Risk Factors of Postpartum Depression

Association of maternal postpartum depression, anxiety, and stress symptoms: a network analysis

BACKGROUND

New mothers frequently encounter postpartum depression, anxiety, and stress symptoms, which pose challenges in diagnosis and treatment owing to their intricate interplay. This study employs network analysis to explore the interconnections between these symptoms and identify potential intervention points.

METHODS

The study was carried out from December 2023 to June 2024 at the postpartum clinics of three representative tertiary hospitals in Nantong City. The participants were mothers undergoing their 42-day postpartum check-up. Participants completed the Edinburgh Postnatal Depression Scale (EPDS), the Depression, Anxiety, and Stress Scales (DASS-21), and the Maternal postpartum stress scale (MPSS). The R language was used to construct the network. Network analysis was also carried out to explore the network structure, centrality indices (strength, closeness, betweenness, and expected influence), and the stability of the network.

RESULTS

A total of 625 women were included. The resulting network indicates a close interconnection between communities associated with depression, anxiety, and stress. As assessed on the centrality index, "I have felt sad or miserable" (EPDS-8), "Baby's irregular patterns of daily sleep" (MPSS-9), "lack of time for myself" (MPSS-19), "I have been so unhappy that I have been crying" (EPDS-4), and "Physical appearance after childbirth" (MPSS-20) are the five most important nodes of these three network structures. High network stability (> 0.7).

CONCLUSION

Postpartum-specific stress symptoms play a significant role in the network of postpartum depression, anxiety, and stress, and identifying the central symptoms of depression, anxiety, and stress can provide a scientific basis for the development of precise interventions.

CLINICAL TRIAL NUMBER

Not Applicable.

Improving perinatal depression screening uptake: The impact of Medicaid reimbursement policy in Massachusetts

OBJECTIVE

To evaluate the impact of the Massachusetts Medicaid program's reimbursement policy change for perinatal depression screening on utilization rates.

STUDY SETTING AND DESIGN

This study employed a difference-in-differences design to compare insurance-paid prenatal and postpartum depression screening rates as well as postpartum antidepressant receipt rates between Medicaid and privately insured individuals before and after policy implementation in May 2016.

DATA SOURCES AND ANALYTIC SAMPLE

Data are from the 2014-2020 Massachusetts All-Payer Claims Database. The study included individuals with a live birth from October 10, 2014, to December 31, 2019, who were continuously insured either by Medicaid or private insurance.

PRINCIPAL FINDINGS

Among 141,085 births, 42.6% were covered by Medicaid. Among those with Medicaid, 1.9% had a paid postpartum depression screening prior to the policy and 16.9% after (1.5% vs. 12.3% for prenatal screening); among privately insured, 3.8% had a paid postpartum screening prior to the policy and 10.6% after (0.9% vs. 6.7% for prenatal screening). Antidepressant receipt rose from 6.9% to 8.3% among Medicaid enrollees and from 3.3% to 4.9% among privately insured individuals after the policy. After regression adjustment, implementation of the Massachusetts Medicaid reimbursement policy was positively associated with perinatal depression screening rates with a differential increase of 10.0 percentage points (p < 0.001) for postpartum screening and 3.5 percentage points (p < 0.001) for prenatal screening among Medicaid enrollees versus privately insured. Despite increased depression screening, the policy was not associated with a statistically significant change in antidepressant receipt among Medicaid enrollees compared to privately insured individuals.

CONCLUSIONS

Separate payment for perinatal depression screening significantly improved screening rates among Medicaid beneficiaries, highlighting Medicaid's critical role in identifying mental health needs for vulnerable populations. However, the persistence of sub-optimal screening rates among perinatal individuals underscores the need for a comprehensive approach to ensure universal screening and effective treatment for perinatal depression.

Neuroticism trait and postnatal depression among Chinese women: the mediating role of childbirth experience and the moderating role of perceived social support

BACKGROUND

Despite the link between neuroticism trait and postnatal depression has been confirmed, little is known about the factors that influence this association. This study aimed to examine whether childbirth experience mediated the association between neuroticism trait and postnatal depression, and whether this indirect effect was moderated by perceived social support.

