Obstetric, Somatic, And Demographic Risk Factors.11

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Obstetric, Somatic, and Demographic Risk Factors forPostpartum Depressive Symptoms

Ann Josefsson, MD, Lisbeth Angelsioo, MD, Goran Berg, MD, PhD, Carl-Magnus Ekstrom, MD,Christina Gunnervik, MD, Conny Nordin, MD, PhD, and Gunilla Sydsjo, PhD

OBJECTIVE: To identify and test the predictive power ofpotential independent risk factors of postpartum depres-sive symptoms during pregnancy and the perinatal period.

METHODS: We conducted a case-control study where 132women with postpartum depressive symptoms were se-lected as an index group and 264 women without depres-sive symptoms as a control group. Data related to sociode-mographic status, medical, gynecologic, and obstetric

history, pregnancy, and perinatal events were collectedfrom standardized medical records.

RESULTS: The strongest risk factors for postpartum de-pressive symptoms were sick leave during pregnancy and ahigh number of visits to the antenatal care clinic. Compli-cations during pregnancy, such as hyperemesis, prematurecontractions, and psychiatric disorder were more commonin the postpartum depressed group of women. No associa-tion was found between parity, sociodemographic data, ormode of delivery and postpartum depressive symptoms.

CONCLUSION: Women at risk for postpartum depressioncan be identified during pregnancy. The strongest risk

factors, sick leave during pregnancy and many visits to theantenatal care clinic, are not etiologic and might be ofeither behavioral or biologic origin. The possibilities ofgenetic vulnerability and hormonal changes warrant fur-ther investigation to reach a more thorough understanding.(Obstet Gynecol 2002;99:2238. 2002 by the AmericanCollege of Obstetricians and Gynecologists.)

Epidemiologic data from around the world show thatdepression is approximately twice as common in womenthan men and that its first onset peaks during the child-

bearing years.1 Pregnancy, miscarriage or fetal death,

infertility, and the postpartum period may especially

challenge a womans mental health. Postpartum depres-sion, which often resembles other forms of major depres-sion, affects 1020% of all mothers.211 It may have adeleterious effect on the womans social and personaladjustment, the marital relationship, and the mother-infant interaction. Furthermore, there is a 3050% riskof relapse of depression in a future pregnancy.1,12

Maternal depression early in the infants life mayaffect the childs psychologic development with signifi-cant intellectual deficits as a result.1315 Other conse-quences for the child include higher risk of accidents,sudden infant death syndrome, and a higher frequencyof hospital admissions.1618 Various explanatory modelson the etiology have been proposed; probably postpar-tum depression is a result of an interaction betweengenetic vulnerability, hormonal changes, and major lifeevents.1922 Recent studies have focused on psychoso-cial stressors and previous psychiatric history in a wom-ans life as major risk factors for developing postpartum

depression.

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The literature concerning obstetric andperinatal risk factors is sparse and shows little concor-dance.2,8,28,29 The hypothesis of this study was thatcomplications during pregnancy, delivery, and/or the

perinatal period are associated with an increased risk ofpostpartum depression.

MATERIALS AND METHODS

The Swedish antenatal health care system reaches al-most 100% of all pregnant women (Swedish NationalBoard of Health and Welfare). The antenatal care clinics

provide regular check-ups on the physical and psycho-logic health during pregnancy and puerperium. Thesame percentage, as above, is valid for deliveries as thereare no private maternity hospitals in Sweden and homedeliveries are rare.

The original sample in the present study comprises thetotal population of pregnant women consecutively regis-tered at the antenatal care clinics in four communities inthe southeast region of Sweden.11 Enrollment took placein separate 3-month periods for each of the four commu-

From the Department of Health and Environment, Division of Obstetrics andGynaecology, and Department of Neuroscience and Locomotion, Division of Psy-chiatry, Faculty of Health Sciences, University of Linkoping, Linkoping, Sweden;Department of Obstetrics and Gynaecology, Varnamo, Sweden; Department of Obstetrics and Gynaecology, Norrkoping, Sweden; and Department of Obstetricsand Gynaecology, Kalmar, Sweden.

This study was supported by grants from The Health Research Council in thesoutheast of Sweden.

223VOL. 99, NO. 2, FEBRUARY 2002 0029-7844/02/$22.00

2002 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc. PII S0029-7844(01)01722-7


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nities during 19971999. The eligible women were ap-proached in gestational weeks 3536 and received bothwritten and oral information from their midwife beforegiving consent. A total of 1558 women were approached.Sixty-nine (4.4%) women declined to participate in theoriginal study. The prevalence of depressive symptoms didnot differ between the communities within each assess-

ment. Out of 1489 women, all women with depressivesymptoms on the Edinburgh Postnatal Depression Scale at68 weeks and/or 6 months postpartum from two of thefour communities were selected as an index group (n132). As control group, 264 women without depressivesymptomatology on the Edinburgh Postnatal DepressionScale were randomly chosen from all four communities.Records from three index women and two control womenwere not found. One woman in the controlgroup delivereda dead infant and was therefore excluded.

