The purpose of this study was to evaluate risk factors for antepartum depressive symptoms that can be assessed in routine obstetric care. We evaluated articles in the English-language literature from 1980 through 2008. Studies were selected if they evaluated the association between antepartum depressive symptoms and ≥1 risk factors. For each risk factor, 2 blinded, independent reviewers evaluated the overall trend of evidence. In total, 57 studies met eligibility criteria. Maternal anxiety, life stress, history of depression, lack of social support, unintended pregnancy, Medicaid insurance, domestic violence, lower income, lower education, smoking, single status, and poor relationship quality were associated with a greater likelihood of antepartum depressive symptoms in bivariate analyses. Life stress, lack of social support, and domestic violence continued to demonstrate a significant association in multivariate analyses. Our results demonstrate several correlates that are consistently related to an increased risk of depressive symptoms during pregnancy.
Depression is one of the most common complications in pregnancy. As many as 12.7% of pregnant women experience a major depressive disorder. Several professional organizations now recommend routine screening for antepartum depression. In fact, the American College of Obstetricians and Gynecologists (ACOG) recommends screening for depression during each trimester of pregnancy.
For Editors’ Commentary, see Table of Contents
Prenatal care providers are uniquely suited to address antepartum depression. First of all, providers have already captured their target population, because most women will use obstetric services at some point during their pregnancies. Providers also have multiple opportunities to assess, treat, and follow-up with patients, as obstetric visits are recurring during a several-month span. Despite these qualifications, prenatal care providers are constrained by a lack of education in the evaluation and treatment of depression. Less than half of obstetricians report that residency prepared them to diagnose depression.
Although several metaanalyses have summarized risk factors for postpartum depression, there has been no systematic synthesis of the literature regarding risk factors for depressive symptoms during pregnancy, when obstetric providers will have their most frequent contact with patients. We cannot assume that the risk factors during pregnancy are the same as those postpartum, because certain factors, such as pregnancy intention and social support, may operate differently before and after the arrival of a baby.
If providers know the clinical significance of risk factors for depression in pregnancy, they may be able to more easily identify women with the highest chance for developing this condition. Therefore, the purpose of our study was to examine risk factors for antepartum depression that can be assessed in routine obstetric care.
Materials and methods
In consultation with an experienced research librarian, we developed Boolean search strategies ( Appendix ) with the key words “depression,” “screening,” and “pregnancy.” We searched for articles, abstracts, and dissertations from January 1980 through March 2008 in the following databases: PubMed, CINAHL, SCOPUS, PsycINFO, Sociological Abstracts, ISI Proceedings, and ProQuest Dissertations and Theses. In addition, we searched the bibliographies of a large systematic review, 2 ACOG Committee Opinions, and 3 medical guidelines. Finally, we hand-searched the bibliographies of each included article.
The Figure outlines the selection process. Two independent reviewers examined each article for inclusion. If the 2 reviewers disagreed on whether to include an article, they repeated the review of inclusion/exclusion criteria and met to discuss these criteria in regard to the article in question. A third reviewer was available to resolve any disagreements that could not be resolved by consensus of the first 2 reviewers. However, all disagreements were resolved without the need for a third review.
We included studies that assessed for depressive symptoms during pregnancy and evaluated the association between depressive symptoms and ≥1 potential risk factors. We excluded studies that provided only descriptive statistics; studies in a non-English language; studies performed outside of the United States, Canada, Europe, Australia, or New Zealand; studies with an exclusively adolescent sample; studies of women with known depression at the time of screening; and case series, case reports, and review articles with no original data. In addition, we excluded studies with <20 subjects so that the included studies would have sufficient power to examine the association for at least 1 potential risk factor.
