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Risk for postpartum depression associated with assisted reproductive technologies and multiple births: A systematic review
Abstract
It has been hypothesized that certain obstetrical populations, including women who conceive using assisted reproductive technologies (ART) and women with multiple births, may be at increased risk for postpartum depression. In this systematic literature review, we examine the published evidence for this hypothesis.
The databases Medline, CINAHL, EMBASE, PsycINFO and the Cochrane Library were searched from their start dates through to April 1, 2009 using relevant keywords. All published, peer-reviewed articles in English, Spanish or French including a standardized assessment of depression administered between 2 and 52 weeks postpartum were considered for inclusion. Two independent reviewers abstracted and critically appraised a total of 13 eligible articles.
The data indicate little or no increased risk for postpartum depression among women who use ART to conceive. In contrast, most studies of adequate quality indicate that mothers of multiples may be at elevated risk for symptoms of depression. However, existing data do not permit differentiation between transient maternal distress and clinically significant postpartum depression.
Studies included in this review were often limited by small samples and lack of appropriate comparison groups, making further research in this area essential. In particular, lack of control for maternal psychiatric history and other important sociodemographic predictors of depression is a serious limitation of existing research on this topic. Further, the use of reproductive technologies and multiple births often co-occur, and few study designs enabled separation of the effects of these two variables. However, evidence of increased risk for symptoms of postpartum depression among women with multiple births, if confirmed, may warrant targeted interventions for this population.
... daily shots, hormone treatments, egg retrieval, embryo transfer) are largely performed on the woman. Women who have achieved a clinical pregnancy using ART may be at an increased risk for experiencing depression (Ross et al., 2011;Gda nska et al., 2017). This heightened risk for depression and avoidance of negative feelings may continue during the transition to parenthood especially for first-time mothers who may be more likely to idealize parenthood, experience greater concerns about their child's health, and feel less entitled to seek social support when they feel doubts or uncertainty about parenting (Ulrich et al., 2004;Fisher et al., 2005;Gressier et al., 2015). ...
... To the best of our knowledge, the psychometric properties of the PHQ-8 have not been previously evaluated in a sample of mothers who conceived using ART. Given increasing rates of infertility (Ravitsky and Kimmins, 2019) and the potential of a greater propensity for depression among first-time mothers who conceived via ART during the transition to parenthood (Ross et al., 2011;Gda nska et al., 2017), the current study sought to evaluate the reliability and validity of the PHQ-8 in first-time mothers of children 5 years old or younger who conceived using ART. ...
... Women who have conceived via ART are at an increased risk for experiencing emotional distress (Aimagambetova et al., 2020). Ross et al., 2011), in the current sample, 36.4% of mothers reported moderate to severe depressive symptoms. Since maternal depression can be detrimental to both the mother and the child (Cox et al., 1987), it is critical to have psychometrically sound measures that assess depression in mothers who have conceived using ART. ...
Study question
Is the Patient Health Questionnaire-8 (PHQ-8) a valid and reliable measure of depression in first-time mothers who conceived via Assisted Reproductive Technology?
Summary answer
The results from this study provide initial support for the reliability and validity of the PHQ-8 as a measure of depression in mothers who have conceived using ART.
What is known already
Women who achieved a clinical pregnancy using Assisted Reproductive technology experience many stressors and may be at an increased risk of depression. The PHQ-8 is a brief measure designed to detect the presence of severity of depressive symptoms. It has been validated in many populations; however, it has not been validated for use in this population.
Study design, size, duration
This is a cross-sectional study of 171 first time mothers in the United States, recruited through Amazon’s Mechanical Turk (MTurk).
Participants/materials, setting, methods
The reliability of the PHQ-8 was measured through a Cronbach’s alpha, the convergent validity was measured though the correlation between the PHQ-8 and the General Anxiety Disorder-7 (GAD-7) measure of anxiety symptoms, and the structural validity was measured through a Confirmatory Factor Analysis.
Main results and the role of chance
The Cronbach’s alpha for the total PHQ-8 was acceptable (α =.922). The correlation between the PHQ-8 and the GAD-7 was large (r=.88) indicating good convergent validity. Ultimately, a bifactor model provided the best model fit (χ2(13) = 23.8, p = 0.033; Comparative Fit Index (CFI) =0.987; Root Mean Square Error of Approximation (RMSEA) = 0.07, Tucker-Lewis Index (TLI) = 0.972).
Limitations, reasons for caution
The results are limited by: the predominantly white and well-educated sample, a lack of causation between the use of artificial reproductive technology and depressive symptoms, including mothers with children up to 5 years old, convergent validity being based on associations with a related construct instead of the same construct, lack of test-retest reliability, divergent validity, and criterion-related validity, data collected through MTurk, and the fact that the measures used were all self-report and therefore may be prone to bias.
Wider implications of the findings
Consistent with previous literature, a bifactor model for the PHQ-8 was supported. As such, when assessing depression in first-time mothers who conceived via Assisted Reproductive Technology, using both the PHQ-8 total score and subdomain scores may yield the most valuable information. The results from this study provide preliminary support for the reliability and validity of the PHQ-8 as a measure of depression in first-time mothers who conceived using Assisted Reproductive Technology.
Study funding/competing interest(s)
No specific funding was used for the completion of this study. Throughout the study period and manuscript preparation, the authors were supported by the department funds at Baylor University. The authors declare that they have no conflicts of interest.
Trial registration number
N/A
... Even though some studies did not find any significant differences between twin and singleton births (Taubman-Ben-Ari et al., 2008) or between being parents of twins and being parents of two singleton children (Walke, 2002), it seems that multiple pregnancy could be a risk factor for decreased quality of the couple relationship . The mixed findings about the effect of twin pregnancy on couple relationship may be partially attributed to the fact that twin pregnancy is also frequently associated with the use of assisted reproductive technologies (ART; Ross et al., 2011) and ART conception seems to negatively affect the couple relationship (Sydsjö et al., 2008). Thus, the combination of ART conception and twin pregnancy could make the situation even more complicated, with potential consequences on parental well-being and marital relationship (Ross et al., 2011;Smorti, & Smorti, 2013). ...
... The mixed findings about the effect of twin pregnancy on couple relationship may be partially attributed to the fact that twin pregnancy is also frequently associated with the use of assisted reproductive technologies (ART; Ross et al., 2011) and ART conception seems to negatively affect the couple relationship (Sydsjö et al., 2008). Thus, the combination of ART conception and twin pregnancy could make the situation even more complicated, with potential consequences on parental well-being and marital relationship (Ross et al., 2011;Smorti, & Smorti, 2013). To date, it is difficult to understand whether the lower quality of the couple relationship results from the twin pregnancy or from the difficult period of medically assisted conception, which is known to have a significant impact on the couple (Smorti & Smorti, 2013). ...
... Regarding women pregnant with twins, given the mixed results on quality of relationship of pregnant couples both after ART (Ross et al., 2011;Sydsjö et al., 2008) and related to parity, we selected only pregnant mothers expecting twins (after natural conception) in the first gestation. Our findings show that the perception of couple relationship quality of mothers expecting one child is significantly different from that of mothers expecting twins. ...
Objective
The aim of this study was to explore the changes in quality of couples' relationships from pregnancy to postpartum in pregnant Italian women who conceived spontaneously and to analyze the differences in transition to motherhood with respect to birth of (a) first child, (b) second child, and (c) twins.
Background
The transition to motherhood leads to several changes for parents and can significantly affect a couple's adaptation. The couple's adaptation to parenthood may depend on whether they are having a first child, a second child, or twins.
Method
A total of 119 women (61 primiparous women with single pregnancy, 42 multiparous women with single pregnancy, and 16 primiparous women with twin pregnancy) completed the Dyadic Adjustment Scale during the third trimester of pregnancy and 3 months after childbirth. To explore whether the three groups differed regarding the quality of the couple relationship during pregnancy, a multivariate analysis of variance (MANOVA) was conducted. Subsequently, a series of mixed 2 × 3 ANOVA with Time (pregnancy and postpartum) as the within factor and Group as the between factor for each dependent variable linked to the dimensions of the Dyadic Adjustment Scale was carried out to explore whether the quality of the couple relationship differed 3 months after childbirth.
Results
Results highlighted that, during pregnancy, mothers expecting one child (both primiparas and multiparas) reported a higher level of couple relationship quality than did women expecting twins. However, after childbirth, mothers of twins reported significant improvements on some qualitative aspects of their couple relationship (Affective Expression), whereas the other mothers reported some worsening in the perceived couple relationship 3 months after the birth of the child, especially regarding global score, Dyadic Cohesion, and Affective Expression.
Conclusion
In conclusion, birth preparation courses must pay attention not only to parenting transition but also to promoting involvement of both partners in household duties. Anticipating a fair division of household chores can allow partners to prepare for childbirth and limit the stress of the couple.
Implications
The promotion of dyadic adjustment can reduce parenting stress and increase parents' well-being.
... In vitro fertilization, typically characterized by repeated rounds of high-dose ovarian stimulation and intense hormonal fluctuations, has been postulated to contribute to increased peripartum mood disorders, 28 although not consistently so. 29 Although numerous studies have indicated substantial psychological distress during and after infertility treatment, 10,11 one systematic review found that IVF is not clearly associated with diagnosed postpartum depression except among individuals with multiple gestation pregnancies. 29 The authors of this review noted that the sample sizes of included studies were small and studies did not use appropriate comparison groups, indicating the need for more rigorous investigation into this topic. ...
... 29 Although numerous studies have indicated substantial psychological distress during and after infertility treatment, 10,11 one systematic review found that IVF is not clearly associated with diagnosed postpartum depression except among individuals with multiple gestation pregnancies. 29 The authors of this review noted that the sample sizes of included studies were small and studies did not use appropriate comparison groups, indicating the need for more rigorous investigation into this topic. Individuals in our cohort who underwent IVF had a low absolute rate of postpartum mental illness; in particular, they had the lowest rate of severe mental illness requiring hospital admission or an emergency department visit when compared with other exposure groups. ...
Background:
Subfertility and infertility treatment can be stressful experiences, but it is unknown whether each predisposes to postpartum mental illness. We sought to evaluate associations between subfertility or infertility treatment and postpartum mental illness.
Methods:
We conducted a population-based cohort study of individuals without pre-existing mental illness who gave birth in Ontario, Canada, from 2006 to 2014, stratified by fertility exposure: subfertility without infertility treatment; noninvasive infertility treatment (intrauterine insemination); invasive infertility treatment (in vitro fertilization); and no reproductive assistance. The primary outcome was mental illness occurring 365 days or sooner after birth (defined as ≥ 2 outpatient visits, an emergency department visit or a hospital admission with a mood, anxiety, psychotic, or substance use disorder, self-harm event or other mental illness). We used multivariable Poisson regression with robust error variance to assess associations between fertility exposure and postpartum mental illness.
Results:
The study cohort comprised 786 064 births (mean age 30.42 yr, standard deviation 5.30 yr), including 78 283 with subfertility without treatment, 9178 with noninvasive infertility treatment, 9633 with invasive infertility treatment and 688 970 without reproductive assistance. Postpartum mental illness occurred in 60.8 per 1000 births among individuals without reproductive assistance. Relative to individuals without reproductive assistance, those with subfertility had a higher adjusted relative risk of postpartum mental illness (1.14, 95% confidence interval 1.10-1.17), which was similar in noninvasive and invasive infertility treatment groups.
Interpretation:
Subfertility or infertility treatment conferred a slightly higher risk of postpartum mental illness compared with no reproductive assistance. Further research should elucidate whether the stress of infertility, its treatment or physician selection contributes to this association.
... However, most studies did not find differences in depression between infertile women undergoing treatment for infertility and controls [16][17][18][19][20][21], and one found its prevalence to be reduced in IVF women compared to controls [22]. Results match the conclusions of systematic reviews and meta-analyses, which ruled out a relationship between MAR and postpartum depression [23,24]. However, one study found more postpartum depression in IVF mothers related to predictors such as caesarean delivery, multiple treatment cycles, and inadequate social support [25,26], while another found, in MAR women, a higher age of the woman, economic difficulties, infertility duration, and multiple unsuccessful attempts to increase depression and a soothing effect of partner support [27]. ...