METHODS

A cross-sectional study was conducted with 1686 women within one year postpartum from 38 hospitals in China. Participants completed anonymous questionnaires measuring neuroticism trait, postnatal depression, childbirth experience, perceived social support, and demographic and obstetric variables. Data were analyzed using SPSS 26.0 and PROCESS 4.0.

RESULTS

The prevalence of postnatal depression among Chinese women was 24.1%, higher than the global pooled prevalence. The results showed a positive correlation between neuroticism trait and postnatal depression, which was partially mediated by childbirth experience. The negative correlation between neuroticism trait and childbirth experience was moderated by perceived social support. Specifically, the negative impact of neuroticism trait on childbirth experience was stronger among women with high perceived social support.

CONCLUSIONS

Our findings highlight the critical importance of interventions dedicated to improving the childbirth experience, which may help reduce postnatal depression. Moreover, neuroticism and perceived social support are highly correlated and must be considered simultaneously to inform individualized interventions for postnatal depression.

Risk and protective factors for postpartum depression among Polish women - a prospective study

This prospective study conducted at a single center in 2022 aims to identify risk and protective factors for postpartum depression (PPD) in Polish women and to assess the impact of pregnancy, delivery, the postpartum period, and psychosocial factors on PPD. After delivery and 4 weeks later, 311 women filled out two questionnaires of our design related to risk factors for PPD. Immune Power Personality Questionnaire, Walsh Family Resilience Questionnaire, and Edinburg Postnatal Depression Scale were also applied. The predictors of PPD identified at two time points included: use of antidepressants, previous depressive episodes, family history of depression, risk of preterm delivery, anxiety about child's health, and breastfeeding and sleep problems. Risk factors for PPD found only after delivery were: suicidal ideation before pregnancy, stressful life events, premature rupture of the membranes, and cesarean section. Inhalation analgesia during labor reduced the PPD frequency. At 4 weeks' postpartum, regular physical activity was also predictive of PPD, while breastfeeding, financial satisfaction, and sufficient sleep duration were protective factors. PPD after delivery was negatively correlated with capacity to confide, hardiness, assertiveness, self-complexity, and communication. PPD at 4 weeks postpartum decreased belief systems, organization patterns, and communication. Two proposed self-designed questionnaires can be useful for effectively screening PPD in the Polish population.

Neighborhood socioeconomic status and postpartum depression among commercial health insurance enrollees: a retrospective cohort study

BACKGROUND

Postpartum depression (PPD) is a prevalent psychological condition. Although the effect of obstetrical and maternal complications on PPD are well described, the impact of neighborhood socioeconomic status (SES) on PPD is relatively unexplored.

OBJECTIVES

This study examined the relationship between neighborhood SES score and PPD.

METHODS

A summary SES measure for each U.S. zip code was constructed using income, education, and occupational 2021 Census data and linked to national commercial claims for 2017-2023. PPD status using diagnosis codes at outpatient and inpatient visits, and prescription drug use 3, 6, 9, and 12 months postpartum, were determined. Multivariate analysis controlled for potential confounders.

RESULTS

PPD prevalence in commercial claims was 11.48%. Patients with PPD had higher rates of obstetrical (OR: 1.555, p < .0001) and maternal complications (OR: 1.145, p < .0001), and more lifestyle risk factors (OR: 1.113, p < .0001). Comorbidity scores were higher for patients with PPD. Controlling for age and clinical factors, living in a disadvantaged neighborhood was associated with an increased incidence of PPD (OR: 1.137, p < .0001).

LIMITATIONS

Claims data may include potential inaccurate coding of diagnoses/procedures. Clinical information is limited to conditions and treatments defined by ICD-10-CM codes. Area-based SES measures inevitably misclassify people on both ends of the socioeconomic spectrum (this misclassification is random; direction of bias is known).

CONCLUSIONS

The inverse and significant effect of area-based high SES on PPD rates demonstrates that preventive efforts may require interventions focusing on both the patient and the lived environment.