Our initial sample contained 197 articles, covering >100 potential risk factors. Using existing guidelines and prenatal intake forms, we narrowed our analysis to include 20 risk factors that could be clinically assessed in routine obstetric practice: maternal anxiety; life stress; depression history; social support; domestic violence; unintended pregnancy; insurance status; socioeconomic status (SES); income; employment; education; age; race/ethnicity; cohabitation status; relationship quality; smoking; alcohol use; illicit drug use; parity; and obstetric history. Excluded risk factors included items such as negative self-schema and acculturation. In addition, we excluded risk factors for which there were <3 studies in the literature.
The primary investigator developed a data extraction tool a priori that was used to assess the following article details: study design; screening method; patient characteristics; and associations between predictor variables and depression, including appropriate statistics. A second reviewer examined the extracted data for accuracy. Whenever there was insufficient information to calculate the association between a risk factor and depression, an effort was made to contact the corresponding author. If a study assessed the relationship between a predictor and depressive symptoms at multiple time points, the most conservative effect size was recorded.
In addition, we developed an article quality assessment tool adapted from methods of the US Preventive Services Task Force and a systematic review of perinatal depression. The tool included items related to internal validity, external validity, and precision in relation to our study’s key question. Therefore, these ratings reflected the quality of each article for the purpose of our study and not necessarily for the original purpose of the research. The scores from each item were summed to yield a total rating of 0-10. Two independent reviewers assessed each study for quality. When there was disagreement between raters, the article was assigned the most conservative quality score.
The heterogeneity among studies for all risk factors precluded the use of meta-analytic techniques. For each study, the primary investigator recorded the effect size of the association between a given risk factor and depressive symptoms. The effect was recorded in units of standardized effect size, using Cohen’s definitions of small, medium, and large effects.
Then, for each potential risk factor, 2 blinded, independent reviewers evaluated the data from the included studies. If there was consistency of effect across the studies, each reviewer determined the overall trend of association, based on the magnitude of effect sizes, statistical significance, sample size, and direction of effect. The intraclass correlation for interrater reliability was 0.86 (95% confidence interval, 0.79–0.93). Any disagreements between the 2 reviewers were resolved by consensus. In this case, the 2 reviewers met to discuss their assessments and mutually decided on the best estimate of the overall trend of association.
For example, 11 studies involving 4696 women examined the bivariate association between maternal anxiety and antepartum depressive symptoms. All 11 studies showed a statistically significant association. One small study showed a less than small effect size, but 5 studies showed a medium effect and 5 studies showed a large effect. Therefore, we summarized the trend of evidence as demonstrating a medium-to-large effect. Even though the 11 studies were heterogeneous in their samples, the trend of evidence was consistent across them.
However, if heterogeneity of effect precluded our ability to assess the trend of evidence, we determined that the results were inconclusive for that particular risk factor. For example, 14 studies examined race and antepartum depression. Six studies showed a significant association (n = 3567), but in 8 studies (n = 3104) the association was not statistically significant. Seven studies showed a negligible effect, and 7 studies demonstrated a small-to-medium effect. Therefore, we concluded that the evidence is inconclusive regarding any association between race and antepartum depression.
All final summary trends were reviewed by the entire panel of coauthors.
Trends of evidence were stratified by bivariate and multivariate comparisons.
Results
A total of 159 articles met inclusion criteria ( Figure ). Studies were most often excluded because they did not assess predictors for depression (n = 55) or they presented only postpartum data (n = 45). A table of the excluded articles is available by request from the corresponding author (C.A.L.).
The 159 included articles had a mean sample size of 522 subjects (SD = 1014; median = 175). Approximately half (54.1%) of the studies were performed in the United States. Seventeen studies (10.7%) were longitudinal in design, and 52 studies (32.7%) included multivariate analysis. The 159 studies used 24 different depression screeners, with the Center for Epidemiological Studies Depression Scale (31.4%), the Edinburgh Postnatal Depression Scale (18.2%), and the Beck Depression Inventory (17.0%) being the most common. Only 20 studies (12.6%) used a formal diagnostic assessment for depression.