... Despite psychological stress and hormonal stimulation treatments that may expose patients with infertility or subfertility to stress disorders such as depression and anxiety [2], a higher risk of perinatal depressive symptoms has been indicated by one study [17]; our study confirmed in an Italian population the findings of systematic reviews and meta-analyses, showing a lack of correlation between depression and MAR [23,24]. A greater risk of depression in IVF women was also not confirmed by a large Swedish longitudinal study that used the EPDS at the same timepoints as our study [19], and in an Australian study, which found more postpartum adjustment difficulties in women who had gone through several IVF attempts [35,36]. ...
Background: Women taking advantage of medically assisted reproduction (MAR) techniques may differ from spontaneously conceiving women (nonMAR) in risk of depression and/or anxiety. We aimed to investigate possible differences between MAR and nonMAR through the use of the Edinburgh Postnatal Depression Scale in a sample of Italian-speaking women at their third trimester of pregnancy. Methods: We administered the Edinburgh Postnatal Depression Scale (EPDS) to two groups of pregnant women, MAR and nonMAR, at the third trimester of pregnancy (T0), one month after delivery (T1), and three months after delivery (T2) from February 2013 to December 2019. EPDS total scores cutoffs were ≥9 for risk of depression, 9–11 mild depression, ≥12 major depression, and the EPDS-3A cluster ≥4 was a proxy for anxiety. Results: Included were 1303 nonMAR women and 92 MAR, an expected disproportion. NonMAR and MAR women did not differ on depression or anxiety at any assessment timepoint. MAR women were older than nonMAR, consumed more alcohol and medical drugs, and displayed more complications during pregnancy. Scoring over the threshold on depression risk was associated with foreign nationality, unemployment, psychiatric history of the patient, family or partner, psychiatric problems in past pregnancies, hyperemesis, premenstrual syndrome (PMS), and stressful life events in the last year at baseline, and, for some of them, at other timepoints. In contrast, MAR past or current was associated with having suprathreshold depression at the first-month postpartum follow-up. Conclusions: Taken together, our data show that women opting for MAR do not differ from spontaneously conceiving women regarding psychiatric outcomes but do differ on some sociodemographic and clinical variables.
... However, multiple births occur more often in mothers who used infertility treatment than those conceiving naturally, and that may increase the likelihood of depression. 51 In a systematic review of 7 studies, researchers concluded that multiple births is a risk factor for postpartum depressive symptoms, 51 elevated symptoms can persist for at least 3 years postpartum. This study reveals that assessing depression only once or too early in the postpartum period (ie, at 6 months or earlier, as recommended by the AAP 1 ) may make it difficult to discern the future course. ...
... However, multiple births occur more often in mothers who used infertility treatment than those conceiving naturally, and that may increase the likelihood of depression. 51 In a systematic review of 7 studies, researchers concluded that multiple births is a risk factor for postpartum depressive symptoms, 51 elevated symptoms can persist for at least 3 years postpartum. This study reveals that assessing depression only once or too early in the postpartum period (ie, at 6 months or earlier, as recommended by the AAP 1 ) may make it difficult to discern the future course. ...
Objectives:
To identify homogenous depressive symptom trajectories over the postpartum period and the demographic and perinatal factors linked to different trajectories.
Methods:
Mothers (N = 4866) were recruited for Upstate KIDS, a population-based birth cohort study, and provided assessments of depressive symptoms at 4, 12, 24, and 36 months postpartum. Maternal demographic and perinatal conditions were obtained from vital records and/or maternal report.
Results:
Four depression trajectories were identified: low-stable (74.7%), characterized by low symptoms at all waves; low-increasing (8.2%), characterized by initially low but increasing symptoms; medium-decreasing (12.6%), characterized by initially moderate but remitting symptoms; and high-persistent (4.5%), characterized by high symptoms at all waves. Compared with the high-persistent group, older mothers (maximum odds ratio [OR] of the 3 comparisons: 1.10; 95% confidence interval [CI]: 1.05 to 1.15) or those with college education (maximum OR: 2.52; 95% CI: 1.36 to 4.68) were more likely to be in all other symptom groups, and mothers who had a history of mood disorder (minimum OR: 0.07; 95% CI: 0.04 to 0.10) or gestational diabetes mellitus diagnosis (minimum OR: 0.23; 95% CI: 0.08 to 0.68) were less likely to be in other symptom groups. Infertility treatment, multiple births, prepregnancy BMI, gestational hypertension, and infant sex were not differentially associated with depressive symptom trajectories.
Conclusions:
One-quarter of mothers in a population-based birth cohort had elevated depressive symptoms in 3 years postpartum. Screening for maternal depression beyond the postpartum period may be warranted, particularly after mood and diabetic disorders.
... Preliminary data indicate that there are no significant differences in terms of psychological https://doi.org/10.1016/j.jad.2020.08.006 Received 21 April 2020; Received in revised form 15 July 2020; Accepted 8 August 2020 stress, depression and anxiety between mothers who undergo IVF and those who do not (Ross et al., 2011;Gressier et al., 2015). However, these findings are limited by the significant heterogeneity in case selection, design and outcome measurements of the studies. ...
... This manuscript has the objective to improve the available knowledge and to increase the interest in this topic among researchers. Only two previous systematic reviews, focused exclusively on the postpartum consequences, have been realized till now (Ross et al., 2011;Gressier et al., 2015), whilst no recent reviews have been published on this field. IVF is the most widely used ART procedure worldwide and for this reason we focused on this technique in the present review. ...
Background
Since mothers who undergo in vitro fertilization (IVF) may experience more anxiety and depressive symptoms than mothers who conceive naturally, a review of the literature was conducted to investigate whether IVF may be considered a risk factor for the development of anxiety or depression during pregnancy and post-partum.
Methods
A thorough search of articles in Pubmed, PsycINFO and Isi Web of Knowledge was performed in order to produce a comprehensive review regarding the potential association of in vitro fertilization and anxiety/depression.
Results
The search resulted in a total of 10 articles. Contradictory results were reported in the articles about the possible association between IVF and the occurrence of anxiety and depressive symptoms both during pregnancy and postpartum period. Three studies found that women who resorted to IVF showed less anxiety and depressive symptoms than those who conceived naturally especially with the progression of pregnancy and in the postpartum.
Limitations
Vulnerability to affective disorders of women affected by infertility may be independent from the outcome of IVF. Other limits are the limited research in this area, the small sample sizes, the heterogeneity of the tools used to assess affective symptoms.
Conclusions
The available data indicate that IVF is not associated with perinatal affective symptoms. Women who resorted to IVF could have less perinatal depressive symptoms as the result of a positive outcome of the technique and the satisfaction of the desire to become mothers. Further studies are necessary in order to draw definitive conclusions about this topic.
... Evidence from systematic reviews and meta-analyses have consistently shown that pre-existing mental health disorder is a major risk factor for poor perinatal mental health [1,[24][25][26][27]. Other potential relevant risk factors include sociodemographic factors (abuse, stable relationship, financial difficulties etc.), obstetric complications and the use of reproductive therapies [28][29][30][31]. ...
... Our study reports a significant negative association between a history of IVF treatment and postnatal depression and/or anxiety (adjusted OR 0.6, 95% CI 0.4-0.9). Previous studies examining the use of ART with perinatal mental disorders have shown conflicting results with the majority of studies reporting no association [28,30,31,[51][52][53][54][55][56]. Some studies suggest that women with multiple versus singleton pregnancies were affected differently by ART (IVF or intracytoplasmic sperm injection (ICSI)), whereby women with multiple pregnancies experienced greater psychological distress [57][58][59]. ...
Women with polycystic ovary syndrome (PCOS) have many risk factors associated with perinatal mental disorders, but research in this area is scarce. This study aims to compare the prevalence of common perinatal mental disorders in women with and without PCOS, and examine the relationship between PCOS and common perinatal mental disorders. We performed a cross-sectional study on self-reported data of 5239 women born between 1973 to 1978 in the Australian Longitudinal Study on Women’s Health. Compared with women not reporting PCOS, women reporting PCOS had higher prevalence of antenatal depression (8.9% vs. 4.4%, p < 0.001), antenatal anxiety (11.7% vs. 5.6%, p < 0.001), postnatal depression (26.8% vs. 18.6%, p < 0.001) and postnatal anxiety (18.4% vs. 12.0%, p < 0.001). PCOS was positively associated with antenatal depression and/or anxiety (adjusted odds ratio 1.8, 95% confidence interval 1.2–2.6) but not postnatal depression and/or anxiety after controlling for sociodemographic and lifestyle factors, reproductive history, obstetric complications and pre-existing depression and anxiety. General perinatal guidelines currently do not recognize PCOS as a risk factor and the international evidence based PCOS guideline noted inadequate evidence in this area. This paper addresses the gap in literature and highlights the need to screen for common perinatal mental disorders in women with PCOS.
... In general, women who undergo infertility treatment have fewer risk factors of PND. Ross et al. (2011) speculated that future studies controlling for these factors may in fact find the risk of PND to be increased among women who have undergone infertility treatment 11 . Since an increasing number of couples use IVF treatment to conceive 12 it is important to determine if this treatment increases the risk of PND [13][14][15] . ...
... In general, women who undergo infertility treatment have fewer risk factors of PND. Ross et al. (2011) speculated that future studies controlling for these factors may in fact find the risk of PND to be increased among women who have undergone infertility treatment 11 . Since an increasing number of couples use IVF treatment to conceive 12 it is important to determine if this treatment increases the risk of PND [13][14][15] . ...
Background: Women who go through unsuccessful IVF treatment were at increased risk of depressive disorders. Objective: investigate the association between the unsuccessful IVF and depression among women with primary infertility. Methods: a cross-sectional study included infertile women attending fertility center. Socio-demographic and clinical variables were compiled. Self-Reporting Questionnaire (SRQ-20) to identify mental illnesses; DSM-V criteria for depression and Hamilton-17 Scale for severity of depression, were used. Results: high prevalence of depression among infertile women 80%. Unsuccessful IVF were 46%. About 26 % of infertile women with unsuccessful IVF were depressed. Depression was significantly associated with education, monthly income, duration of marriage, smoking, medication, chronic illness, and religion. Conclusion: Depressive disorders are the most frequently observed disorder among infertile women exposed to unsuccessful IVF
... However, if the demands of parenthood are important, then the risk should increase in a dose-response fashion with increasing number of children being associated with greater load in parental tasks and responsibilities and, thus, greater risk of mental health difficulties. Previous cross-sectional research has linked multiparity with elevated risk of maternal mental health problems; however, evidence is inconsistent Ross et al. 2010). It is also unclear whether this risk is due to the characteristics of mothers who have multiple children or increased mental health risk as a consequence of having multiple children. ...
... Consistent with existing research, we found evidence that mothers with increasing numbers of children by age 30 years are at a substantially increased risk of a wide range of mental health disorders (Mayberry et al. 2007;Ross et al. 2010). ...
Parenthood represents a major biological, social and environmental life change. Mental health disorders are common in parents and impact both the parent and their offspring. However, the relationship between parenthood and mental health and the direction of these effects are poorly understood. Longitudinal data from the Pelotas 1982 birth cohort, Southern Brazil, on 3701 individuals was used to investigate the association between number of children by age 30 years and mental health disorders using DSM-IV diagnoses at age 30 years, suicidal risk and the change in symptoms using repeated measures (using the SRQ-20) from age 19 to 30 years. Mothers, but not fathers, with higher number of children by age 30 years, were at a substantially increased risk of a wide range of mental health disorders compared to women with no children. There was evidence that motherhood was associated with an increase in symptoms over time rather than higher symptoms at baseline. Younger age at first child was also a risk factor for mental health disorders. Mothers, particularly those with multiple children, are at risk of a wide range of mental health disorders. The mechanisms to explain these risks are yet to be elucidated; however, the risk of mental health disorders was not replicated in fathers, which would be expected if residual confounding explained observed associations. Thus, multiparous mothers represent a high-risk group and should be prioritised for supportive interventions.
