Laura Schwartz1, Angela Bowen2*, and Nazeem Muhajarine1
1Department of Community Health and Epidemiology, University of Saskatchewan, 104 Clinic Road, Saskatoon, SK Canada S7N 5E5
2College of Nursing, University of Saskatchewan, Canada
Received: 20 August, 2015; Accepted: 01 September, 2015; Published: 03 September, 2015
Angela Bowen, RN, PhD, College of Nursing, University of Saskatchewan, Canada, Tel: 306-966-8949; E-mail:
Schwartz L, Bowen A, Muhajarine N (2015) The Effects of Episodic Versus Continuous and Major Versus Mild Depression and Anxiety Symptoms on Pregnancy and Labour Complications. Arch Depress Anxiety 1(1): 010-018.DOI: 10.17352/2455-5460.000003
© 2015 Schwartz L, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Depression; Anxiety; Pregnancy; Postpartum
Background: Depression occurs in approximately 20% of pregnant women, with up to 25% experiencing anxiety. Various pregnancy and labour complications have been associated with maternal mood problems.
Methodology: This population study of antenatal and early postpartum depression and maternal, child outcomes involved 649 women assessed three times: the second trimester, the third trimester, and in the early postpartum. Our objective was to determine the occurrence and outcomes on pregnancy and labour of major and mild depression.
Results: Major depression in the second trimester was significantly associated with developing gestational diabetes and swelling/edema. Major depression that occurred continuously throughout pregnancy was significantly associated with induced labour and antenatal bleeding/abruption. Mild depression in the second trimester was significantly associated with antenatal bleeding/abruption and premature rupture of the membranes. Mild depression in the third trimester was associated with caesarean birth. Mild depression that occurred continuously throughout pregnancy was significantly associated with the use of vacuum/forceps or operative delivery.
Conclusions: Our findings show that either episodic depression or mild depression can have significant negative impact on pregnancy and labour complications.
The prevalence of antenatal depression ranges between 10% and 20%, depending on the population studied and the stage in pregnancy [1,2]. Anxiety during pregnancy is also common, and is experienced by 12% to 60% of women [3,4]. Antenatal depression and anxiety have been associated with several pregnancy complications. Andersson et al. report that women with antenatal depression and/or anxiety were twice as likely to have nausea, vomiting, and more absenteeism from work . They were also more likely to visit their obstetrician, and express feelings of excessive fear of childbirth . Depression and anxiety in pregnancy are associated with an increase in somatic symptoms such as headaches, dizziness, difficulty breathing, and stomach pain . Other researchers describe an association with antenatal depression and obstetrical complications such as gestational diabetes [7-9]. Depression and anxiety are also reported to be associated with hypertension, preeclampsia , bleeding and placental abruption , as well as preterm labour and birth [10,12-16].
In addition to these pregnancy complications, women who are depressed or anxious are less likely to access prenatal care . They are also more likely to engage in more risk behaviours during pregnancy, such as smoking , alcohol, and recreational drug use . The literature also links antenatal depression and anxiety to complications during labour . For example, women suffering from depression appear to feel pain more acutely, request more pain medications, and often report their deliveries to be more painful than women without mood problems . Consequently, antenatal depression and anxiety are often associated with an increased use of epidural or pain medication during labour [5,19]. Lastly, depression and anxiety during pregnancy are associated with an increased rate of caesarean birth [5,9], and instrument use (i.e., vacuum or forceps) .
There is a paucity in knowledge about the impact of continuous versus episodic depression (mild or major) or anxiety on pregnancy and labour complications. This study sought to explore this issue and to begin to fill this gapL.
This study had three key objectives and hypotheses: We sought to examine the association between pregnancy and labour complications and major depression symptoms, when depression is episodic (occurs once in pregnancy) compared to when the depression is chronic (occurs each time measured in pregnancy). We hypothesized that women with chronic major depression symptoms would be more likely to have associated complications, compared to those with episodic major depression. The second objective was to determine if there is a difference between pregnancy and labour complications and mild depression, when the mild depression is episodic (occurs once in pregnancy) compared to when the depression symptoms are chronic (occurs multiple times throughout pregnancy). We hypothesized that women with chronic mild depression would be more likely to have associated complications, compared to those with episodic mild depression. Finally, the third objective was to determine if there is difference between pregnancy and labour complications and anxiety symptoms, when the anxiety is episodic (occurs once in pregnancy) compared to when anxiety is chronic (occurs throughout pregnancy). We hypothesized that women with chronic anxiety would be more likely to have associated complications, than those with episodic anxiety.
Data were collected for the Feelings in Pregnancy and Motherhood Study (FIP), a longitudinal study of antenatal and early postpartum depression in Canada. The study was approved by the University Behavioural Research Ethics Board. Participants were recruited from doctor's offices, maternity stores, posters, radio advertising, and prenatal classes. Participants were interviewed at three times: Time 1, in the second trimester; Time 2, in the third trimester; and Time 3, in the early postpartum. Women were given similar questionnaires at each Time; however, Time 1 and Time 3 questionnaires included additional self-reported information about health history and pregnancy outcomes.