The Edinburgh Postnatal Depression Scale is a 10-itemself-report scale, specifically designed to screen for postpar-

tum depression in community samples.30 Each item isscored on a 4-point scale (03), the minimum and maxi-mum total score ranging from 0 to 30, respectively. Thescale rates the intensity of depressive symptoms presentwithin the previous 7 days. Five of the items are concernedwith dysphoric mood, two with anxiety, and one each withguilt, suicidal ideas, and not coping. The EdinburghPostnatal Depression Scale has been translated into at least11 languages,31 including Swedish.32 Validity of the Swed-ish version has been tested, and the findings were identicalor similar to earlier studies.9,10 Coxetal30proposeda cutofflevel of 10 if the test is to be used for screening purposes in

the postpartum period. The Edinburgh Postnatal Depres-sion Scale cannot confirm a diagnosis of depressive illness,

but when selecting this threshold, the sensitivity for thedetection of major depression was almost 100% and thespecificity 82%.33 The Edinburgh Postnatal DepressionScale is easy to administer, takes only a few minutes tocomplete, and is well accepted by the women and the staff.In this study, the cutoff level of 10 was used as the depen-dent variable. The prevalence of depressive symptoms, anEdinburgh Postnatal Depression Scale score of 10 or more,was 13% at the 68 weeks assessment and unaltered at 6months postpartum.11

All data related to the pregnancy, delivery, and thepuerperium were registered in the standardized andidentical Swedish antenatal, delivery, and neonatalrecords. The data were manually extracted from therecords by the main author (AJ), and are thus prospec-tively related to the development of depressive symp-toms. In multiparas, medical records from earlier deliv-eries were also scrutinized. The following data werecollected: age, parity, marital status, occupation, andnumber of induced abortions, miscarriages, or extrauter-

ine pregnancies. Any history of infertility, psychiatricdisorder, or obstetric complications, actual chronic med-ical diseases, number of visits at the antenatal care clinics

before delivery (midwife and physician), pregnancycomplications, sick leave during pregnancy, and perina-tal events were obtained.

All analyses were done using the SPSS program 10.1

(SPSS Inc., Chicago, IL). Statistical significance was de-fined as two-sided Pvalues using a significance level of5%. Differences were tested with Student ttest for nor-mally distributed continuous variables and the Mann-

Whitney U test for continuous variables not normallydistributed. Odds ratios, presented with 95% confidenceintervals, were calculated for categoric variables. Logisticregression with conditional stepwise backward elimina-tion was used when multiple variables were consideredsimultaneously. The dependent variables were de-

pressed or nondepressed. The explanatory variableswere sociodemographic data, medical, gynecologic, and

obstetric history, pregnancy, delivery, and neonataldata. The study was approved by the Regional EthicsCommittee for Human Research of the Faculty ofHealth Sciences, Linkoping University (No. 97133).

RESULTS

Distributions of independent variables are shown inTables 15. The sociodemographic variables are shownin Table 1. No differences were found between womenwith or without a depressive symptomatology.

In Table 2, we describe earlier medical history with

focus on gynecologic and obstetric data. Women with anearlier history of two or more abortions and a history ofearlier obstetric complications, mainly acute cesareansection and instrumental delivery, were significantlymore prone to develop depressive symptoms postpar-tum.

Complications during the present pregnancy (Table3), such as hyperemesis, premature contractions, and

psychiatric disorder, were more common in the postpar-tum depressed group of women. Number of visits at theantenatal care clinics and number of women on sickleave were also more frequent in this group (Table 3).

Concerning delivery data, presented in Table 4, nodifferences were found, except from intrapartal analgesiawith morphine analogues. As the women included in thisstudy were enrolled in pregnancy weeks 3536, there areno premature deliveries in the sample. Women with

postpartum depressive symptoms stayed longer at thehospital after delivery but did not have a higher fre-quency of complicated puerperium than nondepressedwomen (Table 5). Women who gave birth to babies withcongenital major malformations were also more de-

2 24 J ose fsso n et al Postpartum Depressive Symptoms OBSTETRICS & GYNECOLOGY


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pressed than the others were (Table 5). Subsequentmultivariable analysis is shown in Table 6. Sick leaveduring pregnancy and number of visits at the antenatal

care clinic are the variables with the strongest associationto postpartum depressive symptoms for all women. Tofacilitate comparisons, multivariable analyses were per-

Table 1. Sociodemographic Data

Variable Depressed NondepressedUnadjusted OR

(95% CI)