... This condition, if left untreated, has potentially dire consequences for not only the woman affected by depression, but also for her infant and family. There are many well-described risk factors for postpartum depression including preexisting depression, depression during pregnancy, lack of social support, preterm birth, traumatic birth experience, public health insurance, unintended pregnancy, stressful life events, multiple gestation, and domestic violence [3][4][5][6][7][8][9]. ...
... This signifies that other factors besides insurance status and physician access may place nonwhite women at increased risk compared to their white counterparts. Interestingly, preterm birth and multiple gestation, though described elsewhere as risk factors for postpartum depression [5][6][7] were not found to be significant in this study. This is especially interesting given that preterm birth may potentially be a traumatic birth experience, though it did not remain a risk factor in our study. ...
Objective: To determine risk factors for a positive postpartum depression screen among women with private health insurance and 24/7 access to care.
Study design: Retrospective cohort study of all patients delivered by a single MFM practice from April 2015 to September 2016. All patients had private health insurance and 24/7 access to care. All patients were scheduled to undergo the Edinburgh Postnatal Depression Scale (EPDS) at their 6-week postpartum visit and a positive screen was defined as a score of 10 or higher, or a score greater than zero on question 10 (thoughts of selfharm). Using logistic regression, risk factors for postpartum depression were compared between women with and without a positive screen.
Results: Of the 1237 patients delivered, 1113 (90%) were screened with the EPDS. 81 patients (7.3, 95%CI 5.9–9.0%) of those tested had a positive screen. On regression analysis, risk factors associated with a positive screen were nulliparity (aOR 1.8, 95%CI 1.1, 2.9), cesarean delivery (aOR 1.7, 95%CI 1.1, 2.8), non-White race (aOR 2.0, 95%CI 1.1, 3.5), and a history of depression or anxiety (aOR 4.6, 95%CI 2.6, 8.1). Among the 100 women with a history of depression or anxiety, selective serotonin reuptake inhibitor (SSRI) use in the postpartum period was not associated with a reduced risk of a positive screen (25.5% in those taking an SSRI versus 18.4% of those not taking an SSRI, p = .39).
Conclusions: Among women with private health insurance and access to care, the incidence of a positive screen for postpartum depression is approximately 7%. The use of an SSRI did not eliminate this risk. All women should be screened for postpartum depression.
... Previous research has shown increased risk of PPD in twin compared to singleton mothers, [13][14][15]30,31 although some have also shown no difference. 13,32 In the present study, we used a register-based approach, securing a large study population of both mothers and fathers, and our findings align with a recent population-based study, which found an increased risk of mental illness in twin mothers compared to singleton mothers from birth till 365 days postpartum. ...
Background
Parents of twins appear to be at increased risk of postpartum depression (PPD), yet little is known about the magnitude and timing of onset in the postpartum period compared to singleton parents.
Methods
We conducted a cohort study using the Danish nationwide health registers. We defined a study population of parents that is, mothers and fathers of all twin and singleton livebirths between 1997 and 2019. Postpartum depression was defined as incident depression diagnosis or a redeemed antidepressant prescription from childbirth through 365 days postpartum. We performed a parametric time‐to‐event analysis based on Poisson regression. The time scale was time since birth, modeled using restricted cubic splines. From this we estimated the hazard ratio (HR) representing the momentary risk, and the cumulative risk ratio (RR) over the first year postpartum, in twin compared to singleton parents.
Results
The study population was based on 27,095 twin and 1,350,046 singleton births. In adjusted analyses, the HR of twins compared to singletons was highest around 2 months postpartum (HR 1.28, 95% CI 1.10–1.49) for mothers, and around 6 months (1.20, 95% CI 1.02–1.42) for fathers. The 6 months adjusted cumulative RR of PPD in twins compared to singletons was 1.24 (95% CI 1.10–1.40) for mothers and 1.11 (95% CI 0.95–1.30) for fathers.
Conclusions
Twin mothers had increased risk of PPD compared to singleton mothers, which was driven by an immediate increase after childbirth. The risk among twin fathers was not increased immediately after childbirth, but we found slightly elevated risk around 6 months postpartum. This could suggest diverse patterns of PPD symptomatology in twin parents compared to singleton parents and between mothers and fathers. Our findings underline parents of twins as a potentially vulnerable group to PPD and emphasize the need for increased awareness of their mental health.
... Multiple pregnancies significantly increase the risk of various negative health outcomes, including higher rates of maternal mortality and morbidity, increased prematurity, low birth weight, intrauterine growth retardation, higher neonatal mortality, and an elevated risk of disabilities and malformations. Multiple births may also be associated with an increased risk of postpartum depression due to the high levels of parenting stress, fatigue, and other risk factors [13]. The primary risk factor for antepartum depression is having had a previous female child [14]. ...
Postpartum depression is a prevalent health disorder which affecting women’s mental condition during the postnatal period, characterized by mood swings, anxiety, and depressive symptoms. PPD is a complex condition influenced by a combination of biological, psychological, and social factors. It can lead to significant adverse outcomes for both mothers and infants if not identified and managed promptly. Various biological, psychological, and social factors contribute to the onset of PPD, including hormonal fluctuations, genetic predisposition, prenatal anxiety, and lack of social support. Understanding these risk factors is essential for early diagnosis and effective intervention. This study conducted a comprehensive review of existing literature to identify the primary risk factors associated with PPD. The analysis included data from diverse populations across different countries, examining biological, psychological, and social determinants. Key studies were selected based on their relevance, sample size, and methodological rigor. The prevalence of PPD was analysed in relation to factors such as prenatal depression, caesarean section, vitamin D deficiency, and genetic markers. Additionally, therapeutic interventions like Cognitive-Behavioural Therapy (CBT), Interpersonal Therapy, and pharmacological managements were evaluated for their effectiveness in managing PPD. Early identification and intervention are critical to mitigating its impact on mothers and infants. Effective management strategies should include a combination of psychological therapies, pharmacological treatments, and strong social support systems. Public health initiatives must prioritize education, awareness, and access to mental health services to ensure timely diagnosis and treatment of PPD, thereby improving maternal and child health outcomes.
... There were a number of variables identified as potential confounders 21 . These were maternal age at the time of the OGTT 22,23 , tobacco smoking during pregnancy 24,25 , singleton versus multiple pregnancy 26,27 and other obstetric complications (pre-eclampsia and/or gestational hypertension) 28,29 . CMD prior to pregnancy ('preconception' CMD) was also measured using Read codes and medication prescriptions in the primary care record from the woman's birth to the date of conception of the woman's first ever pregnancy (supplementary material S1). ...
Gestational diabetes and the maternal mental disorders of anxiety and depression have been implicated in adverse offspring neuro-behavioural outcomes but these exposures have only been studied in isolation. 1051 children whose mothers were diagnosed with gestational diabetes in UK’s Born in Bradford cohort had linkage to maternal primary care records, providing diagnostic and treatment codes for depression and anxiety. Education record linkage provided results of the Early Years Foundation Stage Profile from the first year of school, aged five. Risk of not attaining a ‘Good level of development’ was analysed using multivariable Poisson regression within a generalised estimating equation framework. Multiple imputation was implemented for missing data. There was limited evidence of increased risk of failure to attain a ‘good level of development’ in those additionally exposed to maternal mental disorders (adjusted RR 1.21; 95% CI 0.94, 1.55). However, there was more evidence in children of Pakistani maternal ethnicity (adjusted RR 1.36; 95% CI 1.04, 1.77) than White British; this may have been driven by English not being the primary language spoken in the home. Therefore there may be groups with GDM in whom it is particularly important to optimise both maternal physical and mental health to improve child outcomes.
... We are aware of the need for further exploration of this topic. A review of the literature shows inconsistent evidence that female multiparity is associated with an increased risk of maternal mental health problems [48,49]. It is possible that in the later decades of their lives, the multiplied experience of being a mother increases the ability to mobilize resources to support their ageing and provides a more favourable context for the reconstruction of the female self. ...
The purpose of this study was to analyse women’s perceptions of their transition to motherhood in the late decades of their female adulthood. The research problem was whether and to what extent the meaning of the transition to motherhood changes for women from different birth cohorts. Our sample included mothers from two generational cohorts: 50 women in middle adulthood (M = 47.66), and 52 women in late adulthood (M = 69.35). The results were analysed using qualitative data analysis methods, including frequency analysis and qualitative narrative analysis. Based on the analyses, the category of transition to motherhood was found to be a standard feature for all the women studied in middle and late adulthood. In both older generations, some women recalled the birth of their first child as a coping with change. Indicators of criticality were extracted from their narratives: potential bivalence, the unpredictability of consequences, and longevity of life changes. The results showed that the generation of women in late adulthood exhibited significantly fewer difficulties related to their own motherhood. The semantic dominant of the narratives studied is motherhood as taking responsibility for another person.
... The fact that the majority of the sample, were already mothers, or were about to give birth for the second or third time, could justify their smooth transition to the motherly role, despite the unprecedented nature of the pandemic and related home restrictions. Previous cross-sectional research, has linked multiparity with an elevated risk of maternal mental health problems with, however, inconsistent evidence [24,25]. It is also unclear, whether this risk is due to the characteristics of mothers, who have multiple children, or an increased mental health risk, as a consequence, of having multiple children. ...
... Previous research utilizing resource theory has included the number of children (i.e., resource depleting) and the length of marriage (i.e., resource enhancing) as control variables (Carlson et al., 2018;Thompson et al., 2020). We controlled for whether the pregnancy was single-child or multiple-children (e.g., twins) because previous research has suggested that parents of twins are at higher risk of postpartum depressive symptoms due to the high levels of parenting stress and fatigue associated with caring for multiple newborn babies (Choi et al., 2009;Ross et al., 2011). None of these latter control variables changed the magnitude or significance of the results; thus, given recommendations about the inclusion of superfluous control variables (Becker, 2005; Carlson & Wu, 2012), we excluded these variables from our final analyses. ...
Using a sample of 297 working mothers across three time periods (their last trimester of pregnancy, while on maternity leave, and after returning to the workplace), we examined the role of vicarious abusive supervision, beyond their own experience of abusive supervision, on turnover intentions through experiences of maternal mental health. Utilizing the unfolding model of turnover and Conservation of Resources theory, we found that experiencing the shock event of vicarious abusive supervision contributed to job‐related negative emotions as well as postpartum depressive symptoms in working new moms. Further, this experience of vicarious abusive supervision contributed to job‐related emotional exhaustion and turnover intentions, even after controlling for the mother’s own experience of being targeted with abusive supervision behaviors. Finally, we examined the moderating role of financial dependence on this process and found that when working mothers’ families were financially dependent on her job, the mothers were less likely to have turnover intentions. Implications for research and practice are provided.
... Also included were the sociodemographic characteristics of maternal ethnicity (as a three category variable of Pakistani, White British or Other) and socioeconomic status (SES) (Anna et al., 2008;Bhui et al., 2001;Howard et al., 2014); rather than using index of multiple deprivation (Department for Communities and Local Government, 2015) to assign SES, a five category variable of maternal education was used a proxy, as the high levels of deprivation in BiB result in a highly skewed distribution of participants across deprivation categories. Analyses of antenatal CMD additionally controlled for preconception CMD, any tobacco smoking during pregnancy (Bar-Zeev et al., 2020;Tong et al., 2016), singleton versus multiple pregnancy (Ben-Haroush et al., 2004;Ross et al., 2011) and the continuous variable of BMI (body mass index) at pregnancy booking as a measure of pre-pregnancy BMI . ...
Background
anxiety and depression are common in women with gestational diabetes but it is not clear whether they are more likely to precede the onset of gestational diabetes or to co-occur with it. Our aims were to compare the strength of association between common mental disorders of anxiety and depression i) before pregnancy and ii) during pregnancy in women with and without gestational diabetes.
