Prevalence of Depression or Anxiety During Antepartum Hospitalizations for Obstetric Complications: A Systematic Review and Meta-analysis

Association Between Antepartum Admission and Postpartum Depressive Symptoms: Short Title: Antepartum Hospital Admission and Postpartum Depressive Symptoms

BACKGROUND

Postpartum depression affects 14% of pregnant individuals and is a leading cause of preventable maternal mortality. Complications of pregnancy, such as preterm labor or pre-eclampsia, may require hospitalization for close monitoring and management. The impact of an antenatal hospitalization during pregnancy on postnatal depression remains understudied.

OBJECTIVE

To evaluate whether hospital admission during pregnancy was associated with postpartum depressive symptoms in individuals who were enrolled in a collaborative care model and to evaluate whether enrollment in the collaborative care model during pregnancy mitigated this association.

STUDY DESIGN

This secondary analysis of a prospective cohort study included perinatal people enrolled in a collaborative care model at a quaternary academic center between 2017-2021. The primary outcome was presence of moderately severe or severe postpartum depressive symptoms at 6 weeks postpartum defined as a score of 15 or greater on a PHQ-9. The prevalence of symptoms of this severity was compared between those who experienced an antepartum hospitalization and those who did not using bivariable and multivariable analyses. A Breslow Day test was used to evaluate whether any observed association between antepartum hospitalization and postpartum depressive symptoms differed based on timing of enrollment in the collaborative care model.

RESULTS

During the study period, 1897 individuals met inclusion criteria. Of these, 162 (8.5%) were admitted to the hospital during pregnancy. Of those with an antepartum hospitalization, 20 (12.4%) developed moderately severe to severe postpartum depressive symptoms compared to 136 (7.8%) of those who were not hospitalized (p=0.046). After adjustment for confounders identified through use of a directed acyclic graph, this difference did not persist in multivariable analysis (aOR 1.55, 95% CI [0.87-2.75]). A Breslow Day test demonstrated heterogeneity across enrollment timing, so subgroup analyses were performed for those enrolled during pregnancy (n=930) vs postpartum (n=967). Hospital admission was associated with higher rates of moderately severe to severe postpartum depressive symptoms in those enrolled in the collaborative care model postpartum (19.7% vs 10.6%, p=0.015, aOR 2.25, 95% CI [1.07-4.71]), but not those enrolled antenatally (5.8% vs 5.0%, p=0.735, aOR 1.09, 95% CI [0.38-3.19]).

CONCLUSIONS

Antepartum hospital admission was associated with higher rates of moderately severe to severe depressive symptoms. This association did not exist among individuals enrolled in collaborative care model during pregnancy, suggesting a potential protective effect afforded by engagement in a mental health support programming.

Evaluation of Sleep in Pregnant Inpatients Compared With Outpatients

OBJECTIVE

To evaluate whether antepartum hospitalization was associated with differences in sleep duration or disrupted sleep patterns.

METHODS

This was a prospective cohort study with enrollment of pregnant people aged 18-55 years with singleton gestations at 16 weeks of gestation or more between 2021 and 2022. Each enrolled antepartum patient was matched by gestational age to outpatients recruited from obstetric clinics at the same institution. Participants responded to the ISI (Insomnia Severity Index) and wore actigraph accelerometer watches for up to 7 days. The primary outcome was total sleep duration per 24 hours. Secondary outcomes included sleep efficiency (time asleep/time in bed), ISI score, clinical insomnia (ISI score higher than 15), short sleep duration (less than 300 minutes/24 hours), wakefulness after sleep onset, number of awakenings, and sleep fragmentation index. Outcomes were evaluated with multivariable generalized estimating equations adjusted for body mass index (BMI), sleep aid use, and insurance type, accounting for gestational age correlations. An interaction term assessed the joint effects of time and inpatient status.