LBTQ parents' bonding experiences after complicated births: managing minority stress and traumatic experiences

BACKGROUND

Birth complications increase the risk of birth injuries and neonatal complications, as well as the risk of experiencing childbirth as a trauma. This, in turn, increases the risk of postpartum mental ill-health and may affect early bonding with the baby. Birth complications add additional stress on lesbian, bisexual, transgender and queer (LBTQ) parents, as they also must navigate hetero- and cisnormative assumptions, being subject to othering, and negative attitudes from healthcare staff.

AIM

To explore LBTQ parents' experiences of bonding with their child following a complicated birth.

METHODS

Semi-structured interviews with 22 birthing and non-birthing parents. Interviews were recorded, transcribed, and analysed using thematic analysis.

RESULTS

The results describe obstructive and facilitating factors. Being traumatised was the main obstacle for mentally engaging with the baby. A focus on physical injuries and healing hindered caretaking and bonding for birthing parents. Stress related to their parental role was obstructive for some non-birthing parents, who struggled to find space to process their own experiences when the partner and/or child was not well. Other non-birthing parents experienced a head start in the bonding process when their partner was injured. Some birthing parents had positive bonding experiences despite the birth complications, as they felt an alliance with their child in the harsh situation.

CONCLUSION

Complicated births and minority stressors can increase the risk of bonding difficulties and mental ill-health. Tailored, LBTQ-competent care is essential to support both birthing and non-birthing parents in overcoming these challenges.

Influence of Newborns' Characteristics on Postpartum Depression: The Impact of Birth Season and Male Sex in a Romanian Cohort Study

BACKGROUND

Although risk factors associated with maternal postpartum depression (PPD) have been recognized, it is still unknown how some newborn characteristics could influence the appearance of PPD.

AIM

Our research aimed to unravel the impact of a newborn's features on women with PPD.

METHODS

The study was conducted in the Obstetrics and Gynecology Department at our University Emergency County Hospital, between August 2019 and April 2021. We included 904 women from the second day of the postpartum period, divided into two groups: women with PPD (n = 236) and control (i.e., women without PPD, n = 668), by using the Edinburg Postpartum Depression Scale. Characteristic information on the newborns (i.e., the months in which they were born, premature delivery, birth weight, or sex) was evaluated.

RESULTS

Our results suggest that the winter season (i.e., December and January months, p = 0.01) births and male newborns (p = 0.02) were strongly related with the appearance of depressive symptoms during the postpartum period.

CONCLUSIONS

Therefore, our study sustains that women who give birth to male newborns in the winter season are more prone to developing PPD. This should be analyzed by all public health care systems in order to prevent such a condition earlier in certain groups of women.

Influence of postpartum depression on maternal-infant bonding and breastfeeding practices among mothers in Abeokuta, Ogun state

BACKGROUND

Postpartum Depression (PPD) is a severe mental health condition that adversely affects mothers and their infants. The influence of PPD on maternal-infant bonding and breastfeeding practices has been scarcely reported in Nigeria. Therefore, we examined the prevalence of PPD, the associated factors, and the relationship with maternal-infant bonding and breastfeeding practices in Abeokuta, Nigeria.

METHOD

A descriptive cross-sectional survey was conducted among 600 mothers within the extended postpartum period (≤ 1 year) from three government-owned immunisation clinics at primary, secondary, and tertiary health facilities in Abeokuta, Ogun State. PPD was assessed using the Edinburgh postnatal depression Scale (EPDS ≥ 13), and maternal-infant bonding was evaluated using the Postpartum Bonding Questionnaire (PBQ ≥ 50). We also examined breastfeeding practices (i.e. the time to initiation by 30 min, exclusive breastfeeding for 6 months and early commencement of complementary feeding by 2 months). Data was analysed using chi-square and logistics regression models at a 5% significance level.

