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SMAD. Revista eletrônica saúde mental álcool e drogas

versión On-line ISSN 1806-6976

SMAD, Rev. Eletrônica Saúde Mental Álcool Drog. (Ed. port.) vol.16 no.1 Ribeirão Preto enero/mar. 2020

http://dx.doi.org/10.11606/issn.1806-6976.smad.2020.153332 

REVIEW ARTICLE

 

Depression in pregnancy: risk factors associated with its occurrence*

 

 

Mônica Maria de Jesus Silva; Gabriella Santos Lima; Juliana Cristina dos Santos Monteiro; Maria José Clapis

Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre For Nursing Research Development, Ribeirão Preto, SP, Brazil

Corresponding author

 

 


ABSTRACT

OBJECTIVE: to identify risk factors associated with the occurrence of depression in pregnancy available in the scientific literature.
METHOD: integrative review of articles published in electronic databases MEDLINE by means of Pubmed, SCOPUS, CINAHAL, PsycINFO and LILACS between 2012 and 2016.
RESULTS: 37 studies were analyzed. They identified several risk factors associated with the occurrence of depression in pregnancy. The most relevant risk factors were: sociodemographic and economic factors; obstetric/maternal; psychic and psychosocial.
CONCLUSION: the etiology of depression in pregnancy is multifactorial and complex. Risk factors associated with the occurrence of depression in pregnancy are heterogeneous and their identification is crucial for the promotion of maternal-fetal health.

Descriptors: Nursing; Obstetric Nursing; Pregnancy; Depression; Risk Factors.


 

 

Introduction

The worldwide and Brazilian panorama of depression has been challenging for public health considering its alarming growth in recent years.

Special attention has been given to the occurrence of this disorder in women, since they are twice as likely to develop the disorder as men, with highlight for a special moment of their lives, pregnancy(1).

When depression occurs during pregnancy, it has alarming consequences with negative repercussions not only to maternal but also to fetal health(2-8), which emphasizes the need and the relevance of the screening of this disorder in pregnancy(9), as well as the early identification of pregnant women at risk of developing it(10).

For the identification of pregnant women at risk of developing depression during pregnancy, it is crucial to track the potential risk factors associated with its occurrence at this time in a woman's life. Risk factors include the "aspect of individual behavior or lifestyle, environmental exposure, or hereditary or congenital characteristics that, according to epidemiological evidence, are known to be associated with a health-related condition considered important to be prevented"(11).

Therefore, this study aimed to identify risk factors associated with the occurrence of depression in pregnancy as available in the scientific literature.

 

Method

This is an integrative review of the literature conducted in the following steps: elaboration of the research question, definition of the descriptors for the literature search, establishment of inclusion and exclusion criteria, extraction of the data, evaluation of the included studies, analysis and synthesis of the results, submission of the review(12).

In order to guide the integrative review, the research question was based on the scope of the scientific evidence that is the focus of research, that is, the risk factors for depression in pregnancy. For this purpose, the PICO strategy was used, which uses the acronym for P = Patient, I = Intervention, C = Comparison and O = Outcomes or expected results. Thus, the research question was defined as: What evidence is available in the literature on the risk factors associated with depression in pregnancy? The first element of the strategy (patient) was composed by pregnant women; the second element (intervention) was represented by risk factors, and the fourth element (outcome, expected results) was evidenced by depression in pregnancy. Depending on the review method, not all elements of the PICO strategy are used. In this integrative review, the third element, that is, comparison, was not used.

For the selection of the studies, the electronic databases used were MEDLINE via Pubmed, SCOPUS, CINAHAL, PsycINFO and LILACS. This selection of databases was used to cover the literature published in the countries of Latin America and the Caribbean with the LILACS database and the international literature with the other databases. In addition, we highlight the reference database in behavioral and mental health sciences, PsycINFO, and the one that encompasses the main nursing researches, CINAHAL, which allows drawing an expanded view of the scientific literature on the subject under study.

Primary articles, published in their entirety, related to the risk factors associated with the occurrence of depression in pregnancy or pregnant women, published in the English, Portuguese or Spanish languages, and published in national and international journals in the period 2012 to 2016 were considered eligible. No abstracts of conferences, annals, editorials, comments and reviews, letters to the editor, chapters of books, technical reports, monographs, theses, dissertations, literature reviews, and duplicate texts in databases were included in the study.