RESULTS

Overall 58 participants were included: 18 inpatients and 40 outpatients. Inpatients had significantly lower total sleep duration than outpatients (mean 4.4 hours [SD 1.6 hours] inpatient vs 5.2 hours [SD 1.5 hours] outpatient, adjusted β=-1.1, 95% CI, -1.8 to -0.3, P =.01). Awakenings (10.1 inpatient vs 13.8, P =.01) and wakefulness after sleep onset (28.3 inpatient vs 35.5 outpatient, P =.03) were lower among inpatients. There were no differences in the other sleep outcomes, and no interaction was detected for time in the study and inpatient status. Inpatients were more likely to use sleep aids (39.9% vs 12.5%, P =.03).

CONCLUSION

Hospitalized pregnant patients slept about 1 hour/day less than outpatients. Fewer awakenings and reduced wakefulness after sleep onset among inpatients may reflect increased use of sleep aids in hospitalized patients.

Physical activity among pregnant inpatients and outpatients and associations with anxiety

OBJECTIVE

Physical activity is linked to lower anxiety, but little is known about the association during pregnancy. This is especially important for antepartum inpatients, who are known to have increased anxiety yet may not be able to achieve target levels of physical activity during hospitalization. We compared physical activity metrics between pregnant inpatients and outpatients and explored correlations with anxiety.

MATERIALS AND METHODS

This was a prospective cohort between 2021 and 2022 of pregnant people aged 18-55 years carrying singleton gestations ≥ 16 weeks. Three exposure groups were matched for gestational age: 1) outpatients from general obstetric clinics; 2) outpatients from high-risk Maternal-Fetal Medicine obstetric clinics; and 3) antepartum inpatients. Participants wore Actigraph GT9X Link accelerometer watches for up to 7 days to measure physical activity. The primary outcome was mean daily step count. Secondary outcomes were metabolic equivalent tasks (METs), hourly kilocalories (kcals), moderate to vigorous physical activity (MVPA) bursts, and anxiety (State-Trait Anxiety Inventory [STAI]). Step counts were compared using multivariable generalized estimating equations adjusting for maternal age, body-mass index, and insurance type as a socioeconomic construct, accounting for within-group clustering by gestational age. Spearman correlations were used to correlate anxiety scores with step counts.

RESULTS

58 participants were analyzed. Compared to outpatients, inpatients had significantly lower mean daily steps (primary outcome, adjusted beta -2185, 95 % confidence interval [CI] -3146, -1224, p < 0.01), METs (adjusted beta -0.18, 95 % CI -0.23, -0.13, p < 0.01), MVPAs (adjusted beta -38.2, 95 % CI -52.3, -24.1, p < 0.01), and kcals (adjusted beta -222.9, 95 % CI -438.0, -7.8, p = 0.04). Over the course of the week, steps progressively decreased for inpatients (p-interaction 0.01) but not for either of the outpatient groups. Among the entire cohort, lower step counts correlated with higher anxiety scores (r = 0.30, p = 0.02).

CONCLUSION

We present antenatal population norms and variance for step counts, metabolic equivalent tasks, moderate to vigorous physical activity bursts, and kcals, as well as correlations with anxiety. Antepartum inpatients had significantly lower physical activity than outpatients, and lower step counts correlated with higher anxiety levels. These results highlight the need for physical activity interventions, particularly for hospitalized pregnant people.

Factors associated with postpartum depression among high-risk women during the COVID-19 pandemic

The purpose of this study was to investigate the impacts of the COVID-19 pandemic on multi-level factors associated with depression among a high-risk sample of postpartum women using longitudinal data collected at two timepoints. High-risk postpartum participants in the United States were recruited to participate in a parent study focused on mitigating risk of cardiometabolic disease in postpartum women. Individuals completed a baseline survey which included the Edinburgh Postpartum Depression Scale (EPDS) at 6-weeks postpartum between 2017 through 2019. A modified survey with the inclusion of selected questions from the Coronavirus Health Impact Survey (CRISIS) questionnaire was administered again during the first 6-months of the COVID-19 pandemic and individuals who completed both the baseline assessment and the COVID-19 assessment were included for analyses (n = 46). Multivariate models were run to investigate the impacts of individual-, interpersonal-, and structural-level factors on change in EPDS scores across the postpartum period. Findings suggest that losing contact with social supports (β = 4.5, SE = 1.9, p = .02) and individuals who reported a total household income of less than $75,000 (β = 3.4, SE = 1.7, p = .05) were more likely to report significantly worsening postpartum depression scores compared to others. Recommendations to mitigate the stressors that have been amplified by the COVID-19 pandemic and resulting mental health disparities include screening all high-risk postpartum women for depression and anxiety during both postpartum and pediatric healthcare visits, providing informational flyers with tips related to healthy coping behaviors and free/affordable community resources, and linking individuals to peer-led support groups.

