Multiple Birth Increases Postpartum Depression Risk

Caroline Cassels

April 06, 2009

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April 6, 2009 — Women who give birth to more than 1 infant at a time have a 43% greater risk of having postpartum depressive symptoms compared with those who have singleton births, a large population-based study shows.

Investigators at Johns Hopkins University, in Baltimore, Maryland, examined data from the Early Childhood Longitudinal Study–Birth Cohort, a nationally representative sample of children born in 2001, and found the adjusted odds ratio of having moderate to severe depressive symptoms was 1.43 for mothers of multiple births compared with mothers of singletons.

"The magnitude of the difference between mothers of multiples and singletons was very surprising and very robust," first author Yoonjoung Choi, DrPH, told Medscape Psychiatry.

Another surprising finding, she said, was that, regardless of birth status, only 27% of women with depressive symptoms sought care.

"Only a very small portion, about 27%, of all mothers who had depressive symptoms had talked to a healthcare provider about the problem, and there was no difference between mothers of multiples and singletons in terms of care seeking," she said.

The study is published in the April issue of Pediatrics.

First Population-Based Study

According to Dr. Choi, the multiple birthrate in the United States has increased dramatically over the past 2 decades. In 2004, there were approximately 139,000 multiple births, accounting for 3.4% of all live births. This rate was 76% higher than in 1980.

While there is a lot of information about obstetric and neonatal risks associated with multiple births, there is relatively little information about the impact of multiple births on maternal mental health.

The authors point out that undergoing a high-risk pregnancy and delivering multiple births are stressful life events. Further, they note, the unique demands of parenting multiple infants can result in high levels of parental stress, fatigue, and social isolation.

"This is the first study to look at a potential association between multiple births and postpartum depression using general population data," said Dr. Choi.

The study measured depressive symptoms using an abbreviated version of the Center for Epidemiologic Studies Depression (CES-D) scale in 8069 mothers 9 months after giving birth to a live child or children in 2001.

The results revealed the prevalence of moderate to severe depressive symptoms was 16% and 19% among mothers of singletons and multiple births, respectively. However, after adjustment for demographic and household socioeconomic characteristics and maternal history of mental-health problems, the relative odds of having depressive symptoms were 43% higher among mothers of multiples compared with the mothers of singletons.

The reason mothers of multiple births have a higher risk for postpartum depression than those who had singleton births is not clear and was outside the scope of the study.

Different Neurobiologic Factors at Play?

However, said Dr. Choi, there are several avenues of investigation, including psychosocial factors and parental stress. Beyond this hypothesis, however, it is also possible that there are neurobiologic factors at play that may be different in the 2 groups of mothers.

"We need more studies to elucidate the underlying biologic mechanisms and/or other factors that may influence and increase the risk [for postpartum depression] in these women," said Dr. Choi.

The finding that so few of the women sought care — whether they were mothers of multiples or not — is concerning, said Dr. Choi.

"Clinicians should be aware of these findings and use them as an opportunity to educate, screen, and refer women to mental-health services appropriately," she said.

Senior investigator Cynthia Minkovitz, MD, agreed and said the study reinforces the need for better referral of patients with depressive symptoms.

"Pediatric practices should make an additional effort to educate new and expecting parents of multiples regarding their increased risk for maternal postpartum depression.

"Furthermore, well-child visits are potentially valuable opportunities to provide education, screening, and referrals for postpartum depression among mothers of multiples; such efforts require linkages between pediatric and adult systems of care and adequate community mental-health resources," Dr. Minkovitz said in a statement.

The research was funded by the Maternal and Child Health Bureau. The authors report no conflicts of interest.

Pediatrics. 2009;123:1147-1154. Abstract

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