797 Am J Epidemiol 2002;156:797802

American Journal of Epidemiology

Copyright 2002 by the Johns Hopkins Bloomberg School of Public Health
All rights reserved
Vol. 156, No. 9
Printed in U.S.A.
DOI: 10.1093/aje/kwf131
Maternal Prenatal Depressive Symptoms and Spontaneous Preterm Births among
African-American Women in Baltimore, Maryland
Suezanne T. Orr
1
, Sherman A. James
2
, and Cheryl Blackmore Prince
3
1
Department of Health Education and Promotion, East Carolina University, Greenville, NC.
2
University of Michigan School of Public Health and Center for Research on Ethnicity, Culture and Health, Ann Arbor, MI.
3
Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA.
Received for publication December 21, 2001; accepted for publication June 19, 2002.
The purpose of this study was to examine the relation between maternal depressive symptoms and
spontaneous preterm birth. From 1991 to 1993, pregnant, African-American women were prospectively enrolled
at four hospital-based clinics in Baltimore, Maryland, that serve low-income areas of the city. The Center for
Epidemiologic Studies Depression (CES-D) Scale was used to assess depressive symptoms. Multiple logistic
regression analysis estimated the independent contribution of maternal depressive symptoms to spontaneous
preterm birth, controlling for behavioral, clinical, and demographic variables. Among the 1,399 women in the
sample, 117 (8.4%) had a spontaneous preterm delivery. Spontaneous preterm birth occurred among 12.7% of
those with a CES-D score in the upper 10th percentile and among 8.0% of those with a lower score (relative
risk = 1.59). The adjusted odds ratio for an elevated CES-D score was 1.96 (95% confidence interval: 1.04, 3.72);
hence, maternal depressive symptoms in this sample of African-American women were independently
associated with spontaneous preterm birth. Effective treatment of depression in pregnant women could ultimately
result in a reduction of spontaneous preterm births.
depression; depressive disorder; gestational age; pregnancy outcome
Abbreviations: BMI, body mass index; CES-D, Center for Epidemiologic Studies Depression.
Despite a small decline from 1999 to 2000, the rate of
preterm births (births occurring at less than 37 weeks of
completed gestation) is higher now than in 1981, having
risen steadily for almost two decades (1). The current
preterm birth rate of 11.6 percent is higher than that for 1990
(10.6 percent) (1). Of particular concern is the long-standing
and poorly understood disparity between African-American
and White women. African-American women have approxi-
mately double the risk of preterm outcomes compared with
White women, and this twofold risk disparity has existed for
more than 50 years (26). The continued high rates of
preterm birth, and the persistent excess risk of preterm birth
among African-American women, is of great concern
because of the strong association of preterm birth with infant
death as well as infant and childhood morbidity (5, 7). The
etiology of preterm birth remains poorly understood, and, as
noted recently by Martin et al., until progress is made in this
regard [understanding etiology], meaningful reduction in the
incidence of preterm delivery is unlikely (1, p. 16).
During the past decade, interest has been expressed in the
potential etiologic association of psychosocial factors,
including maternal depression, with preterm birth (8, 9).
Hoffman and Hatch noted in 1996 that accumulating
evidence suggested that maternal depression during preg-
nancy might be associated with preterm birth, but they added
that the evidence was not conclusive (9). The relation
between maternal depression and preterm birth is, in reality,
poorly understood, and prior research has produced
conflicting results. Several previous studies have measured
variables such as distress as a proxy for depression,
without actually measuring depression or depressive symp-
toms during pregnancy (1012). Other research on this topic
has focused on outcomes of pregnancy other than preterm
birth, such as spontaneous preterm labor (13), which is
distinct from preterm birth (14). A retrospective study, using
Correspondence to Dr. Suezanne T. Orr, Department of Health Education and Promotion, East Carolina University, 200 Christenbury,
Greenville, NC 27858 (e-mail: orrs@mail.ecu.edu).

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798 Orr et al.
Am J Epidemiol 2002;156:797802
data from the 1988 Maternal and Infant Health Survey,
reported an association between scores on the Center for
Epidemiologic Studies Depression (CES-D) Scale with low
birth weight (15). However, the data on depressive symptoms
during pregnancy were collected after the birth of the infant
(sometimes as much as 1 year later), and this information
could be biased because of problems with recall and also by
events that may have occurred during or after the pregnancy,
including the birth (or death) of a low-birth-weight infant.