RESULTS

The prevalence of PPD was 21.8%, 95% CI (18.7-25.3). Factors associated with PPD were maternal age: 25-34 years [AOR = 0.52; 95% CI (0.29-0.90)]; ≥ 35 years [AOR = 0.44; 95% CI (0.20-0.96)], being married [AOR = 0.43; 95% CI (0.21-0.85)], perceived stress increased the odds of PPD: moderate stress level [AOR = 8.38; 95% CI (3.50-19.9)]; high-stress level [AOR = 47.8; 95% CI (8.65-263.7)] and self-reported history of emotional problems [AOR = 3.25; 95% CI (1.43-7.38)]. There was a significant direct association between PPD and poor maternal-infant bonding [AOR = 3.91; 95% CI (1.04-4.60)]. PPD reduces the odds of early breastfeeding initiation [AOR = 0.43; 95% CI (0.28-0.68)], but no association was found between PPD and exclusive breastfeeding [AOR = 1.07; 95% CI (0.07-1.67)].

CONCLUSION

The prevalence of PPD was high in our study population and associated with poor maternal-infant bonding and late breastfeeding initiation but not with exclusive breastfeeding. Promoting maternal mental health to foster stronger mother-infant relationships and better breastfeeding practices has become crucial.

Content, Behaviour Change Techniques, and Quality of Postpartum Depression Apps to Be Recommended by Midwives: Systematic Search and Evaluation

BACKGROUND

Postpartum depression is a public health problem that affects a considerable percentage of women. Despite the proliferation of related apps, there are limited data available on the best apps to prevent postpartum depression. We identified which apps available in Spanish could be recommended by midwives based on their content, quality, and behaviour change techniques, as a complementary tool for preventing postpartum depression in women.

METHODS

A systematic search was performed to identify apps available on iOS App Store and Google Play, which were used to replicate how patients' access "postpartum depression prevention" apps. Apps' quality, behaviour change potential, and contents were assessed.

RESULTS

A total of 1408 apps were identified, of which 7 were retrieved for assessment (0.5%). The mean objective and subject quality were 3.1 (SD = 1.01) and 2.7 (SD = 1.27), respectively. A total of 24 topics were identified. The mean ABACUS score was 6.6 (SD = 3.64), and the mean number of topics addressed by the apps was 9.9 (SD = 5.90).

CONCLUSION

The results of the present study suggest that a specific free app is not available in Spanish for the prevention of postpartum depression, and only a small percentage of free apps should be recommended based on their quality, BCTs, and contents. The systematic review protocol was not registered.

Prevalence and factors associated with postpartum depression among Bhutanese mothers: a cross-sectional study

PURPOSE

This study investigated the prevalence of postpartum depression (PPD) and explored associated factors among mothers attending postnatal care in Bhutan.

METHODS

A cross-sectional study was conducted from August to November 2023 at a national referral hospital in Thimphu, the capital city of Bhutan. In total, 314 mothers were recruited. Sociodemographic, psychosocial, obstetric, and infant-related data were collected using questionnaires. The Edinburgh Postnatal Depression Scale, with a threshold of ≥11, was employed to screen for PPD, and logistic regression was used to test the potential factors.

RESULTS

The prevalence of PPD was 14.97%. Mothers with a perceived change in body image (adjusted odds ratio [AOR], 4.40; 95% confidence interval [CI], 1.91-10.17; p=.001), perceived heightened stress after delivery (AOR, 3.74; 95% CI, 1.45-9.67; p=.006), poor relationship with inlaws (AOR, 2.57; 95% CI, 1.24-5.30; p=. 011), and negative birth experience (AOR, 2.42; 95% CI, 1.17-5.00; p=.016) demonstrated significantly higher odds of developing PPD. However, mothers with a higher monthly family income (Bhutanese ngultrum [Nu.] 20,000 to <50,000; AOR, 0.35; 95% CI, 0.13-0.92; p=.033), ≥Nu. 50,000 (AOR, 0.37; 95% CI, 0.13-1.07, p=.067) compared to

CONCLUSION

To mitigate the prevalence and risk of PPD, prioritizing screening strategies and interventions may benefit mothers with perceived changes in body image and heightened perceived stress after delivery, poor relationships with in-laws, and those with negative birth experiences.

