More Mothers Depressed at 4 Years Than Shortly After Births

Larry Hand

May 21, 2014

Maternal depression is more common at 4 years postpartum than at any time during the first 12 months, especially among women who do not have another child during that 4 years.

The study, published online May 21 in BJOG, sheds new light on how long women are subject to depression risk after childbirth and on whether having 1 or more children is a factor.

Hannah Woolhouse, DPsych, from the Murdoch Children's Research Institute and Royal Children's Hospital, Parkville, Victoria, Australia, and colleagues conducted a prospective cohort study of nulliparous women who gave birth in 6 public hospitals in Melbourne, Australia, between April 1, 2003, and December 31, 2005.

A total of 1507 women participated in the study, with a mean gestation of 15 weeks at enrollment. The mean maternal age at birth was 30.9 years, with a range of 18 to 50 years of age. Most women were Australian-born and living with their partners. The authors compared the cohort with routinely collected perinatal data for all nulliparous women older than 18 years who gave birth at Victoria public hospitals during the recruitment period and found that the study cohort had fewer women aged 18 to 24 years and fewer women born overseas of non-English-speaking backgrounds.

Using questionnaires administered at baseline and at 3, 6, 12, 18, and 48 months postpartum, the researchers gathered information on sociodemographic characteristics, relationship status, and income. They used the Edinburgh Postnatal Depression Scale (EPDS), a 10-item self-report scale, to help identify women with depressive symptoms postpartum and the Composite Abuse Scale to measure possible intimate partner abuse. At the 4-year assessment, researchers used the Pregnancy Risk Assessment and Monitoring Study to assess the effects of stressful life events and social health issues.

Subsequent Births May Lower Risk

"To our knowledge, this is the first longitudinal study of maternal mental health that takes into account the impact of subsequent births, and the influence of selective attrition over time," the researchers write.

Participant retention ranged from 88% to 95% for the 18-month period, and 1102 (83.4%) women returned the 4-year follow-up questionnaire. Those returning the questionnaire were more likely to be older and less likely to have reported intimate partner abuse than women who only participated for 18 months.

Although less than 1% of women reported depressive symptoms at every point of follow-up, almost a third (31.4%) reported depressive symptoms at least once between early pregnancy and 4 years postpartum, based on EPDS score (≥13). Among the women reporting symptoms over the entire study period, 53.5% scored 13 or higher on the EPDS on 1 occasion only, 20.1% scored 13 or higher twice, 11.5% scored 13 or higher 3 times, and 14.9% scored 13 or higher 4 or more times.

The prevalence of depressive symptoms was highest (14.5%; 95% confidence interval [CI], 14.2% - 14.8%) at 4 years postpartum and lowest (8.1%; 95% CI, 7.9 - 8.3) at 3 months postpartum.

Among the women reporting symptoms at 4 years postpartum, 59.5% previously had reported symptoms: 27.2% in early pregnancy and 48.1% in the first 12 months postpartum.

Notably, women with 1 child at the 4 year follow-up reported approximately double the prevalence of depressive symptoms at every time compared with women with 2 or more children.

"At 4 years postpartum, 22.9% of women with one child reported depressive symptoms compared with 11.2% of women with two or more children (unadjusted [odds ratio,] 2.34; 95% CI 1.63–3.37)," the researchers write.

The strongest predictor of depressive symptoms at 4 years was previous reporting of symptoms, although intimate partner abuse during 12 months postpartum or during the year before 4-year follow-up was associated with a 4-fold increase in risk of reporting symptoms at 4 years (unadjusted odds ratio, 4.09; 95% CI, 2.82 - 5.92).

More Screening Needed

The researchers conclude: "At a time when so much attention is given to the surveillance of child health, an increased focus on maternal health is warranted, particularly given the strong connections between maternal and child health outcomes."

"This study is among the first to investigate the more long-term incidence of depression among women up to 4 years postpartum," Jennifer F. Kawwass, MD, from the Department of Gynecology and Obstetrics at the Emory University School of Medicine in Atlanta, Georgia, told Medscape Medical News. "Existing evidence had suggested a significant increased risk of depressive symptoms in the immediate postpartum period but had not tracked maternal depressive symptoms beyond 12 months postpartum."

A limitation of the study, however — the underrepresentation of younger women, single women, and women born overseas and non-English speaking — may limit generalizability to the US population, Dr. Kawwass said. "A similar study in the US may help to clarify whether the same pattern exists among women in the States."

She continued, "As a result of the known risk to both mother and infant in the immediate postpartum period, the American Congress of Obstetrics and Gynecology...has made a national push to encourage practitioners to routinely screen for depression at postpartum visits. This study may encourage support of additional routine screening beyond the immediate postpartum period."

This research was supported by the National Health and Medical Research Council, VicHealth Research, ARC Future, Medical Research and Technology in Victoria Fund, and Murdoch Children's Research Institute. The authors and Dr. Kawwass have disclosed no relevant financial relationships.

BJOG. Published online May 21, 2014. Abstract

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