The search in the databases was performed in January 2017, using the controlled descriptors pregnancy (gravidez), pregnant women (gestantes), risk factors (fatores de risco), depression (depressão), prenatal depression (depressão pré-natal), and the uncontrolled descriptors (keywords), pregnancy, pregnant woman, depression, risk factors with the Boolean operators AND and OR, according to the criteria and manuals of each database. The descriptors were defined with the help of the DeCs (Health Sciences Descriptors) and Mesh (Medical Subject Headings). Thus, the search strategy was defined for each database, as described in Figure 1:

 

 

From the association between all the controlled and uncontrolled descriptors, the process of search and selection of the studies was carried out, which was conducted by two reviewers, in an independent and blind manner, being performed in two phases. First, the titles, abstracts and descriptors were read. Then, the full texts were read.

Figure 2 illustrates the general picture of selection of studies.

The flowchart below illustrates the process of identification, selection, and inclusion of the studies for the integrative review according to the consulted database (Figure 3).

For the extraction of data from the sample composed of 37 of the selected primary studies, a validated instrument specially designed for this purpose was adapted, developed by nursing researchers(13). Such instrument included items related to the identification of the article, methodological characteristics, and evaluation of methodological rigor, including identification of the article, basis on which the study was found, title, authors, design, year of publication, place of origin of the research, level of evidence, study objective and main results.

The evaluation of the types of studies selected was based on the classification of studies as observational or clinical trial, the former being divided into analytical and descriptive. Analytical studies, in turn, are classified as cohort, cross-sectional and case-control studies(14).

Regarding the level of evidence, the studies were classified according to the clinical issue, which can be categorized into: 1) Intervention/treatment or diagnosis/testing; 2) Prognosis/prediction or etiology; 3) Meaning. For studies covering the first clinical issue, there is a hierarchy of seven levels of evidence; for the second clinical issue, five levels of evidence may be considered; and in the third clinical question, the hierarchy is composed of six levels(15).

Subsequently, the data identified in the analysis instrument were organized into a Microsoft Excel spreadsheet. After reading the selected studies in their entirety, the analysis was carried out in order to describe and classify the results, evidencing the knowledge produced on the subject.

Data analysis was performed emphasizing the risk factors for depression in pregnancy found in each study, as well as comparisons between them, highlighting differences and similarities.

 

Results

The final sample consisted of 37 studies arranged in alphanumeric sequence for better identification, starting from E1 to E37 (Figure 4).

The selected studies were summarized and classified according to the year and period, country of study, study design, level of evidence, thematic approach, and purpose of the study.

Regarding the year of publication, the selected articles were published from 2012 to 2016. The year of greatest prominence was 2015, with 11 selected studies. Subsequently, in the year 2016, eight studies were identified, followed by the year 2014, with seven studies. Finally, the years 2012 and 2013 had six and five studies, respectively.

Among the 37 selected studies, two were published in national journals and 35 in international journals. Most international publications were in specific journals of psychiatry or mental health, with 18 publications, and obstetrics or women's health/reproductive health, with 15 publications. Among all journals, six are specifically nursing journals. It is also emphasized that one journal is exclusive about depression and another is exclusively dedicated to women's mental health, in which three articles have been published. In total, the studies were published in 32 different journals, four of which were in the Journal of Affective Disorders and three in the Archives Women's Mental Health.

Regarding the country where the studies were performed, most of the studies have Brazilian origin, with six publications, followed by the American and Chinese origins, with three studies each. Among the six Brazilian studies, only two were published in national journals.

Of the 37 articles evaluated, 36 are observational studies and one is an experimental study of the clinical trial type. Among the observational studies, 35 are analytical studies and one study is descriptive with a quantitative approach. The selected analytical studies are divided into 21 cross-sectional studies and 14 longitudinal studies, of which seven are described only as longitudinal and the other seven as cohort studies. Therefore, the level of evidence in the studies ranged from 2, 4 and 6, since a study presented as a clinical issue associated with Intervention/treatment, being classified as level two of evidence because it was the pilot study of a clinical trial. In the remaining 36 articles, we identified the clinical issue associated with prognosis/prediction or etiology. Among these, seven studies were classified as level two of evidence because they were classified as cohort studies and 29 studies presented level four because they were descriptive studies.

Regarding the theme, 35 articles referred to the evaluation of depression and only two also evaluated anxiety, besides depression.

Regarding the objectives, 29 studies were specifically aimed at identifying, assessing or investigating the risk factors for depression in pregnancy, also called prenatal or antenatal depression. The other eight studies presented objectives related to the evaluation of risk factors for perinatal depression, which includes both depression in pregnancy and postpartum depression.

Throughout the reading, a separation between the articles was observed regarding the risk factors for the occurrence of depression in pregnancy. Although not all the studies organized the risk factors identified in categories, it was chosen, in this study, to categorize them for better understanding.

