Depression during pregnancy in the Brazilian public health care system

Depressão durante a gravidez no sistema público de saúde brasileiro

ORIGINAL ARTICLE

Depression during pregnancy in the Brazilian public health care system

Depressão durante a gravidez no sistema público de saúde brasileiro

Ricardo Azevedo da Silva; Karen Jansen; Luciano Dias de Mattos Souza; Inácia Gomes da Silva Moraes; Elaine Tomasi; Giovanna Del Grande da Silva; Michelle de Souza Dias; Ricardo Tavares Pinheiro

Universidade Católica de Pelotas (UCPel), Pelotas, RS, Brazil

^{Correspondence}

ABSTRACT

OBJECTIVE: To estimate the prevalence of depression and correlate clinical and demographic characteristics in pregnant women assisted by the public health system in the city of Pelotas, RS, Brazil.

METHOD: We performed a cross-sectional study focused on pregnant women assisted by the public health service. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for depression.

RESULTS: In a sample of 1,264 pregnant women aged 12-46 years, 21.1% (n = 255) presented a depressive episode during pregnancy. The presence of depression was associated with older age, lower education, lack of a cohabiting partner, not being primiparous, planned pregnancy, abortion thoughts, psychological or psychiatric treatment, smoking and alcohol consumption during pregnancy, and stressful events.

CONCLUSION: Pregnant women assisted by the Brazilian public health system presented a high prevalence of depression. Psychiatric history, lack of support, and stressful events increase the probability of antenatal depression.

Descriptors: Depression; Pregnancy; Health systems; Probability; Public health

RESUMO

OBJETIVO: Estimar a prevalência de depressão, bem como fatores clínicos e características demográficas associados em grávidas assistidas por meio do sistema público de saúde da cidade de Pelotas, RS, Brasil.

MÉTODO: Foi realizado um estudo transversal tendo como população-alvo as grávidas assistidas pelo sistema público de saúde. Para o rastreio da depressão foi utilizada a Edinburgh Postnatal Depression Scale.

RESULTADOS: Em uma amostra de 1.264 mulheres grávidas com idade de 12 a 46 anos, 21,1% (n = 255) apresentaram episodio depressivo durante a gravidez. A presença de depressão foi associada com ter mais idade, menor grau educacional, não morar com companheiro, não ser primigesta, ter planejado a gestação, idealizar o aborto, ter feito tratamento psicológico ou psiquiátrico, consumir tabaco e/ou álcool durante a gravidez e ter sofrido algum evento estressor.

CONCLUSÃO: As mulheres grávidas acompanhadas pelo sistema público de saúde apresentaram alta prevalência de depressão. História psiquiátrica, baixo suporte e eventos estressores aumentam a probabilidade de depressão no período pré-parto.

Descritores: Depressão; Gravidez; Sistema de saúde; Probabilidade; Saúde pública

Introduction

Pregnancy is a period in the life of a woman that requires special attention. It involves physical, hormonal, psychological, and social alterations that can have a direct effect on the woman's overall condition.¹ Studies have reported the risks of not identifying and treating depression during pregnancy. In addition to affecting the psychological health, depressive symptoms during pregnancy are also associated with increased obstetric risk.^2-4 Maternal depression during pregnancy has been found to predict low birth weight^5,6 and postpartum depression.^7-10 The early detection of symptoms can facilitate the timely treatment and prevent the deterioration of the condition.

The scientific literature is vast and comprehensive in relation to the causes of major depression in the general population. However, the evidence on specific predictors of depression in women during the pre and postnatal periods is scarce. In Brazil, this is the first study aimed at furthering the understanding of depression in a significant sample of pregnant women.

Considering the possible adverse effects of depression in pregnant women, there is a need for information on the prevalence of antenatal depression and the factors associated with it. This study was aimed at estimating the prevalence of depression correlated characteristics in pregnant women assisted by the public health system in the city of Pelotas, RS, Brazil.

Method

This is a cross-sectional study focused on pregnant women assisted by the public health system in the city of Pelotas-RS, Brazil. Pregnant women who did not live in the urban area and who were unable to understand or to complete the questionnaire were excluded from the study. Pelotas has approximately 350,000 inhabitants and more than 96% of them live in the urban area.

We contacted potential participants who were enrolled in the Brazilian National System of Public Health (SIS - Pré-Natal) as well as in two services that are not part of that system. These data cover the prenatal assistance in 38 Basic Health Units, representing the whole of the public assistance within the urban area of Pelotas, which is responsible for delivering assistance to 51% of all pregnant women in the city.¹¹ Between 2006 and 2008, candidate participants were informed about and invited to take part in the study. Only pregnant women who signed the informed consent to participate were enrolled. Pregnant women presenting with depression were referred to psychiatric treatment. The research protocol was approved by the ethics committee of the Universidade Católica de Pelotas.

