Objective
Adolescent pregnancy is common and minority adolescents are at high risk. We sought the following: (1) to prospectively assess prevalence of antenatal depression (AND) and postpartum depression (PPD) in minority adolescents and (2) to examine the association of social support and adjustment, trauma, and stress on depression status.
Study Design
A total of 212 pregnant adolescents were recruited from public prenatal clinics and administered a prospective research survey during pregnancy and 6 weeks’ postpartum. Depression was measured using the Edinburgh Postnatal Depression Scale. Univariate, bivariate, and multivariable analyses were performed using logistic regression to assess predictors of AND and PPD.
Results
In our cohort, 20% screened positive for AND and 10% for PPD. The strongest predictor of PPD was AND (odds ratio [OR], 4.89; P < .001). Among adolescents with trauma history, there was a 5-fold increase (OR, 5.01) in the odds of AND and a 4-fold increase (OR, 3.76) in the odds of PPD. AND was associated with the adolescent’s poor social adjustment ( P < .001), perceived maternal stress ( P < .001), less social support ( P < .001), and a less positive view of pregnancy ( P < .001). PPD was significantly associated with primiparity ( P = .002), poor social adjustment ( P < .001), less social support and involvement of the baby’s father ( P < .001), and less positive view of pregnancy ( P < .001).
Conclusion
Significant independent risk factors for PPD include AND, view of pregnancy, and social support. Trauma history was highly prevalent and strongly predicted AND and PPD. Point prevalence decreased postpartum, and this may be due to transient increased social support following the birth, warranting longer follow-up and development of appropriate interventions in future work.
Adolescent pregnancy is a burdensome public health issue in the United States with a prevalence of 10% of adolescent girls under the age of 21 years. In 2008, there were 68 adolescent pregnancies per 1000 women in the United States, and this was a record low. The recent decline in prevalence may be primarily attributed to improved contraceptive use. However, the US adolescent pregnancy rate is among the highest in the developed world, more than twice as high as Canada and Sweden.
There are significant risks associated with adolescent pregnancy including poor maternal weight gain, preterm birth, pregnancy-induced hypertension, low birthweight, and neonatal death. Most adolescent pregnancies are unintended, and this places adolescent mothers and their children at increased risk for depression, poverty, abuse, and neglect during both pregnancy and postpartum.
These negative outcomes are exacerbated in women who are characterized as low income and racial/ethnic minority status, which are common demographic characteristics of adolescent mothers. Adolescent mothers face significant obstacles including the simultaneous developmental tasks of adolescence and parenting an infant, leading to increased risk of depression, emotional and behavioral problems, and parenting difficulties.
Perinatal depression
Depression during pregnancy (antenatal [AND]) and postpartum depression (PPD) have a prevalence of 10-15% in adult women and are associated with significant morbidity to the mother, the newborn, and the family. Despite the significant public health impact of perinatal depression (PND), the risk factors and prevalence of PND in adolescent mothers have not been well described, nor are they part of standard clinical care. Existing estimates for the prevalence of PND in all populations of adolescent mothers ranges from 16% to 44%. However, these estimates are severely limited because they come from small samples of adolescent mothers using cross-sectional survey designs and do not include Spanish-speaking adolescents.
The rate of PND in minority adolescents is estimated to be greater than 40%. Prior studies have reported that adolescents are more likely to be depressed if they have poor social support, increased stress, and low self-esteem. Limitations of these prior studies include small sample sizes of typically less than 100 women, retrospective design, and/or limited measures of depression. To date, no study has assessed multiple risk factors to create a model for examining the risk for PND in adolescent mothers. Our study location in North Carolina presented a unique opportunity to assess PND in minority adolescents. In the state capital of Raleigh, (Wake County) in 2010, adolescent women (younger than 20 years of age) reported 1116 live births (44.8% racial/ethnic minority).
