gemeli sbg risiko ibu depresi

7/29/2019 Gemeli Sbg Risiko Ibu Depresi

1/10

DOI: 10.1542/peds.2008-16192009;123;1147Pediatrics

Yoonjoung Choi, David Bishai and Cynthia S. Minkovitz

SymptomsMultiple Births Are a Risk Factor for Postpartum Maternal Depressive

http://pediatrics.aappublications.org/content/123/4/1147.full.html

located on the World Wide Web at:The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2009 by the American Academypublished, and trademarked by the American Academy of Pediatrics, 141 Northwest Point

publication, it has been published continuously since 1948. PEDIATRICS is owned,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on February 27, 2013pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/content/123/4/1147.full.htmlhttp://pediatrics.aappublications.org/content/123/4/1147.full.htmlhttp://pediatrics.aappublications.org/content/123/4/1147.full.htmlhttp://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/content/123/4/1147.full.html


2/10

ARTICLE

Multiple Births Are a Risk Factor for PostpartumMaternal Depressive Symptoms

YoonjoungChoi, DrPHa, DavidBishai, MD,MPH, PhDb, Cynthia S.Minkovitz, MD,MPPb

Departments ofaInternational Health and bPopulation, Family, and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore,

Maryland

The authors have indicated they have no financial relationships relevant to this article to disclose.

WhatsKnown on This Subject

Themultiplebirthrate hasincreasedsteadily,andneonatal andobstetricrisksassociatedwith

multiple births have been well documented. However, little is known about associations

between multiplebirthsand maternalmentalhealth, particularly postpartumdepression, at

a populationlevel.

What This Study Adds

Mothers of multiple births had 43% greater odds of having moderate/severe, 9-month

postpartum, depressive symptoms, compared with mothers of singletons.

ABSTRACT

OBJECTIVE. The purpose of the study was to assess the relationship between multiplebirths and maternal depressive symptoms measured 9 months after delivery.

METHODS. Data were derived from the Early Childhood Longitudinal Study-Birth Co-hort, a longitudinal study of a nationally representative sample of children born in2001. Depressive symptoms were measured at 9 months by using an abbreviatedversion of the Center for Epidemiologic Studies Depression Scale. Logistic regressionanalyses were conducted to study the association between multiple births andmaternal depressive symptoms, with adjustment for demographic and householdsocioeconomic characteristics and maternal history of mental health problems. Atotal of 8069 mothers were included for analyses.

RESULTS. The prevalence of moderate/severe depressive symptoms at 9 months afterdelivery was estimated to be 16.0% and 19.0% among mothers of singletons andmultiple births, respectively. Only 27.0% of women who had moderate/severedepressive symptoms reported talking about emotional or psychological problems

with a mental health specialist or a general medical provider within the 12 monthsbefore the interview. The proportions of women with depressive symptoms whowere receiving mental health services did not vary according to plurality status.

CONCLUSIONS. Mothers of multiple births had 43% greater odds of having moderate/severe, 9-month postpartum, depressive symptoms, compared with mothers of sin-gletons. Greater attention is needed in pediatric settings to address maternal depres-sion in families with multiple births. Pediatrics 2009;123:11471154

APPROXIMATELY 139 000 MULTIPLE births occurred in the United States in 2004, accounting for 3.4% of all livebirths. The multiple birth rate (ie, the proportion of live multiple births among all live births) has increased overthe past 2 decades, reaching a record high in 2004 (33.9 multiple births per 1000 live births) that was 76% higherthan the rate in 1980 (19.3 multiple births per 1000 live births).1 Although increases in multiple birth rates have beengreatest among non-Hispanic white women and among women 35 years of age, the increasing trend has beenobserved for all races and age groups.1 Risks associated with multiple births, such as preterm labor, low birth weight,and prematurity, have been well documented.13 The infant mortality rate among multiple births was estimated to

be 30.5 deaths per 1000 live births in 2004, which was 5 times higher than the rate among singleton births of 5.9deaths per 1000 live births,4 and the impact of increasing numbers of multiple births on overall infant mortalitytrends has been identified.5

The impact of multiple births on maternal mental health, particularly postpartum depression, has been under-studied.6 Undergoing a high-risk pregnancy and delivering multiple births are stressful life events, and the uniquedemands of parenting multiple infants can result in high levels of parental stress, fatigue, and social isolation. 7 In aprospective study of 175 women who conceived after in vitro fertilization (IVF) treatment, mothers of multiple birthswere 3 times more likely to show clinically significant depressive symptoms 6 weeks after delivery, compared withmothers of singletons.8 Another study reported that mothers of multiple births conceived through IVF had higherlevels of parental stress and anxiety 1 year after delivery, compared with mothers of singletons conceived through

www.pediatrics.org/cgi/doi/10.1542/peds.2008-1619

doi:10.1542/peds.2008-1619

Key Words

postpartum depression, multiple births,

screening

Abbreviations

ECLS-BEarly Childhood Longitudinal

Study-Birth Cohort

CES-DCenter for Epidemiologic Studies

Depression Scale

SESsocioeconomic status

IVFin vitro fertilization

CIconfidence interval

Accepted for publication Aug 12, 2008

Address correspondence to Yoonjoung Choi,DrPH, Department of International Health,

Bloomberg School of Public Health, Johns

Hopkins University, 615 North Wolfe St, E 8648,

Baltimore, MD 21205. E-mail: ychoi@jhsph.

edu.