One in five women will experience an episode of depres-
sion during her lifetime (16), and Weissman and Olfson
noted that depression is primarily a disorder of women of
childbearing age (17). Thus, depression is a prevalent condi-
tion among women of childbearing ages, and there is a need
for an improved understanding of the relation between
maternal prenatal depression and preterm birth.
In the prospective study reported on in this paper, we
measured depressive symptoms in a sample of low-income,
clinic-attending, African-American women. At the end of
their pregnancies, we assessed the outcome of their pregnan-
cies, which enabled us to ascertain the association between
maternal prenatal depressive symptoms and preterm birth
outcomes.
MATERIALS AND METHODS
Pregnant, African-American women were enrolled in this
prospective study (the Psychosocial Factors and Preterm
Birth Study) at four hospital-based clinics in Baltimore,
Maryland, from 1991 to 1993. Each clinic serves low-
income areas of the city that also have high rates of infant
mortality. All women aged 18 years or older who sought
prenatal care at one of the four clinics were approached
during their first prenatal visit by a trained research assistant,
who invited them to participate and obtained written
informed consent. Fewer than 5 percent of the women
approached refused to participate. Of the women in the
sample, slightly over one quarter sought prenatal care during
their first trimester, and 75 percent had started care by the
end of their second trimester. The median number of weeks
of gestation for starting prenatal care was 17. Each woman
completed a questionnaire that included items to assess
demographic data (e.g., education, marital status, employ-
ment, age) as well as depressive symptoms.
The CES-D Scale was included in the questionnaire to
assess depressive symptoms. It was developed by the
National Institute of Mental Health to assess depressive
symptoms in samples drawn from communities (18). The
CES-D Scale contains 20 items and is self-administered; the
women were able to complete it in about 15 minutes while
waiting to be seen during their first prenatal visit. Reliability
and validity of the CES-D Scale are well established (18
20), and the instrument has been widely used in epidemio-
logic studies to assess depressive symptoms as an exposure
variable. By using the CES-D Scale, respondents indicate the
presence of salient symptoms of depression, such as sadness,
crying, hopelessness, and sleep and appetite changes. Clini-
cians generally use the presence of these symptoms as a basis
for diagnosing clinical depression. CES-D scores range from
0 to 60, with a score of 16 or higher used as the customary
cutpoint to define the high-risk or exposed group. While it
does not provide a diagnosis of clinical depression, the CES-
D Scale gives a valid and reliable indication of the presence
of elevated levels of symptoms of depression.
Using the CES-D Scale among pregnant women involves
special assessment problems. Certain common symptoms of
pregnancy, such as fatigue and sleep or appetite changes, are
also common symptoms of depression. As a result, the CES-
D scores of pregnant women could be elevated for reasons
other than depression per se. To address this problem, we
took a more conservative approach to defining high-risk;
namely, only those women whose scores were in the upper
10 percent were considered high risk. We reasoned that
few, if any, women would rank in the upper 10 percent of
CES-D scores solely on the basis of pregnancy-related
symptoms. Others have similarly raised the usual cutpoint of
the CES-D Scale, with the rationale that those in the highest
group of scores would be likely to meet the criteria for a
diagnosable depressive disorder (21).
The CES-D Scale repeatedly has been demonstrated to be
a valid and reliable measurement tool in diverse populations
(18, 22, 23). Prior research has shown that, among adults,
about 4050 percent of those with elevated CES-D scores
(using the traditional cutpoint of 16 or higher) would be clas-
sified as clinically depressed (19). Scores on the CES-D
Scale correlate well with clinical assessments (18, 23), and
CES-D scores decrease when depression is treated (18).
Whereas elevated depressive symptoms (sometimes called
depressive syndrome) are not the same as clinical depres-
sion, the upper 10 percent of scores identifies women with a
large number and frequency of symptoms. Likely, more than
half of these women would meet the criteria for clinical
depression. Furthermore, prospective research has demon-
strated that elevated levels of depressive symptoms is a
significant classification by itself and is a prodrome to clin-
ical depression (24).