Overall, the mean study quality score was 6.3 (SD = 1.1). Due to the large number of studies and heterogeneity of study designs, we limited our analysis to the top 25th percentile of quality scores (≥7). In addition, to reach a score of 7, studies must have addressed quality items involved in both internal and external validity. A total of 57 studies met this quality cutoff (hereafter referred to as “high-quality studies”) and are presented in Table 1 .
| Study | Assessment | Country | Sample size | Mean maternal age, y (SD) | Gestational age at screen | Potential risk factors | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DEM | DV | OB | PSY | REL | SS | STR | SUB | ||||||
| Affonso | HSCL, SADS | US | 202 | 30 (4.72) | 10-14, 20-22, and 30-32 wk | ✓ | ✓ | ✓ | ✓ | ||||
| Alati et al | DSSI | Australia | 4527 | 25 (5.0) | First antenatal care visit | ✓ | |||||||
| Alvik et al | HSCL | Norway | 1424 | 30.8 (4.4) | 17-18 and 30 wk | ✓ | |||||||
| Armstrong | CESD | US | 40 | 32.6 (4.6) | 15-32 wk | ✓ | ✓ | ||||||
| Bennett et al | CESD | US | 766 | 26.1 (5.4) | Unknown | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Bergner et al | DEPS | Germany | 108 | 32.1 (6.4) | Each trimester | ✓ | ✓ | ✓ | ✓ | ||||
| Berle et al | HADS | Norway | 680 | 28.9 (4.8) | Varied | ✓ | |||||||
| Bernazzani et al | BDI | Canada | 213 | 29.3 (4.0) | Second trimester | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Blaney et al | CESD | US | 307 | 28.7 (6.1) | ≥24 wk | ✓ | ✓ | ✓ | ✓ | ||||
| Bowen and Muhajarine | EPDS | Canada | 39 | 23.2 (4.1) | Varied (mean = 17 wk) | ✓ | ✓ | ✓ | ✓ | ||||
| Cooklin et al | EPDS, POMS | Australia | 144 | 31.3 (4.9) | Third trimester | ✓ | ✓ | ||||||
| Condon | Self-developed | Australia | 165 | 25 a | Varied (58% in third trimester) | ✓ | |||||||
| Da Costa et al | DACL | Canada | 80 | 29.1 (3.7) | Every month | ✓ | ✓ | ✓ | |||||
| Edge et al | EPDS | England | 301 | 28.8 (6.5) | Third trimester | ✓ | |||||||
| Elsenbruch et al | ADS-K | Germany | 896 | 29.2 (5.0) | First trimester | ✓ | |||||||
| Flynn et al | CESD | US | 1131 | 28.7 (5.3) | Varied (mean = 25 wk) | ✓ | ✓ | ✓ | ✓ | ||||
| Flynn et al | CESD | US | 1054 | 28.2 (5.6) | Varied (mean = 25 wk) | ✓ | ✓ | ✓ | |||||
| Franche and Mikail | BDI | Canada | 62 | 29.8 (4.5) | 10-24 wk | ✓ | ✓ | ||||||
| Glazier et al | CESD | Canada | 2052 | 30.7 (4.5) | 24 wk | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Grant et al | EPDS, MINI | Australia | 100 | 32.0 (4.4) | Third trimester | ✓ | ✓ | ||||||
| Heaman | POMS | Canada | 56 | 28.2 (4.9) | Third trimester | ✓ | ✓ | ||||||
| Hobfoll et al | BDI, SADS | US | 192 | 24.5 (5.1) | Second and third trimester | ✓ | ✓ | ||||||
| Hoffman and Hatch | CESD | US | 662 | 27.5 (4.5) | 13, 28, and 36 wk | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Holzman et al | CESD | US | 1321 | b | 16-26 wk | ✓ | ✓ | ✓ | ✓ | ||||
| Jesse et al | Self-developed | US | 120 | b | 16-28 wk | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Jesse | Self-developed | US | 120 | b | 16-28 wk | ✓ | |||||||