PEDIATRICS (ISSNNumbers:Print, 0031-4005;

Online, 1098-4275). Copyright 2009by the

AmericanAcademy of Pediatrics

PEDIATRICS Volume 123, Number 4, April 2009 1147at Indonesia:AAP Sponsored on February 27, 2013pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/


3/10

IVF or naturally, whereas there was no significant dif-ference among mothers of singletons according to con-ception mode.9 Greater parental stress and more-preva-lent maternal depressive symptoms were still reported 2to 5 years after delivery among mothers of multiple

births conceived through IVF, compared with mothers ofsingletons conceived through IVF.10

Drawing inferences about the effects of multiple ges-

tation on maternal depression is complicated, however,because known risk factors for depression, such as pre-maturity,11 use of assisted reproductive technologies,6,12

and cesarean delivery,13 are more common amongmothers of multiple births than among mothers of sin-gletons. Little is known about the population prevalenceof postpartum depression among mothers of multiple

births. Only a few small, facility-based studies examinedthe different effects on maternal depression and parentalstress of multiple births, compared with singleton births,controlling for infertility,8,9,12 and the results were lim-ited by potential selection bias in the samples. One pop-ulation-based study reported a higher prevalence of

emotional disturbance indicative of depression amongmothers of multiple births 5 years after delivery, but theanalysis was limited by the small number of multiple

births sampled.14 The primary purpose of the study wasto assess the relationship between multiple births andmaternal depressive symptoms, by using a nationallyrepresentative, population-based survey, the EarlyChildhood Longitudinal Study-Birth Cohort (ECLS-B).

METHODS

Data

The ECLS-B monitors a nationally representative sampleof children born in 2001, with oversampling of selectedethnic minority groups, low birth weight infants, andtwins. Births were sampled within primary samplingunits from the National Center for Health Statistics vitalstatistics system, and primary sampling units were strat-ified on the basis of geographical region, median house-hold income, proportion minority population, and met-ropolitan versus nonmetropolitan area. Children whodied or were adopted before 9 months of age and chil-dren born to women 15 years of age were excluded.15

Three data sources were used for the analyses, that is,a parental self-administered questionnaire and a paren-tal interview at 9 months and the birth certificate. Theself-administered questionnaire included items regard-ing depressive symptoms during the previous week andlifetime episodes of alcohol or drug abuse problems orhospitalization attributable to mental health problems.The interview reported demographic and socioeconomiccharacteristics, maternal health care utilization beforeand during pregnancy, and consultation with health careproviders regarding mental health problems in the pre-ceding 12 months. Interviews were conducted in Englishor Spanish.15 Birth certificates provided information onobstetric and neonatal characteristics.

At 9 months, 9878 parents or guardians of 10 688children completed parental interviews, among whom

were 9747 biological mothers living with the sampledchild; 9672 of those women reported whether they hadsingleton or multiple births. We included the 8069mothers (83.4%) who completed all of the depressivesymptom questions. Rates of completion of the ques-tions did not vary according to plurality.

Measures

Maternal depressive symptoms at 9 months after deliv-ery were measured by using an abbreviated form of theCenter for Epidemiologic Studies Depression Scale (CES-D).16 A high CES-D score does not constitute a clinicaldiagnosis of depression, but higher scores are more com-mon among patients with clinical depression, and theCES-D correlates strongly with other depression ratingscales.17 The original 20-item form and various abbrevi-ated forms of the CES-D have been used widely to screenfor depression in general populations.1822 The abbrevi-ated form used in the ECLS-B includes 12 symptoms,with each item coded on a 4-point scale between 0(never) and 3 (often). The range of total scores is 0 to 36,

and Cronbachs for the study sample was .88, compa-rable to that in previous studies.20,23 Total scores between10 and 14 and 15 represent moderate and severe de-pressive symptoms, respectively.20

The main independent variable of the study was mul-tiple birth. We also included variables associated withpostnatal maternal stress and/or depression, such asneonatal and obstetric characteristics at birth (prematu-rity,11 cesarean section,13 and complications during laborand delivery24), demographic and socioeconomic char-acteristics (age,25,26 parity,24 race,24 marital status,24,27

household income,24,27 and education24,28,29), and historyof mental illness.24,27,30 Gestational age at delivery was

examined as a categorical variable, that is,

37 weeks(term), 33 to 36 weeks (moderately preterm), or 33weeks (severely preterm). Mode of delivery was codedas vaginal delivery or cesarean section. A single binaryvariable was constructed to indicate whether a motherhad1 of the 14 obstetric complications specified on the

birth certificate (Table 1).We examined maternal age at the time of the inter-

view as a continuous variable, because we found mini-mal nonlinear age effects with categorical transforma-tion of maternal age. Maternal parity was coded asprimapara or multipara. Current marital status was cat-egorized as currently married or currently not married(divorced, separated, widowed, or never married). Mod-els in which the separate categories of nonmarriage wereassessed independently did not alter the principal find-ings regarding the effects of multiple births on depres-sion. Maternal race/ethnicity was categorized as non-Hispanic white, non-Hispanic black, Hispanic, or other.We also used a household socioeconomic status (SES)index variable defined in the ECLS-B, which includedhousehold income, parental education, and occupa-tion.31,32 This variable was coded into 3 groups, that is,low, middle, and high SES (for household SES indexscores in the lowest quintile, the middle 3 quintiles, andthe highest quintile among all sampled households, re-spectively). Finally, 2 binary variables for maternal life-

1148 CHOI et alat Indonesia:AAP Sponsored on February 27, 2013pediatrics.aappublications.orgDownloaded from


4/10

time history of mental health problems were con-structed, that is, history of hospitalization attributable tomental health problems and history of alcohol and/ordrug abuse problems. Mothers also reported whetherthey had talked to a mental health specialist or a generalmedical provider (ie, a psychiatrist, psychologist, doctor,or counselor) regarding any emotional or psychological

problem in the preceding 12 months, and a binary vari-able was measured (ie, talking once or more versusnever).

Statistical AnalysesThe unit of analysis was a biological mother living withthe sampled child. Logistic regression analysis was con-ducted to study associations between moderate/severe

depressive symptoms (CES-D scores of 10) and covari-ates. Only covariates that had P values of .2 in unad-

justed models were included in multivariate modeling.In adjusted models, we started with the initial modelwith only the multiple birth variable and then intro-duced other covariates, in the following order: prematu-rity, obstetric variables, maternal demographic variables,household socioeconomic characteristics, and maternalhistory of mental health problems. Any changes in thecoefficient of the multiple birth variable with inclusionof an additional set of covariates suggested that anydifferences in outcomes according to plurality statuswere associated with the newly introduced covariates.

