Review Article
The association between pregnancy processes, preterm delivery, low birth weight, and postpartum depressions—The need for interdisciplinary integration

https://doi.org/10.1016/j.ajog.2005.02.103Get rights and content

Pregnancy and peripartum/perinatal periods are characterized by significant biologic as well as psychosocial processes and changes that influence the 2 individuals at focus (mother and fetus), as well as their interactions with the immediate environment.

Multiple intertwined pathologic pregnancy processes (hormonal, biologic, stress and other mental occurrences) may lead to fetal distress, preterm delivery (PTD), low birth weight (LBW), and other delivery complications as well as to postpartum disorders. PTD and LBW in particular have been demonstrated to be associated with significant mortality as well as short- and long-term morbidity. Underlying processes and risk factors for PTD, LBW and postpartum disorders may overlap. Their impact on the offspring is compounded.

Currently, the multiple clinical and research disciplines that are concerned with the various aspects of pregnancy, delivery, and postpartum period are not conceptually and practically integrated. Specifically, obstetricians are more concerned with delivery complications, whereas mental health professionals are concerned with postpartum depression. An interdisciplinary approach is needed for better understanding of developmental processes and the development of measurements and interventions to prevent long-term impact on the offspring.

Section snippets

Anxieties, stress, and depressions during pregnancy

Pregnancy is perceived by many as a period of happiness in anticipation of motherhood. However, depressive, anxiety, stress, and distress symptoms are quite prevalent during pregnancy. The prevalence of depression during this period has been estimated at 10% to 15% and prevalence of various anxiety disorders among pregnant women has been estimated at 10%.2, 3, 4, 5, 6, 7, 8, 9, 10 Some estimates are even higher.11 Pregnancy per se may be a stressful life event,12 especially when it is unplanned

PTD and LBW

PTD (birth before 37 weeks of pregnancy) is of major public health concern. It occurs in about 10% of births. PTD rates are especially high (more than 20%) among poor, inner city, and minority pregnant mothers. Despite improvement in many health indicators, the rate of PTD has not decreased over the last 3 decades.33 In the United States, the rate of PTD actually increased to 11.9% of pregnancies during 2001.34 PTD is associated with 70% to 80% of neonatal mortality and increased morbidity in

Postpartum symptoms and disorders

The DSM IV14 indicates that postpartum disorders are distinguished not by their phenomena but by their timing. Any major depressive, manic or mixed episode, bipolar I disorder or bipolar II disorder, as well as brief psychotic disorder should get a postpartum specifier if it occurs within 4 weeks postdelivery. Most publications estimate that PPD affects 10% to 15% of women.2, 8 Anxiety disorders are estimated to affect another 10% of new mothers.5, 9

A more detailed review of the literature

Predictors (risk factors) of post partum disorders

More than 70 (partly overlapping) risk factors of PPD have been reported. They may be clustered as reflecting past lifetime history and family history of mental disorders, past and current (during pregnancy and postpartum) socioeconomic factors, disturbed family relations and relations with the immediate environment, factors relating to the recent pregnancy as well as delivery and early postpartum periods, factors related to the infant, hormonal, biologic, and genetic factors, and cultural

Relation among PTD, LBW, and PPD

The 3 situations—PTD, LBW, and PPD—may be an outcome of similar or partially overlapping pregnancy processes. There is quite an overlap of risk factors leading to both adverse delivery outcomes and postpartum mental disorders. This overlap is more apparent regarding environmental, mother-supply/fetus-demand deficiencies and stress-related factors. It is unlikely that there is a causal effect of LBW/PTD on PPD (unless the infant's special needs severely affect the mother). It may be, however,

Hormonal processes associated with stress during pregnancy

Stress during pregnancy may be psychological as well as physiologic. The 2 types may lead to the same consequences concerning birth-related adversities, as well as depressions during pregnancy and postpartum.

The HPA system and the placental-adrenal (PA) system as well as the immune system may be components of that link. The association between the physiologic and psychological stress processes is bidirectional. For instance, high levels of psychosocial stress and low levels of social support

Influence of stress and depressions during pregnancy on children

A series of retrospective epidemiologic studies has demonstrated an association between LBW and PTD, which are considered to be indicators of adversities during pregnancy, childhood,109 and adulthood110 as well as hypertension, coronary heart disease (CHD), hypercholesterolemia, glucose imbalance, and noninsulin-dependent diabetes mellitus.111, 112, 113, 114, 115, 116, 117, 118 These reports led to the theory, formulated mostly by the group led by Barker, that adversities during pregnancy

Influence of maternal postnatal depression and stress on children

Children of women with PPD have been suggested to perform worse on cognitive and behavioral measures128, 129, 130, 131, 132, 133, 134 and to exhibit high rates of increased attachment.130, 131, 135 Disturbed mother-baby interaction of depressed mothers has been suggested to be a predictor of poor infant cognitive outcomes at 18 months.136 Because child abuse and neglect are prevalent worldwide, it is of importance to assess the contribution of the mother's mental status to the parent-baby

Prevention of stress-related PTD

The recognition that stress during pregnancy may lead to adverse outcomes of delivery has been leading to stress-reducing interventions. Cognitive behavioral psychotherapy aimed at helping pregnant women to cope effectively with specific stressful situations of their lives has been reported to improve psychological well-being and reduce PTDs, provided that the interventions were applied to selected populations of women and individuals at risk.21, 141, 142, 143, 144, 145, 146 However, when the

Conclusion

It is currently well substantiated that the external and in utero environment have an impact on delivery outcomes. Furthermore, adversities during pregnancy may influence the trajectory of offspring toward long-term developmental problems and disorders. It may also be plausible that the same processes influence the mother not only during pregnancy but also postpartum and probably even beyond that period. The placenta plays a mediating role between the mother's physical supplies and the fetus's

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