| Jesse et al | BDI | US | 128 | b | 16-28 wk | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Kleiverda et al | HSCL | Netherlands | 170 | 28.9 a | 18 and 34 wk | ✓ | ✓ | ✓ | ✓ | ||||
| Larsson et al | EPDS | Sweden | 1489 | b | 35-36 wk | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Leathers and Kelley | CESD | US | 124 | 30 (4.1) | 2-3 mo before birth | ✓ | ✓ | ✓ | |||||
| Lindgren | CESD | US | 252 | 29.5 (6.1) | 20-40 wk | ✓ | ✓ | ✓ | |||||
| Morse et al | EPDS | Australia | 251 | 30 c | 24-26 and 36 wk | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Najman et al | DSSI | Australia | 6642 | b | First clinic visit (mean = 18 wk) | ✓ | |||||||
| Nicholson et al | CESD | US | 175 | 28 (6.2) | ≤20 wk (mean = 14.6 wk) | ✓ | ✓ | ✓ | ✓ | ||||
| Norbeck and Tilden | DACL | US | 117 | 26.2 (4.2) | 12-20 wk (mean = 16.2 wk) | ✓ | |||||||
| O’Heron | BDI, SCID | US | 92 | 28.5 a | Second-third trimester | ✓ | ✓ | ✓ | ✓ | ||||
| Orr and Miller | CESD | US | 1163 | b | First prenatal care visit | ✓ | |||||||
| Pajulo et al | EPDS | Finland | 391 | 28 (4.8) | 18-35 wk (mean = 23 wk) | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Pascoe et al | CESD | US | 105 | b | Varied | ✓ | |||||||
| Pascoe et al | CESD | US | 139 | 24.5 (2.3) | 24-28 wk | ✓ | ✓ | ||||||
| Records and Rice | CESD | US | 139 | 27 (5.2) | Third trimester | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ||
| Ritter et al | BDI | US | 191 | 24.5 a | Second and third trimester | ✓ | ✓ | ✓ | |||||
| Rodriguez et al | BDI | US | 210 | 27.7 (5.8) | ≥12 wk | ✓ | ✓ | ||||||
| Rowe et al | HADS | Australia | 134 | 29.1 (4.7) | 8-14 wk (mean = 12 wk) | ✓ | |||||||
| Rubertsson | EPDS | Sweden | 3011 | b | 15 wk | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Seguin et al | BDI | Canada | 144 | 24.2 (5.0) | 30 wk | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Smith et al | PHQ | US | 387 | b | Varied (mean = 24 wk) | ✓ | |||||||
| Söderquist et al | BDI | Sweden | 951 | 28.7 (4.5) | 12-20 wk (mean = 18 wk) | ✓ | |||||||
| Tilden | DACL | US | 141 | 26.3 a | Second trimester | ✓ | |||||||
| van de Pol et al | CESD | Netherlands | 511 | 30 (3.6) | 12 and 36 wk | ✓ | ✓ | ✓ | |||||
| Vander Weg et al | CESD | US | 245 | 25.6 (5.2) | Unknown | ✓ | ✓ | ✓ | |||||
| Ward et al | CESD | US | 248 | 24.2 (5.1) | Varied (mean = 21 wk) | ✓ | ✓ | ||||||
| Westdahl et al | CESD | US | 1047 | 20.4 (2.6) | Second trimester (mean = 18 wk) | ✓ | ✓ | ✓ | ✓ | ||||
| Zayas et al | BDI | US | 106 | 25 (5.6) | Third trimester | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Zelkowitz et al | EPDS | Canada | 119 | 30.6 (4.9) | Varied (mean = 29 wk) | ✓ | ✓ | ✓ | ✓ | ✓ | |||
| Zuckerman et al | CESD | US | 1014 | b | First or second prenatal care visit | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | |
| Zuckerman et al | CESD | US | 1123 | b | Unknown | ✓ | |||||||
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