So, 34 risk factors or factors associated with the development of depression in pregnancy were identified in the studies and grouped into four categories: 1. Socioeconomic risk factors; 2. Psychiatric risk factors; 3. Obstetric and/or maternal risk factors; and 4. Psychosocial risk factors. These categories, in turn, were subdivided into subcategories. It should be highlighted that in more than one factor was identified a same study.

The risk factots are shown below (Figure 5).

 


Figure 5 - Click to enlarge

 

Socioeconomic risk factors

This category covers studies that have identified, assessed, or investigated social and economic risk factors. Of the 37 articles selected, 17 (45.95%) identified risk factors that belong to this category.

Psychiatric risk factors

This category includes studies in which the psychiatric, psychological, or emotional risk factors were investigated, identified or evaluated. Of the total of 37 articles selected, 14 (37.8%) belong to this category.

Obstetrical/maternal risk factors

Among the studies, 12 (32.4%) were included in this category, which included factors associated with current and previous obstetric history, as well as health conditions.

Psychosocial risk factors

Psychosocial factors were identified in 31 (83.7%) studies and grouped into use of psychoactive substances, psychosocial stressors, social support, violence, and personal relationships.

 

Discussion

The findings of the integrative review revealed that there is a great diversity of risk factors that may be associated with the development of depression during pregnancy, evidencing the complex and multifactorial etiology of depression.

The data revealed that the publications in the line of research "depression in pregnancy" constitute an extensive field. There was also an increase in the number of publications on the theme in countries of all continents, reinforcing the importance of this discussion for maternal health.

The analysis of the studies evidenced four distinct categories of risk factors that corroborate the occurrence of depression in pregnancy. The review included risk factors related to the pregnant woman, such as those related to her mental and obstetric health, already ratified as preponderant for depression in pregnancy, and factors related to the social environment in which she is inserted, as well as her living conditions. Factors resulting from the social and cultural interaction provided by this environment were also contemplated, which reiterates the importance of holistic care involving all aspects of women's life during prenatal care.

Among the socioeconomic risk factors, restricted socioeconomic conditions predominated, with reference to low family income and financial difficulties(19,29,31,42-43).

Social vulnerability was identified as an impact factor for the occurrence of depression in pregnancy with inference for pregnant women living in socially unprotected conditions. Some studies have highlighted food insecurity as a risk factor and other articles highlight the serious and persistent social difficulties ratified by unfavorable housing conditions with housing difficulties(27,31,33,38-39,47), as well as unfavorable living conditions(29).

Low maternal schooling or lack of formal education and unemployment, either from the pregnant woman herself, from the spouse, or from another family member, were identified as risk factors for depression in pregnancy in four studies each(19,25,31,36-37,43,48-49).

The role of maternal age in increasing the risk of depression during pregnancy is not clear. Women of young age are at increased risk of developing pregnancy depression according to some studies(25,27,49,52), while other studies consider that women of advanced age are at greater risk of having depression in pregnancy than young women(35,50).

Regarding psychiatric risk factors, many studies have shown that the previous occurrence of depression impacts on its recurrence during prenatal period. Also, the history of depression is a major risk factor for the development of depression in pregnancy(16,18,23-24,30,37,47), as well as the psychiatric history involving the occurrence of another mental disorder at any stage of the pregnant woman's past life(24,36,41,45,47). Also, another study also highlights the history of family depression as a risk factor for depression in pregnancy(37).

The development of concurrent mental disorders in pregnancy contributes to the onset of depression along with the disorder at this important stage of a woman's life(22,39). Thus, some studies have reported that the development of maternal anxiety in pregnancy is a risk factor for the development of depression in this period(17,21,24,32,43,46).

We also detected risk factors related to the emotions and feelings of the pregnant woman such as unhappiness/sadness with pregnancy(32), maternal stress(17,21,46), besides preoccupation in the gestation(22). There is also the risk factor "adaptation to new life situations", which points to the difficulty of adaptation as a predictor of depression in pregnancy and integrates the subcategory resilience(33).

Regarding obstetric/maternal risk factors, risk factors for current and previous gestation were identified. Regarding current gestation, many studies have shown that women facing pregnancy with obstetric complications are at increased risk for depression during prenatal period(35,44).

The history of unfavorable obstetric outcomes in previous pregnancies has a prominent position among the risk factors. Thus, women who have experienced losses from previous pregnancies and have a history of miscarriage or stillbirth are at higher risk of developing depression in the current pregnancy(22,30,35,40,43).

Some studies have evidenced the health status of the pregnant woman as a predictor of depression in pregnancy. Four studies have identified the presence of diseases or symptoms related to physical health as a risk factor for the occurrence of gestational depression(23,28,35,39).