Behavioral Health Integration on Inpatient Obstetric Units: Program Development, Strategies for Implementation, and Lessons Learned

Perinatal mood and anxiety disorders and substance use disorders are the primary causes of maternal mortality in the postpartum period and represent major public health concerns. Despite this, these conditions remain undertreated. Behavioral health integration in outpatient obstetric settings is necessary but insufficient to meet the needs of all patients. Inpatient behavioral health integration represents a promising avenue for addressing gaps in care. Results from recent program development indicate that needs assessment, stakeholder backing, collaboration with existing programs, and adaptability are key factors in successful implementation.

Relationship between depressive symptoms and sleep quality and cognitive inhibition ability in prenatal pregnant women

BACKGROUND

Sleep problems and cognitive changes are typical in pregnant women with depressive symptoms. However, the relationship between sleep quality and executive dysfunction remains unclear. This study aims to explore the differences in sleep quality and cognitive inhibition between pregnant women with and without depressive symptoms in the third trimester of pregnancy and investigate the correlations between sleep quality, cognitive inhibition and depressive symptoms.

METHODS

In the third trimester, 169 women without depressive symptoms and 88 women with depressive symptoms participated in the study. Edinburgh Postpartum Depression Questionnaire (EPDS) was used to assess depressive symptoms, and Pittsburgh Standard Sleep Quality Index Questionnaire (PSQI) was used to investigate sleep quality. The color-word Stroop task is used to evaluate cognitive inhibition.

RESULTS

Compared with women without depressive symptoms, pregnant women with depressive symptoms showed worse sleep quality and Stroop task performances (response speed and accuracy). In addition, the speed of cognitive inhibition plays a mediating role in the relationship between sleep quality and prenatal depressive symptoms.

CONCLUSION

This research emphasizes the importance of sleep quality screening and cognitive training for depression during pregnancy and childbirth in ensuring women's mental health during pregnancy and childbirth.

Mental health, sleep quality, and hormonal circadian rhythms in pregnant women with threatened preterm labor: a prospective observational study

BACKGROUND

Threatened preterm labor (TPL) is an important obstetrical challenge. Pregnant women with TPL may develop psychological and physical problems such as mental health disorders, sleep disturbance, and hormonal circadian rhythm disruption. This study aimed to investigate the current state of mental health, sleep quality, and circadian rhythms of cortisol and melatonin secretion in pregnant women with TPL and normal pregnant women (NPW).

METHODS

A prospective observational clinical study was conducted at a maternal and child health hospital in Fuzhou, China, between June and July 2022. A total of 50 women between 32 and 36 weeks of gestation (TPL group, n = 20; NPW group, n = 30) were recruited. Data on anxiety symptom (Zung's Self-rating Anxiety Scale, SAS), depression symptom (Edinburgh Postnatal Depression Scale, EPDS), subjective sleep quality (Pittsburgh Sleep Quality Index, PSQI) and objective sleep outcomes (measured by actigraphy) of the pregnant women were collected at the time of enrolment. Salivary samples were collected once every 6 h (i.e., at 06:00, 12:00, 18:00, and 00:00) during 2 consecutive days to measure the circadian rhythm of hormone (cortisol and melatonin).