Study-specific aim
To address the gaps in knowledge described above, the aims of our study were 2-fold: (1) to prospectively estimate the prevalence of depression status and severity of comorbid psychiatric symptoms in pregnant adolescents at 2 time points: time 1, during pregnancy (12-40 weeks’ gestation), and time 2, at 6 weeks postpartum; and (2) to examine risk factors for PND including association of trauma history, functional impairment, social support, social adjustment, self-efficacy, view of pregnancy, and current stressors in adolescents mothers at these 2 time points. We hypothesized that a history of trauma and poorer social support would be associated with increased prevalence of depression at both study time points.
Study-specific aim
To address the gaps in knowledge described above, the aims of our study were 2-fold: (1) to prospectively estimate the prevalence of depression status and severity of comorbid psychiatric symptoms in pregnant adolescents at 2 time points: time 1, during pregnancy (12-40 weeks’ gestation), and time 2, at 6 weeks postpartum; and (2) to examine risk factors for PND including association of trauma history, functional impairment, social support, social adjustment, self-efficacy, view of pregnancy, and current stressors in adolescents mothers at these 2 time points. We hypothesized that a history of trauma and poorer social support would be associated with increased prevalence of depression at both study time points.
Materials and Methods
We collected self-reported survey data at 2 time points (pregnancy and 6 weeks’ postpartum) from 212 consecutive adolescent women presenting for care at a low-risk urban health department obstetrical clinic in Raleigh, NC, from July 2010 to August 2011. Eligible subjects were English- and Spanish-speaking pregnant adolescents between the ages of 12 and 20 years. The subjects were recruited and completed the first survey at a prenatal visit in the second or third trimester. The second survey was administered at the routine 6 week postpartum visit. There were 187 adolescent mothers who completed both surveys, reflecting an 88% retention rate. Twenty-five subjects were lost to follow-up after delivery or had incomplete data and are not included in this study.
The study was approved by the University of North Carolina Institutional Review Board Committee for the Protection of Human Subjects. All subjects gave informed consent and signed the Health Insurance Portability and Accountability Act release.
Measures
In addition to questionnaires to assess demographic information, medical history, and obstetrical history, the following instruments were included in either the antenatal survey or postnatal survey.
Edinburgh Postnatal Depression Scale
The 10 item Edinburgh Postnatal Depression Scale (EPDS) was developed specifically for assessing PPD and is one of the most commonly used and well-validated self-report instruments. A cutoff of score of 12 or greater on the EPDS has been consistently shown to be associated with major depression, when compared with a structured clinical interview. The EPDS scores of 10-12 have been associated with an accurate diagnosis of minor depression. In our analysis, we used a cutoff score of 11 or greater as a positive screen.
Trauma inventory
Trauma history, including neglect and emotional and sexual and physical abuse history, was obtained by modifying a structured interview from previous research. Sexual abuse was defined as genital touching or vaginal or anal intercourse during which force or a threat of harm was present. In children younger than 13 years, the threat of force or harm was indicated by a 5 year age differential between the victim and perpetrator. Physical abuse was defined as incidents separate from sexual abuse that included life-threatening physical attack with the intent to kill or seriously injure or other physical abuse such as being beaten, kicked, or burned. A summary measure of number of cumulative categories of lifetime traumas was constructed.
Social support: Medical Outcomes Survey
The Medical Outcomes Survey (MOS) is a widely used scale considered universally applicable to assess social support with coefficient alphas greater than 0.91. The survey consists of 4 separate social support subscales and an overall functional social support index. Higher scores indicate higher levels of support.
Social adjustment scale self-report
We used the 9 question Social and Leisure Doman of the Social Adjustment Self-Report (SAS-SR). Questions address the performance at expected tasks, friction with others, interpersonal relationships, and feelings and satisfactions. Each item is scored on a 5 point scale, with higher scores indicating poorer functioning. An internal consistency reliability of alpha = 0.76 has been reported for the SAS-SR total score.
Social support from baby’s father
Social support received from the baby’s father was measured using an 8 item scale (DAD) that has good internal consistency of 0.90 and has been validated in an adolescent population. This measure addresses how much the baby’s father has provided material support, assisted with tasks, listened to worries, and helped solve problems. Additional questions address how often the father had disappointed the mother or was critical or short tempered, and the final item assesses overall satisfaction with support from the baby’s father.