In addition, mental health consultation history wasanalyzed among all mothers, as well as among thosewith moderate/severe depressive symptoms. Proportionsof mothers who had obtained mental health consulta-tions were estimated according to maternal demo-graphic, household socioeconomic, and maternal mentalhealth history variables. All estimates of means, propor-tions, regression coefficients, and SEs were adjusted forsampling weights used in the survey. A P value of .05was considered statistically significant. Stata 9.0 statisti-cal software (Stata, College Station, TX) was used for allanalyses. The study was declared exempt by the Com-mittee on Human Research at Johns Hopkins Bloomberg

School of Public Health.

RESULTSHigher risks of obstetric and neonatal complications withmultiple gestations were apparent (Table 1). Adjustedodds ratio of having moderate-to-severe depressivesymptoms was 1.43 for mothers of multiple births com-pared to mothers of singletons. Maternal demographicand household socioeconomic characteristics varied sig-nificantly between mothers of singletons and mothers ofmultiple infants. Mothers of multiple births were morelikely to be older, to be currently married, to be edu-cated, and to have higher household SES. There was nosignificant difference in maternal history of mentalhealth problems according to plurality status.

The mean CES-D scores were 4.9 (95% confidenceinterval [CI]: 4.8 5.1) and 5.3 (95% CI: 4.8 5.7) amongmothers of singletons and multiple births, respectively.The prevalence of moderate/severe depressive symp-toms (CES-D score of10) was 16.0% (95% CI: 15.0%17.1%) among mothers of singletons and 19.0% (95%CI: 16.0%21.9%) among mothers of multiple births.The prevalence of severe depressive symptoms (CES-Dscore of15) was estimated to be 6.5% (95% CI: 5.8%7.2%) and 6.7% (95% CI: 4.9%8.6%) among mothersof singletons and mothers of multiple births, respec-tively.

TABLE 1 Characteristicsof Study Population According to

Plurality (N 8069)

Proportion, % (95% CI)

Mothers of

Singletons

(N 7293)

Mothers of

Multiple Infants

(N 776)

Neonatal characteristics at birth

Gestational age at deliveryModerately preterm (3336 wk) 7.8 (7.18.6) 38.7 (34.942.5)a

Severely preterm (33 wk) 1 .9 (1.72.2) 23.5 (19.827.2)a

Cesarean section 25.5 (24.326.8) 66.0 (62.369.7)a

Any complication during

labor/deliveryb31.3 (20.032.7) 64.1 (60.367.9)a

Maternal demographic and

educational characteristics

Primapara 41.2 (39.742.7) 19.2 (16.122.3)a

Age at interview

20 y 7.6 (6.98.3) 3.2 (1.94.4)a

2034 y 75.5 (74.276.7) 72.8 (69.276.3)

35 y 16.9 (15.818.0) 24.1 (20.627.5)a

Race/ethnicityc

White, non-Hispanic 60.9 (59.562.3) 69.6 (66.073.2)a

Black, non-Hispanic 13.5 (12.714.4) 12.4 (9.914.9)

Hispanic 19.9 (18.721.1) 13.7 (10.916.5)a

Asian/Pacific Islander 3.1 (2.93.4) 2.7 (1.63.8)

Other 2.5 (2.22.9) 1.6 (0.82.5)

Marital statusc

Currently married 67.4 (66.068.7) 75.6 (72.278.9)a

Separated 2.7 (2.33.2) 2.2 (1.13.4)

Divorced 3.8 (3.24.4) 3.4 (1.85.0)

Widowed 0.2 (0.10.4) 0.3 (0.00.8)

Never married 25.9 (24.627.1) 18.5 (15.521.4)a

Educational attainmentd

Graduated from high school 75.3 (74.176.6) 82.1 (79.285.1)a

Graduated from college 25.5 (24.226.8) 35.0 (31.238.9)a

Household SES index in relation to

distribution of all householdsin survey

Lowest quintile 17.6 (16.518.7) 13.7 (11.116.4)a

Middle 3 quintiles 61.3 (59.962.8) 54.7 (50.758.7)a

Highest quintile 21.0 (19.822.3) 31.6 (27.835.4)a

Maternal lifetime mental health history

Hospitalization attributable to

mental health problem

4.1 (3.54.7) 2.9 (1.64.3)

Alcohol and/or drug problem 4.8 (4.25.5) 4.1 (2.65.6)

a Statistically significant difference (P.05) between groups.b Having1 of the following: (1) fever (100F); (2) moderate/heavy meconium-stained

amniotic fluid; (3) membranerupturefor12 hours; (4) placental abruption;(5) placenta

previa; (6) other excessive bleeding; (7) seizures during labor; (8) precipitated labor (3

hours); (9)prolongedlabor (20 hours); (10)dysfunctional labor; (11)breech/malpresen-

tation orcephalopelvicdisproportion;(12) cordprolapse;(13) anestheticcomplications;or

(14) fetal distress. The variable was treated as missing values unless information for all 14items was complete.c Presented in more detail for descriptive purposes. Continuous variables or aggregated

categories (Tables 2 and 3) were used in regression analyses.d Presented for descriptive purposes only; data were not included in regression models.



5/10

The unadjusted odds of having moderate/severe de-pressive symptoms was 1.23 among mothers of multiple

births, compared with mothers of singletons (Table 2). Inbivariate models, severe preterm delivery (33 weeks),age, race, marital status, SES, and history of mentalillness were associated with the outcome (Table 2). With

adjustment for preterm delivery, the odds ratio for mul-tiple births was no longer significant; however, withcontrolling for additional demographic and socioeco-nomic covariates, multiple births showed a positive as-sociation with maternal depressive symptoms (Table 3).In the full model, the odds of depressive symptoms were43% greater for mothers of multiple births, comparedwith mothers of singletons (Table 3). Non-Hispanic blackmothers had 27% greater odds, compared with non-Hispanic white mothers. Mothers with a history of hos-pitalization attributable to mental health problems oralcohol/drug abuse also had significantly increased odds(odds ratios of 1.84 and 2.67, respectively). In contrast,

currently married status, Hispanic ethnicity, and highhousehold SES were negatively associated with the out-come. We examined interaction effects of multiple birthson depressive symptoms according to marital status orHispanic ethnicity, but we did not find statistical signif-icance, possibly because of the small number of womenin each of the interaction categories. We also conductedmultivariate analyses excluding 70 mothers of triplets orhigher-order multiple births from our sample, and esti-mated associations between multiple births and mater-nal depressive symptoms were comparable to those es-timated by using the full sample of all mothers ofmultiple births.