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Key Words

• Depression
• Postpartum period
• Prevalence
• Risk factors
• Bhutan

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MESH Headings

• Humans
• Female
• Cross-Sectional Studies
• Depression, Postpartum/epidemiology
• Depression, Postpartum/psychology
• Bhutan/epidemiology
• Adult
• Prevalence
• Mothers/psychology
• Mothers/statistics & numerical data
• Surveys and Questionnaires
• Risk Factors
• Pregnancy
• Psychiatric Status Rating Scales

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Affiliation(s)

Sherab Zangmo Faculty of Public Health, Chiang Mai University, Chiang Mai, Thailand Faculty of Nursing and Public Health, Thimphu, Bhutan
Waraporn Boonchieng Faculty of Public Health, Chiang Mai University, Chiang Mai, Thailand
Chalinee Suvanayos Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand
Kelzang Gyeltshen Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
Pallop Siewchaisakul Faculty of Public Health, Chiang Mai University, Chiang Mai, Thailand

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The relationship between traumatic childbirth and first-time mothers' social identity and wellbeing: a cross-sectional observational study

BACKGROUND

Experiencing childbirth as traumatic is common and can have long-lasting negative consequences for women's mental health. However, fostering a sense of social identity has been shown to protect psychological wellbeing and mental health during life transitions, such as entering parenthood. This study therefore investigated the relationship between traumatic childbirth and first-time mothers' social identity and their psychological wellbeing, and more specifically whether strength of identity as a first-time mother protected psychological wellbeing following traumatic childbirth.

METHOD

Women over the age of 18 who were living in the UK and had given birth to their first child in the past nine months were recruited to the study from clinical and community settings. They completed digital self-report questionnaires about their birth experience, social identity, mental health, and psychological wellbeing. Women who perceived themselves to have had a traumatic birth (the trauma group; N = 84) were compared to women who did not perceive themselves to have had a traumatic birth (the control group, N = 39). T-tests and chi square tests assessed preliminary group differences before multivariate analyses of covariance controlled for covariates. Post-hoc tests identified the direction of differences. Multiple regression and moderation analyses analysed interaction effects.

RESULTS

The trauma group had significantly lower psychological wellbeing (mean = 41.5, 95% CI [39.4-43.7], p = .008, partial η2 = 0.059), compared to the control group (mean = 48.4, 95% CI [45.3-51.5]), but the two groups did not differ in the strength of their first-time mother identity, which was high across both groups. Strength of identity did not moderate the relationship between traumatic childbirth and psychological wellbeing. Giving birth by caesarean section independently reduced the strength of the first-time mother identity (p = .017, partial η2 = 0.049). All analyses controlled for emotional and practical support, perceptions of healthcare staff, and mode of birth.

CONCLUSIONS

Having a traumatic birth was associated with lower psychological wellbeing, and the strength of first-time mother identity does not appear to moderate this relationship. Factors such as mode of birth may be more important. Further research, including longitudinal designs, is needed to understand the relationship between these constructs and identify more effective ways of protecting first-time mothers' mental health.

Effect of online health training/counseling and progressive muscle relaxation exercise on postpartum depression and maternal attachment: A randomized controlled trial

OBJECTIVE

To evaluate the effect of online health training/counseling and a progressive muscle relaxation exercise (PMRE) program on postpartum depression and maternal attachment.

METHODS

The present study was a randomized, controlled, experimental trial. Participants were asked to complete the Prenatal Attachment Inventory (PAI) and the Edinburgh Postpartum Depression Scale (EPDS) at 35 weeks of pregnancy. Group assignment was done by stratified block randomization according to EPDS score (0-9, 10-30) and parity. Women in the experimental group received training in progressive muscle relaxation, postpartum depression, and maternal attachment via online video calls twice a week starting at 36-37 weeks of pregnancy. They were asked to complete the PMRE program from 36 weeks of pregnancy until 6 months postpartum, and online counseling was provided throughout this period. Participants completed the Maternal Postpartum Attachment Scale (MPAS) and the EPDS at 6 weeks postpartum.

