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doi: 10.1111/ppe.12096

The Influence of Anxiety and Depressive Symptoms During Pregnancy on Birth Size Birit F. P. Broekman,a,b,c Yiong-Huak Chan,b,d Yap-Seng Chong,b,c,e Kenneth Kwek,f Sharon Cohan Sung,g,h Charlotte Louise Haley,g Helen Chen,i Cornelia Chee,a,b Anne Rifkin-Graboi,c Peter D. Gluckman,c,j Michael J. Meaney,c,k Seang-Mei Sawb,l,m on behalf of the GUSTO Research Group a

Department of Psychological Medicine, National University Hospital, Singapore

b

Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore c

Singapore Institute for Clinical Sciences, Singapore

d

Biostatistics Unit, National University of Singapore, Singapore

e

Department of Obstetrics and Gynaecology, National University Hospital, Singapore

f

Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore g h

Office of Clinical Sciences, Duke-NUS Graduate Medical School Singapore

Department of Child and Adolescent Psychiatry, Institute of Mental Health, Singapore

i

Department of Psychological Medicine, KK Women’s and Children’s Hospital, Singapore j

Liggins Institute, University of Auckland, New Zealand

k

Douglas Mental Health University Institute, McGill University, Canada

l

Saw Swee Hock School of Public Health, National University of Singapore, Singapore m

Singapore Eye Research Institute, Singapore National Eye Centre, Singapore

Abstract Background: Mental health problems during pregnancy can influence fetal growth. However, studies examining the influence of maternal mental health across the normal range of birth outcomes are uncommon. This study examined the associations between symptoms of maternal depression and anxiety during pregnancy on birth size among term Asian infants. Methods: One thousand forty-eight Asian pregnant women from a cohort Growing Up in Singapore Towards Healthy Outcomes were recruited between 2009 to 2010 at two Singaporean maternity hospitals. At 26 weeks gestation, depressive symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS) and the Beck Depression Inventory II (BDI-II), and anxiety was measured with the Spielberger State-Trait Anxiety Inventory (STAI). Health personnel recorded birthweight, birthlength, gestational age, and head circumference at birth. Results: Nine hundred forty-six women who delivered term infants had complete data. For this sample, the mean birthweight was 3146.6 g [standard deviation (SD) 399.0], the mean birthlength was 48.9 cm (SD 2.0). After controlling for several potential confounders, there was a significant negative association between STAI and birthlength [β = −0.248, confidence interval (CI) [−0.382, −0.115], P < 0.001] and a small negative association between EPDS and birthlength (β = −0.169, CI [−0.305, −0.033], P = 0.02). No associations were found between scores on the EPDS, BDI-II, and STAI with birthweight or head circumference. Conclusions: Our preliminary data suggest that among term infants, anxiety and depressive symptoms are not associated with birthweight, while anxiety and depressive symptoms are associated with a shorter birthlength. Keywords: birthweight, birthlength, anxiety, depression, pregnancy.

Correspondence: Birit F. P. Broekman, Department of Psychological Medicine, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Singapore. E-mail: [email protected]

The impact of early life conditions on neurodevelopment and health outcomes has received increasing attention. Less than optimal fetal growth has longterm implications on health and human capital by affecting cognitive development and lifetime physical and mental health and even mortality.1–3 For example, low birthweight predicts an increased risk for a range

© 2013 John Wiley & Sons Ltd Paediatric and Perinatal Epidemiology, 2014, 28, 116–126

Maternal mental health and birth size of mental disorders including attention-deficit hyperactivity disorder and depression.4 An obvious question concerns the nature of the conditions that associate with restrained fetal growth. Although it has been well established that exposure to stressful life events during pregnancies, such as nature disasters or war, influences birthweight, birthlength, and gestational age of offspring,5–8 the association between maternal mental health and birth outcomes in normal populations is less conclusive. For example, Rondo et al.9 found an association between maternal scores on perceived stress and anxiety during pregnancy and birthweight with a relative risk of 1.97 (P = 0.002).9 However, such findings appear inconsistent; although some large cohort studies show that maternal mental health during pregnancy is indeed negatively associated with birthweight,9,10 other studies have not found such an association.11–14 Although most studies have focused on maternal depression during pregnancy, more recent studies found associations between maternal anxiety during pregnancy and birth outcomes.15 Interestingly, depression and anxiety during pregnancy appear to have differing effects even on the same birth parameters.1 However, such studies have largely been limited to measures of birthweight, but there are only a few studies comparing the relative influence of depression and anxiety across multiple birth outcome measures. Also, while many studies investigated the effect of maternal health on birth size across the whole gestational continuum, effects of antenatal mental health may be more clearly observed in term infants to reduce the effect of more extreme factors associated with prematurity. Thus, the aim of this study was to examine in term infants of a birth cohort the association between maternal mental health at the end of the second trimester of the pregnancy and birthweight, birthlength, and head circumference at birth, as surrogates of intrauterine fetal growth. The second trimester appears to be a sensitive period for the effects of maternal mental health on birth outcomes, with also effects on cognitive and socio-emotional development at age 2.16,17