Of the 8069 mothers included in this study, 7972completed questions on mental health consultations(completion rate: 98.8%). The completion rate did notvary according to depressive symptom status. Overall,11.4% (95% CI: 10.4%12.3%) of mothers reportedtalking to a mental health specialist or a general medicalprovider regarding any emotional or psychological prob-lem in the 12 months before the interview. The estimatewas significantly higher among mothers with moderate/severe depressive symptoms (27.0% [95% CI: 23.8%30.2%]) than among their counterparts (8.4% [95% CI:7.5%9.3%]). Among mothers with depressive symp-toms, the rates of consulting were nearly twice as highamong mothers who had a history of mental health

TABLE 2 Prevalence of Moderate/Severe Maternal Depressive

Symptoms 9 Months After Delivery According to

Selected Characteristics and Factors Associated With

Depressive Symptoms in Bivariate Logistic Regression

Analyses (N 8069)

Na Prevalence of

Depressive

Symptoms, %(95% CI)

Odds Ratio

(95% CI)b

Neonatal and obstetric

characteristics

Plurality

Singletonc 7293 16.0 (15.017.1) 1.00

Multiple birth 776 19.0 (16.021.9) 1.23 (1.001.51)

Missing data 0

Gestational age at delivery

Term (37 wk)c 6049 15.8 (14.716.9) 1.00

Moderately preterm (3336

wk)

1029 16.4 (13.319.6) 1.05 (0.821.34)

Severely preterm (33 wk) 902 21.4 (16.826.1) 1.46 (1.091.94)

Missing data 89

Delivery mode

Vaginal deliveryc 5494 16.5 (15.317.7) 1.00

Cesarean section 2519 14.7 (12.816.5) 0.87 (0.731.04)

Missing data 56

Any complication during labor/

delivery

Noc 5001 15.6 (14.416.9) 1.00

Yes 2990 17.3 (15.419.2) 1.13 (0.961.33)

Missing data 78

Maternal demographic

characteristics

Maternal age at interviewd 0.95 (0.930.96)

Missing data 0

Parity

Multiparac 4830 16.5 (15.117.9) 1.00

Primapara 3205 15.5 (13.917.1) 0.93 (0.791.08)Missing data 34

Race/ethnicity

White, non-Hispanicc 3866 14.9 (13.516.3) 1.00

Black, non-Hispanic 1301 24.2 (21.427.0) 1.83 (1.512.20)

Hispanic 1313 13.9 (11.716.1) 0.92 (0.751.14)

Asian/Pacific Islander or other 1579 17.1 (14.319.9) 1.18 (0.941.48)

Missing data 10

Marital status

Currently married 2764 25.0 (22.927.2) 0.40 (0.340.47)

Currently not marriedc 5297 11.8 (10.712.9) 1.00

Missing data 8

Household SESe

Low 1455 23.8 (21.026.6) 1.58 (1.321.89)

Middlec 4793 16.5 (15.117.8) 1.00

High 1821 8.5 (6.710.3) 0.47 (0.370.60)

Missing data 0

Maternal lifetime mental health

history

History of hospitalization

attributable to mental

health problem

Noc 7662 15.3 (14.316.4)

Yes 330 33.9 (27.440.4)

Missing data 77

History of alcohol/drug

problems

Noc 7567 15.0 (14.016.0)

TABLE 2 Continued

Na Prevalence of

Depressive

Symptoms, %

(95% CI)

Odds Ratio

(95% CI)b

Yes 439 37.7 (31.444.0)

Missing data 63

a Unweighted number of observations.b Weighted bivariate logistic regression analyses, excluding missing values.c Reference category for regression analyses.d Continuous variable.e Household SES index in relation to the distribution of all households in the survey. Low,

middle, and high refer to the lowest quintile, the middle 3 quintiles, and the highest

quintile of the index, respectively.



6/10

problems and non-Hispanic white mothers, comparedwith their counterparts (Table 4). The rates of consultingdid not vary according to plurality, age, parity, maritalstatus, or household SES.

DISCUSSIONWe examined associations between multiple births andmaternal depressive symptoms, using nationally repre-sentative data. Our study suggested that 19% of mothersof multiple infants had moderate/severe depressivesymptoms 9 months after delivery, compared with 16%of mothers of singletons. Mothers of multiple births were40% more likely to have depressive symptoms, com-pared with their singleton counterparts, with adjustmentfor demographic and socioeconomic characteristics.

Parental stress in raising multiple infants has beensuggested as a primary cause for maternal depressionamong mothers of multiple births.8,9 Although no directcausal relationship between postpartum depression and

neurobiological factors has been documented, little in-formation is available regarding the magnitude and du-ration of hormonal changes and dysregulation associatedwith multiple births.33 The adverse impact of maternaldepression on child health and development has beenwell documented,3438 and children of multiple birthsmight have increased risk of developmental delay result-ing from prematurity and low birth weight3942 as well assuboptimal health service utilization associated with ma-ternal depression.