RESULTS

There were no differences found in the total scores of SAS, EPDS scores, subjective sleep quality between the TPL and NPW groups (P > 0.05). In contrast, significant differences were found in sleep efficiency, total sleep time, wake time after sleep onset, and average awakening time between the groups (P < 0.05). The circadian rhythm of melatonin secretion was disrupted in the TPL group (P = 0.350); however, it was maintained in the NPW group (P = 0.044). The circadian rhythm of cortisol secretion was disrupted in both groups (P > 0.05).

CONCLUSIONS

In the third trimester of pregnancy, women with TPL suffer from poorer sleep quality and disruption of circadian rhythm of melatonin secretion compared with NPW. Nevertheless, there were no differences found in mental health (i.e., anxiety and depression) and circadian rhythm of cortisol secretion. Large-scale studies should be conducted to evaluate these changes in women with TPL.

TRIAL REGISTRATION

The study was registered from Chinese Clinical Trial Registry (Number: ChiCTR2200060674) on 07/06/2022.

Perinatal anxiety and depression amidst the COVID-19 pandemic in Dubai, United Arab Emirates

BACKGROUND

Pregnancy and COVID-19 increase the risk of mental health conditions. The stress of pregnancy, childbirth, and uncertainty about the global pandemic has negatively affected the obstetrical population.

OBJECTIVE

This study aimed to investigate the effects of the COVID-19 pandemic in terms of anxiety and depression in antenatal and postnatal mothers.

STUDY DESIGN

This was a cross-sectional observational study conducted at Dubai Hospital, United Arab Emirates, evaluating depression and anxiety (point prevalence) with the Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scale.

RESULTS

Of the 784 women approached, 438 consented to participate in our survey; 43.6% of the women screened positive for depression by the Edinburgh Postnatal Depression Scale (with a cutoff score ≥10), and 42% had a Generalized Anxiety Disorder-7 score of ≥5, indicating anxiety. Both anxiety and depression were found in 32.4% of the women; 7.5% had considered self-harm in the last 14 days, and 15% had COVID-19 during the current pregnancy. The 11.87% who had COVID-19, but before the pregnancy, had higher mean Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores than others. Surprisingly, the women who had COVID-19 during pregnancy had statistically significantly (P<.05) lower Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores. University graduates had significantly (P<.05) higher Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores. Women of Middle Eastern ethnicity (50% positive for depression and 48.5% for anxiety) were more prone to depression and anxiety compared with South Asian (29% positive for depression and 25.2% for anxiety) and African women (39.6% positive for depression and 43.4% for anxiety). There was no statistically significant difference between antenatal and postnatal patients in the prevalence of anxiety or depression.

CONCLUSION

The COVID-19 pandemic is associated with an increase in depression and anxiety in pregnant and postnatal women. Women who were more concerned about the effects of the pandemic had higher mean Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores. Additional psychological support for women is necessary during the pandemic for maternal perinatal well-being.

Perceived stress and its predictors in women with threatened preterm labour: A cross-sectional study

AIM

To determine prevalence and predictors of perceived stress in women with threatened preterm labour.

DESIGN

Cross-sectional.

METHODS

We recruited 409 women with threatened preterm labour, hospitalized at two tertiary hospitals. We assessed their socio-demographic and obstetrics characteristics, and their perceived stress, perceived social support, experience of violence using validated scales. Multiple linear regression was used to determine the predictors.

RESULTS

Data from all recruited women were analysed. Most of them had borderline (36%) or high (42%) level stress. Overall, 17 predictors were identified explaining 89.5% of variation in the stress score. Predictors of the higher stress score included: urban living, experience of sexual and psychological violence, perceived insufficient social support, experience of vaginal bleeding during current pregnancy, abnormal results in initial pregnancy tests, having multiple roles at home, being less than 28 weeks pregnant, being parous, sleep disorders, history of health problems, insufficient income and unwanted pregnancy.