The dependent variable was spontaneous preterm birth.
Prior research has suggested that preterm birth may actually
be comprised of etiologically distinct categories (2527).
Preterm births can be subdivided into those that are medi-
cally indicated (i.e., delivery is performed at less than 37
weeks of gestation in the absence of preterm labor or rupture
of the chorioamniotic membranes, usually because of severe
complications that threaten the fetus and/or mother) and
those that are spontaneous. Spontaneous preterm births
occur when a woman presents with either preterm labor or
preterm premature rupture of the chorioamniotic membranes
at less than 37 completed weeks of gestation. Prior research
has suggested that focusing efforts on more homogeneous
categories of preterm birth (e.g., spontaneous preterm births,
the dependent variable in the study reported on in this paper)
may lead to an enhanced understanding of this outcome (25,
26).
Length of gestation was obtained from obstetric, delivery,
and nursery records. The obstetricians providing care to the
women in the sample made a best obstetric estimate of
gestational age at the time of labor and delivery based on
sonograms, date of last menstrual period, when the first fetal
heart rate was heard with a stethoscope, and fundal height.
We used the traditional cutpoint of less than 37 weeks of

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Maternal Prenatal Depressive Symptoms and Preterm Births 799
Am J Epidemiol 2002;156:797802
completed gestation to define preterm birth. In addition, all
preterm births were categorized as medically indicated or
spontaneous (as described in the previous paragraph),
depending on the presentation of the woman for delivery
(i.e., with or without spontaneous labor or rupture of
membranes). The physicians providing care to the women at
the clinical sites addressed any questions about classification
as spontaneous or medically indicated. Since our focus was
on spontaneous preterm births, we excluded those women
with medically indicated preterm births (1.4 percent of all
births) from the analyses, since these are likely etiologically
different from spontaneous preterm births (2527).
Two trained abstractors obtained data on potentially
confounding factors from the clinical records of the women
in the sample. Behavioral factors included in the data collec-
tion were alcohol consumption, illicit drug use, and cigarette
smoking. Underreporting of these undesirable behaviors was
of concern; however, in our sample, the percentages of
women who reported smoking, drug use, and alcohol
consumption were similar to those reported in other studies
(28, 29). Data were also collected on clinical factors that
were potential confounders, including current medical char-
acteristics of the mother (such as low prepregnancy body
mass index (BMI; weight (kg)/height (m)
2
), chronic diseases
such as asthma, diabetes, and hypertension); previous repro-
ductive history; and course of the current pregnancy
(complications such as first- and second-trimester bleeding,
hospitalization during pregnancy, poor total weight gain,
preeclampsia, abruptio placentae, and placenta previa).
Multiple logistic regression analysis was used to estimate
the independent contribution of maternal depressive symp-
toms to spontaneous preterm birth, controlling for clinical,
behavioral, and demographic variables. The beta coefficients
from the model were used to estimate the odds ratios and
associated 95 percent confidence intervals.
RESULTS
Postenrollment, 244 women (approximately 15 percent of
those enrolled) were excluded from the sample for reasons
that included pregnancy loss (including ectopic pregnancy
and therapeutic or spontaneous abortion), multiple preg-
nancy (because of its very strong association with preterm
delivery), lost medical record, and moving from the area.
The women who were excluded were not systematically
different from those who were retained in the sample. An
additional 34 women were excluded because they experi-
enced medically indicated preterm births (20) or preterm
births for which the etiologic group could not be determined
(14). The final sample consisted of 1,399 African-American
women.
The demographic, behavioral, and clinical characteristics
of the women in the sample are shown in table 1. As indi-
cated in this table, approximately 81 percent of the women
were 20 years of age or older, about 75 percent had at least a
high school education, 22 percent were married or were
living with a male partner, and 32 percent were employed
outside of the home. Table 1 also shows that slightly over
one quarter of the women smoked cigarettes, approximately
7 percent reported consuming alcohol during pregnancy, and
about 9 percent used drugs. Regarding the clinical character-
istics of the sample, approximately 27 percent had a chronic
disease, 12 percent had a low BMI (20), 18 percent experi-
enced poor weight gain (less than 21 pounds (9.53 kg)), and
29 percent had a history of a poor pregnancy outcome (i.e.,
prior preterm or low-birth-weight birth, stillbirth, or fetal
death).