A prenatal information questionnaire was used for data collection, containing standardized questions about maternal age, education, marital status, pregnancy planning, abortion thoughts, alcohol consumption (CAGE)¹² and others. Socioeconomic status was defined using the criteria of the Associação Brasileira de Empresas de Pesquisa (ABEP), which determines the socioeconomic status according to a comfort index.¹³

Depression in pregnancy was screened with the Edinburgh Postnatal Depression Scale (EPDS), a self-rated scale composed of 10 topics with scores ranging from 0 to 3 to describe the presence or intensity of depressive symptoms. The questions refer to depressive and dysphoric mood, sleep disorders, loss of pleasure, thoughts of death or suicide, reduction of performance, and guilt. The scale has been validated to assess the prevalence of depression with a 60% positive predictive value for the cutoff point of 13 (59.5% sensitivity; 88.4% specificity).¹⁴

To ensure data integrity, the EpiInfo 6.04d software¹⁵ was used to customize the input of data and to automatically validate their amplitude and consistency. Statistical analyses were carried out using the Stata 9 software.¹⁶

After obtaining the simple frequencies of all variables, a gross analysis was performed using the chi-square test. In the adjusted analysis, Poisson regression was used to evaluate the prevalence ratio of the independent variables associated with the outcome (depression), because depression prevalence was higher than 10%.¹⁷ Since the etiology of depression is not well established and many explanatory factors can be involved, the independent variables were stratified into three hierarchical levels for the multivariate analysis.¹⁸ The first level included sociodemographic variables; the second included obstetric variables, substance use during pregnancy, and a history of psychological or psychiatric treatment; and the third level referred to experiences of stressful events in the previous year.

All the variables with p-values < 0.2 in the gross analysis were included in the adjusted analysis. The model of analysis used was adjusted to check for effects remaining between variables in order to ensure that, after adjusting for the first level, variables that did not keep p-values < 0.2 were not included in the analysis of the second hierarchical level. The same procedure was carried out for the variables of the second level in order to set the third hierarchical level. After the adjusted analysis, the statistical significance was consistently evaluated using the level of 0.05 (two-tailed) as indicative of statistical significance.

Results

A total of 1,340 pregnant women were identified. Seventy-six (6%) refused to take part or were excluded from the study. Overall, 1,264 women were enrolled, out of which 268 (21.2%) were diagnosed with depressive disorder (EPDS > 13) during pregnancy.

The mean age of participants was 25 years old (SD=6.5) and the mean gestational age was 27.7 weeks (SD=9.4). With regard to the other variables, 42.4% had not finished elementary school, 73.7% were married or lived with a partner, 53.6% belonged to the medium socioeconomic class, and 69% were not working. Moreover, 56.5% of the participants were primiparous, 58.8% had planned the pregnancy, 8.4% had considered an abortion, 84.2% were not in therapy with a psychologist or a psychiatrist, 19.1% were smokers, 8.2% consumed alcohol, and 61.3% had suffered stressful events in the previous year (Table 1).

In the gross analysis, the associations between pregnancy and depression were related to older age (p > 0.05), lower education (p < 0.001), marital status [no cohabiting partner (p < 0.001)], lower socioeconomic status (p < 0.001), not being at work (p < 0.05), more than one pregnancy (p < 0.001), planned pregnancy (p < 0.001), thoughts of abortion (p < 0.001), being in therapy with a psychologist or a psychiatrist (p < 0.001), smoking (p < 0.001), alcohol consumption during pregnancy, and stressful events (p < 0.001).

Table 2 shows the Poisson regression in which all variables except socioeconomic and work status were associated with depression.

Discussion

This is the first study to investigate a population of pregnant women assisted by the public health system in a Brazilian city; therefore, it can bring an important contribution to the understanding of the depressive phenomenon during pregnancy.

The prevalence of depression found was high (21.2%) for pregnant population. It was also higher than the prevalence rates reported in two review papers published in 2004 and 2005 (6.5% and 12.9%).^19,20 However, the presently found rate was similar to the 20.5% prevalence found in a Thai study using the same methods²¹ and lower than the one observed in a study carried out in Brazil using the same methods, with low income women in a small hospital sample (37.9%).²²

The relevance of these results lies in that antenatal depression is the highest risk factor for postpartum depression.¹⁰ Furthermore, when identified as a risk factor, it can be treated.

"Two relevant limitations of this study can be pointed out. The first is for possible update errors occurred in the central administration. The second limitation of this study is the presupposition that pregnant women with a severe depression would seek antenatal assistance. Unfortunately we could only minimize the first limitation. For this, the date was gathered within the Brazilian National System of Public Health and within public health services in the city of Pelotas."