Estimates of postpartum depression prevalence varygreatly because of the use of different diagnostic toolsand different times of symptom assessment. Althoughthe clinical definition of postpartum depression is limitedto the onset of symptoms during the first 4 weeks afterchildbirth,43 many studies on maternal depression in-cluded women whose symptoms began 3 to 12 monthsafter delivery.30 A meta-analysis reported that the prev-alence of maternal depression 6 months after delivery

TABLE 3 Factors Associated With Moderate/Severe Maternal Depressive Symptoms 9 Months After Delivery in Multivariate Logistic

Regression Analyses

Odds Ratio (95% CI)

Model 1 (N 7980) Model 2 (N 7865) Model3 (N 7847) Model4 (N 7847) Model 5 (N 7764)

Plurality

Singlea 1.00 1.00 1.00 1.00 1.00

Multiple 1.14 (0.901.44) 1.14 (0.901.46) 1.34 (1.051.71) 1.39 (1.091.77) 1.43 (1.121.84)

Gestational age at deliveryTerm (37 wk)a 1.00 1.00 1.00 1.00 1.00

Moderately preterm (3336 wk) 1.04 (0.811.34) 1.03 (0.801.33) 0.96 (0.741.24) 0.93 (0.721.21) 0.91 (0.691.19)

Severely preterm (33 wk) 1.42 (1.051.92) 1.40 (1.031.91) 1.23 (0.911.66) 1.20 (0.881.62) 1.21 (0.891.66)

Obstetric characteristics

Delivery mode

Vaginal deliverya 1.00 1.00 1.00 1.00

Cesarean section 0.84 (0.701.01) 0.91 (0.751.10) 0.89 (0.731.08) 0.88 (0.721.07)

Complications during labor/delivery

Noa 1.00 1.00 1.00 1.00

Yes 1.15 (0.961.37) 1.11 (0.921.32) 1.11 (0.931.33) 1.12 (0.931.34)

Maternal demographic characteristics

Age, y 0.97 (0.960.99) 0.98 (0.97-1.00) 0.99 (0.97-1.00)

Marital status

Currently married 0.48 (0.390.59) 0.53 (0.430.65) 0.57 (0.460.70)

Currently not marrieda 1.00 1.00 1.00

Race/ethnicity

White, non-Hispanica 1.00 1.00 1.00

Black, non-Hispanic 1.19 (0.961.48) 1.13 (0.911.40) 1.27 (1.021.59)

Hispanic 0.72 (0.570.90) 0.65 (0.510.82) 0.71 (0.550.90)

Asian/Pacific Islander or other 1.14 (0.901.44) 1.15 (0.911.46) 1.17 (0.921.48)

Household SESb

Low 1.27 (1.021.57) 1.24 (0.991.54)

Middlea 1.00 1.00

High 0.60 (0.460.78) 0.63 (0.480.82)

History of mental health problem

History of hospitalization

Noa 1.00

Yes 1.84 (1.302.62)

History of alcohol/drug problemsNoa 1.00

Yes 2.67 (1.933.68)

a Reference category.b HouseholdSES indexin relation tothe distributionof allhouseholdsin thesurvey.Low,middle, andhighrefer tothe lowestquintile, themiddle3 quintiles, andthe highest quintile of

the index, respectively.



7/10

was 10%, similar to that in the general population,44

but the prevalence in the first 5 weeks after birth was 3times higher than the prevalence in the general popula-tion.45 Our results are limited to 9 months after delivery,and the prevalence of maternal depressive symptomsand the risk according to plurality in earlier postpartummonths may differ from our estimates.

The small numbers of women receiving mental healthcounseling despite depressive symptoms highlight theneed for better referral of patients with depressive symp-toms. A high index of suspicion for depression should bemaintained for mothers of multiple births, as well as formothers with a history of mental health problems andunmarried mothers. Mothers of multiple births havemore regular contact with health care providers through-out the prepregnancy, prenatal, and postpartum periods,which allows ample opportunities for health care pro-viders to educate women about depression. In our studysample, 24.6% of mothers of multiple births underwentovulation stimulation and/or artificial insemination forthe pregnancy. Mothers of multiple births had an aver-age of 20.7 prenatal visits (95% CI: 19.721.8 visits),compared with 14.2 visits (95% CI: 14.014.4 visits) for

their counterparts. Parents of multiple births also arelikely to obtain more-frequent pediatric care, because ofthe higher prevalence of neonatal complications amongmultiple births, compared with singleton births. In ourstudy, however, we found that the level of mentalhealth consultation was low among mothers with mod-erate/severe depressive symptoms, regardless of theirplurality status.

The importance of providing education and screeningfor postpartum depression has been addressed previous-ly.3638,4649 Because a routine postpartum visit is recom-mended only 4 to 6 weeks after delivery, 50 routine pe-diatric visits, which are recommended 3 times duringthe first 2 months and 7 times during the first 12months,51 may provide better opportunities for timelyeducation, screening, referrals, and preventive interven-tions for postpartum depression. Maternal depressionscreening at well-child visits is accepted by mothers andis a feasible effective means of providing early detectionand referral for postpartum depression.47,52 Pediatricpractice guidelines recommend that pediatricians ask

parents about stress and specific depressive symptoms.53Such screening in pediatric practices also may increasehealth service seeking for mothers at risk of depression. 19

Current guidelines for maternal depression screeningidentify risk factors for maternal depression, such aspoverty, chronic maternal health conditions, domesticviolence, substance abuse, and marital discord, but mul-tiple births are not included.54

Our analysis was limited in identifying mechanismsfor the increased risk of depressive symptoms amongmothers of multiple births, because of the lack of data onpotential key psychosocial covariates of maternal de-pression, including spousal/partner support and marital

relationship6,24,27,29,49,55

and social support,24,27,30,49,55

whichwere independent of maternal depressive symptoms atthe time of the interview. Multiple births have beenassociated with increased stress and anxiety levels forfathers as well,9 increased social isolation for mothers,7

and decreased marital adjustment.7 Any difference in theimpact of multiple births according to the quantity andquality of spousal support should be further assessed.The lower risk of depressive symptoms among Hispanicmothers also needs to be examined further with familysupport variables, because Hispanic fathers show higherlevels of engagement with their children5659 and theextended family provides a primary social support net-work for Hispanic mothers.59,60 Finally, although theECLS-B sample is nationally representative, motherswho completed all 12 depressive symptom questionswere significantly more likely to be currently marriedand from higher household SES quintiles, comparedwith those who did not complete the questions (resultsnot shown), which partially compromises the nationalrepresentation of the sample.

