Professional Documents
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Obstetric Outcome
Liselott Andersson, MD, Inger Sundstrom-Poromaa, MD, PhD, Marianne Wulff, MD, PhD,
Monica strom, MD, PhD, and Marie Bixo, MD, PhD
OBJECTIVE: To investigate the obstetric outcome and health
care consumption during pregnancy, delivery, and the
early postpartum period in an unselected populationbased sample of pregnant women diagnosed with antenatal depressive and/or anxiety disorders, compared with
healthy subjects.
METHODS: Participants were 1,495 women attending 2 obstetric clinics in Northern Sweden. The Primary Care Evaluation of Mental Disorders was used to evaluate depressive
and anxiety disorders in the second trimester of pregnancy.
To assess demographic characteristics, obstetric outcome,
and complications, the medical records of the included
women were reviewed.
RESULTS: Significant associations were found between depression and/or anxiety and increased nausea and vomiting, prolonged sick leave during pregnancy and increased
number of visits to the obstetrician, specifically, visits related to fear of childbirth and those related to contractions.
Planned cesarean delivery and epidural analgesia during
labor were also significantly more common in women with
antenatal depression and/or anxiety.
CONCLUSION: There is an association between antenatal depressive and/or anxiety disorders and increased health care
use (including cesarean deliveries) during pregnancy and
delivery. (Obstet Gynecol 2004;104:46776. 2004 by
The American College of Obstetricians and Gynecologists.)
LEVEL OF EVIDENCE: II-2
Depression and anxiety disorders are common health problems that affect women more often than men.1 The World
Health Organizations Global Burden of Disease Study2
has estimated unipolar major depression to be the leading
cause of disease-related disability among women in the
world today. Reproductive events have been suggested to
be involved in the onset and course of depression and
From the Department of Clinical Sciences, Obstetrics and Gynecology, Ume
University, Ume, Sweden; Department of Obstetrics and Gynecology, Sunderby
Hospital, Lule, Sweden; Department of Womens and Childrens Health,
University Hospital, Uppsala, Sweden; and Department of Clinical Sciences,
Psychiatry, Ume University, Ume, Sweden.
The authors thank all personnel involved in the ultrasound screening procedures at
the 2 sites and especially Mrs. Marie Wallgren and Mrs. Yvonne Hoff.
VOL. 104, NO. 3, SEPTEMBER 2004
2004 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.
Financial Disclosure
This study was supported by research grants from Pfizer AB,
Stockholm, Sweden, Visare Norr, Ume University Insamlingsstiftelsen, and by grants to Inger Sundstrom-Poromaa from the Swedish
Society for Medical Research.
0029-7844/04/$30.00
doi:10.1097/01.AOG.0000135277.04565.e9
467
468
Andersson et al
RESULTS
In the study population of 1,495 women, 211 (14.1%;
95% confidence interval CI 12.40 15.99%) had one or
more psychiatric diagnoses. Depressive disorders were
most common, with a prevalence of 174 (11.6%; 95% CI
10.04 13.36%) subjects. Major depression was present
Andersson et al
469
Table 1. Characteristics of Study Population Versus Group of Women Not Included in Study
Age (y)
Marital status
Married or cohabiting
Not married or cohabiting
Socioeconomic status
Professional employee
Laborer
Smoking status
Nonsmoker
Smoker
Snuff taking status
Not snuff taker
Snuff taker
Parity
Nullipara
Multipara
Previous psychiatric disorder
No
Yes
Study population
(n 1,495)*
Not-included women
(n 768)*
29.6 4.6
29.7 5.2
1,433 (96.6)
51 (3.4)
650 (95.4)
31 (4.6)
687 (46.5)
791 (53.5)
265 (38.9)
416 (61.1)
1,374 (92.8)
106 (7.2)
615 (91.1)
60 (8.9)
1,392 (94.1)
88 (5.9)
654 (96.9)
21 (3.1)
649 (43.5)
844 (56.5)
308 (44.3)
388 (55.7)
1,424 (95.8)
63 (4.2)
656 (95.1)
34 (4.9)
P
.42
.22
.01
.16
.01
.75
.50
470
Andersson et al
Table 2. Selected Demographic, Behavioral, and Medical Characteristics Associated With Prevalence of Antenatal
Psychiatric Diagnosis
Psychiatric
diagnosis
(n 211)*
Age (y)
19
2029
3039
40
Marital status
Married or cohabiting
Not married or cohabiting
Socioeconomic status
Professional employee
Laborer
Smoking status
Nonsmoker
Smoker
Snuff taking status
Not snuff taker
Snuff taker
Parity
Nullipara
Multipara
Alcohol use
Rarely/never
Yes
Chronic disease
No
Yes
First-trimester BMI
18.5
18.524.9
25.029.9
30.0
Previous miscarriage
No
Yes
Infertility treatment
No
Yes
No psychiatric
diagnosis
(n 1,284)*
Odds ratio
95%
Confidence
interval
4 (1.9)
93 (44.1)
111 (52.6)
3 (1.4)
15 (1.2)
621 (48.4)
631 (49.1)
17 (1.3)
1.78
Referent
1.18
1.18
0.585.48
193 (91.5)
18 (8.5)
1,240 (97.4)
33 (2.6)
Referent
3.50
1.946.35
63 (29.9)
148 (70.1)
512 (40.4)
755 (59.6)
Referent
1.59
1.162.18
182 (86.7)
28 (13.3)
1,192 (93.9)
78 (6.1)
Referent
2.35
1.493.72
198 (94.3)
12 (5.7)
1,194 (94.0)
76 (6.0)
Referent
0.95
0.511.78
77 (36.5)
134 (63.5)
572 (44.6)
710 (55.4)
Referent
1.40
1.041.90
210 (99.5)
1 (0.5)
1,268 (99.9)
1 (0.1)
Referent
6.04
0.3896.91
198 (97.1)
6 (2.9)
1,229 (97.9)
27 (2.1)
Referent
1.36
0.553.32
4 (2.0)
108 (12.7)
54 (27.1)
33 (16.6)
22 (1.8)
744 (61.8)
328 (27.3)
109 (9.1)
1.25
Referent
1.13
2.09
169 (80.1)
42 (19.9)
1,045 (81.7)
234 (18.3)
Referent
1.11
0.771.60
207 (98.1)
4 (1.9)
1,237 (96.8)
41 (3.2)
Referent
0.58
0.211.64
0.871.58
0.344.10
0.423.70
0.801.61
1.343.23
P .001.