Methods
the sample comprised 12,239 women with 13,539 pregnancies from the UK's Born in Bradford cohort. Gestational diabetes was diagnosed by oral glucose tolerance test (OGTT). Indicators of common mental disorders were obtained from linked primary care records. Multivariable robust Poisson and logistic regression were employed. Multiple imputation by chained equations was implemented to handle missing data. Models were adjusted for maternal age, ethnicity, education and obstetric complications. Analyses of common mental disorders during pregnancy were additionally adjusted for maternal smoking, pre-pregnancy BMI, multiple pregnancy and common mental disorders prior to pregnancy.
Results
there was no evidence for an association between common mental disorders prior to pregnancy and gestational diabetes (adjusted RR 0.96; 95% CI 0.80,1.15) or between gestational diabetes and common mental disorders during pregnancy (adjusted OR 0.91; 95% CI 0.73,1.12).
Limitations
high levels of deprivation and multi-ethnic composition of the cohort may limit generalisability of these findings to other populations.
Conclusions
routine primary care records did not identify an increased risk of gestational diabetes in women with common mental disorders prior to pregnancy or of gestational diabetes in women with common mental disorders during pregnancy.
... Otros autores (Gressier et al., 2015;Ross et al., 2010) han hallado que la prevalencia de síntomas depresivos maternos en el posparto no es significativamente diferente entre los embarazos espontáneos y los logrados a través de la fecundación in vitro, incluyendo solamente embarazos únicos y excluyendo los múltiples, que ya se han relacionado con un aumento de depresión posparto per se. Importancia de la intervención preventiva de la depresión Hasta ahora, la consideración de los efectos psicológicos positivos del tratamiento de la infertilidad ha eclipsado la evidencia de que los estados psicológicos negativos están asociados con el mismo proceso (Boivin, 2003). ...
Introducción. La infertilidad y el tratamiento por medio de métodos de reproducción asistida tienen implicaciones psicológicas importantes para la pareja: desde manifestaciones positivas por la esperanza que ofrecen estas técnicas ante el éxito de las mismas, al igual que manifestaciones negativas por la incertidumbre y el posible fracaso; una de ellas es la depresión. Por tanto, se planteó por objetivo analizar la relación entre la depresión y las técnicas de reproducción asistida, así como la influencia que tiene el asesoramiento profesional en las parejas que optan por estas técnicas. Metodología. Fue un estudio descriptivo de síntesis mediante una búsqueda bibliográfica del conocimiento actual existente sobre la relación depresión-técnicas de reproducción asistida, así como los efectos de la misma en el posparto. Resultados. En la relación de direccionalidad se halló que la infertilidad es un factor de riesgo para la depresión, y esta un predictor de fracaso de las técnicas de reproducción asistida. No hubo evidencia de un aumento de la depresión posparto en los embarazos logrados por técnicas de reproducción asistida. Se describen las estrategias de prevención posibles. Conclusión. Al parecer, existe una relación entre técnicas de reproducción asistida y la depresión, aunque se requiere una mayor investigación. No obstante, cabe resaltar la importancia de tratar psicoterapéuticamente a ambos miembros de la pareja antes, durante y después del proceso de reproducción asistida.
... However, in the literature, we have found three meta-analyses on PPD and none reported pregnancy via ART as a potential risk factor for PPD (24)(25)(26). In a systematic review, Ross et al. (27) showed that the risk of a higher prevalence of PPD in mothers who become pregnant via ART was very low or unchanged in comparison to those with natural pregnancies. It seemed that women who have conceived through ART usually have a more intense emotional attachment to the fetus than women with spontaneous pregnancies (28). ...
Background:
It is thought that mothers who conceive via assisted reproductive technology (ART) may be at greater risk of postpartum depression (PPD) because of the problems and psychological stresses associated with ART treatment. The aim of the present study is to determine the occurrence of PPD among mothers who conceive by ART in comparison with those who naturally conceive. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess PPD.
Materials and methods:
This historical cohort study investigated 406 mothers with infants aged 3-9 months. Three hundred and eight women with natural pregnancies were selected as the control group from mothers who referred to Tehran healthcare centres for infant vaccinations. The ART group consisted of 98 women who conceived via ART at Royan Institute. Participants completed a general questionnaire that asked about education, occupation, number of children, delivery method, history of infant hospitalization, breastfeeding, mothers' and infants' ages, cause of infertility (ART group), and history of depression. A validated Persian version of the EPDS was used to measure depressive symptoms.
Results:
The mean EPDS score in mothers who naturally conceived was 8.38 ± 0.35 in comparison with mothers who conceived via ART (7.59 ± 0.63). The proportions of women who reported PPD were 26.0% for the control group and 20.4% for the ART group. There was no statistically significant difference in PPD between the control and ART groups (P=0.26).
Conclusion:
The occurrence of PPD in mothers who conceived via ART was similar to those who conceived naturally.
... Subfertility is consistently associated with poorer QOL and higher levels of emotional distress than population norms and healthy or gynaecological controls (typically, women attending gynaecology services for non-fertility reasons) [171][172][173] . In addition, the effects of subfertility on emotional distress can persist into pregnancy; women using ARTs report more anxiety about fetal viability and health than women with good fertility 174,175 but have a similar rate of postpartum depression 176 . Longer-term adjustment to subfertility in longitudinal research (>10 years) shows positive adjustment for most women 177 . ...
Subfertility is common and affects one in six couples, half of whom lack an explanation for their delay in conceiving. Developments in the diagnosis and treatment of subfertility over the past 50 years have been truly remarkable. Indeed, current generations of couples with subfertility are more fortunate than previous generations, as they have many more opportunities to become parents. The timely access to effective treatment for subfertility is important as many couples have a narrow window of opportunity before the age-related effects of subfertility limit the likelihood of success. Assisted reproduction can overcome the barriers to fertility caused by tubal disease and low sperm count, but little progress has been made in reducing the effect of increasing age on ovarian function. The next 5-10 years will likely see further increases in birth rates in women with subfertility, a greater awareness of lifestyle factors and a possible refinement of current assisted reproduction techniques and the development of new ones. Such progress will bring challenging questions regarding the potential benefits and harms of treatments involving germ cell manipulation, artificial gametes, genetic screening of embryos and gene editing of embryos. We hope to see a major increase in fertility awareness, access to safe and cost-effective fertility care in low-income countries and a reduction in the current disparity of access to fertility care.
... [37] Unlike the above results, the results of a systematic review revealed that no relationship was found between infertility, fertility treatment, and postpartum depression. [38] Perhaps, the reason for relation between infertility with depression is that's infertile women suffer more stress than others and that they need counseling because of extreme stress. And that event stressful is source for postpartum depression. ...
BACKGROUND AND AIM
Prenatal mental health has been shown to be related with postpartum depression. However, the role of mental and psychological factors in postpartum depression requires especial attention. Furthermore, the relationship between demographic factors and postpartum depression is contradictory. The study was aimed to identify role of prenatal anxiety and depression and demographic factors with postpartum depression.
MATERIALS AND METHODS
A prospective cohort study was conducted with 303 pregnant women who have gestational age from 28 to 36 weeks and referred to health-care centers in Isfahan city and follow-up for 6–12 weeks after postpartum. Data were collected using the demographic form, Edinburgh depression, and anxiety Spielberger questionnaire during pregnancy and Edinburgh depression inventory in the 6th and 12th weeks after childbirth. Descriptive statistics and linear logistic regression were used to analyze the data. In demographic factors, data were analyzed using the Student's t-test, Chi-square, Pearson and Spearman test and after the meaningfulness of regression was used.
RESULTS
Results showed that the 6 and 12 weeks after childbirth, 61 patients (20/1%) and 33 patients (10/9%) had postpartum depression. The most important risk factors for depression in the first 6 weeks were history of infertility (confidence interval [CI]: 0.56–0.767) (P = 0.018) and history of depression (CI: 1.155–1.369) (P = 0.000) and in 12 weeks, postpartum were history of depression (CI: 0.072–1.305) (P = 0.001).
CONCLUSION
Infertility and history of depression during pregnancy were two risk factors of postpartum depression which should be taken into consideration during prenatal care.
... When faced with an individual request for ART, providers have a right, albeit circumscribed, to refuse services based on their professional responsibility to consider the well-being of their patients. This right may conflict with patient autonomy, as expressed through the desires of women or couples to access ART services [2]. ...
Purpose of review:
This review aims to provide guidance to clinicians facing requests for assisted reproduction from women with mental illness.
Recent findings:
The paper explores the clinical and safety aspects of initiating fertility treatment in this context, including the use of psychotropic medication and the risk of untreated psychiatric mood or psychotic disorders. It also presents the ethical considerations involved in candidate selection, including treating similar cases equitably to avoid biased decisions based solely on "gut-feelings," respect for women's reproductive autonomy, and an effort to protect patients and prospective fetuses/children from harm by employing optimal strategies regarding medication and psychosocial support. Clinicians ought to be informed regarding recent evidence related to the safety and efficacy of psychopharmacologic treatment of women during pregnancy and the post-partum. They should also carry out a thoughtful ethical analysis to ensure minimal violation of women's reproductive autonomy.
... This fact has been described in simple gestations, as is the case of the participants in our study. It should be noted, however, that multiple gestation, often associated with ART, conditions an increased risk of perinatal depression [27]. ...
Aim: We designed this study to ascertain the prevalence of depressive disorders and anxiety at the beginning of the pregnancy, studying possible associated factors and assessing the influence of mood disorders on perinatal outcomes.
Methods: A representative sample of 191 pregnant women at first trimester of their pregnancies completed a questionnaire that included the Whooley´s questions, the Spanish version of the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory and a series of questions related to health status, general mood and sociodemographic variables. Later, we prospectively evaluated the influence of anxiety and depression on the perinatal and obstetric results in 145 of them.
Results: More than 20% of pregnant women presented high levels of anxiety. The mean values of the state and trait anxiety scores were 38.7 (SD 9.8) and 34.5 (SD 9.5). The mean BDI score was 5.97 (SD 4.9), with 9.5% of participants achieving scores compatible with depression, (61% mild in, 22.2% moderate, and 16.6% severe). BDI scores were significantly lower in women who became pregnant after assisted reproductive techniques. We observed an association between depression and trait anxiety scores with an infant’s low birth weight. The multivariate analysis showed that the feeling of happiness at the beginning of pregnancy was the best predictor of foetal weight.
Conclusion: The prevalence of emotional disorders in the first trimester of pregnancy is high, with more than 20% of pregnant women presenting high levels of anxiety, and more than 9.5% presenting depression. During the first trimester, depression and anxiety were associated with low birth weight.
Background
Pregnancy and postpartum periods are one of the most transformative times in a woman’s life, especially the first 3–12 months postpartum. This period holds a great significance from the psychiatric point of view, as women are at an increased risk of developing various psychiatric disorders. In the recent times, many reviews have emerged on various aspects of postpartum depression (PPD).
Aim
Accordingly this article aims to review the available review articles on various aspects of PPD to have a comprehensive understanding.
Methodology
For this review, different databases (PubMed, ScienceDirect, and Google Scholar) were searched using different keywords, i.e. depression, post-partum, peripartum, post-natal, peri-natal, post-partum depression, and postnatal depression. All the available reviews and recent articles were reviewed and relevant articles were selected.
Results
In recent times, data with respect to the epidemiology, risk factors, and various management strategies have been reviewed by different reviews and meta-analyses. Treatment guidelines have also emerged focusing specifically on the PPD. The incidence of PPD is 12%, and the prevalence ranges from 17% to 22%. A host of risk factors have been linked to the development of PPD. A detailed biopsychosocial evaluation is important for the assessment of patients with PPD. Breastfeeding is not a contraindication for the use of antidepressants.
Conclusions
One in every six females develops PPD after delivery and untreated PPD can have a grievous impact on mother, child, and mother–child interaction. Hence, all women should be screened for depression during the antenatal and postnatal periods.