Scores on the CES-D Scale ranged from 0 to 57, with a
median score of 16. Scores in the upper 10th percentile were
from 33 through 57. Table 1 shows the characteristics of the
sample overall and for women with low compared with high
levels of depressive symptoms. With one exception (alcohol
consumption), the demographic, behavioral, and clinical
characteristics of the women with high, as compared with
low, levels of depressive symptoms were very similar.
Of the 1,399 women in the sample, 117 experienced spon-
taneous preterm deliveries (8.4 percent), representing 85
percent of all preterm births to women in the sample for
which an etiologic category could be ascertained. Of the
women with elevated levels of depressive symptoms, 12.7
percent experienced spontaneous preterm births; of the
women with low levels of depressive symptoms, 8.0 percent
had this outcome (relative risk = 1.59), as shown in table 1.
Several variables were significantly (p < 0.05) associated
with spontaneous preterm births in this sample, including
abruptio placentae, bleeding, low prenatal BMI, drug use,
poor weight gain (less than 21 pounds), previous poor preg-
nancy outcome, and smoking. We omitted abruptio
placentae from the logistic regression analysis because the
number of women experiencing this complication was small
and the regression coefficient was unstable. Poor weight
gain was also omitted from the logistic regression analyses
because weight gain is so closely tied to length of gestation
(i.e., a woman with a shortened pregnancy has less opportu-
nity to gain weight).
The logistic regression model contained the following
behavioral and clinical predictors associated with the
outcome at p < 0.2 (30): bleeding, drug use, low prepreg-
nancy BMI, previous poor pregnancy outcome, smoking,
and depressive symptoms. Alcohol consumption was also
included in the model because of its association with the
exposure. As shown in table 2, the adjusted odds ratio for an
elevated CES-D score was 1.96 (95 percent confidence
interval: 1.04, 3.72). Low prepregnancy BMI was also asso-
ciated with spontaneous preterm birth (odds ratio = 2.58, 95
percent confidence interval: 1.52, 4.35), as was previous
poor pregnancy outcome (odds ratio = 1.59, 95 percent
confidence interval: 1.01, 2.52).
DISCUSSION
Our results document an association between elevated
levels of maternal depressive symptoms and spontaneous
preterm birth. Spontaneous preterm births represent about 85
percent of all preterm deliveries in the United States (26).
These results may enhance our understanding of the etiology
of preterm birth among African-American women, who have
a twofold increase in risk of spontaneous preterm birth
compared with White women (35).

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800 Orr et al.
Am J Epidemiol 2002;156:797802
TABLE 1. Demographic, behavioral, and clinical characteristics of
African-American women, by CES-D category, in the Psychosocial
Factors and Preterm Birth Study, Baltimore, Maryland, 19911993
* p < 0.05; ** 0.05 < p < 0.10.
CES-D, Center for Epidemiologic Studies Depression.
Score > 33.
1 pound = 0.454 kg.
Maternal characteristic
CES-D score
Low
(lower 90%)
High
(upper 10%)
No. % No. %
Demographic
Age (years)
1819 255 19.4 23 20.0
20 1,060 80.6 92 80.0
Education
<High school graduate 330 25.1 26 22.6
High school graduate 984 74.9 89 77.4
Marital status
Married or living with a partner 290 22.1 28 24.3
Not married or living with a partner 1,025 77.9 87 75.7
Employment
Not working outside of the home 896 68.2 84 73.0
Employed outside of the home 418 31.8 31 27.0
Behavioral
Smoking
Yes 343 26.1 34 29.6
No 972 73.9 81 70.4
Alcohol consumption*
Yes 93 7.1 14 12.2
No 1,221 92.9 101 87.8
Drug use
Yes 113 8.6 12 10.4
No 1,201 91.4 103 89.6
Clinical
Chronic disease
Yes 357 27.2 37 32.2
No 957 72.8 78 67.8
Low body mass index (20 kg/m
2
)
Yes 132 11.8 15 14.6
No 988 88.2 88 85.4
Poor weight gain (<21 pounds)
Yes 232 18.3 23 21.1
No 1,035 81.7 86 78.9
Previous poor pregnancy outcome
Yes 377 28.7 37 32.2
No 935 71.3 78 67.8
Hospitalization during pregnancy
Yes 149 11.3 17 14.8
No 1,166 88.7 98 85.2
Spontaneous preterm birth**
Yes 103 8.0 14 12.7
No 1,183 92.0 96 87.3
Bleeding during pregnancy
Yes 38 2.9 3 2.6
No 1,276 97.1 112 97.4

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Maternal Prenatal Depressive Symptoms and Preterm Births 801
Am J Epidemiol 2002;156:797802
We used a valid and widely used tool, the CES-D Scale, to
measure depressive symptoms. We also used a prospective
design, thus reducing the risk of recall bias of symptoms of
depression. In addition, we controlled for confounding by
behavioral and clinical factors.
