Psychological Disorders in Women with Spontaneous Preterm Delivery

authors:

avatar Ladan Haghighi 1 , avatar Shabnam Nohesara 2 , avatar Yousef Moradi 3 , avatar Mandana Rashidi 4 , avatar Mahdieh Moridi 5 , *

MD, Professor of Obstetrics and Gynecology, Endometriosis and Gynecologic Disorders Research Center, Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
MD, Bipolar Disorders Research Group, Mental Health Research Centre, Iran University of Medical Sciences and Health Services, Tehran, Iran
Pars Advanced and Minimally Invasive Manners Research Center, Pars Hospital, Tehran, Iran
MD, Assistant Professor of Obstetrics and Gynecology, Fellowship of Infertility and IVF. Shahid Akbar-abadi Hospital, Iran University of Medical Sciences, Tehran, Iran
MD, Resident of Obstetrics and Gynecology, Iran University of Medical Sciences, Tehran, Iran
Shiraz E-Medical Journal: Vol.17, issue 10; e39033
published online: October 22, 2016
article type: Research Article
received: May 11, 2016
revised: October 1, 2016
accepted: October 10, 2016
DOI: https://doi.org/10.17795/semj39033

how to cite: Haghighi L, Nohesara S, Moradi Y, Rashidi M, Moridi M. Psychological Disorders in Women with Spontaneous Preterm Delivery. Shiraz E-Med J. 2016;17(10):e39033. https://doi.org/10.17795/semj39033.

Abstract

Background:

Preterm delivery is a major cause of mortality in infants. The prevalence of preterm delivery is rising over time. Psychological disorders have been associated with preterm delivery. In this study, we aimed to compare the frequency of psychological disorders among women with spontaneous preterm versus term delivery.

Methods:

In this cross- sectional study, psychological disorders in 60 women, who experienced spontaneous term delivery and in 60 women who had spontaneous preterm delivery (gestational age of less than 37 weeks) were examined , using symptom checklist-90-revised questionnaire (SCL-90-R) in Akbarabadi teaching hospital during 2014. The question scales were compared between the two groups, using Chi 2 test and independent t- test.

Results:

The mean age of the participants was 23.58 ± 4.26, and 23.90 ± 4.71 in preterm-delivery and term-delivery groups, respectively (P value = 0.22). The mean score of Symptom checklist-90-revised questionnaire (SCL-90-R) was 102.21 (± 35.81) in women with preterm delivery, and it was 59.14 ± 22.17 in women with term delivery, which was significantly different (P value < 0.001). In addition, the total score and the score for all the subscales of psychological disorder were higher in women with preterm delivery (P value < 0.001).

Conclusions:

Psychological disorders in pregnancy are associated with an increased risk of preterm delivery. Therefore, future studies should focus on finding ways to lower psychological disorders in late pregnancy.

1. Introduction

Preterm labor is defined as regular uterine contractions, which result in changes in cervical length before 37 weeks of pregnancy (1). An estimated 15 million preterm births occur each year worldwide, with a global preterm birth rate of 11.1% (among 184 countries). While more than 60% of these preterm births occur in Sub-Saharan Africa and South Asia, preterm labor remains a significant problem in developed countries. Preterm birth rates remain as high as 9% and above for upper middle- and high-income countries. Preterm birth rose from 10.6% in 1990 to a peak rate of 12.8% in 2006 in the United States; however, this rate declined to 11.39% in 2013. Preterm delivery is an important cause of mortality in infants, with the frequency of 5 - 11% (2-5). A worldwide study reported a rising trend in preterm birth during the past decades (6). Complications of preterm birth can cause permanent disability in the survivors (5). On the other hand, increased rate of preterm delivery poses a significant economic burden on the society (6). Psychological disorders during pregnancy are important predicting factors of birth weight and gestational age, and can lead to preterm delivery (7, 8). Some mechanisms for this include: (1) unhealthy coping and life style behavior; (2) stress-dependent hormones; and (3) psycho-immunological factors (9).