Introduction: Assisted reproductive technology (ART) is associated with an increased risk of monozygotic twinning. This narrative review attempts to summarise the known literature regarding the aetiology, incidence, risk factors, diagnosis, and prognosis of monozygotic twinning following ART. Aetiology: Monozygotic twinning is caused by the splitting of the early embryo during the peri-implantation phase. According to the classical hypothesis, the timing of the split determines the chorionicity and amnionicity, however this has been questioned in recent literature. Incidence and risk factors: The incidence of monozygotic twinning in natural conception appears to be independent of extrinsic factors such as ethnicity and age. The incidence of monozygotic twinning is increased from 0.4% of natural conceptions to around 0.9–2.24% of pregnancies following ART. The available literature supports a role of ovarian stimulation and extended culture to the blastocyst stage in increasing the risk of monozygotic twinning. The impact of maternal age and micromanipulation techniques such as assisted hatching and intra-cytoplasmic sperm injection appear to depend on the stage of the embryo being transferred leading to significant heterogeneity between studies. Diagnosis: The gold standard for diagnosing monozygotic twinning is genetic testing but its cost precludes it from routine widespread use. Most epidemiological studies utilise statistical estimates such as Weinberg’s differential rule and tailored questionnaires. Most studies from ART units have utilised transvaginal sonography for counting the number of gestational sacs or assessing the chorionicity. Prognosis: The prognosis of twins appears to be dependent on the chorionicity and amnionicity and is largely independent of the zygosity.
Background:
Maternal antenatal depression experienced around conception or during pregnancy may adversely affect child development. This study explores three potential mechanisms of the effects of antenatal depression on children's developmental delays at 2-3 years: gestational age of the child, continued depressive symptoms postnatally, and interrupted breastfeeding practices.
Methods:
Mothers (N = 2888) of 3450 children, including 2303 singletons and 1147 multiples from the Upstate KIDS cohort provided data. Linked hospital discharge data was combined with mothers' reports to identify women with moderate to severe antenatal depression. Gestational age was extracted from birth certificates. Mothers completed a depression screener at 4 months postpartum, reported about their breastfeeding practices from 4 to 12 months postpartum, and completed a developmental delay screener when children were 24, 30, and 36 months.
Results:
In unadjusted path analysis models, mothers with antenatal depression had more postnatal depressive symptoms and breastfed fewer months, which translated into children being more likely to have developmental delays. Gestational age was not a mediator. Effects were similar across girls and boys and singletons and twins, and largely held when adjusting for covariates.
Limitations:
Main limitations were the relatively advantaged sample and reliance on maternal report.
Conclusions:
Maternal antenatal depression may impact child development through continued depressive symptoms in the postpartum period and through reduced breastfeeding duration suggesting additional targets for intervention.
Rationale
Understanding whether postpartum depressive (PPD) symptoms vary by pregnancy intention and use of fertility treatments has implications for reproductive health policies and practices.
Objective
The first aim of this study was to determine whether PPD symptoms differ between women who had unintended pregnancies, women who conceived spontaneously and were unsure about their pregnancy intention, women who used fertility treatments to conceive, and women who conceived spontaneously and intentionally. The second aim was to determine whether PPD symptoms differed based on the fertility treatment used to conceive (fertility drugs only, medicated insemination, or assisted reproductive technology [ART]).
Methods
Data from the Pregnancy Risk Assessment Monitoring System (2012–2019), a cross-sectional survey administered to women throughout the U.S. who have recently given birth, was used to carry out our aims.
Results
For the first aim (unweighted N = 243,677), compared to women who had spontaneous, intended pregnancies, women who had unintended pregnancies (OR: 1.32, 95% CI: 1.26–1.39, p < 0.01) and those with spontaneous pregnancies who were unsure about their intention (OR: 1.30, 95% CI: 1.23–1.38, p < 0.01) had higher odds of elevated PPD symptoms, adjusting for a range of covariates. Women who conceived with fertility treatments did not have higher odds of elevated PPD symptoms (OR: 0.97, 95% CI: 0.84–1.10, p = 0.61). For the second aim (unweighted N = 2,210), compared to those in the ART group, those who conceived using only fertility enhancing drugs had greater odds of developing elevated PPD symptoms (OR: 2.00, 95% CI: 1.24–3.24, p < 0.01).
Conclusions
These findings suggest that giving birth to an unintended pregnancy in the U.S. increases risk of elevated PPD symptoms. While overall women who conceive with the use of fertility treatments are not at increased risk of experiencing elevated PPD symptoms, there may be variability in risk based on the specific fertility treatments used.
Purpose: This study investigated the correlation between mother-infant bonding and postpartum depression in women with a history of infertility. Methods: The sample consisted of 169 women divided into two: infertile group (n=56) and fertile group (n=112). Data were collected using a descriptive information questionnaire, the Edinburgh Postnatal Depression Scale (EPDS), and the Mother-to-Infant Bonding Scale (MIBS). Results: The fertile and infertile groups had a mean age of 28.95±3.38 and 36.55±3.55, respectively (p=0.001). The infertile group had a higher mean MIBS score (3.73±2.91) than the fertile group (1.50±1.29) (p=0.001). However, there was no significant difference in EPDS scores between the two groups (p > 0.05). Moreover, there was a positive correlation between MIBS and EPDS score in the fertile group (r = 0.354, p = 0.001), suggesting that the higher the risk for postpartum depression, the lower the mother-infant bonding. There was no correlation between MIBS and EPDS score in the infertile group (p > 0.05). Conclusion: Future studies should recruit larger samples of infertile women with cultural and ethnic diversity and take confounding factors into account to investigate the relationship between postpartum depression and mother-infant bonding.
Objective Postpartum depression (PPD) remains an understudied research area despite its high prevalence. The goal of this study is to develop an ontology to aid in the identification of patients with PPD and to enable future analyses with electronic health record (EHR) data.
Methods We used Protégé-OWL to construct a postpartum depression ontology (PDO) of relevant comorbidities, symptoms, treatments, and other items pertinent to the study and treatment of PPD.
Results The PDO identifies and visualizes the risk factor status of variables for PPD, including comorbidities, confounders, symptoms, and treatments. The PDO includes 734 classes, 13 object properties, and 4,844 individuals. We also linked known and potential risk factors to their respective codes in the International Classification of Diseases versions 9 and 10 that would be useful in structured EHR data analyses. The representation and usefulness of the PDO was assessed using a task-based patient case study approach, involving 10 PPD case studies. Final evaluation of the ontology yielded 86.4% coverage of PPD symptoms, treatments, and risk factors. This demonstrates strong coverage of the PDO for the PPD domain.
Conclusion The PDO will enable future researchers to study PPD using EHR data as it contains important information with regard to structured (e.g., billing codes) and unstructured data (e.g., synonyms of symptoms not coded in EHRs). The PDO is publicly available through the National Center for Biomedical Ontology (NCBO) BioPortal ( https://bioportal.bioontology.org/ontologies/PARTUMDO ) which will enable other informaticists to utilize the PDO to study PPD in other populations.
Perinatal depression (PND) is one of the most common complications of pregnancy. Estimates of prevalence range from 10% to 20%. The perinatal period is associated with complex and unique biological, socio-environmental, and psychological changes for each woman. PND is a burdensome disorder with a profound intrusive impact on the (expectant) mother (to be), her (unborn) child, but also the supporting system. PND is heterogeneous in presentation with likely multifactorial etiologies for each woman. Apart from psychosocial factors, researchers investigated potential underlying endocrinological, immunological, and (epi)genetic factors associated with PND. The Edinburgh Postnatal Depression Scale (EPDS) is the gold standard for detection. The main goals of treating PND are to reduce maternal psychiatric symptoms and to support maternal–child attachment. A stepped-care approach is advocated, in which mild to moderate symptoms should be treated with psychotherapeutic interventions, whereas women with severe symptoms or women who do not respond to nonpharmacological treatment, pharmacological treatment can be suggested. A weighted decision should be made.
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Postpartum depression (PPD) is a major depressive disorder that affects women during the perinatal period. Our study aimed to evaluate the onset of psychological effects in spontaneous pregnancies in contrast with pregnancies resulting from in vitro fertilization (IVF). We carried out a prospective cohort study using the Edinburgh Postnatal Depression Scale to evaluate postpartum depression. Patients were divided into 3 different groups based on their conception method: group A included spontaneous pregnancies, group B included pregnancies after homologous IVF, and group C pregnancies after heterologous IVF. The study included 245 patients. In the first year postpartum the incidence of psychological disorders was different exclusively at discharge from hospital (24.8% A vs. 38.7 B vs. 19% C) [P < .05] and one year after childbirth (13.3% A vs. 3.4% B vs. 4.8% C) [P < .05]. The multifactorial analysis showed a significant positive association between psychological distress and advanced maternal age, low parental education, nulliparity, preterm delivery and low fetal weight at birth, multiple pregnancies and multiple births, low pain threshold, and high rate of requesting analgesia intrapartum [P < .05]. Our results suggest a high correlation between PPD and pregnancies resulting from homologous IVF at the time of discharge, whereas there is a higher chance that spontaneous pregnancies develop postpartum depression one year after delivery.
Background:
Having twins is associated with more depressive symptoms compared to having singletons. However, the association between having twins and psychiatric morbidity requiring Emergency Department (ED) visit or inpatient hospitalization is less well-known.
Objectives:
To determine whether women have higher risk of having a psychiatric diagnosis at an ED visit or inpatient admission in the year after having twins versus singletons.
Study design:
This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes within the Florida State Inpatient and State ED Databases, which have an encrypted identifier allowing nearly all inpatient and ED encounters statewide to be linked to the medical record. The first delivery of Florida residents aged 13 to 55 years old from 2005 to 2014 was included, regardless of parity; women with ICD-9-CM coding for psychiatric illness or substance misuse during pregnancy or for stillbirth or higher-order gestations were excluded. The exposure was an ICD-9-CM code during delivery hospitalization of liveborn twins. The primary outcome was an ICD-9-CM code during an ED encounter or inpatient admission within one year of delivery for a psychiatric morbidity composite (suicide attempt, depression, anxiety, post-traumatic stress disorder (PTSD), psychosis, acute stress reaction, or adjustment disorder). The secondary outcome was drug or alcohol use or dependence within one year of delivery. We compared outcomes after delivery of liveborn twins versus singletons using multivariable logistic regression adjusting for sociodemographic and medical factors. We tested for interactions between independent variables in the primary model and conducted sensitivity analyses stratifying women by insurance type and presence of severe intrapartum morbidity (SMM) and/or medical comorbidities.
Results:
17,365 women who had liveborn twins and 1,058,880 who had singletons were included. Within one year of birth, 1.6% (n=270) of women delivering twins and 1.6% (n=17,236) of women delivering singletons had an ED encounter or inpatient admission coded for psychiatric morbidity (adjusted odds ratio (aOR) 1.00 (95% Confidence Interval (CI) 0.88 - 1.14)). Coding for drug or alcohol use or dependence in an ED encounter or inpatient admission in the year following twin versus singleton delivery was also similar (n=96 (0.6%) versus 6,222 (0.6%); aOR 1.11 (95% CI 0.91 - 1.36)). However, women with Medicaid were more likely to have PTSD after twin versus singleton delivery (n=75 (1.2%) versus n=4,858 (n=1.0%); aOR 1.27 (95% CI 1.01 - 1.60)). Women with ≥1 medical comorbidity or SMM or who were low income also had increased risk of psychiatric morbidity after twin delivery (comorbidities: n=7,438 (42.8%), aOR 1.30 (95% CI 1.25 - 1.34); SMM: n=940 (5.4%), aOR 1.65 (95% CI 1.49 - 1.81); lowest income quartile: n=4,409 (26.8%), aOR 1.31 (95% CI 1.23 - 1.40); second-lowest income quartile: n=4,770 (29.0%), aOR 1.34 (95% CI 1.26 - 1.43).
Conclusions:
Overall, diagnostic codes for psychiatric illness or substance misuse in ED visits or hospital admissions in the year after delivery is similar after twins and singletons. However, women with Medicaid, who are low-income, or who have comorbidities or SMM are at increased risk of postpartum psychiatric morbidity after twin versus singleton delivery.
Trial registration:
Not Applicable.
Purpose
Postpartum depression (PPD) is the most common psychiatric condition after childbirth which not only effects the mother´s health, but also might have impact on child's development and parenting behaviors. Because the etiology of PPD has not been fully cleared, the efforts towards identification of risk factors are crucial for both the children and mother's health.