Methods Study design and participants A cohort of 1153 pregnant women was recruited from the two major Singaporean hospital maternity units © 2013 John Wiley & Sons Ltd Paediatric and Perinatal Epidemiology, 2014, 28, 116–126

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from 2009 to 2010. This cohort was part of the Growing Up in Singapore Towards Healthy Outcomes (GUSTO), which enrolled natural conceiving women. Only women who were of Chinese, Malay, or Indian ethnicity with homogeneous parental ethnic background were included in this study. Women with major medical complications (e.g. Type I diabetes and cancer) and women taking psychotropic medications were excluded from the GUSTO study. This study has been described in detail in an earlier article.18 Pregnant women who were Singaporean citizens or Singapore Permanent Residents of age 18 years and above, intending to eventually deliver in the above named hospitals and to reside in Singapore for the next 5 years, were included when they attended the first trimester antenatal ultrasound scan clinic. A mental health assessment was performed at 26 weeks gestation. Birth parameters were measured and recorded by health personnel. As determinants of preterm birth are complex, for our analyses, we only included women who delivered term infants with a gestational age of 37–40 weeks. We also excluded women with complicated obstetric complications [stillbirths, on in vitro fertilisation (IVF) treatment, multiple births]. All women were recruited by research coordinators trained in conducting the interview and consent process. After a detailed explanation of the study, written informed consent was obtained. The Institutional Review Boards of both hospitals approved the study, and the tenets of the declaration of Helsinki were observed.

Measures of maternal mental health Information on depressive and anxiety symptoms during pregnancy were obtained by questionnaires between 26 and 28 weeks of gestation, during the scheduled late second trimester ultrasound scan. Depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale (EPDS) and the Beck Depression Inventory II (BDI-II). These measures are validated self-report instruments that contain respectively 10 and 21 items of common depressive symptoms over the past week. The EPDS has proven to be reliable and sensitive in detecting perinatal depression and is also used to screen for antenatal depression in pregnant women.19 Based on Spitzer’s Research Diagnostic Criteria, a cut-off of 14/15 is generally used as its prediction on possible antenatal depression for most women.20 The BDI-II is a widely

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used questionnaire that assesses the existence and severity of symptoms of depression and predicts the severity of the clinical depressive symptoms, with cut-off scores for minimal depression (0–13), mild depression (14–19), moderate depression (20–28), and severe depression (29–63).21 Anxiety was measured using the Spielberger State-Trait Anxiety Inventory (STAI),22 which consists of 40 items with a 4-point Likert scale. Twenty items assess the trait measure. The trait measure reflects a more stable personality characteristic, such as an anxious personality. The other 20 items assess the state measure, reflecting transient characteristics of anxiety, such as anxiety disorders. The cut-off for high STAI scores is normally determined by the top 75th percentile suggested by Nasreen et al. and Teixeira et al., and is 55 for the present sample.23,24

Measures of birth parameters Birth history data were obtained from documented medical record booklets. In Singapore, the hospital physician or nurse records details of the birth history at or shortly after the time of parturition. A validation study of 911 children with gestational data and birth outcomes from both medical chart booklets and the National Birth and Death Registry in Singapore revealed a Spearman correlation coefficient of +0.92.25 Birth parameters included birthweight (kg), birthlength (cm), head circumference (cm), and gestational age (weeks). Gestational age was determined by ultrasound scan before 14 weeks of gestation, which is thought to be accurate to within 1 week. Only infants with a gestational age ≥37 weeks were included in our analyses.

Measurement of other variables Parents completed a baseline questionnaire on sociodemographic information in English, Chinese, Malay, or Tamil. Household income was classified into five categories as follows: (1) SGD 0–999/month, (2) SGD 1000–1999/month, (3) SGD 2000–3999/month, (4) SGD 4000–5999/month, and (5) more than or equal to SGD 6000/month. According to Singapore Government Statistical survey 2010 (http://www.singstat .gov.sg), the median monthly household income in Singapore residents was SGD 5000. Ethnicity, life style, such as alcohol intake and cigarette smoking during pregnancy, and past medical history, such as hyperten-

sion, diabetes, and depression, were obtained from the clinic interview. Ethnicity of the child was determined based on the parental background of mother, father, maternal grandmother, paternal grandmother, maternal grandfather, and paternal grandfather. Only children with a Chinese, Malay, or Indian ethnicity with homogenous parental background (i.e. all the six persons are from the same race) were included.