P .05.
P .01.
Andersson et al
471
No psychiatric
diagnosis
(n 1,284)*
Odds ratio
95%
Confidence
interval
114 (54.3)
96 (45.7)
671 (53.0)
596 (47.0)
Referent
0.99
0.731.35
169 (81.3)
39 (18.8)
1,171 (92.2)
99 (7.8)
Referent
2.04
1.402.98
126 (68.9)
57 (31.3)
946 (84.3)
176 (15.7)
Referent
2.06
1.412.96
80 (44.2)
101 (55.8)
731 (66.0)
376 (34.0)
Referent
2.10
1.493.00
119 (56.4)
92 (43.6)
787 (61.4)
495 (38.6)
Referent
1.16
0.851.59
137 (64.9)
74 (35.1)
954 (74.5)
327 (25.5)
Referent
1.52
1.102.12
196 (92.9)
15 (7.1)
1,182 (92.3)
99 (7.7)
Referent
0.82
0.441.53
184 (87.2)
27 (12.8)
1,176 (91.8)
105 (8.2)
Referent
1.56
0.972.51
187 (88.6)
24 (11.4)
1,218 (95.1)
63 (4.9)
Referent
2.38
1.414.02
185 (87.7)
26 (12.3)
1,186 (92.6)
95 (7.4)
Referent
1.68
1.032.75
Odds ratio adjusted for age, marital status, socioeconomic status, smoking habits, parity, and body mass index.
P .001.
P .01.
P .05.
472
Andersson et al
Our study suggests that women with antenatal depressive and/or anxiety disorder were on sick leave earlier in
the pregnancy and for a longer time period throughout
pregnancy than women without any diagnosis. Although not specifically concerned with a pregnant population, similar results were obtained in DEPRES (Depression Research in European Society), which was the
first pan-European study on depression in the community, performed by Lepine and coworkers.17 DEPRES
was performed on a large population (78,463 adults) in 6
countries and was not performed exclusively on pregnant women. The results of the DEPRES study revealed
more lost days of productivity in depressed subjects and
also a strong correlation between the severity of depression and number of sick-leave days. Those who suffered
from major depression lost 4 times as many working
days over a 6-month period as nonsufferers (13 versus 3
Induced labor
No
Yes
Planned cesarean delivery
No
Yes
Acute caesarean delivery
No
Yes
Instrumental delivery
No
Yes
Normal vaginal delivery without complications
Yes
No
Oxytocin during labor
No
Yes
Epidural analgesia
No
Yes
Time from start of labor to delivery
12 h
12 h
Time from arrival in delivery unit to delivery
12 h
12 h
Psychiatric
diagnosis
(n 211)*
No
psychiatric
diagnosis
(n 1,284)*
Odds ratio
95%
Confidence
interval
180 (85.3)
31 (14.7)
1,103 (86.0)
180 (14.0)
Referent
0.97
0.631.50
187 (88.6)
24 (11.4)
1,198 (93.3)
86 (6.7)
Referent
1.76
1.052.93
190 (90.9)
21 (10.0)
1,169 (91.0)
115 (9.0)
Referent
1.07
0.621.82
199 (94.3)
12 (5.7)
1,187 (92.4)
97 (7.6)
Referent
0.66
0.321.37
125 (59.2)
86 (40.8)
788 (61.4)
496 (38.6)
Referent
1.17
0.841.63
101 (56.1)
79 (43.9)
648 (55.6)
517 (44.4)
Referent
1.13
0.791.62
121 (65.1)
65 (34.9)
855 (72.0)
333 (28.0)
Referent
1.56
1.082.56
100 (58.1)
72 (48.9)
750 (69.3)
332 (30.7)
Referent
1.88
1.302.73
130 (72.6)
49 (27.4)
891 (78.1)
250 (21.9)
Referent
1.42
0.962.13
Odds ratio adjusted for age, marital status, socioeconomic status, smoking habits, parity, and body mass index.