Method
PubMed, EMBASE and PsycINFO databases were searched since inception until July 2019 to collect data about the risk factors of PPD and only systematic review and meta-analysis can be included.
Result
To identify the real risk factors, protective factors and controversial factors, nineteen parts of the interpretation were adopted. The risk factors are mainly concentrated in the following aspects: violence and abuse, immigration status, gestational diabetes, cesarean section, depressive history, vitamin D deficiency, obese and overweight, postpartum sleep disruption and poor postpartum sleep, lack of social support, traditional dietary pattern (Japanese, Indian, United Kingdom, and Brazilian dietary pattern), multiple births, preterm and low-birth-weight infants, postpartum anemia, negative birth experience. The controversial factors are serum level of cortisol, thyroid peroxidase autoantibodies status, acculturation, traditional confinement practices. Skin-to-skin care, higher concentrations of DHA in mothers’ milk, greater seafood consumption, healthy dietary patterns, multivitamin supplementation, fish and PUFA intake, calcium, Vitamin D, zinc and possibly selenium are protective factors.
Conclusion
Thirteen risk factors were identified, but five factors still controversial due to the insufficient of the evidence. What’s more, skin-to-skin care and some nutrition related factors are protective factors against PPD.
Objective
To determine the prevalence of symptoms of postpartum depression (PPD) and examine how fathers’ presence and involvement in the care of their newborns affect symptoms of PPD within the first 2 weeks after birth among mothers with newborns in the NICU.
Design
Observational cohort study.
Setting
Open-bay, 40-bed, tertiary level NICU in Eastern Canada.
Participants
Mothers (N = 105) of newborns who were anticipated to survive and required more than 5 days of hospitalization in the NICU.
Methods
Participants completed the Postpartum Depression Screening Scale (PDSS) 14 days after they gave birth. They kept daily diaries to record the amount of time that fathers spent by the newborns’ bedsides (i.e., presence) and actively caring for their newborns (i.e., involvement such as skin to skin). Participants completed daily diaries from the time of enrollment in the study until their newborns were discharged home. We analyzed the data using linear regression; score on the PDSS was the dependent variable, and fathers’ presence and involvement were the independent variables. We adjusted for covariates.
Results
The prevalence of positive screening for symptoms of major PPD was 24.1% (n = 20), and the prevalence of significant symptoms of PPD was 27.7% (n = 23). Participants reported that fathers were present in the NICU an average of 3.8 hours per day and were actively involved with their newborns 53% of the time. Fathers’ involvement was significantly associated with lower scores on the PDSS (adjusted β = −3.85; 95% confidence interval [CI] [−6.10, −1.60]). A history of anxiety was significantly associated with greater scores on the PDSS (adjusted β = 12.06, 95% CI [2.07, 22.05]). Maternal age and income less than $50,000 CAD were marginally associated with greater scores on the PDSS (adjusted β = −0.86, 95% CI [−1.77, 0.05] and adjusted β = 10.69, 95% CI [−0.73, 22.11], respectively). The overall explained variance in the PDSS scores with the independent variables was R² = 0.35.
Conclusion
Fathers’ involvement in the care of their newborns in the NICU was significantly associated with fewer symptoms of PPD among mothers. We recommend research with targeted interventions to promote fathers’ involvement in the NICU to potentially mitigate the symptoms of PPD among mothers of newborns in the NICU.
Objective
Recent reports have shown a considerable number of couples received infertility treatment, raising new concerns about the association between infertility treatment and perinatal depressive symptoms. However, the conclusions of existing studies were inconsistent. Therefore, we conducted a meta-analysis to determine whether infertility treatment increase the risk of developing perinatal depressive symptoms.
Methods
A systematic literature search was performed in several databases up to July 2018 for relevant articles. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model. Subgroup and sensitivity analyses were performed to explore possible sources of heterogeneity.
Results
Twenty-two studies with a total of 69,201 individuals were included in this study. The pooled OR of the association between infertility treatment and perinatal depressive symptoms was 1.01(95% CI: 0.83, 1.23), with substantial heterogeneity (I² = 63%, P < .001). However, in subgroup analyses, a significantly positive association between infertility treatment and depressive symptoms was observed only in some Asian countries (six studies), and the pooled OR was 1.73 (95% CI:1.07, 2.81). An inverse association was found in 6–12 months after delivery (OR = 0.56, 95% CI:0.33, 0.96). Sensitivity analyses validated evidence of the robustness of the findings.
Conclusion
The results show that women who receive infertility treatment do not appear to be at increased risk of significant perinatal depressive symptoms compared with those after spontaneous conception.
Research question:
Are self-reported symptoms of stress and depression associated with pregnancy outcomes within the first year after referral to a tertiary recurrent pregnancy loss unit?
Design:
Prospective cohort study with online questionnaires using the Major Depression Inventory (MDI) and Cohen's Stress Scale (PSS) at referral and after 1 year. The study was conducted between 2010 and 2014. A total of 301 women who had experienced recurrent pregnancy loss completed the first questionnaire. One year after referral, 185 women (61%) completed a follow-up questionnaire.
Results:
A score above the threshold for major depression on the MDI at referral was not a predictor for outcome in the first pregnancy after referral; OR (95% CI) for live birth 1.71 (0.66 to 4.44), neither was increasing scores on the PSS: OR 0.98 (95% CI 0.94 to 1.02). At follow-up, women who had achieved a pregnancy resulting in a live birth had significantly lower scores on both the MDI: 13.45 (11.05) versus 11.04 (11.07); difference -2.41 (95% CI -4.60 to -0.23); and the PSS: mean 17.69 (7.59) versus 13.03 (6.83); difference -4.66 (95% CI -6.04 to -3.28), respectively. This was not the case for women who did not have a successful pregnancy. Women who experienced recurrent pregnancy loss after a successful birth were less likely to report symptoms corresponding to major depression than women who had only experienced losses (n = 7 [5%] versus 19 [12%]; P = 0.04).
Conclusions:
Self-reported emotional distress did not affect future chance of live birth. A live born child decreased emotional distress.
Many are aware of the recent "epidemic of multiple" in industrialized nations, with a multiple birth rate that has increased by 76% in the past three decades. The main contributors to this increase are increased utilization of assisted reproductive technologies and an increased risk of spontaneous twinning in women delaying childbearing. Multiple gestations are at high risk for both maternal and fetal morbidity and mortality, which increase as fetal number increases. Zygosity and chorionicity are important predictors of perinatal morbidity, with monochorionic diamniotic and monochorionic monoamniotic twins at higher risk. There is evidence that the risk of monozygotic twinning is increased in IVF, etiologies may include zona pellucida manipulation and extended in vitro culture. Most neonatal complications in multiple gestations are sequelae of prematurity, including low birth weight, respiratory distress syndrome, NICU admission, intraventricular hemorrhage, and necrotizing enterocolitis. Up to 80% of women with multiple gestations experience antepartum complications, which include preterm labor, PPROM, and placental abruption. Women carrying multiples are at increased risk for the three major causes of maternal mortality: postpartum hemorrhage, venous thromboembolism, and hypertensive disorders. Multiple gestations are also associated with increased financial and psychosocial costs. Strategies for decreasing the rate of multiples resulting from ART include increasing the number of single embryo transfers performed in IVF and using "low and slow" protocols for superovulation cycles with gonadotropins. Multifetal pregnancy reduction can be performed to decrease the fetal number and lower the risk of morbidity, although the procedure does involve some medical and psychological risk.
We determined the prevalence of postpartum depression and related risk factors in Turkey based on relevant research. This study is a systematic review and meta-analysis and was conducted by performing a scan of the Turkish and English literature over the period January-February 2016. Most of the research included in this systematic compilation made use of the Edinburgh Postpartum Depression Scale. The scans executed indicated that 4740 women out of 18780 were at risk for postpartum depression. In the computations made based on these data, it was found that the consolidated prevalence of postpartum depression was 24% (21%-27% at a confidence interval of 95%) and that this rate varied between 9% and 51%. The study revealed 54 risk factors related to postpartum depression. Those most commonly reported were mental problems/depression prior to pregnancy, unplanned/unwanted pregnancy, low income/socioeconomic level, bad marital relationship/problems with spouse/dissatisfaction with married life and being a housewife. In this study, we showed that the prevalence rate of postpartum depression is significantly high, that it varies within a wide range, that the prevalence of depression decreased with the increase of the time passed after childbirth, and that it is related to numerous and different factors.
EpidemiologyEffects of Lifestyle Factors on TreatmentTreatment / ManagementDefinitions and Consequences of TreatmentsAdoptionTreatment AbroadEthical IssuesGiving Up TreatmentCounsellingGuidelines / PolicySummaryReferences
Objective
Postpartum depression is related to many adverse effects in both mothers and their children; therefore, proper screening and early interventions are needed. This study aims to identify the risk factors of postpartum depression. Our primary focus is on obstetric risk factors.
Methods
This study is a cross-sectional study which we extracted the data of women who gave birth between January 1st, 2010 and December 31st, 2012 from the Health Insurance Review and Assessment service (HIRA) database. We analyzed the data using multivariable logistic regression models.
Results
A total of 17,483 (1.4%) women suffered from depression during the postpartum period. Younger (< 20 years) and advanced maternal age (≥ 35 years), primiparity, previous depression, peripartum hysterectomy, uterine artery embolization, preterm delivery, placental abruption, cesarean delivery, induced labor, and preeclampsia were found to increase the likelihood of having depression after delivery.
Conclusions
Our findings suggest that there are several risk factors that lead women to postpartum depression. Therefore, early detection and well-management of the symptoms and risk factors for postpartum depression along with social support can help both physical and psychological conditions of women after childbirth.
Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.
Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7].
In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).
Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA
Completing a Systematic Review Is an Iterative Process
The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
The average prevalence rate of non-psychotic postpartum depression based on the results of a large number of studies is 13%. Prevalence estimates are affected by the nature of the assessment method (larger estimates in studies using self-report measures) and by the length of the postpartum period under evaluation (longer periods predict high prevalences). A meta-analysis was undertaken to determine the sizes of the effects of a number of putative risk factors, measured during pregnancy, for postpartum depression. The strongest predictors of postpartum depression were past history of psychopathology and psychological disturbance during pregnancy, poor marital relationship and low social support, and stressful life events. Finally, indicators of low social status showed a small but significant predictive relation to postpartum depression. In sum, these findings generally mirror the conclusions from earlier qualitative reviews of postpartum depression risk factors.
It is known that infertility affects emotional well-being, satisfaction with life and self-esteem and that failed assisted reproductive technology (ART) treatment is associated with diminished life satisfaction, reduced self-confidence and substantial psychological distress. Investigations of whether these persist when treatment results in a pregnancy and live birth have been undertaken.
A systematic search for English-language research articles on psychological and social aspects of pregnancy, childbirth and the first post-partum year after ART conception.
Of 466 retrieved papers, 46 met inclusion criteria. These reported data from 28 studies. There is consistent evidence that marital satisfaction, emotional well-being and self-regard in pregnancy, attachment to the fetus and parent-infant relationship in ART groups are similar to comparison groups. Anxiety about the survival of the fetus and early parenting difficulties appear to be higher and post-natal self-confidence lower. Evidence about adjustment to pregnancy and parenthood and the experience of childbirth is inconclusive and reports of parental perceptions of infant temperament and behaviour are contradictory. Between-study methodological differences may explain the lack of consistency in findings of the influence of infertility and ART on some aspects of the transition to parenthood.
Overall, this body of evidence is best described as emergent. It is possible that in pregnancy after ART, parenthood might be idealized and this might then hinder adjustment and the development of a confident parental identity.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
Several studies found that maternal symptoms of anxiety or depression are related to functioning and development of the offspring. Within a population-based study of 2,724 children, we investigated the effect of maternal anxiety or depression on infant neuromotor development. Symptoms of anxiety and depression were measured during pregnancy and after giving birth; infant neuromotor development was assessed by trained research nurses during a home visit at the age of 3 months. The current study showed that mothers who were anxious during pregnancy had an elevated risk of having an infant with non-optimal neuromotor development.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
To provide an overview of methods to identify postnatal depression (PND) in primary care and to assess their validity, acceptability, clinical effectiveness and cost-effectiveness, to model estimates of cost, to assess whether any method meets UK National Screening Committee (NSC) criteria and to identify areas for future research.