PRÁTICA PSICODRAMÁTICA NO CONTEXTO HOSPITALAR

RESUMO A hospitalização, essencial para recuperação da saúde, costuma ampliar o sofrimento psíquico dos pacientes, na medida em que impõe uma rotina de cuidados, afasta o paciente da família e do meio social. O objetivo deste estudo é apresentar a compreensão psicodramática desse contexto e possibilidades de intervenção. Foi realizada uma articulação teórica com a experiência psicoterapêutica de enfoque psicodramático. Observou-se que a existência de conservas culturais hospitalares e limitações impostas pelo adoecimento gera perda da espontaneidade e cristalização no papel de doente, aumentando o sofrimento e prejudicando a recuperação do indivíduo. O estabelecimento de uma relação télica e o uso de técnicas psicodramáticas mostraram-se relevantes no resgate da espontaneidade e na promoção da saúde mental dos pacientes.

Acceptance, experiences, and needs of hospitalized pregnant women toward an electronic mindfulness-based intervention: A pilot mixed-methods study

BACKGROUND

Anxiety disorders and depression during pregnancy are highly prevalent. Hospitalized pregnant women with high maternal or fetal risk represent a particularly vulnerable population often excluded from research samples. Screening for mental health disorders is not routinely offered for this particular patient group. Electronic mindfulness-based interventions constitute an accessible, convenient, and cost-effective mental health resource but have not yet been evaluated for acceptance in inpatient settings. To date, little is known about the needs and perceptions of this group of women.

OBJECTIVE

The aim of this study was to examine whether a brief electronic mindfulness-based intervention (eMBI) is accepted among hospitalized high-risk pregnant women. We assessed personal motivation and barriers, experiences, usability requirements, and overall acceptance of the eMBI, as well the specific needs and demands of patients with high-risk pregnancies regarding mental health services.

METHODS

An exploratory pilot study with a mixed-methods study design was carried out among 30 women hospitalized with a high obstetric risk. The study participants were given access to an eMBI with a 1-week mindfulness program on how to deal with stress, anxiety, and depressive symptoms. Semi-structured interviews were conducted with the 30 participants and analyzed using systematic content analysis. In addition, acceptance and usability were assessed via questionnaires.

RESULTS

Study findings showed a high level of acceptance of the eMBI. Most of the respondents were satisfied with the usability and considered the eMBI program to be helpful. The greatest barriers to using the eMBI were a general negative attitude toward using apps, preference for personal contact, or no current need for psychotherapy. Participants criticized the lack of awareness of mental health issues during pregnancy and expressed a need for low-threshold treatment offers, especially during hospitalization.

CONCLUSIONS

There is a strong need for mental health services in pregnancy care, especially for pregnant women with risk profiles. An eMBI offers an acceptable means of providing mental health support for hospitalized women with a severe obstetric risk.

Exposure and perception of PM2.5 pollution on the mental stress of pregnant women

Prenatal exposure to ambient PM_2.5 has been proved to be related to pregnant women's physical health and birth outcomes. However, the damage from air pollution on pregnant women's mental health has not been fully discussed. A case-control study was conducted to evaluate the effects of PM_2.5 exposure and risk perception on the mental stress of pregnant women. A total of 605 pregnant women, including 403 high symptoms of stress cases and 202 matched controls, were recruited from January 2018 to December 2018 in Nanjing, among which 313 high symptoms of stress cases and 144 matched controls were included in the analysis. Meaningfully high symptoms of anxiety were defined with a score of 6 points or greater on the phobic anxiety subscale of the Crown-Crisp index. We found that the PM_2.5 effect perceived by the case group was significantly higher than the control group, and the PM_2.5 exposure of the case group was also significantly higher than that of the control group. Binary logistic regression showed that for each increase in unit of PM_2.5 exposure, the risk of pregnant women suffering from high mental stress increased by 13.76% (95 %CI: 8.26-19.53%). Through path analysis modeling, we found that in the case group, perceived indoor attributions not only had a direct impact on mental stress (p < 0.001), but also played a key mediating role in the impact of average daily dose of PM_2.5 on mental stress (p < 0.001). The high level of mental stress is not only affected by objective exposure, but also by subjective perceptions in the case group. Considering the significant effect of PM_2.5 exposure on mental stress, pregnant women are recommended to spend appropriate amounts of time outdoors during clean air days. In addition, the mediating role of risk perception cannot be ignored. It is necessary to reassure pregnant women not to become overly concerned about the risk of PM_2.5 pollution and reduce their psychological burden.

