartum, women were screened for depression using the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome measure was a prespecified EPDS score of ≥12.

RESULTS

During the study period, 323 women were admitted. In all, 248 agreed to enrol and 213 completed 3 months' follow-up (21 were lost to follow-up and 14 withdrew). Of the 213 women who were included, 26 (12.2%) were considered to meet criteria for postpartum depression. Serum 25[OH]D levels in women with no postpartum depression were significantly higher than those in women with postpartum depression (P < 0.0001). Based on the receiver operating characteristic curve, the optimal cutoff value for serum 25[OH]D level as an indicator for screening for postpartum depression was estimated to be 10.2 ng/ml, with an area under the curve of 0.801 (95%CI 0.704-0.896). In multivariate analysis, there was an increased risk of postpartum depression associated with 25[OH]D levels ≤10.2 ng/ml (OR 7.17, 95%CI 3.81-12.94; P < 0.0001) after adjusting for possible confounders.

CONCLUSION

Our study demonstrated that lower serum 25[OH]D levels were associated with postpartum depression. This association was independent of other possible variables.

Adult physical, sexual, and emotional abuse and postpartum depression, a population based, prospective study of 53,065 women in the Norwegian Mother and Child Cohort Study

BACKGROUND

Postpartum depression (PPD) has detrimental consequences to the women, their infants and families. The aim of the present study was to assess the association between adult abuse and PPD.

METHODS

This study was based on data from 53,065 pregnant women in the Norwegian Mother and Child Cohort Study (MoBa), conducted by the Norwegian Institute of Public Health. Women were recruited through a postal invitation in relation to a routine ultra-sound invitation at week 18 of gestation. Exposure to adult emotional, sexual, physical abuse was based on self-report at week 30, also differentiating if the perpetrator was known or a stranger, and whether the abuse was recent or not (<12 month since abuse). PPD was measured with a four items version of the Edinburgh Postnatal Depression Scale (EDS) at six months postpartum. The associations between different types of adult abuse and PPD were performed with logistic regression, adjusting for age, parity, civil status, education, child abuse, social support, and depression prior to pregnancy.

RESULTS

Altogether, 11% had PPD, and 19% had been exposed to adult abuse. Women reporting adult abuse had an 80% increased fully adjusted odds of PPD (OR 1.8 95% CI 1.7-1.9) compared to non-abused women. There was a tendency towards higher odds of PPD for women reporting combinations of adult abuse (emotional, sexual and physical), as compared with those reporting sexual, emotional or physical abuse only. Exposure from known perpetrator was more strongly associated with PPD than exposure from an unknown perpetrator. Compared with women without adult abuse, the fully adjusted odds of PPD was 2.6 (95% CI 2.4-2.9) higher for women with any recent adult abuse and 1.5 (95% CI 1.5-1.7) higher for women with any adult abuse, but not recent.

CONCLUSIONS

The results from this large prospective population-based cohort study support initiatives aiming to assess and adequately address abuse when counseling and treating women of PPD.

Perinatal psychiatric disorders: an overview

Perinatal mental illness has a significant implication on maternal health, birth outcomes, and the offspring's development. Prevalence estimates of perinatal psychiatric illnesses range widely, with substantial heterogeneity in different population studies, with a lower prevalence rate in high- rather than low- or middle-income countries. Because of the potential negative impact on maternal and child outcomes and the potential lability of these disorders, the perinatal period is a critical time to identify psychiatric illnesses. Thus, obstetricians and midwives play a crucial role in assessing women's mental health needs and to refer identified women promptly for multidisciplinary specialist assessment. However, there is still limited evidence on best practice assessment and management policies during pregnancy and postpartum. This review focuses on the prevalence of common perinatal mental disorders and antenatal screening policies to identify women at risk. The effect of these conditions and their management on pregnancy, fetal outcomes, and child development are discussed.

Intimate partner abuse before and during pregnancy as risk factors for postpartum mental health problems

BACKGROUND

Although research has established the profound effects that intimate partner abuse can have on postpartum mental health, little is known regarding how this association may change as a function of the timing and type of abuse. This study examined associations of psychological, physical and sexual abuse experienced as adults before and during pregnancy with symptoms of postpartum mental health problems in a non-clinical sample of women.

METHODS

English-speaking mothers aged 18 years and older in the metropolitan area of a large, Western Canadian city were recruited to participate in a study of women's health after pregnancy. The study was advertised in hospitals, local newspapers, community venues, and relevant websites. One-hundred women completed standardized, self-report questionnaires during semi-structured interviews conducted by female research assistants at approximately 2 months postpartum. In addition to questions about their general health and well-being, participants answered questions about their experiences of intimate partner abuse and about their mental health during the postpartum period.

RESULTS

Almost two-thirds (61.0%) of women reported postpartum mental health symptoms above normal levels, with 47.0% reporting symptoms at moderate or higher levels. The majority reported some form of intimate partner abuse before pregnancy (84.0%) and more than two-thirds (70.0%), during pregnancy; however, the abuse was typically minor in nature. Multivariate models revealed that women who experienced intimate partner abuse-whether before or during pregnancy-reported higher levels of postpartum mental health problems; however, associations differed as a function of the timing and type of abuse, as well as specific mental health symptoms. Multivariate models also showed that as the number of types of intimate partner abuse experienced increased, so did the negative effects on postpartum mental health.

CONCLUSIONS

Results of this study provide further evidence that intimate partner abuse is a risk factor for postpartum mental health problems. They also underscore the complex risks and needs associated with intimate partner abuse among postpartum women and support the use of integrated approaches to treating postpartum mental health problems. Future efforts should focus on the extent to which strategies designed to reduce intimate partner abuse also improve postpartum mental health and vice versus.

Selective serotonin reuptake inhibitors (SSRIs) for post-partum depression (PPD): a systematic review of randomized clinical trials

BACKGROUND

The treatment of postpartum depression with selective serotonin reuptake inhibitors (SSRIs) has been claimed to be both efficacious and well tolerated, but no recent systematic reviews have been conducted.

METHODS

A qualitative systematic review of randomized clinical trials on women with postpartum depression comparing SSRIs to placebo and/or other treatments was performed. A comprehensive literature search of online databases, the bibliographies of published articles and grey literature were conducted. Data on efficacy, acceptability and tolerability were extracted and the quality of the trials was assessed.

RESULTS

Six randomised clinical trials, comprising 595 patients, met quality criteria for inclusion in the analysis. Cognitive-behavioural intervention, psychosocial community-based intervention, psychodynamic therapy, cognitive behavioural therapy, a second-generation tricyclic antidepressant and placebo were used as comparisons. All studies demonstrated higher response and remission rates among those treated with SSRIs and greater mean changes on depression scales, although findings were not always statistically significant. Dropout rates were high in three of the trials but similar among treatment and comparison groups. In general, SSRIs were well tolerated and trial quality was good.

LIMITATIONS

There are few trials, patients included in the trials were not representative of all patients with postpartum depression, dropout rates in three trials were high, and long-term efficacy and tolerability were assessed in only two trials.

CONCLUSIONS

SSRIs appear to be efficacious and well tolerated in the treatment of postpartum depression, but the available evidence fails to demonstrate a clear superiority over other treatments.