Searches of 20 electronic databases (including MEDLINE, CINAHL, PsycINFO, EMBASE, CENTRAL, DARE and CDSR), forward citation searching, personal communication with authors and searching of reference lists.
A generalised linear mixed model approach to the bivariate meta-analysis was undertaken for the validation review with quality assessment using QUADAS. Within the acceptability review, a textual narrative approach was employed to synthesise qualitative and quantitative research evidence. For the clinical and cost-effectiveness reviews methods outlined by the Centre for Reviews and Dissemination and the Cochrane Collaboration were followed. Probabilistic models were developed to estimate the costs associated with different identification strategies.
The Edinburgh Postnatal Depression Scale (EPDS) was the most frequently explored instrument across all of the reviews. In terms of test performance, postnatally the EPDS performed reasonably well: sensitivity ranged from 0.60 (specificity 0.97) to 0.96 (specificity 0.45) for major depression only; from 0.31 (specificity 0.99) to 0.91 (specificity 0.67) for major or minor depression; and from 0.38 (specificity 0.99) to 0.86 (specificity 0.87) for any psychiatric disorder. Evidence from the acceptability review indicated that, in the majority of studies, the EPDS was acceptable to women and health-care professionals when women were forewarned of the process, when the EPDS was administered in the home, with due attention to training, with empathetic skills of the health visitor and due consideration to positive responses to question 10 about self-harm. Suggestive evidence from the clinical effectiveness review indicated that use of the EPDS, compared with usual care, may lead to reductions in the number of women with depression scores above a threshold. In the absence of existing cost-effectiveness studies of PND identification strategies, a decision-analytic model was developed. The results of the base-case analysis suggested that use of formal identification strategies did not appear to represent value for money, based on conventional thresholds of cost-effectiveness used in the NHS. However, the scenarios considered demonstrated that this conclusion was primarily driven by the costs of false positives assumed in the base-case model.
In light of the results of our evidence synthesis and decision modelling we revisited the examination of PND screening against five of the NSC criteria. We found that the accepted criteria for a PND screening programme were not currently met. The evidence suggested that there is a simple, safe, precise and validated screening test, in principle a suitable cut-off level could be defined and that the test is acceptable to the population. Evidence surrounding clinical and cost-effectiveness of methods to identify PND is lacking. Further research should aim to identify the optimal identification strategy, in terms of key psychometric properties for postnatal populations. In particular, research comparing the performance of the Whooley and help questions, the EPDS and a generic depression measure would be informative. It would also be informative to identify the natural history of PND over time and to identify the clinical effectiveness of the most valid and acceptable method to identify postnatal depression. Further research within a randomised controlled trial would provide robust estimates of the clinical effectiveness.
Postpartum depression occurs in at least one in seven new mothers, usually within the first 6 months after delivery. By the time of onset of postpartum depression, the mother has usually long since been discharged from the maternity hospital. Early identification and treatment of these mothers reduces both maternal and infant suffering. Careful risk-benefit decision-making regarding various treatment options in the postpartum should be discussed with the mother. Risks of untreated depression include poor bonding with the infant, lack of self care, infant neglect and infanticide.
To evaluate the effectiveness of telephone based peer support in the prevention of postnatal depression.
Multisite randomised controlled trial.
Seven health regions across Ontario, Canada.
701 women in the first two weeks postpartum identified as high risk for postnatal depression with the Edinburgh postnatal depression scale and randomised with an internet based randomisation service.
Proactive individualised telephone based peer (mother to mother) support, initiated within 48-72 hours of randomisation, provided by a volunteer recruited from the community who had previously experienced and recovered from self reported postnatal depression and attended a four hour training session.
Edinburgh postnatal depression scale, structured clinical interview-depression, state-trait anxiety inventory, UCLA loneliness scale, and use of health services.
After web based screening of 21 470 women, 701 (72%) eligible mothers were recruited. A blinded research nurse followed up more than 85% by telephone, including 613 at 12 weeks and 600 at 24 weeks postpartum. At 12 weeks, 14% (40/297) of women in the intervention group and 25% (78/315) in the control group had an Edinburgh postnatal depression scale score >12 (chi(2)=12.5, P<0.001; number need to treat 8.8, 95% confidence interval 5.9 to 19.6; relative risk reduction 0.46, 95% confidence interval 0.24 to 0.62). There was a positive trend in favour of the intervention group for maternal anxiety but not loneliness or use of health services. For ethical reasons, participants identified with clinical depression at 12 weeks were referred for treatment, resulting in no differences between groups at 24 weeks. Of the 221 women in the intervention group who received and evaluated their experience of peer support, over 80% were satisfied and would recommend this support to a friend.
Telephone based peer support can be effective in preventing postnatal depression among women at high risk.
ISRCTN 68337727.
Although twin deliveries after assisted reproduction treatment (ART) are common, the mental health of the parents has scarcely been addressed. Therefore, we evaluated the psychological well-being of ART and spontaneously conceiving parents of twins and singletons. Furthermore, the impact of parity and children's health-related factors on mental health was evaluated.
We conducted a prospective longitudinal questionnaire study among ART parents of 91 pairs of twins and of 367 singletons and on control parents of 20 pairs of twins and of 379 singletons in the 2nd trimester of pregnancy (T1), and when the children were 2 months (T2) and 1-year old (T3). Symptoms of depression and anxiety, sleeping difficulties and social dysfunction were addressed via a questionnaire. The effects of parity and child-related factors were assessed at T2.
At T1, ART mothers of twins showed fewer symptoms of depression than control mothers of twins (P < 0.05). At T2, both ART and control mothers of twins had more symptoms of depression and anxiety than all mothers of singletons (F = 5.20, P < 0.05 and F = 3.93, P < 0.05, respectively). At T3, both ART and control mothers of twins continued to report more symptoms of depression than the mothers of singletons (F = 10.01, P < 0.01), but a difference in anxiety symptoms was seen only in the control group. All fathers had similar mental health at T1. At T2, ART and control fathers of twins reported more symptoms of depression (F = 4.15, P < 0.05) and social dysfunction than fathers of singletons. At T3, both ART and control fathers of twins had more symptoms of depression (F = 4.29, P < 0.05) and anxiety (F = 5.40, P < 0.05) than fathers of singletons. Control fathers of twins had more sleeping difficulties than fathers of singletons (F = 6.66, P < 0.01). Parity did not differently affect parental mental health at T2 in the study groups. Prematurity did not affect maternal mental health, but it had a negative impact on control fathers' social dysfunction (F = 3.34, P < 0.05).
Twin parenthood, but not ART, has a negative impact on the mental health of mothers and fathers during the transition to parenthood. ART parents' mental health was not affected by parity or children's health-related factors.
The aim of this study was to compare 70 couples who had conceived by in-vitro fertilization (IVF) with 63 matched controls
for the prevalence of anxiety and quality of attachment to the baby during pregnancy. Results for mothers showed no group
differences using a global measure of anxiety, the Spielberger State-Trait Anxiety Inventory. However, pregnancy-specific
measures revealed significantly higher levels of anxiety in IVF mothers about the survival and normality of their unborn babies,
about damage to their babies during childbirth and about separating from their babies after birth. When IVF mothers were differentiated
according to the number of treatment cycles, more differences in anxiety level were revealed, with most increases occurring
in mothers who had experienced two or more treatment cycles. IVF fathers did not differ from controls on the global anxiety
measure. No data on pregnancy-specific anxiety were available for fathers. Neither IVF mothers nor IVF fathers differed from
controls on measures of attachment to the baby during pregnancy. Results are discussed in the context of the need for researchers
to employ differentiated and issue-specific measures to identify concerns that may be unique to IVF couples. Clinical implications
regarding the need for psychological support during pregnancy are also discussed.
Objective:
To determine whether women who get pregnant as a result of IVF differ psychologically from pregnant women who conceived naturally.
Design:
Prospective, longitudinal study.
Setting:
Healthy volunteers from outpatient infertility and obstetrics practices.
Patient(s):
Seventy-four women who became pregnant via IVF and 40 women conceiving without medical intervention.
Intervention(s):
Subjects completed self-report questionnaires about demographic and reproductive history, rewards and concerns of pregnancy, self-esteem, marital adjustment, depressive symptoms, and anxiety at 12 and 28 weeks' gestational age.
Main outcome measure(s):
Self-esteem, depression, and anxiety scores.
Result(s):
There were no significant differences between groups on any of the outcome measures assessing psychological status at the two assessment times. Differences were found on specific items assessing the rewards and concerns of pregnancy. Within-group changes over time indicated that IVF women, not controls, showed an increase in self-esteem and a decrease in anxiety during pregnancy.
Conclusion(s):
Pregnant IVF women are similar psychologically to women who become pregnant naturally on dimensions of self-esteem, depression, and anxiety at 12 and 28 weeks' gestational age. The IVF group, not controls, reported improved self-esteem and decreased anxiety as the pregnancy progressed.
The aim of the study was to identify differences in psychological characteristics between couples with fertility disorders, especially idiopathic infertility, and a representative sample.
A total of 564 couples was examined using psychological questionnaires pertaining to sociodemographic factors, motives for wanting a child, dimensions of life satisfaction and couple relationships, physical and psychic complaints, and a personality inventory.
Specific to our sample was the high educational level of the couples, and the large number with idiopathic infertility (27% of all diagnoses). There were no remarkable differences in psychological variables between the infertile couples and a representative sample, except that the infertile women showed higher scores on the depression and anxiety scales. Couples with idiopathic infertility showed no remarkable differences in the questionnaire variables compared with couples with other medical diagnoses of infertility.
A typical psychological profile for infertile couples could not be identified using standardized psychometric rating methods. This may be an effect of the specific characteristics of our sample. For some couples, the infertility crisis can be seen as a cumulative trauma, which indicates that these couples have a marked need for infertility counselling.
Objective: The postpartum period is recognized as a time of vulnerability to affective disorders, particularly postpartum depression. In contrast, the prevalence and clinical presentation of anxiety disorders during pregnancy and the postpartum period have received little research attention. In this article, we review the medical literature as it relates to the prevalence and clinical presentation of panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder during pregnancy and the postpartum period. Data Sources: MEDLINE (1966 to July 2005 week 1) and PsycInfo (1840 to July 2005 week 1) were searched using combinations of the following search terms: pregnancy, childbirth, postpartum, panic disorder, phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. Study Selection: All relevant papers published in English and reporting original data related to perinatal anxiety disorders were included. Data Extraction: Studies were examined for data related to the prevalence, presentation, predictors/risk factors, new onset, course, and treatment of anxiety disorders during pregnancy and the postpartum period. Data Synthesis: Anxiety disorders are common during the perinatal period, with reported rates of obsessive-compulsive disorder and generalized anxiety disorder being higher in postpartum women than in the general population. The perinatal context of anxiety disorders presents unique issues for detection and management. Conclusions: Future research is needed to estimate the prevalence of perinatal anxiety disorders more precisely, to identify potential implications of maternal anxiety disorders for maternal quality of life and child development, and to determine safe and effective treatment methods.
Data on a comparative study between a group of 26 primiparous women who gave birth to a child after an homologous In Vitro Fertilization Treatment (IVF) and a group of 26 women also primiparous, who gave birth to a child after a natural conception, were analyzed to explore the prevalence of psychopathology in the IVF group as opposed to the control group. No differences were detected as regards the psychological parameter of depression between the two groups. The results of the Eysenck Personality Scale point out that there are no differences between the personality profile of women who resort to IVF treatment and women who conceive naturally, as no statistically significant differences were discovered in three of the four sub-scales of the EPI among the two groups. There was a differentiation only in the first sub-scale (psychoticism), where the IVF group recorded lower scores to a statistically significant degree.