Life stressors
The Everyday Stressors Index (ESI) is a 20 item instrument with good internal consistency designed to capture the level of daily stressors faced by mothers of young children. It uses a 4 point scale that is summed for a total level of stress and assesses parenting concerns, quality/safety of living arrangements, finances/employment, health, and relationship issues.
General Self-Efficacy Scale
The 17 item General Self Efficacy Scale (GSES) measures general self-efficacy expectancies by addressing a willingness to initiate behavior, expend effort in completing the behavior and persistence in the face of adversity, and demonstrates excellent reliability with a reported Cronbach alpha coefficient of 0.86. A total score was calculated by summing the scores, with the higher total scores indicating higher levels of self-efficacy.
Postpartum Adjustment Questionnaire
We used the 9 item New Baby Subscale of Postpartum Adjustment Questionnaire (PPAQ) to assess the mother’s relationship with her baby. The PPAQ has good reliability (coefficient alpha is 0.75). Most items were scored on a scale of 1 to 5, with higher scores indicating poorer functioning. Scores for all 9 items were summed to calculate an overall score.
Statistical methods
Analyses were conducted using SAS statistical software (SAS Inc., Cary, NC). In our sample of adolescent mothers, we performed descriptive statistics that included percent tabulations for categorical variables and means with SDs for continuous variables. The statistical significance level was set at P < .05, and there were no corrections for multiple comparisons. Our primary outcome measure was depression status as defined by a positive score on the EPDS (11 or greater) in both the prenatal and postpartum surveys. Bivariate analyses were conducted using χ 2 statistics for categorical variables and analysis of variance for continuous variables to compare the depression status in both the prenatal and postpartum groups to the sum scores of the measures of social adjustment (SAS), social support (MOS and DAD), life stressors (ESI), trauma history, and general self-efficacy (GSES). We also compared depression status with how positively the pregnancy was viewed by the adolescent mother and compared trauma history with the adolescent’s perception of self-efficacy and social adjustment. Finally, we performed multivariable logistic regression analyses to identify predictors of AND and postpartum PPD.
Results
Demographic characteristics
Table 1 describes the demographic characteristics for our study cohort and compares the characteristics of the depressed (EPDS score of 11 or greater) vs nondepressed (EPDS score less than 11) adolescent mothers at the antenatal assessment. Respondents averaged 18 years of age and 87% were self-identified as a minority group (37% African American and 46% Latina). The vast majority (89%) reported never being married. Approximately 24.5% of the respondents reported completing high school and 50.3% reported partial completion of high school. Most respondents were living in poverty, with approximately 80% having an annual household income of less than $30,000 per year. Subjects reported high rates of physical and sexual abuse, with 50% reporting a history of at least 1 traumatic event. Importantly, a history of abuse or trauma emerged as the only statistically significant demographic variable that differed between groups (depressed vs nondepressed adolescent mothers) at the first antenatal assessment (71.73% of depressed vs 44.4% of nondepressed, P < .005).
| Variable | Depressed (EPDS 11 or greater) | Nondepressed (EPDS less than 11) | P value |
|---|---|---|---|
| Age, y | 18.4 years | 18.2 | .41 |
| Race (% minority) | 89.2% minority | 86.3% | .79 |
| Marital status (% never married) | 91.4% | 88.2% | .77 |
| Relationship status | 37.8% cohabitating with partner | 47.6% | .36 |
| Parity (% primiparous) | 74.0% | 75.7% | .99 |
| Unplanned pregnancy | 78.0% unplanned | 86.5% | .19 |
| Household income (% less than $30K annually) | 79.0% | 89.0% | .22 |
| School status (% not in school) | 69.0% | 69.4% | .99 |
| Work status (% unemployed) | 74.3 | 77.3 | .83 |
| Trauma history | 71.73% with physical or sexual trauma | 44.4% with physical or sexual trauma | .0047 |
| Contraception | 64.9% not using at postpartum visit | 60.0% not using at postpartum visit | .71 |
| Sexual activity | 32.4% active at postpartum visit | 32.6% active at postpartum visit | .99 |
| Breast vs bottle feeding | 41.7% exclusively bottle feeding | 44.9% exclusively bottle feedings | .86 |
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