Pregnancy affects mothers physically and mentally (10-12). Mental complications of pregnancy include depression, anxiety disorders, and postpartum psychosis. The prevalence of perinatal major and minor depression is up to 20% (13, 14). Compared to the physical aspect, fewer studies have evaluated the psychological aspect of preterm delivery and its effects on pregnancy outcome. In this study, we compared the prevalence of psychological disorders among women with spontaneous preterm versus term delivery.

2. Materials and Methods

In this cross- sectional study, 60 women with spontaneous term delivery and 60 women with spontaneous preterm delivery (gestational age of less than 37 weeks), who referred to Shahid Akbarabadi teaching hospital from April to October 2014 were recruited. The prevalence of psychiatric disorders was compared between the two groups. All participants provided a written informed consent. The ethics committee of Iran University of Medical Sciences approved the study protocol. We provided an informed consent about the aims to the participants. The data file remained anonymous, and the identity of the participants was protected. The inclusion criteria were as follows: Singleton pregnancy, intact membranes at the time of admission, and normal vaginal delivery. The exclusion criteria were incomplete medical documents, history of discharge or symptoms of infection, intrauterine fetal death, and mothers who needed intensive care. To assess the psychological health of the mothers, we asked them to complete the validated Persian version of the questionnaire 12 to 24 hours post-delivery. Literate women filled out the form individually, whereas in the case of illiterate women, another educated person, who accompanied the mother, filled it out. The symptom checklist-90-revised (SCL-90-R) questionnaire has 90 items and nine subscales that measure somatization, obsessive-compulsive, depression, anxiety, phobic anxiety, hostility, interpersonal sensitivity, paranoid ideation, and psychoticism. Score rating is based on a five-point scale and evaluates the individual mental status during the last week (0 = none, 1 = a little, 2 = to some extent, 3 = much, 4 = very much) (Blacker, 2000). Total scores from 90 to 200 represent a significant mental health problem and a need to visit a psychiatrist, and scores more than 200 represent a serious mental health problem, including psychotic and mood disorders. Scores on each of the nine subscales, which are less than 2.5, represent the absence of a disorder; scores from 2.5 to 3 represent the presence of a disorder; and scores higher than 3 represent the presence of a serious disorder. In 1994, Bagheri Yazdi et al. evaluated the reliability and validity of SCL-90-R test, and found that it could successfully be used as a screening tool in studies. Possible confounders, including: height, weight before pregnancy, mother’s birth weight, marital status, and health behavior (smoking, diet, intake of alcohol during pregnancy), were identified from background data and were matched between the two groups.

2.1. Statistical Analysis

The obtained data were entered into SPSS software version 17 (IBM; Chicago, IL, USA). Mean and standard deviation (SD) were used to describe numerical variables, and relative frequency percentage was used to describe the nominal or categorical variables. Chi 2 test was employed to compare qualitative outcomes between the two groups, and independent t-test was utilized to compare the quantitative outcomes between the two groups.

3. Results

In this study, we studied 120 women: 60 women with spontaneous preterm delivery and 60 with spontaneous term delivery. The mean age of women with preterm delivery was 23.58 ( ± 4.26), and it was 23.90 ( ± 4.71) in women with term delivery, which was not significantly different (P value = 0.22), (Table 1). The mean score of SCL-90-R in women with preterm delivery was 102.21 ( ± 35.81), and it was 59.14 ( ± 22.17) in women with term delivery, which was significantly different (P value < 0.001). The mean scores for each subscale were 2.5 or less in the two groups, but it was significantly higher in the preterm delivery group (P value < 0.03). The mean score of all the nine subscales was higher in the preterm-delivery group. Table 2 demonstrates a summary of the mean score of each of the nine subscales in the two groups. Mental health disorders were only observed in preterm delivery group. Table 3 presents a summary of mental health disorders in the preterm delivery group.