Background: Psychological outcomes of successful in vitro fertilization (IVF) treatment are poorly understood, particularly in couples experiencing a multiple birth. Methods: Anxiety and depression at 18 weeks of pregnancy, 28 weeks of pregnancy, and at 6 weeks postpartum were compared in couples conceiving twins or triplets following IVF (IVFM), couples conceiving a single baby (IVFS), and couples conceiving without treatment for infertility (NC). Parenting stress was also assessed at 1 year postpartum. Results: The IVFM group was significantly more anxious at 18 weeks and 28 weeks of pregnancy than both the IVFS group and the naturally conceiving group. Over 30% of female partners in this group had levels of anxiety suggestive of a clinical disorder. There was no evidence that women conceiving following IVF treatment were at increased risk of developing postnatal depression. In couples with a single birth, male rates of postpartum depression were significantly lower than those of females, but in the IVFM group, men had rates that were higher but statistically similar to females. Conclusion: Psychological complications of multiple IVF pregnancies include increased anxiety during pregnancy and, for fathers, poorer mental health in the early postpartum period.
Based on American Society for Reproductive Medicine (ASRM) and Society for Assisted Reproductive Technology data available in 2007, ASRM's guidelines for the number of embryos to be transferred in in vitro fertilization cycles have been further refined in continuing efforts to reduce the number of higher-order multiple pregnancies. This version replaces the document of the same name that was published most recently in November 2008. (Fertil Steril (R) 2009;92:1518-9. (C) 2009 by American Society for Reproductive Medicine.)
Motherhood and Mental Health Ian Brockington Oxford University Press, 1996,612 p.
Depression or anxiety disorders may affect more than 25% of multiple birth parents during the perinatal period. Such parents often are uninformed, suffer in silence and fear, and are reticent to seek help. When depression, panic attacks, and obsessive-compulsive disorder are not recognized or are left untreated, parent health, parent-infants interaction, child development, and family stability may be seriously compromised. Nurses, as partners in care at the family and community levels, have a pivotal role to play in prevention-focused health, education, and social support programs; the identification of parents at risk; and the early recognition and support of women and families affected by these disorders.
A review of our recent research suggests that infants of depressed mothers appeared to be less responsive to faces and voices as early as the neonatal period. At that time they have shown less orienting to the live face/voice stimulus of the Brazelton scale examiner and to their own and other infants' cry sounds. This lesser responsiveness has been attributed to higher arousal, less attentiveness and less "empathy." Their delayed heart rate decelerations to instrumental and vocal music sounds have also been ascribed to their delayed attention and/or slower processing. Later at 3-6 months they showed less negative responding to their mothers' non-contingent and still-face behavior, suggesting that they were more accustomed to this behavior in their mothers. The less responsive behavior of the depressed mothers was further compounded by their comorbid mood states of anger and anxiety and their difficult interaction styles including withdrawn or intrusive interaction styles and their later authoritarian parenting style. Pregnancy massage was effectively used to reduce prenatal depression and facilitate more optimal neonatal behavior. Interaction coaching was used during the postnatal period to help these dyads with their interactions and ultimately facilitate the infants' development.
Despite the progress made in assisted reproductive technology, live birth rates remain disappointingly low. Multiple-embryo transfer has been an accepted practice with which to increase the success rate. This has led to a higher incidence of multiple-order births compared with natural conception, which not only increase the risk of mortality and morbidity to both mother and children but are also associated with social and economic consequences. Elective single-embryo transfer (eSET) was developed in an effort to increase singleton pregnancies in assisted reproduction. Studies comparing eSET with multiple-embryo transfer highlight the benefit of this approach and suggest that, with careful patient selection and the transfer of good-quality embryos, the risk of a multiple-order pregnancy can be reduced without significantly decreasing live birth rates. Although the use of eSET has gradually increased in clinical practice, its acceptance has been limited by factors such as availability of funding and awareness of the procedure. An open discussion of eSET is warranted in an effort to enable a broader understanding by physicians and patients of the merits of this approach. Ultimately, eSET may provide a more cost-effective, potentially safer approach to patients undergoing assisted reproduction technology.
The purpose of the study was to assess the relationship between multiple births and maternal depressive symptoms measured 9 months after delivery.
Data were derived from the Early Childhood Longitudinal Study-Birth Cohort, a longitudinal study of a nationally representative sample of children born in 2001. Depressive symptoms were measured at 9 months by using an abbreviated version of the Center for Epidemiologic Studies Depression Scale. Logistic regression analyses were conducted to study the association between multiple births and maternal depressive symptoms, with adjustment for demographic and household socioeconomic characteristics and maternal history of mental health problems. A total of 8069 mothers were included for analyses.
The prevalence of moderate/severe depressive symptoms at 9 months after delivery was estimated to be 16.0% and 19.0% among mothers of singletons and multiple births, respectively. Only 27.0% of women who had moderate/severe depressive symptoms reported talking about emotional or psychological problems with a mental health specialist or a general medical provider within the 12 months before the interview. The proportions of women with depressive symptoms who were receiving mental health services did not vary according to plurality status.
Mothers of multiple births had 43% greater odds of having moderate/severe, 9-month postpartum, depressive symptoms, compared with mothers of singletons. Greater attention is needed in pediatric settings to address maternal depression in families with multiple births.
Postpartum depression (PPD) affects up to 15% of mothers. Recent research has identified several psychosocial and biologic risk factors for PPD. The negative short-term and long-term effects on child development are well-established. PPD is under recognized and under treated. The obstetrician and pediatrician can serve important roles in screening for and treating PPD. Treatment options include psychotherapy and antidepressant medication. Obstacles to compliance with treatment recommendations include access to psychotherapists and concerns of breastfeeding mothers about exposure of the infant to antidepressant medication. Further research is needed to examine systematically the short-term and long-term effect of medication exposure through breastmilk on infant and child development.
To determine the psychosocial risks associated with multiple births (twins or triplets) resulting from assisted reproductive technology (ART).
Transverse study.
Infertility units of a university hospital and a private hospital.
Mothers and fathers of children between 6 months and 4 years conceived by ART (n = 123). The sample was divided into three groups: parents of singletons (n = 77), twins (n = 37), and triplets (n = 9).
The questionnaire was self-administered by patients. It was either completed at the hospital or mailed to participants' homes.
Scales measured material needs, quality of life, social stigma, depression, stress, and marital satisfaction.
Logistic regression models were applied. Significant odds ratios were obtained for the number of children, material needs, social stigma, quality of life, and marital satisfaction. The results were more significant for data provided by mothers than by fathers.
The informed consent form handed out at the beginning of ART should include information on the high risk of conceiving twins and triplets and on the possible psychosocial consequences of multiple births. As soon as a multiple pregnancy is confirmed, it would be useful to provide information on support groups and institutions. Psychological advice should also be given to the parents.
Recent evidence suggests that the prevalence of postnatal depression (PND) is highest in low-income developing countries. This study aimed to estimate the prevalence of PND and its associated risk factors among Bangladeshi women.
The study was conducted in the Matlab subdistrict of rural Bangladesh. A cohort of 346 women was followed up from late pregnancy to post-partum. Sociodemographic and other related information on risk factors was collected on structured questionnaires by trained interviewers at 34-35 weeks of pregnancy at the woman's home. A validated local language (Bangla) version of the Edinburgh Postnatal Depression Scale (EPDS-B) was used to measure depression status at 34-35 weeks of pregnancy and at 6-8 weeks after delivery.
The prevalence of PND was 22% [95% confidence interval (CI) 17.7-26.7%] at 6-8 weeks post-partum. After adjustment in a multivariate logistic model, PND could be predicted by history of past mental illness [odds ratio (OR) 5.6, 95% CI 1.1-27.3], depression in current pregnancy (OR 6.0, 95% CI 3.0-12.0), perinatal death (OR 14.1, 95% CI 2.5-78.0), poor relationship with mother-in-law (OR 3.6, 95% CI 1.1-11.8) and either the husband or the wife leaving home after a domestic quarrel (OR 4.0, 95% CI 1.6-10.2).
The high prevalence of PND in the study was similar to other countries in the South Asian region. The study findings highlight the need for programme managers and policy makers to allocate resources and develop strategies to address PND in Bangladesh.
The differences in maternal identity and early mothering behavior were compared in previously infertile and never infertile women in this pilot study to evaluate the relationship between previous infertility and the early maternal experience. Women were tested by questionnaire, observation, and interview. No significant differences were noted between groups for quantitative early mothering behavioral measurements. Previously infertile mothers demonstrated lower postpartum maternal identity scores, delay in preparation of the home environment, and less self-confidence.
The present study was conducted to assess the immediate psychological impact of failed in vitro fertilization (IVF). Emotional status and marital functioning were also examined pre-IVF, and both demographic information and psychological test scores were evaluated as predictors of reaction to treatment failure. After a failed first cycle, both males and females showed significant increases in anxiety and depressive symptoms. Although group means were not clinically elevated and most participants were coping adequately, the prevalence of both mild and moderate depression increased substantially, particularly among women. In addition, women without children were a subgroup particularly vulnerable to the stress of failure. Predisposition towards anxiety, pre-IVF depressive symptoms, and fertility history were the most important predictors of emotional response. Treatment implications of these findings were discussed.
This report is an explication of the process of conception in infertile couples as illuminated by 24 infertile couples and a comparison group of 6 couples with no fertility impairments. Employing techniques generic to grounded theory research, the investigators found that infertile couples lived conception as a series of biological and phenomenological moments. The process of biomedically-assisted conception consisted of three components including: (a) forcing conception; (b) resolving conceptional ambiguity; and (c) reconciling conception as an idea and as an event. The findings suggest the need for a re-examination of current orientations to pregnancy time and space and appraisal of couples' interpretations of conception. In addition, the convergence of the conception experiences of infertile and fertile couples raises questions about the meaning of normal conception in the current technological context of reproduction.
The development of a 10-item self-report scale (EPDS) to screen for Postnatal Depression in the community is described. After extensive pilot interviews a validation study was carried out on 84 mothers using the Research Diagnostic Criteria for depressive illness obtained from Goldberg's Standardised Psychiatric Interview. The EPDS was found to have satisfactory sensitivity and specificity, and was also sensitive to change in the severity of depression over time. The scale can be completed in about 5 minutes and has a simple method of scoring. The use of the EPDS in the secondary prevention of Postnatal Depression is discussed.
Several new methods of infertility treatment have been developed. There is therefore an increasing interest among physicians
in gaining knowledge about the occurrence of infertility in order to estimate the need for treatment. This article examines
epidemiological studies in industrialized countries 1970–1992 on the prevalences of infertility, involuntary infecundity,
and the seeking of medical advice for infertility. The studies are compared on the basis of study design, definitions, methods
of measurement and results. Comparison of the studies is difficult, as researchers use different concepts and there is a large
variation in the delineation of the populations involved. The current prevalence of infertility among women in the fertile
age group varies from 3.6 to 14.3%, the life-time prevalence varies from 12.5 to 32.6%, the prevalence of involuntary infecundity
from 2.6 to 5.9%, and medical contact for infertility from 3.6 to 17%. It is probable that these large differences in prevalences
are mainly due to differences in definitions and methods of measurement. We recommend that future studies be carried out in
representative population groups, and that only couples who have tried to have children should be included in the estimated
prevalences.
The study was designed to examine the extent to which the psychological profiles of couples entering an IVF programme were influenced by evidence of previous fertility, the history of fertility investigations, the diagnosis made, and the coping strategies adopted. A sample of 152 couples was administered a number of standardized psychological instruments and a coping strategies questionnaire. They showed little variation from the normative range on the standardized measures. There was little evidence of differences between couples referred for primary or secondary infertility, between those with some evidence of fertility and those with none, or between different diagnostic groups. In relation to coping strategy, for women at least, taking direct action appears to be effective if it is associated with some degree of acceptance of one's position. For males, the picture is less clear, though direct action and acceptance again appear to be effective coping strategies.
The present study compares the experience of pregnancy and delivery among in-vitro fertilization (IVF) parents (45 couples),
other formerly infertile parents (35 couples) and fertile parents (35 couples). All deliveries concerned primaparous women
and singleton births. In addition, the burden of fertility treatments was investigated. Results show that the psychologic