We conducted additional analyses to explore the possi-
bility of a dose-response relation between depressive symp-
toms and spontaneous preterm birth. This possibility was
evaluated in several ways, which involved developing quar-
tiles, tertiles, and quintiles to represent CES-D scores in
these exploratory analyses. There was no evidence of a dose-
response association, probably because of an underlying
threshold effect for depression (as indicated by very high
scores on the CES-D Scale) and spontaneous preterm birth.
It is likely that the biochemical or other processes that link
CES-D scores to spontaneous preterm birth operate only
when depression (i.e., the very highest CES-D scores) is
present. This possibility warrants further study.
Approximately one in five women will experience an
episode of clinical depression during her lifetime (16). The
usual age of onset and time of greatest risk is 2040 years,
thus coinciding with the childbearing years for most women.
We assessed depressive symptoms, not clinical depression;
however, elevated symptoms of depression (also known as
depressive syndrome), the exposure of interest in our study,
occur with even greater frequency than clinical depression
and are viewed as a prodrome to clinical depression (24).
Our exposure variable occurs with relatively high prevalence
among women of childbearing age, although the validity of
the CES-D Scale as a good measure of depression in preg-
nant women requires further study. If the findings reported
here are causal, however, high levels of depressive symp-
toms may indeed be a major risk factor for poor pregnancy
outcomes in African-American women.
Prior research has linked depression and elevated levels of
depressive symptoms to a variety of deleterious health
outcomes, such as cancer (3133), heart disease (34), and
poor pregnancy outcome (8). One factor that may link
depressive symptoms and depression to such diverse health
outcomes is immune system functioning. Several studies
have indicated that depression alters the functioning of the
immune system (3539). Depression has been shown to be
associated with measures of immunity such as reduction of
natural killer (NK) cell activity and decreased lymphocyte
proliferation (4042). Since reproductive tract infection is
emerging as an important risk factor for preterm births (43,
44), it may be that altered host susceptibility to reproductive
tract infection, associated with elevated levels of depressive
symptoms, is a potential etiologic pathway through which
elevated levels of depressive symptoms may be associated
with risk of spontaneous preterm births. We did not have
data on reproductive tract infection and thus could not
directly examine this hypothetical etiologic pathway.
A recent report noted the lack of progress in reducing the
rate of preterm birth in the United States in the past two
decades (1). Until now, the main approach to preventing
preterm births has been to focus largely on medically
oriented interventions, with limited attention being given to
psychosocial interventions, including interventions directed
at improving the mental health of lower income, pregnant
women. Treatment of elevated levels of depressive symp-
toms among pregnant women, especially economically
disadvantaged African-American women, could result in a
reduction of spontaneous preterm births in this population. If
the findings reported in this study are shown to be reproduc-
ible in other settings, new and viable psychosocial
approaches to preventing spontaneous preterm births may be
possible.
ACKNOWLEDGMENTS
This research was partially supported by Cooperative
Agreement SO17-13/14 from the Association of Schools of
Public Health and the Centers for Disease Control and
Prevention.
The study protocol was reviewed and approved by the
Johns Hopkins University Human Subject Protection
Committee.
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* Estimated by conditional logistic regression with all variables
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CES-D, Center for Epidemiologic Studies Depression.
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