AWHONN Members' Recommendations on What to Include in Updated Standards for Professional Registered Nurse Staffing for Perinatal Units

OBJECTIVE

To solicit advice from members of the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) on what to include in an update of nurse staffing standards.

DESIGN

Online, single-question survey with thematic analysis of responses.

SETTING

Electronic survey link sent via e-mail.

PARTICIPANTS

AWHONN members who shared their e-mail with the association and who responded to the survey (n = 1,813).

MEASURES

Participants were asked to answer this single question: "The AWHONN (2010) Guidelines for Professional Registered Nurse Staffing for Perinatal Units are being updated. During their initial development, feedback from nearly 900 AWHONN members was extremely helpful in providing specific details for the nurse staffing guidelines. We'd really like to hear from you again. Please give the writing team your input. What should AWHONN consider when updating the AWHONN nurse staffing guidelines?"

RESULTS

The e-mail was successfully delivered to 20,463 members; 8,050 opened the e-mail, and 3,050 opened the link to the survey. There were 1,892 responses. After removing duplicate and blank responses, 1,813 responses were available for analysis. They represented all hospital practice settings for maternity and newborn care and included nurses from small-volume and rural hospitals. Primary concerns of respondents centered on two aspects of patient acuity-the increasing complexity of clinical cases and the need to link nurse staffing standards to patient acuity. Other themes included maintaining current nurse-to-patient ratios, needing help with implementation in the context of economic challenges, and changing wording from "guidelines" to "standards" to promote widespread adoption.

CONCLUSION

In a single-question survey, AWHONN members offered rich, detailed recommendations that were used in the updating of the AWHONN nurse staffing standards.

Association of ambient air pollution with depressive and anxiety symptoms in pregnant women: A prospective cohort study

BACKGROUND

Air pollution is associated with depressive and anxiety symptoms in the general population. However, this relationship among pregnant women remains largely unknown.

OBJECTIVE

To evaluate the association between pregnancy air pollution exposure and maternal depressive and anxiety symptoms during the third trimester assessed using the Center for Epidemiologic Studies-Depression and State-Trait Anxiety Inventory scales, respectively.

METHODS

We analyzed 1481 pregnant women from a cohort study in Seoul. Maternal exposure to particulate matter with an aerodynamic diameter <2.5 μm (PM_2.5) and <10 μm (PM₁₀), as well as to nitrogen dioxide (NO₂) and ozone (O₃) for each trimester and the entire pregnancy was assessed at participant's residential address by land use regression models. We estimated the relative risk (RR) and corresponding confidence interval (CI) of the depressive and anxiety symptoms associated with an interquartile range (IQR) increase in PM_2.5, PM₁₀, NO₂, and O₃ using modified Poisson regression.

RESULTS

In single-pollutant models, an IQR increase in PM_2.5, PM₁₀, and NO₂ during the second trimester was associated with an increased risk of depressive symptoms (PM_2.5 RR = 1.15, 95% CI: 1.04, 1.27; PM₁₀ RR = 1.13, 95% CI: 1.04, 1.23; NO₂ RR = 1.15, 95% CI: 1.03, 1.29) after adjusting for relevant covariates. Similarly, an IQR increase in O₃ during the third trimester was associated with an increased risk of depressive symptoms (RR = 1.09, 95% CI: 1.01, 1.18), while the IQR increase in O₃ during the first trimester was associated with a decreased risk (RR = 0.89, 95% CI: 0.82, 0.96). Exposure to PM_2.5, PM₁₀, and NO₂ during the second trimester was significantly associated with anxiety symptoms. The associations with PM_2.5 and O₃ in single-and multi-pollutant models were consistent.

CONCLUSIONS

Our findings indicate that increased levels of particulate matter, NO₂, and O₃ during pregnancy may elevate the risk of depression or anxiety in pregnant women.