RESULTS

Mean PAI score was 64.24 ± 9.61 in the experimental group before the intervention and 62.14 ± 10.13 in the control group. The mean EPDS score of the experimental group was 9.12 ± 5.05 and the mean score of the control group was 9.77 ± 6.30 (P > 0.05). The mean MPAS score after the intervention was 13.92 ± 5.54 in the experimental group and 17.51 ± 6.12 in the control group. The mean EPDS score of the experimental group was 3.40 ± 3.00 and the mean score of the control group was 11.40 ± 5.91 (P < 0.05).

CONCLUSION

Online health training/counseling and PMRE reduce the risk of postpartum depression and increase maternal attachment.

Social support as a coping resource for psychosocial conditions in postpartum period: a systematic review and logic framework

PURPOSE

This review seeks to examine the current state of postpartum social support and psychosocial conditions among women around the world, as well as explore the relationship between these factors. Additionally, it aims to propose a logical framework for enhancing postpartum social support and psychosocial conditions in this population.

METHODS

Following the development of a search strategy, two databases, PubMed and Science Direct, were searched for studies published between January 2019 and May 2023. The search was conducted throughout the entire month of May 2023. The risk of bias in the included cross-sectional studies was assessed using the Newcastle-Ottawa Quality Assessment Scale, which was adapted for this specific study design. To determine if the main objective of the cross-sectional studies was to investigate the relationship between social support and postpartum psychosocial conditions, a review was conducted based on the AMSTAR checklist, PRISMA checklist and PRISMA flow diagram. Data extraction was performed with the consensus of two authors, and a narrative synthesis approach was chosen for data synthesis, following the guidelines provided by the Centre for Reviews and Dissemination (CRD).

RESULTS

Eleven cross-sectional studies were included in the final analysis. Our findings revealed that all reviewed studies provided evidence of a positive association between social support and healthy psychosocial conditions in postpartum period. However, due to the absence of standardized measurement indicators to identify and compare the outcomes of various studies, there was a need to develop a conceptual framework that could enhance our understanding of the postpartum psychosocial condition including anxiety, depression, unfavorable quality of life and social support status up to 24 month after child birth. This framework aimed to incorporate childbirth and motherhood as "stressful events," while considering social support as a crucial "coping resource." Furthermore, it acknowledged empowerment, help-seeking behavior, and peer support as important "coping actions," alongside implementing client-centered interventions. Lastly, it recognized postpartum mental health and optimal quality of life as significant "effects" of these factors.

CONCLUSIONS

The proposed conceptual framework could define postpartum women's health as "the ability to adapt and self-manage."

Mendelian randomization analyses for the causal relationship between early age at first sexual intercourse, early age at first live birth, and postpartum depression in pregnant women

Introduction

There are insufficient epidemiological studies on the impact of age at first sexual intercourse (AFS) and age at first live birth (AFB) on postpartum depression (PPD) in pregnant women, and the conclusions of these studies are inconsistent.

Methods

We performed a Mendelian randomization (MR) study to determine the causal relationship between AFS or AFB and the risk of PPD. The summary data were extracted from genome-wide association study (GWAS) summary datasets. We selected the instrumental variables according to the P value of exposure-related single nucleotide polymorphisms (P<5 ×10-9 for AFS and P<5 ×10-8 for AFB) and estimated the linkage disequilibrium using the clump parameter (10,000 kb, r2 < 0.001). Single nucleotide polymorphisms were considered instrumental variables that were significantly associated with exposure factors without linkage disequilibrium. The F-statistics of the instrumental variables should all be larger than 10. A random-effects model of IVW was constructed as the main method in our study.

Results and discussion

MR studies based on GWAS data revealed that both AFS (OR = 0.4, P <0.001) and AFB (OR = 0.38, P <0.001) were negatively correlated with the risk of PPD. Early AFS and early AFB should be studied as possible risk factors for PPD in the future. Public health departments should attach importance to sex education for young girls. The results of our TSMR should be verified by high-quality prospective epidemiological studies in the future.