Many studies have shown that psychosocial risk factors play an important role in the onset of depression in pregnancy. The use of psychoactive substances was reported in seven studies, which identified that the use of alcohol, tobacco, and illicit drugs in pregnancy puts women at greater risk of developing depression in this period(25,27,35,37,45,48-49,51).

Risk factors categorized as psychosocial stressors include the presence of gestational pressures(22) and occurrence of major events in recent life, that is, in the last 12 months, such as the death of a family member, diagnosis of disease, and marital separation. These events were also referred to as adverse, stressful, important, or life-threatening events(20,23-24,30-31,45,47) and were present in seven publications. In this category, it was also evidenced that women who experience an unwanted pregnancy or an unplanned pregnancy have an increased risk for depression during prenatal period(18,20,25,28,30,32,36-39,47,49-50).

A number of studies, more precisely eleven of them, have found risk factors for depression in pregnancy belonging to the social support dimension. This group includes both poor social support(26-29,38) and restricted support specifically from friends, spouse, or family in general(18,30-31,33,37,47).

Among the risk factors that are psychosocial stressors, those related to violence, be it physical or sexual suffering during pregnancy or at any stage of life, have a considerable impact on women's mental health in the perinatal period. Of the total number of studies, 12 mentioned violence as a risk factor for depression in pregnancy. Among these, six studies identified as a risk factor the violence suffered during pregnancy(16,34,36,38,45,49) and six pointed to the history of violence suffered by the pregnant woman in the past(20,24,26-27,47,37).

Women with a history of abuse frequently experience more than one traumatic event during their lives and are at increased risk of developing depression in pregnancy, as mentioned in some studies that describe the past experience of sexual violence as a risk factor(24,27). Other publications mention women's experience of having suffered both physical and sexual violence prior to pregnancy as a factor associated with the development of depression during pregnancy(37,47). There are also publications with reference to the aggressor, mentioning violence perpetrated by an intimate partner(20,26,37).

Regarding violence perpetrated during pregnancy, a study mentions physical violence against pregnant women as a risk factor for depression(38). Another Brazilian study mentions domestic violence suffered during the gestational period(45), while a study conducted in Turkey describes it as violence during pregnancy in general(36). There is also records on the aggressor, as a study conducted in Nigeria that points to gender violence as a risk factor for depression in pregnancy(49), as well as other authors that describe the findings consistent with violence by an intimate partner experienced during this period(16,34,38).

Finally, a study carried out in Italy highlighted women's personal relationships as predominant for depression in pregnancy, especially marital conflicts and conflicting family relationships(41). The woman in a family circle permeated by conflicts and disagreements, as well as the one that faces fights and conflicts with her partner, is at greater risk of developing depression during pregnancy.

In addition, other studies mentioned the absence of a partner, referred to in some articles as a single marital status and in others as absence of a relationship with the child's father(20,27,35,37,47,49-51).

 

Conclusion

The results demonstrate the complex and multifactorial etiology of depression in pregnancy. The risk factors associated with the occurrence of this disorder are heterogeneous and include socioeconomic, obstetric/maternal, psychiatric, and psychosocial variables. However, although diverse, some factors tend not to vary according to the cultural context.

The identification of risk factors associated with the occurrence of depression in pregnancy is crucial for the promotion of maternal-fetal health. By identifying such risk factors, health professionals can focus on early risk management, minimizing complications, potentially reducing the chances of depression during pregnancy and consequent mental distress for women.

As a limitation, the present review does not include a meta-analysis, which could increase additional information on the differential impact of each risk factor.

 

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Corresponding author:
Mônica Maria de Jesus Silva
E-mail: monicamjs@usp.br

Received: Jan 3rd 2019
Accepted: Apr 2nd 2019

 

 

Authors' contributions: Research conception and design: Mônica Maria de Jesus Silva, Maria José Clapis. Data collection: Mônica Maria de Jesus Silva, Gabriella Santos Lima. Data analysis and interpretation: Mônica Maria de Jesus Silva, Gabriella Santos Lima, Maria José Clapis. Funding acquisition: Mônica Maria de Jesus Silva. Manuscript writing: Mônica Maria de Jesus Silva, Maria José Clapis. Critical revision of the manuscript: Mônica Maria de Jesus Silva, Juliana Cristina dos Santos Monteiro, Maria José Clapis.
All authors approved the final version of the text.
Conflict of interest: The authors have stated that there are no conflicts of interest.
* Paper extracted from doctoral dissertation “Escala de risco de depressão na gravidez: construção e validação”, presented to Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre For Nursing Research Development, Ribeirão Preto, SP, Brazil. This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil – Finance Code 001.

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