In addition, maternal depressive symptoms are re-ported to be associated with a history of infertility6,61 andthe use of assisted reproductive technology.6,12 However,few studies examined the association between maternaldepressive symptoms and infertility treatment control-ling for multiple births, because of the small number of

TABLE 4 Prevalence of Mental Health Consulting Within 12

MonthsBefore the InterviewAmong Mothers With

Moderate/Severe Depressive Symptoms 9 Months After

Delivery, According to Selected Characteristics

N Prevalence, Mean

(95%CI), %

Alla 1423 27.0 (23.830.2)

PluralitySingleton 1268 27.0 (23.730.3)

Multiple 155 25.0 (17.532.4)

Mothers age at interview

20 y 160 27.9 (18.637.2)

2034 y 1056 27.3 (23.631.0)

35 y 207 24.3 (15.533.1)

Parity

Multipara 887 26.3 (22.130.4)

Primapara 531 28.3 (23.133.6)

Race/ethnicity

White, non-Hispanicb 619 33.9 (29.138.7)

Black, non-Hispanic 320 15.4 (10.620.3)c

Hispanic 209 19.0 (12.125.9)c

Asian/Pacific Islander 160 11.0 (5.216.8)c

Other 113 34.0 (18.949.1)

Marital status

Currently married 698 27.0 (22.531.6)

Currently not married 725 26.9 (22.331.5)

Household SES index

Low 376 22.7 (16.828.6)

Middle 863 28.1 (24.032.2)

High 184 30.4 (20.140.8)

History of mental health-related hospitalization

or alcohol/drug problems

Nob 1170 22.3 (18.925.7)

Yes 244 50.3 (41.758.9)c

a Twenty-eight mothers with moderate/severe depressive symptoms did not complete

the mental health consulting questionnaire.b

Reference category.c Estimate is different from that of the reference category (P .05).



8/10

multiple births sampled.12 We were also unable to studyassociations among maternal depressive symptoms, mul-tiple births, and infertility, because infertility informa-tion was requested only from mothers of multiple in-fants in the ECLS-B. In our study sample, mothers ofmultiple births who received infertility counseling forthe pregnancy had a depressive symptom prevalence of13.9% (95% CI: 9.2%18.5%; n 234), compared with

21.1% (95% CI: 17.4%24.8%; n 540) among moth-ers of multiple births who never received infertilitycounseling. With adjustment for maternal education andhousehold SES, however, the odds of having depressivesymptoms did not vary according to infertility counsel-ing status among mothers of multiple births. Additionalstudies are needed for better understanding of the asso-ciations among maternal depressive symptoms, multiple

births, and infertility treatment, which might indicateclinical implications for counseling of infertility patients.

CONCLUSIONS

Mothers of multiple births had a 43% increased risk ofhaving moderate/severe, 9-month postpartum, depres-sive symptoms, compared with mothers of singletons, inpopulation-based data. Pediatric practices should makean additional effort to educate new and expecting par-ents of multiple infants regarding their increased risk formaternal postpartum depression. Furthermore, pediatricwell-child visits are potentially valuable opportunities toprovide education, screening, and referrals for postpar-tum depression for mothers of multiple births.

ACKNOWLEDGMENTS

Dr Bishai was supported in part by a grant from the Maternal

and Child Health Bureau (grant R40MC05475).

REFERENCES1. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F,

Kirmeyer S. Births: final data for 2004. Natl Vital Stat Rep.

2006;55(1):1101

2. American College of Obstetricians and Gynecologists. Multiple

Gestation: Complicated Twin, Triplet, and High-Order Multifetal

Pregnancy. Washington, DC: American College of Obstetricians

and Gynecologists; 2004. ACOG Practice Bulletin 56

3. Ayres A, Johnson TRB. Management of multiple pregnancy:

prenatal care: part 1. Obstet Gynecol Surv. 2005;60(8):527537

4. Mathews TJ, MacDorman MF. Infant mortality statistics from

the 2004 period linked birth/infant death data set. Natl VitalStat Rep. 2007;55(14):132

5. Blondel B, Kogan MD, Alexander GR. The impact of the in-

creasing number of multiple births on the rates of preterm birth

and low birthweight: an international study. Am J Public Health.

2002;92(8):13231330

6. Klock SC. Psychological adjustment to twins after infertility.

Best Pract Res Clin Obstet Gynaecol. 2004;18(4):645656

7. Robin M, Corroyer D, Casati I. Childcare patterns of mothers of

twins during the first year. J Child Psychol Psychiatry. 1996;

37(4):453460

8. Sheard C, Cox S, Oates M, Ndukwe G, Glazebrook C. Impact of

a multiple, IVF birth on post-partum mental health: a compos-

ite analysis. Hum Reprod. 2007;22(7):20582065

9. Glazebrook C, Sheard C, Cox S, Oates M, Ndukwe G. Parenting

stress in first-time mothers of twins and triplets conceived after

in vitro fertilization. Fertil Steril. 2004;81(3):505511

10. Olivennes F, Golombok S, Ramogida C, Rust J. Behavioral and

cognitive development as well as family functioning of twins

conceived by assisted reproduction: findings from a large pop-

ulation study. Fertil Steril. 2005;84(3):725733

11. Halbreich U. The association between pregnancy processes,

preterm delivery, low birth weight, and postpartum

depressions: the need for interdisciplinary integration. Am J

Obstet Gynecol. 2005;193(4):13121322

12. Fisher JR, Hammarberg K, Baker HW. Assisted conception is a

risk factor for postnatal mood disturbance and early parenting

difficulties. Fertil Steril. 2005;84(2):426430

13. Lobel M, DeLuca RS. Psychosocial sequelae of cesarean

delivery: review and analysis of their causes and implications.