The Edinburgh Postnatal Depression Scale (EPDS) was used at all three times to screen for possible depression and anxiety. The EPDS has been translated into multiple languages and is validated for use in several populations, both antenatal and postnatal . Each item on the EPDS has four possible answers, which are scored between 0-3. The total possible score for all ten items can range between 0-30. The scale has a 87% sensitivity and 78% specificity . For this study, a cut-off score of ≥ 12 on the EPDS scale was used to indicate major depression symptoms and 10-11 for mild depression symptoms [21,23], we have used 10.
The EPDS contains an anxiety subscale comprised of items 3, 4, and 5 and for this study; a cut-off score of ≥ 4 was used, which has been used in previous studies . We suggested that women who scored greater than 12 talk to their family doctor or to our local Maternal Mental Health Program for further assessment and appropriate management.
Other data included sociodemographic factors (age, marital status, education, ethnicity, and household income). Psychosocial questions about history of mental illness, and whether the person was currently seeking treatment or counselling for depression, anxiety and other mental health issues were asked. These questions also reflected whether the person was taking medication for mental health. Summative emotional support was reported as the number of supports a woman had (partner, mother, friend, or other). A summative stress variable was calculated by the number of stressors a woman reported experiencing including items such as the relationship with their partner, money issues, other children etc. Self-report obstetrical and medical questions included nausea and vomiting, gestational diabetes, gestational hypertension, bleeding, infections, and hospitalizations. Finally, we asked about health behaviours such as physical activity, tobacco, alcohol, and recreational drug use, and prenatal vitamins and lessons.
To analyze the association between major depression, mild depression, or anxiety symptoms, the outcome variables of interest included pregnancy complications. The predictor variable of interest for examining associated complications was the EPDS, mild or major depression, and anxiety. Other variables of interest included sociodemographic factors, history of mental illness, mental health treatment, stress, and emotional support.
Prospective multivariate logistic regression models were built to understand the association between the predictor and outcome variables. Once a model with only significant predictors (those with p≤0.05) was established, the variables were tested for possible interactions. This was completed for primary predictor of interest (major depression, mild depression, and anxiety symptoms) at Time 1, Time 2, and then at both times.
There were 649 (100%) women who completed Time 1 (second trimester), 604 (93.1%) women completed Time 2 (third trimester), and 596 (91.8%) women completed Time 3 (early postpartum). Time 1 was completed at 17.37 (± 4.95) mean gestational weeks, Time 2 was completed at 30.63 (± 2.67) mean gestational weeks, and Time 3 was completed at 4.17 (± 2.12) mean postpartum weeks. Five hundred and eighty-one women completed all three questionnaires. The age range of the women within the study was 15-44 years and the mean age was 28.99 ± 4.83. As seen in Table 1, participants were highly educated, more likely to be in a relationship, many reported a higher than average income and most reported completing post-secondary education.
The prevalence of mild and major depression symptoms decreased over pregnancy with a minority of women depressed chronically throughout pregnancy. At Time 1 (episodic second trimester), 10.2% of women experienced mild depression symptoms, while 14.0% scored in the range for major depression symptoms. At Time 2 (episodic late third trimester), 9.3% were considered to have mild depression, while 10.3% were experiencing major depression symptoms. Only 1.8% and 4.8% of women scored in the range for chronic mild and major depression symptoms respectively. The prevalence of anxiety in this study was substantially higher than depression, 47.5% (Time 1), 38.5% at Time 2, and lastly 26.6% of participants scored within the range for chronic anxiety symptoms, i.e., occurred at Time 1 and Time 2. Figure 1 shows the pregnancy complications, while Figure 2 shows the labour complications.
Four pregnancy complications were significantly associated with major depression symptoms: gestational diabetes, induced labour, swelling/edema, and bleeding/abruption. See Table 2 for the logistic regression models. Women who experienced episodic major depression symptoms at Time 1 were 3.5 times more likely to suffer from gestational diabetes; those who smoked were three times more likely to have gestational diabetes. Finally, social support was protective of having gestational diabetes.
Participants who were chronically experiencing major depression symptoms were 2.4 times more likely to have induced labour compared to women who did not have depression in either trimester. The greater the amount of stress the participants experienced, the more likely they were to have induced labour.
Participants with episodic major depression symptoms at Time 1 were twice as likely to have swelling/edema during their pregnancy. Married participants were 50% less likely to experience swelling/edema during pregnancy. Participants in the older age category (29-44 years) were 1.43 times more likely to have swelling/edema during pregnancy. Additionally, engaging in physical activity was lowered the risk of swelling/edema during pregnancy; the more exercise a woman engaged in, the less likely she was to have swelling and/or edema.
As shown in Table 2, participants who experienced chronic depression symptoms were 2.7 times more likely to experience abruption or bleeding during pregnancy. Support at Time 1 had a protective association over having bleeding/abruption during pregnancy.
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