Is the mental health of couples with twins more at risk? Results from an Italian cohort study

Introduction

Our retrospective study aimed to investigate whether parents of twins encounter heightened psychological and emotional distress one year after childbirth, in comparison to parents of singletons within an Italian cohort.

Methods

Exclusion criteria included multiparity, preterm birth, congenital anomalies, stillbirth, >2 fetus pregnancies, and pre-existing maternal mental health disorders. Out of the 300 couples (600 parents) invited to participate, 286 parents (158 mothers, 128 fathers) successfully completed a self-administered survey. We analyzed three scores separately for mothers and fathers, differentiating between singleton and twin pregnancies: the Edinburgh Postnatal Depression Scale (EPDS) score, the State and Trait Anxiety Inventory (STAI)-Y1 score, and the STAI-Y2 score.

Results

Logistic models were used to assess the influence of age, BMI, marital status, education, and employment on the three binary scores (EPDS, STAI-Y1, and STAI-Y2), revealing no significant differences in absolute scores between parents of singletons and twins. Paired analysis revealed significantly higher EPDS (mean increase: 3.8, SD: 6.5), STAI-Y1 (mean increase: 5.4, SD: 12.5), and STAI-Y2 (mean increase: 4.5, SD: 12.4) scores for mothers (p < 0.0001). Approximately 10% of women and 8% of men reported suicidal thoughts.

Discussion

Contrary to expectations, no substantial psychological differences emerged between parents of twins and singletons. Adjusting for confounders through univariate analysis maintained nonsignificant trends. Nevertheless, caution in interpretation is warranted due to strict inclusion criteria favoring twin pregnancies with better outcomes. Unintended bias could have resulted from routine psychological support offered to mothers of twins in our clinic. This presents an important framework for future research, including randomized controlled trials comparing parents of multiples with psychological support to those without.Finally, the elevated prevalence of depression symptoms and suicidal thoughts in our cohort underscores the importance of mental health during pregnancy and early parenting. We advocate for the screening of parents for postpartum depression and various psychological conditions, encompassing a spectrum of anxiety disorders. Those at elevated risk of mental distress should be proactively offered appropriate support.

Testing a Behavioral Activation Gaming App for Depression During Pregnancy: Multimethod Pilot Study

BACKGROUND

Depression during pregnancy is increasingly recognized as a worldwide public health problem. If untreated, there can be detrimental outcomes for the mother and child. Anxiety is also often comorbid with depression. Although effective treatments exist, most women do not receive treatment. Technology is a mechanism to increase access to and engagement in mental health services.

OBJECTIVE

The Guardians is a mobile app, grounded in behavioral activation principles, which seeks to leverage mobile game mechanics and in-game rewards to encourage user engagement. This study seeks to assess app satisfaction and engagement and to explore changes in clinical symptoms of depression and anxiety among a sample of pregnant women with elevated depressive symptoms.

METHODS

This multimethod pilot test consisted of a single-arm, proof-of-concept trial to examine the feasibility and acceptability of The Guardians among a pregnant sample with depression (N=18). Participation included two web-based study visits: (1) a baseline assessment to collect demographic and obstetric information and to assess clinical symptoms and (2) an exit interview to administer follow-up measures and explore user experience. Participants completed biweekly questionnaires (ie, Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7) during the trial to assess depression and anxiety symptom severity. App satisfaction was measured using 2 self-report scales (ie, Mobile Application Rating Scale and Player Experience of Needs Satisfaction scale). Engagement with The Guardians was captured using game interaction metric data. We used backward-eliminated mixed effects longitudinal models to examine the effects of app engagement and satisfaction and length of time in the study on symptoms of depression and anxiety. Content analysis was conducted on qualitative data from exit interviews.