Statistics Only women who delivered term infants were included. The association between reported mental health problems on the questionnaires and birthlength, birthweight, and head circumference were analysed as continuous variables and as quintiles in multivariable linear regression models. Adjustments were made for ethnicity, mother’s age at birth, household income, history of hypertension, history of cigarette smoking and alcohol use during pregnancy, and maternal height. Manual backward stepwise modelling was performed to determine the simplest and best fitting model. To avoid collinearity, maternal anxious and depressive symptoms were not included in the same model. All P values were two tailed and considered statistically significant when the values were below 0.05. All statistical procedures used SPSS version 16.0 (SPSS Inc., Chicago, IL, USA).

Results Of the total cohort of 1153 pregnant women, 105 (9.1%) were excluded, as they did not receive a mental health screening at 26 weeks of gestation. Of the remaining 1048, we excluded women with stillbirths (n = 6). Of the remaining 1042, we excluded preterm infants (n = 78) and women with missing gestational age data (n = 18). There were no women with IVF treatment, multiple births, or gestational age born from 41 weeks onwards. Hence, 946 (82.0%) pregnant women were eligible for our analyses. Table 1 presents the maternal and child characteristics of mothers with or without maternal mental health screening. Although a potential lack of statistical power should be considered, the results in this table show that pregnant women without maternal health screening differed from those with mental health screening in having a lower age (29.1 years vs. 30.5 years, P = 0.011), are more often from Malay or Indian © 2013 John Wiley & Sons Ltd Paediatric and Perinatal Epidemiology, 2014, 28, 116–126

Maternal mental health and birth size

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Table 1. Basic characteristics of mothers with term born infants. Comparison between mothers with maternal mental health screening and mothers without maternal mental health screening (EPDS, BDI-II, STAI) With mental health screening (n = 946) Variables Age in years Ethnicity Chinese Malay Indian In vitro fertilisation (IVF) 1. No Stillbirth 1. No Miscarriage in history 1. No 2. Yes Abortion in history 1. No 2. Yes Preterm delivery history 1. No 2. Yes Ectopic pregnancy history 1. No 2. Yes Household income 1. SGD 0–999/month 2. SGD 1000–1999/month 3. SGD 2000–3999/month 4. SGD 4000–5999/month 5. ≥SGD 6000/month Cigarette smoking history 1. Past or current smokers 2. Non-smokers Alcohol intake history 1. Past or current alcohol drinker 2. Non-alcohol drinker Hypertension history 1. No 2. Yes Diabetes history 1. No 2. Yes Weight of mother (kg) Height of mother Body mass index (kg/m2 of mother) Weight of baby at birth (kg) Length of baby at birth (cm) Gestational age baby at birth (weeks)

n

Mean or %

SD

Without mental health screening (n = 98) n

Mean or %

SD

946

30.5

5.1

98

29.1

5.7

527 252 167

55.7 26.6 17.7

– – –

41 34 23

41.8 34.7 23.5

– – –

946

100.0



98

100.0



946

100.0



98

100.0



865 81

91.4 8.6

– –

93 5

94.9 5.1

– –

888 58

93.9 6.1

– –

95 3

96.9 3.1

– –

937 9

99.0 1.0

– –

96 2

98.0 2.0

– –

942 4

99.6 0.4

– –

98 0

100.0 0.0

– –

21 106 272 226 257

2.3 12.0 30.8 25.6 29.1

– – – – –

5 17 33 22 14

5.5 18.7 36.3 24.1 15.4

– – – – –

108 838

11.4 88.6

– –

8 83

8.8 91.2

– –

328 618

34.7 65.3

– –

10 81

11.0 89.0

– –

930 16

98.3 1.7

– –

98 0

100.0 0.0

– –

939 7 935 938 935 946 944 946

99.3 0.7 65.5 158.2 26.2 3146.6 48.9 38.6

– – 12.0 5.7 4.5 399.0 2.0 1.0

98 0 36 38 36 49 49 49

100.0 0.0 68.2 158.3 27.1 3073.2 48.3 38.5

– – 12.5 5.0 4.6 436.2 2.2 1.0

P-value 0.011 0.032

– – 0.236

0.217

0.315

0.519

0.015

0.448

11.0 P for trend BDI-II score in quintiles First quintile, ≤4.0 Second quintile, 4.1–6.0 Third quintile, 6.1–8.0 Fourth quintile, 8.1–13.0 Fifth quintile, >13.0 P for trend STAI score in quintiles First quintile, ≤53 Second quintile, 54–64 Third quintile, 65–74 Fourth quintile, 75–87 Fifth quintile, >87 P for trend

n 944 944 944 n 944 197 221 166 212 148 944 270 160 143 208 163 944 192 200 191 187 174

Model 2

Mean difference [95% CI] −0.228 [−0.355, −0.100]

The influence of anxiety and depressive symptoms during pregnancy on birth size.

Mental health problems during pregnancy can influence fetal growth. However, studies examining the influence of maternal mental health across the norm...
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