In our sample, the social and demographic characteristics associated with depression during pregnancy were increased maternal age, lower education, and marital status. In regard to maternal age, our results differ from earlier evidence correlating youth and depression.²³ The lower prevalence of depression among younger women was similar to the rate found in an American study.²⁴ The absence of a spouse or domestic partner has been described as a risk factor for depression before^7,23,25 and is probably related to the lack of emotional and social support that can be provided by the presence of a companion.

In respect to the characteristics of pregnancy, women who had had a previous pregnancy, who planned the pregnancy, who considered having an abortion, and who suffered any stressful events during pregnancy had a greater probability of presenting a depressive episode in the antenatal period. In our study, women who thought about having an abortion were more likely to have depression, in consonance with the results of a Japanese multicenter study.²⁶ It remains to be cleared out whether such negative attitudes toward pregnancy can lead to depression or if pre-existing depressive features are the cause of these attitudes. Thoughts about having an abortion have already been suggested to be related to postpartum depression in one of our studies.²⁷

The association between having planned the pregnancy and depression was an unexpected finding. We believe this can be a consequence of the expectations related to motherhood and of the intrinsic fears experienced during pregnancy. However, this is an inconclusive finding, since the predictive value could not be evaluated.

Studies indicate that the fact of having undergone psychological and/or psychiatric treatment at some point in the past can be a risk factor for depression during and after pregnancy.¹⁰ At the same time that previous treatment may suggest that a group of pregnant women were properly assisted in terms of mental health care, it might also indicate that pregnancy can trigger recurrent depressive episodes. This finding underscores the necessity for health teams to have adequate instruments to correctly evaluate the occurrence of depressive episodes in the antenatal period and to provide adequate assistance in such cases.

Our results suggest that there is an association between cigarette use or dependence and depression during pregnancy. There is little evidence from previous studies in this regard.²⁸ This finding indicates that, although pregnant women may feel concerned about the negative consequences of tobacco consumption over the development of the embryo and the offspring, many of them do not quit using tobacco during pregnancy, possibly because nicotine can help to deal with some psychiatric symptoms. In this regard, it is important that health professionals can clarify the risks of nicotine use related to psychiatric disorders. It is also important to offer treatment alternatives to nicotine dependence, as well as to the associated psychiatric disorders.

The significant association between stressful events and depression found in this as well as in other studies performed in different countries is a clear indication that life events may cause depression.^7-25 Accordingly, health teams should try to identify pregnant women exposed to such events and to devise strategies for evaluation and assistance.

Pregnant women assisted by the Brazilian public health system have a high prevalence of depression. The evidence related to the harms and negative consequences of antenatal depression available in the scientific literature suggests that the application of brief instruments to screen for severe depressive symptoms, such as the EPDS, the Beck depression Inventory (BDI), and the Hamilton Scale for women during prenatal assistance could be highly beneficial.

In conclusion, it can be stated that multiparous women at a higher age, with low education, not living with a spouse or domestic partner, who have planned their pregnancy, who have thought about an abortion, with a history of psychological and/or psychiatric treatment, and reporting the use of tobacco or alcohol or the experience of stressful events in the previous year should be evaluated for depression. Once significant depressive symptoms are identified, attention on the part of a mental health professional in close contact with the professionals responsible for the prenatal assistance is desirable.