P .01.
P .05.
Thomassen,24 who found a higher frequency of psychological problems in women with severe anxiety over
childbirth compared with controls, and likewise, significant associations between antenatal depressive and/or
anxiety disorders and pronounced fear of childbirth
have been reported.9
Finally, we noted significant associations between antenatal depression and/or anxiety and consultations related to premature contractions, planned cesarean delivery, use of epidural analgesia during labor, and a selfexperienced longer time of labor. The higher incidence
of cesarean deliveries might be explained by a covariation between depression and/or anxiety and fear of childbirth, as already mentioned. Sjogren and Thomassen24
noted in their study that 68% of the women with severe
anxiety over childbirth initially requested cesarean delivery. In Sweden, the cesarean delivery rate has increased
from 10.6% in 1990 to 16.0% in 2001.13 Because there
Andersson et al
473
Table 5. Complications of Pregnancy and Delivery Associated With Prevalence of Antenatal Psychiatric Diagnosis
Psychiatric
diagnosis
(n 211)*
No
psychiatric
diagnosis
(n 1,284)*
Odds ratio
95%
Confidence
interval
203 (96.2)
8 (3.8)
1,251 (97.6)
31 (2.4)
Referent
1.37
0.573.27
197 (93.4)
14 (6.6)
1,181 (92.0)
103 (8.0)
Referent
0.78
0.431.44
205 (97.2)
6 (2.8)
1,249 (97.3)
35 (2.7)
Referent
0.91
0.352.37
209 (99.1)
2 (0.9)
1,268 (98.8)
16 (1.2)
Referent
0.75
0.163.45
208 (98.6)
3 (1.4)
1,269 (98.8)
15 (1.2)
Referent
1.43
0.405.14
194 (93.3)
14 (6.7)
1,210 (94.5)
70 (5.5)
Referent
1.20
0.642.25
161 (86.1)
26 (13.9)
995 (83.1)
202 (16.9)
Referent
0.83
0.501.36
209 (99.1)
2 (0.9)
1,268 (98.8)
16 (1.2)
Referent
0.75
0.163.45
193 (91.5)
18 (8.5)
1,198 (93.4)
85 (6.6)
Referent
1.36
0.762.42
180 (96.3)
7 (3.7)
1,169 (97.7)
28 (2.3)
Referent
2.03
0.854.86
Odds ratio adjusted for age, marital status, socioeconomic status, smoking habits, parity, and body mass index.
are no firm somatic explanations for this increase, psychological factors have been suggested to be involved.
The increased use of epidural analgesia found among
patients with depressive and/or anxiety disorders in our
study was also supported by Chung and colleagues.11
This finding, together with the experienced longer time
of labor, might be associated with more sensations of
pain. As previously mentioned,22 somatic complaints
seem to be associated with depressive and/or anxiety disorder, and pain especially has been noted to complicate the
diagnosing of depression.25 Likewise, McWilliams and colleagues26 found associations between chronic pain and
mood and anxiety disorders. In their study, anxiety disorders were more strongly associated with pain than were
mood disorders.
Other studies have noted associations between antenatal depressive symptoms and adverse events in pregnancy and/or delivery,6,11,27 including increased frequency of operative deliveries, preterm delivery, and
474
Andersson et al
Table 6. Early Postpartum Complications Associated With Prevalence of Antenatal Psychiatric Diagnosis
Postpartum infection
No
Yes
Postpartum admission
No
Yes
Mastitis
No
Yes
Other postpartum complications
No
Yes
Hospital stay after delivery
3d
3d
Psychiatric
diagnosis
(n 211)*
No psychiatric
diagnosis
(n 1,284)*
Odds ratio
95%
Confidence
interval
208 (98.6)
3 (1.4)
1,234 (96.2)
49 (3.8)
Referent
0.38
0.121.24
211 (100)
0
1,271 (99.1)
11 (0.9)
Referent
0.02
Not calculated
206 (97.6)
5 (2.4)
1,248 (97.3)
35 (2.7)
Referent
0.96
0.342.37
207 (98.1)
4 (1.9)
1,264 (98.5)
19 (1.5)
Referent
0.73
0.362.53
153 (73.2)
56 (26.8)
917 (71.5)
366 (28.5)
Referent
1.12
0.811.65
Odds ratio adjusted for age, marital status, socioeconomic status, smoking habits, parity, and body mass index.
3.
4.
5.
6.
7.
8.
9.
10.
Andersson et al
475
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Address reprint requests to: Liselott Andersson, MD, Department of Obstetrics and Gynecology, Sunderby Hospital,
S-97180 Lule, Sweden; e-mail: liselott.andersson@nll.se and
lise-lott@bredband.net.
Received February 18, 2004. Received in revised form May 12, 2004.
Accepted May 21, 2004.