Age (y)1624 15.5 12.6 1.29 (0.70, 2.37)2534 68.2 71.6 1 (reference)3546 16.3 15.7 1.09 (0.61, 1.95)

Mean age (y)* 29.5 29.7Parity0 41.9 45.6 1 (reference)12 38.8 35.6 1.19 (0.74, 1.90)3 19.4 18.8 1.12 (0.63, 2.01)

Marital statusSolitary 2.3 2.3 1.10 (0.25, 4.11)Married/cohabiting 97.7 97.7 1 (reference)

Socioeconomic groupsUnskilled workers 20.9 25.3 0.94 (0.47, 1.88)Skilled workers 14.0 13.4 1.18 (0.55, 2.56)Lower white collar workers 15.5 17.6 1 (reference)Middle/high white collar workers and self-employed 25.6 24.9 1.17 (0.60, 2.29)Students 7.0 7.7 1.04 (0.40, 2.67)Unemployed 10.1 6.9 1.66 (0.69, 4.03)

Others 7.0 4.2 1.88 (0.68, 5.25)OR odds ratio; CI confidence interval.

Values are given as %, unless otherwise stated.* Student ttest, P .766.

Table 2. Gynecologic/Obstetric History


(95% CI)

Chronic medical disease including drug addiction* 13.2 9.2 1.50 (0.77, 2.90)Psychiatric disorder 4.7 2.3 2.07 (0.66, 6.56)Induced abortions

0 86.8 89.3 1 (reference)1 7.8 9.6 0.83 (0.39, 1.79)2 5.4 1.1 4.85 (1.23, 19.13)

Miscarriages0 86.8 80.5 1 (reference)1 10.1 14.2 0.66 (0.34, 1.29)2 3.1 5.3 0.54 (0.17, 1.67)

Extrauterine pregnancies0 97.7 98.5 1 (reference)1 1.6 0.8 2.04 (0.28, 14.65)2 0.8 0.8 1.02 (0.09, 11.35)

Infertility (1 y) 13.2 10.3 1.32 (0.69, 2.51)

Obstetric complicationsNo complications 45.1 64.0 1 (reference)Acute cesarean section 13.4 6.7 2.85 (1.12, 7.28)Elective cesarean section 7.3 8.0 1.30 (0.45, 3.71)Instrumental delivery 17.1 8.7 2.79 (1.20, 6.50)Perineal tears/excessive bleeding intrapartum 7.3 6.0 1.73 (0.58, 5.20)Premature delivery 4.9 1.3 5.19 (0.91, 29.54)Preeclampsia 4.9 5.3 1.30 (0.37, 4.57)

Abbreviations as in Table 1.Values are given as %, unless otherwise stated.* A woman can have more than one chronic disease.A woman can have more than one obstetric complication. Only women with earlier deliveries are analyzed.

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Table 3. Pregnancy-Related Data


(95% CI)

Visits to midwife at the ANC8 visits 33.3 47.1 1 (reference)912 visits 58.1 47.9 1.72 (1.09, 2.69)13 visits 8.5 5.0 2.42 (1.01, 5.81)

Visits to physician at the ANC2 visits 68.2 80.8 1 (reference)3 visits 31.8 19.2 1.97 (1.21, 3.18)

SmokingNo 93.8 90.0 1 (reference)Yes 6.2 10.0 0.60 (0.26, 1.36)

Admission to hospital because of pregnancy complications 10.9 10.0 1.10 (0.55, 2.19)Number of days* 5.9 5.7Pregnancy complication

No complications 36.3 57.3 1 (reference)Preeclampsia 1.9 4.3 0.70 (0.19, 2.58)Hyperemesis 5.1 1.8 4.49 (1.41, 14.29)Back pain 17.2 17.2 1.58 (0.90, 2.76)Vaginal bleeding 1.9 1.1 2.81 (0.55, 14.31)Premature contractions 15.3 8.2 2.93 (1.53, 5.59)

Miscellaneous 12.1 7.2 2.67 (1.33, 5.35)Psychiatric disorder 10.2 2.9 5.61 (2.28, 13.82)

Delivery in gestational week 40.3 40.7Reason for sick leave during pregnancy

No sick leave 57.6 76.8 1 (reference)Pregnancy-related complications 36.1 22.4 2.15 (1.37, 3.36)Psychiatric disorder 4.9 0.4 17.63 (2.14, 145.48)Miscellaneous 1.4 0.4 5.04 (0.45, 56.29)

ANC antenatal care. Other abbreviations as in Table 1.Values are given as %, unless otherwise stated.* Mann-Whitney Utest, P .551.A woman can have more than one pregnancy complication. Student ttest, P .005. Preeclampsia, hyperemesis, back pain, vaginal bleeding, premature contractions, and miscellaneous. Psychiatric disorders listed in DSM-IV, American Psychiatric Association.