^{Clique para ampliar}

Submitted: April 24, 2009

Accepted: March 11, 2010

• 1. Camacho RS, Cantinelli FS, Ribeiro CS, Cantilino A, Gonsales BK, Braguittoni E, Renno Jr J. Psychiatry disorders in pregnancy and puerperium: classification, diagnosis and treatment. Rev Psiquiatr Clin. 2006;33(2): 92-102.
• 2. Kurki T, Hiilesmaa V, Raitasalo R, Mattila H, Ylikorkala O. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstet Gynecol. 2000;95(4):487-90.
• 3. Chung TK, Lau TK, Yip AS, Chiu HF, Lee DT. Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosom Med. 2001;63(5):830-4.
• 4. Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. BMJ. 2001;323(7307): 257-60.
• 5. Rahman A, Bunn J, Lovel H, Creed F. Association between antenatal depression and low birthweight in a developing country. Acta Psychiatr Scand. 2007;115(6):481-6.
• 6. Dayan J, Creveuil C, Marks MN, Conroy S, Herlicoviez M, Dreyfus M, Tordjman S. Prenatal depression, prenatal anxiety, and spontaneous preterm birth: A prospective cohort study among women with early and regular care. Psychosom Med. 2006;68:938-46.
• 7. Leigh B, Milgrom J. Risk factors for antenatal depression, postnatal depression and parenting stress. BMC Psychiatry. 2008;8:24.
• 8. Rich-Edwards JW, Kleinman K, Abrams A, Harlow BL, McLaughlin TJ, Joffe H, Gillman MW. Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. J Epidemiol Community Health. 2006;60(3):221-7.
• 9. Figueiredo B, Pacheco A, Costa R. Depression during pregnancy and the postpartum period in adolescent and adult Portuguese mothers. Arch Womens Ment Health. 2007;10(3):103-9.
• 10. Milgrom J, Gemmill AW, Bilszta JL, Hayes B, Barnett B, Brooks J, Ericksen J, Ellwood D, Buist A. Antenatal risk factors for postnatal depression: a large prospective study. J Affect Disord. 2008;108(1-2):147-57.
• 11. Santos IS, Baroni RC, Minotto I, Klumb AG. Criteria for choosing health care facilities for prenatal care in Pelotas, RS, Brazil. Rev Saude Publica 2000;34(6):603-9.
• 12. Paz Filho GJ, Sato LJ, Tuleski MJ, Takata SY, Ranzi CC, Saruhashi SY, Spadoni B. Use of the CAGE questionnaire for detecting alcohol use disorders in the emergency room. Rev Assoc Med Bras. 2001;47(1):65-9.
• ¹³
  13. Associação Brasileira de Empresas em Pesquisa - ABEP. Critério de classificação econômica no Brasil. [citado 30 Jun 2007]. Disponível em: http://www.abep.org/codigosguias/ABEP_CCEB.pdf
• 14. Santos IS, Matijasevich A, Tavares BF, Barros AJ, Botelho IP, Lapolli C, Magalhães PV, Barbosa AP, Barros FC. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in a sample of mothers from the 2004 Pelotas birth cohort study. Cad Saude Publica. 2007;23(11):2577-88.
• 15. Henrique IFS, de Micheli D, Lacerda RB, Lacerda LA, Formigoni MLOS. Validação da versão brasileira do teste de triagem do envolvimento com álcool, cigarro e outras substâncias (ASSIST). Rev Assoc Med Bras. 2004;50:199-206.
• ¹⁶
  16. STATA: Data Analysis and Statistical Software. Version 9.0. StataCorp LP, 1996-2009. Disponível em: http://www.stata.com
• 17. Barros AJ, Hirakata VN. Alternatives for regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003;3:21.
• 18. Victora CG, Huttly SR, Fuchs SC, Olinto MT. The role of conceptual frameworks in epidemiological analysis: a hierarchical approach. Int J Epidemiol 1997;26(1):224-7.
• 19. Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR. Prevalence of depression during pregnancy: systematic review. Obstet Gynecol. 2004;103(4):698-709.
• 20. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: a systematic review of prevalence and incidence. Obstet Gynecol. 2005;106(5):1071-83.
• 21. Limlomwongse N, Liabsuetrakul T. Cohort study of depressive moods in Thai women during late pregnancy and 6-8 weeks of postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Arch Womens Ment Health 2006;9(3):131-8.
• 22. da Silva VA, Moraes-Santos AR, Carvalho MS, Martins ML, Teixeira NA. Prenatal and postnatal depression among low income Brazilian women. Braz J Med Biol Res. 1998;31(6):799-804.
• 23. Webster J, Linnane JWJ, Dibley M, Pritchard M. Improving antenatal recognition of women at risk for postnatal depression. Aust N Z J Obstet Gynaecol. 2000;40(4):409-12.
• 24. Hasin DS, Goodwin RD, Stinson FS, Grant BF. Epidemiology of major depressive disorder: results from the National Epidemiologic Survey on Alcoholism and Related Conditions. Arch Gen Psychiatry. 2005;62(10):1097-106.
• 25. Vesga-Lopez O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry. 2008;65(7):805-15.
• 26. Kitamura T, Yoshida K, Okano T, Kinoshita K, Hayashi M, Toyoda N, Ito M, Kudo N, Tada K, Kanazawa K, Sakumoto K, Satoh S, Furukawa T, Nakano H. Multicentre prospective study of perinatal depression in Japan: incidence and correlates of antenatal and postnatal depression. Arch Womens Ment Health. 2006;9(3):121-30.
• 27. Moraes IGS, Pinheiro RT, Silva RA, Horta BL, Sousa PL, Faria AD. Prevalence of postpartum depression and associated factors. Rev Saude Publica. 2006;40(1):65-70.
• 28. Goodwin RD, Keyes K, Simuro N. Mental disorders and nicotine dependence among pregnant women in the United States. Obstet Gynecol. 2007;109(4):875-83.

Publication Dates

• Publication in this collection
  16 July 2010
• Date of issue
  June 2010

History

• Received
  24 Apr 2009
• Accepted
  03 Nov 2010