Soc Sci Med. 2007;64(11):22722284

14. Thorpe K, Golding J, MacGillivray I, Greenwood R. Compari-

son of prevalence of depression in mothers of twins and moth-

ers of singletons. BMJ. 1991;302(6781):875878

15. National Center for Education Statistics. Users Manual for the

ECLS-B Nine-Month Restricted-Use Data File and Electronic Code

Book. Washington, DC: National Center for Education

Statistics; 2004

16. Radloff LS. The CES-D Scale: a self-report depression scale forresearch in the general population. Appl Psychol Meas. 1977;

1(3):385401

17. Weissman MM, Sholomskas D, Pottenger M, Prusoff BA, Locke

BZ. Assessing depressive symptoms in five psychiatric

populations: a validation study. Am J Epidemiol. 1977;106(3):

203214

18. Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening

for depression in well older adults: evaluation of a short form

of the CES-D (Center for Epidemiologic Studies Depression

Scale). Am J Prev Med. 1994;10(2):7784

19. Minkovitz CS, Hughart N, Strobino D, et al. A practice-based

intervention to enhance quality of care in the first 3 years of

life: the Healthy Steps for Young Children Program. JAMA.

2003;290(23):30813091

20. Paulson JF, Dauber S, Leiferman JA. Individual and combined

effects of postpartum depression in mothers and fathers on

parenting behavior. Pediatrics. 2006;118(2):659668

21. Thomas JL, Jones GN, Scarinci IC, Mehan DJ, Brantley PJ. The

utility of the CES-D as a depression screening measure among

low-income women attending primary care clinics. Int J Psy-

chiatry Med. 2001;31(1):2540

22. Brantley PJ, Mehan DJ, Thomas JL. The Beck Depression

Inventory (BDI) and the Center for Epidemiologic Studies De-

pression Scale (CES-D). In: Maruish ME, ed. Handbook of Psy-

chological Assessment in Primary Care Settings. Mahwah, NJ:

Erlbaum; 2000:291 422

23. Ross CE, Mirowsky J, Huber J. Dividing work, sharing work,

and in-between: marriage patterns and depression. Am Sociol

Rev. 1983;48(6):80982324. OHara M, Swain A. Rates and risk of postpartum depression:

a meta-analysis. Int Rev Psychiatry. 1996;8(1):3754

25. Kumar R, Robson KM. A prospective study of emotional dis-

orders in childbearing women. Br J Psychiatry. 1984;144:3547

26. OHara MW, Neunaber DJ, Zekoski EM. Prospective study of

postpartum depression: prevalence, course, and predictive fac-

tors. J Abnorm Psychol. 1984;93(2):158171

27. OHara MW, Schlechte JA, Lewis DA, Varner MW. Controlled

prospective study of postpartum mood disorders: psychologi-

cal, environmental, and hormonal variables. J Abnorm Psychol.

1991;100(1):6373

28. Campbell SB, Cohn JF. Prevalence and correlates of postpar-

tum depression in first-time mothers. J Abnorm Psychol. 1991;

100(4):594599



9/10

29. Horwitz SM, Briggs-Gowan MJ, Storfer-Isser A, Carter AS.

Prevalence, correlates, and persistence of maternal depression.

J Womens Health (Larchmt). 2007;16(5):678691

30. Burt VK, Hendrick VC. Womens mental health. In: Hales RE,

Yudofsky SC, eds. Textbook of Clinical Psychiatry. 4th ed. Wash-

ington, DC: American Psychiatric Publishing; 2003:15111534

31. Nord C, Edwards B, Andreassen C, Green J, Wallner-Allen K.

Early Childhood Longitudinal Study, Birth Cohort (ECLS-B), Users

Manual for the ECLS-B Longitudinal 9-Month-2-Year Data File and

Electronic Codebook. Washington, DC: National Center for Edu-

cation Statistics; 2006. Publication NCES 2006046

32. Duncan OD. Properties and characteristics of the socioeco-

nomic index. In: Reiss AJ, ed. Occupations and Social Status. New

York, NY: Free Press of Glencoe; 1961:139161

33. Zonana J, Gorman JM. The neurobiology of postpartum de-

pression. CNS Spectr. 2005;10(10):792799, 805

34. Lyons-Ruth K, Wolfe R, Lyubchik A. Depression and the par-

enting of young children: making the case for early preventive

mental health services. Harv Rev Psychiatry. 2000;8(3):148153

35. Murray L, Cooper PJ. Postpartum depression and child devel-

opment. Psychol Med. 1997;27(2):253260

36. McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W.

The timing of maternal depressive symptoms and mothers

parenting practices with young children: implications forpediatric practice. Pediatrics. 2006;118(1). Available at:

www.pediatrics.org/cgi/content/full/118/1/e174

37. McLearn KT, Minkovitz CS, Strobino DM, Marks E, Hou W.

Maternal depressive symptoms at 2 to 4 months post partum

and early parenting practices. Arch Pediatr Adolesc Med. 2006;

160(3):279284

38. Minkovitz CS, Strobino D, Scharfstein D, et al. Maternal de-

pressive symptoms and childrens receipt of health care in the

first 3 years of life. Pediatrics. 2005;115(2):306314

39. Gutbrod T, Wolke D, Soehne B, Ohrt B, Riegel K. Effects of

gestation and birth weight on the growth and development of

very low birthweight small for gestational age infants: a

matched group comparison. Arch Dis Child Fetal Neonatal Ed.