RESULTS

The 15-day and 30-day overall app retention rates were 26.6% and 15.1%, respectively. Mixed effects models found significant negative main effects of week in study (β=-.35; t61=-3.05; P=.003), number of activities completed (β=-.12; t61=-2.05; P=.04), days played (β=-.12; t58=-2.9; P=.005), and satisfaction, according to the Mobile Application Rating Scale (β=-3.05; t45=-2.19; P=.03) on depressive symptoms. We have reported about similar analyses for anxiety. There is preliminary evidence suggesting harder activities are associated with greater mood improvement than easier activities. Qualitative content analysis resulted in feedback falling under the following themes: activities, app design, engagement, fit of the app with lifestyle, perceived impact of the app on mood, and suggestions for app modifications.

CONCLUSIONS

Preliminary results from this multimethod study of The Guardians indicate feasibility and acceptability among pregnant women with depression. Retention and engagement levels were more than double those of previous public mental health apps, and use of the app was associated with significant decrease in depressive symptom scores over the 10-week trial. The Guardians shows promise as an effective and scalable digital intervention to support women experiencing depression.

Substance use during pregnancy and risk of postpartum depression: a systematic review and meta-analysis

Introduction

Postpartum depression (PPD) is a prevalent mental health condition affecting women globally within the first year following childbirth. Substance use during pregnancy has been associated with an increased risk of developing PPD, but the evidence remains inconclusive. This meta-analysis aims to comprehensively assess the effects of different substances on PPD risk, exploring potential modifiers and confounding factors.

Objectives

To examine the proportion of PPD among substance users during pregnancy, compared to non-users, and investigate the specific risk associated with different substances (tobacco, alcohol, and non-specified substance use/multiple substance use).

Methods

A systematic literature search was conducted from inception to November 2022 using the Web of Science database (Clarivate Analytics), incorporating Web of Science Core Collection, the BIOSIS Citation Index, the KCI-Korean Journal Database, MEDLINE®, the Russian Science Citation Index, the SciELO Citation Index, and the Cochrane Central Register of Reviews, and Ovid/PsycINFO databases. Inclusion criteria comprised original studies with pregnant women, using validated depression scales and substance use reporting.

Results

Among the 26 included studies, encompassing 514,441 women, the pooled prevalence of PPD among substance users during pregnancy was 29% (95% CI 25-33). Meta-analyzes revealed an overall odds ratio (OR) of 3.67 (95% CI 2.31-5.85, p < 0.01) indicating a significantly higher risk of PPD among substance users compared to non-users. Subgroup analyzes demonstrated a higher risk for women with non-specified or multiple substance use (OR 4.67, 95% CI 2.59-8.41; p < 0.01) and tobacco use (OR 4.01, 95% CI 2.23-7.20; p < 0.01). Alcohol use showed a trend toward higher risk that did not reach statistical significance (OR 1.88, 95% CI 1.00-3.55; p = 0.051).

Conclusion

This meta-analysis provides evidence of an increased risk of PPD among pregnant substance users, particularly those using multiple substances or tobacco. However, caution is needed in interpreting the association with alcohol use due to its non-significant result.

Systematic review registration

This study protocol was registered at PROSPERO (registration number: CCRD42022375500).

Biopsychosocial correlates of emotional problems in women during pregnancy and postpartum period

Background

Transition to motherhood is associated with several emotional problems that can have long-term consequences on the mother and baby.

Aim

To examine the association of various biomedical and cultural factors with the new onset of emotional problems during pregnancy and postpartum period.

Materials and Methods

This prospective longitudinal study included 300 pregnant women interviewed in the third trimester.

Results

The prevalence of emotional problems in the study group was 31.58%. The prevalence of anxiety disorder NOS and mixed anxiety and depressive disorder in the last trimester of pregnancy in our study was 4% and 1.33%, respectively, and 0.67% and 1.33%, respectively, at 4 days postpartum. At 6 weeks postpartum, the prevalence of anxiety disorder NOS was 1.33%, generalized anxiety disorder was 0.67%, and major depression was 1.33. The prevalence of postpartum blues in our study was 25.33%.

Conclusion

There was a significant association between psychiatric disorders during and postpartum period and the following factors: higher parity, increased maternal age, low hemoglobin levels, cesarean section, planned pregnancy, and extended family. Postpartum blues was associated with higher parity and low blood pressure.