Table 4. Delivery-Related Data


(95% CI)

Induction of labor 10.9 9.2 1.20 (0.60, 2.41)Normal delivery 62.8 69.7 1.37 (0.88, 2.13)Instrumental delivery 10.9 8.4 1.32 (0.65, 2.68)Acute cesarean section 9.3 7.7 1.24 (0.58, 2.61)Elective cesarean section 6.2 3.8 1.66 (0.64, 4.31)Perineal tears and excessive bleeding intrapartum 10.1 10.0 1.01 (0.50, 2.04)Number of hours from established contractions to delivery* 6.58 6.23Number of hours of pushing 0.52 0.51Paracervical blockade 3.1 4.6 0.66 (0.21, 2.10)Pudendal blockade 7.0 2.7 2.72 (0.99, 7.48)Morphine analogues 12.4 4.6 2.94 (1.35, 6.41)N2O 64.3 57.9 1.31 (0.85, 2.03)Epidural anesthesia 37.2 33.0 1.21 (0.78, 1.87)

Abbreviations as in Table 1.Values are given as %, unless otherwise stated.

A woman can have more than one delivery-related variable.* Student ttest, P .470. Student ttest, P .866.



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formed for multiparas and primiparas, respectively, butno further information was gained.

DISCUSSION

In this population-based case-control study, informationregarding a wide range of potential risk factors wascollected. An advantage of this study is the fact that wehad reached the total pregnant population at the time ofthe study and that all data were extracted from standard-ized medical records and not from maternal recall. Toour knowledge, this is the only study that includes earliermedical, gynecologic, and obstetric history. Most of the

predictors found were obvious already during preg-nancy, which could facilitate planning of prevention andintervention in the future.

The strongest risk factors for postpartum depressive

symptoms were sick leave during pregnancy and a highnumber of visits to the antenatal care clinic. The reasonsfor sick leave were mainly psychiatric disorders and

pregnancy-related complications. However, a potentialweakness in this study might be an underestimation ofan earlier or ongoing psychiatric condition influencingthe results. Nevertheless, this result supports our hypoth-esis that pregnancy complications are risk factors for

postpartum depression.Hyperemesis and premature contractions were more

common in the postpartum depressed group of women.Explanatory models for these symptoms might be som-

atization of pregnancy-related anxiety or depression butmight also be an effect of hormonal changes in the

pregnant woman. Antenatal depressive symptoms andpostpartum depression are correlated,11,31 but whetherthis is on a psychosocial basis or a result of hormonal andgenetic vulnerability remains to be investigated. Theabsence of correlation between sociodemographic vari-

ables and depressive symptoms is in line with previousstudies.2,3 The risk factors identified in the gynecologicand obstetric history were two induced abortions ormore and among multiparas a history of acute cesareansection or instrumental delivery in the past. These riskfactors did not remain significant on the multivariablelevel. We found no association between delivery compli-cations and the development of depressive symptoms.

This is consistent with the findings in two recent stud-ies,29,34 but not with some earlier studies, which havereported a strong link between cesarean section and

postpartum depression.28,35

Our results show that women at risk for postpartumdepression can be identified during pregnancy. Thestrongest risk factors, sick leave and a high number ofvisits at the antenatal care clinics, are not etiologic andmight be of either behavioral or biologic origin. The

possibilities of genetic vulnerability and hormonalchanges ought to be investigated further to reach a morethorough understanding.

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Table 5. Perinatal Data


(95% CI)

Neonatal morbidity 9.3 11.5 0.79 (0.39, 1.60)Congenital major malformation 3.9 0.8 5.26 (1.01, 27.50)Birth weight* (g) 3589 3581Postnatal hospital stay

2 days 21.7 29.9 1 (reference)35 days 62.0 59.4 1.44 (0.86, 2.39)6 days 16.3 10.7 2.09 (1.03, 4.26)

Breast-feeding 96.1 97.3 1.46 (0.46, 4.70)Puerperium without complications 93.0 91.6 0.82 (0.36, 1.82)

Abbreviations as in Table 1.Values are given as %, unless otherwise stated.* Student ttest, P .868.

Table 6. Multivariable Analysis*: All Women (n 390)

Variable OR (95% CI) P

Number of visits at the ANC 1.85 (1.17, 2.92) .008Sick leave during pregnancy 1.98 (1.23, 3.19) .005

Abbreviations as in Tables 1 and 3.* Multiple logistic regression, P .001. 0 10 visits, 1 11 visits (midwife physician).

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Address reprint requests to: Ann Josefsson, MD, Division ofObstetrics and Gynaecology, University of Linkoping, Univer-sity Hospital, Linkoping, SE-581-85, Sweden; E-mail: [email protected].

Received June 5, 2001. Received in revised form September 17, 2001.Accepted October 18, 2001.


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Obstetric, Somatic, And Demographic Risk Factors.11