2000;82(3):F208F214

40. Vohr BR, Wright LL, Poole WK, McDonald SA. Neurodevelop-mental outcomes of extremely low birth weight infants 32

weeks gestation between 1993 and 1998. Pediatrics. 2005;

116(3):635643

41. Feldman R, Eidelman AI, Sirota L, Weller A. Comparison of

skin-to-skin (kangaroo) and traditional care: parenting out-

comes and preterm infant development. Pediatrics. 2002;

110(1):1626

42. Feldman R, Eidelman AI. Does a triplet birth pose a special risk

for infant development? Assessing cognitive development in

relation to intrauterine growth and mother-infant interaction

across the first 2 years. Pediatrics. 2005;115(2):443452

43. American Psychiatric Association. Diagnostic and Statistical Man-

ual of Mental Disorders, Text Revision. 4th ed. Washington, DC:

American Psychiatric Association; 200044. 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):

10711083

45. Cox JL, Murray D, Chapman G. A controlled study of the

onset, duration and prevalence of postnatal depression. Br J

Psychiatry. 1993;163:2731

46. Gjerdingen DK, Yawn BP. Postpartum depression screening:

importance, methods, barriers, and recommendations for prac-

tice. J Am Board Fam Med. 2007;20(3):280288

47. Chaudron LH, Szilagyi PG, Kitzman HJ, Wadkins HI, Conwell

Y. Detection of postpartum depressive symptoms by screening

at well-child visits. Pediatrics. 2004;113(3):551558

48. Kavanaugh M, Halterman JS, Montes G, Epstein M, Hightower

AD, Weitzman M. Maternal depressive symptoms are ad-

versely associated with prevention practices and parenting be-

haviors for preschool children. Ambul Pediatr. 2006;6(1):3237

49. Dennis CL. Psychosocial and psychological interventions for

prevention of postnatal depression: systematic review. BMJ.

2005;331(7507):15

50. American Academy of Pediatrics, Committee on Fetus and

Newborn; American College of Obstetricians and Gynecolo-

gists, Committee on Obstetric Practice. Guidelines for Perinatal

Care. 4th ed. Elk Grove Village, IL: American Academy of

Pediatrics; 1997:147182

51. American Academy of Pediatrics, Committee on Practice and

Ambulatory Medicine and Bright Futures Steering Committee.

Recommendations for preventive pediatric health care. Pediat-

rics. 2007;120(6):1376137852. Olson AL, Dietrich AJ, Prazar G, Hurley J. Brief maternal

depression screening at well-child visits. Pediatrics. 2006;

118(1):207216

53. Jellinek M, Patel B, Froehle M. Bright Futures in Practice: Mental

Health Practice Guide. Arlington, VA: National Center for Edu-

cation in Maternal and Child Health; 2002

54. Green M, Palfrey JS, eds. Bright Futures: Guidelines for Health

Supervision of Infants, Children, and Adolescents. 2nd ed, rev.

Arlington, VA: National Center for Education in Maternal and

Child Health; 2002

55. Gotlib IH, Whiffen VE, Wallace PM, Mount JH. Prospective

investigation of postpartum depression: factors involved in

onset and recovery. J Abnorm Psychol. 1991;100(2):122132

56. Roopnarine J, Ahmeduzzaman M. Puerto Rican fathers in-

volvement with their preschool-age children. Hisp J Behav Sci.1993;15(1):96107

57. Caldera Y, Fitzpatrick J, Wampler K. Co-parenting in Mexican

American families: mothers and fathers perceptions. In: Con-

treras JM, Kerns KA, Neal-Barnett AM, eds. Latino Children and

Families in the United States. Westport, CT: Greenwood; 2002:

133154

58. Cabrera NJ. Latino fathers: uncharted territory in need of

much exploration. In: Lamb ME, ed. The Role of Father in Child

Development. 4th ed. Mahwah, NJ: Erlbaum; 2004:417452

59. Cabrera NJ, Shannon JD, West J, Brooks-Gunn J. Parental

interactions with Latino infants: variation by country of origin

and English proficiency. Child Dev. 2006;77(5):11901207

60. Cuellar I, Arnold B, Gonzalez G. Cognitive referents of

acculturation: assessment of cultural constructs in MexicanAmericans. J Community Psychol. 1995;23(4):339356

61. Verhaak CM, Smeenk JM, Evers AW, Kremer JA, Kraaimaat

FW, Braat DD. Womens emotional adjustment to IVF: a sys-

tematic review of 25 years of research. Hum Reprod Update.

2007;13(1):2736



10/10

DOI: 10.1542/peds.2008-1619

2009;123;1147PediatricsYoonjoung Choi, David Bishai and Cynthia S. Minkovitz

SymptomsMultiple Births Are a Risk Factor for Postpartum Maternal Depressive

ServicesUpdated Information &

tmlhttp://pediatrics.aappublications.org/content/123/4/1147.full.hincluding high resolution figures, can be found at:

References

tml#ref-list-1http://pediatrics.aappublications.org/content/123/4/1147.full.hat:This article cites 48 articles, 18 of which can be accessed free

Citations

tml#related-urlshttp://pediatrics.aappublications.org/content/123/4/1147.full.hThis article has been cited by 3 HighWire-hosted articles:

Subspecialty Collections

_and_newbornhttp://pediatrics.aappublications.org/cgi/collection/prematurePremature & Newbornthe following collection(s):This article, along with others on similar topics, appears in

Permissions & Licensing

mlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhttables) or in its entirety can be found online at:Information about reproducing this article in parts (figures,

Reprintshttp://pediatrics.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright 2009 by the American Academy of Pediatrics. Alland trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elkpublication, it has been published continuously since 1948. PEDIATRICS is owned, published,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on February 27, 2013pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/content/123/4/1147.full.htmlhttp://pediatrics.aappublications.org/content/123/4/1147.full.htmlhttp://pediatrics.aappublications.org/content/123/4/1147.full.htmlhttp://pediatrics.aappublications.org/content/123/4/1147.full.html#ref-list-1http://pediatrics.aappublications.org/content/123/4/1147.full.html#ref-list-1http://pediatrics.aappublications.org/content/123/4/1147.full.html#ref-list-1http://pediatrics.aappublications.org/content/123/4/1147.full.html#related-urlshttp://pediatrics.aappublications.org/content/123/4/1147.full.html#related-urlshttp://pediatrics.aappublications.org/cgi/collection/premature_and_newbornhttp://pediatrics.aappublications.org/cgi/collection/premature_and_newbornhttp://pediatrics.aappublications.org/cgi/collection/premature_and_newbornhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/cgi/collection/premature_and_newbornhttp://pediatrics.aappublications.org/content/123/4/1147.full.html#related-urlshttp://pediatrics.aappublications.org/content/123/4/1147.full.html#ref-list-1http://pediatrics.aappublications.org/content/123/4/1147.full.html

gemeli sbg risiko ibu depresi

Documents