Table 1.

Demographic Data

Term Delivery (%), n = 60Preterm Delivery (%), n = 60P Value
Job0.083
House keeper71.775
Worker28.325
Education0.075
Illiterate9.710.3
Primary school23.626.4
Diploma4538.3
Higher levels21.725
Family income ($)0.764
Less than 815.666566.7
815.66 - 1631.3221.725
More than 1631.3213.38.3
Table 2.

The Mean Score of Each of the Nine Subscales in the Two Study Groups

DeliveryLowest ScoreHighest ScoreMeanSDP Value
PsychosisPreterm0.002.500.96330.61671< 0.001
Term0.001.500.53830.51719
Obsessive compulsivePreterm0.002.501.01670.64733< 0.001
Term0.001.300.56830.43628
Paranoid ideationPreterm0.002.500.83670.65146< 0.001
Term0.001.400.60830.47561
AnxietyPreterm0.102.201.07330.561430.03
Term0.001.900.56670.55040
Interpersonal sensitivityPreterm0.002.501.05170.59674< 0.001
Term0.001.400.65500.49143
Phobic anxietyPreterm0.002.201.11500.63535< 0.001
Term0.001.700.73330.50107
HostilityPreterm0.002.201.09830.58324< 0.001
Term0.001.400.47000.48966
SomatizationPreterm0.001.300.57670.56789< 0.001
Term0.001.100.49870.48757
DepressionPreterm0.001.401.0170.65479< 0.001
Term0.001.100.87680.79865
Total scorePreterm18.57187.14102.214335.81673< 0.001
Term10.00108.5759.142922.17692
Global severity index (GSI)Preterm--67.4113.41< 0.001
Term--50.468.94
Positive symptom distress index (PST)Preterm--22.5913.21< 0.001
Term--39.548.94
The positive symptom distress Index (PSDI)Preterm--2.431.04< 0.001
Term--1.270.57
Table 3.

Distribution of Mental Health Disorders in the Preterm and Term Delivery Groups

GroupsN = 120
PsychosisPretermYes2 (3.3 %)
No58 (96.7%)
TermYes0 (0%)
No60 (100%)
Obsessive compulsivePretermYes1 (1.7 %)
No59 (98.7 %)
TermYes0 (0 %)
No60 (100%)
Paranoid ideationPretermYes2 (3.3%)
No58 (96.7%)
TermYes0 (0%)
No60 (100%)
AnxietyPretermYes0 (0%)
No60 (100%)
TermYes0 (0%)
No60 (100%)
Interpersonal sensitivityPretermYes1 (1.7%)
No59 (98.7 %)
TermYes0 (0 %)
No60 (100%)
Phobic anxietyPretermYes0 (0%)
No60 (100%)
TermYes0 (0%)
No60 (100%)
HostilityPretermYes0 (0%)
No60 (100%)
TermYes0 (0%)
No60 (100%)
SomatizationPretermYes0 (0%)
No60 (100%)
TermYes0 (0%)
No60 (100%)
DepressionPretermYes0 (0%)
No60 (100%)
TermYes0 (0%)
No60 (100%)

4. Discussion

In this study, women with spontaneous preterm delivery had significantly higher scores in all the subscales of the SCL-90-R questionnaire. Bjelanovic et al. reached the same result, using this questionnaire (15). Several studies examined the role of stress on preterm delivery and found that the frequency of preterm delivery increases when more events happen in daily lives of the expecting mothers (16, 17). Some studies on depression and frequency of preterm delivery did not detect any significant relationship (18, 19). Gorsuch et al. and Molfese et al. found a significant relationship between anxiety and frequency of preterm delivery, while some other researchers (19, 20) failed to find such a relationship (20-23). We found a significant association between anxiety (one of the nine subscales) and preterm delivery. Women with spontaneous preterm delivery had higher scores of anxiety. Anxiety and its subsequent psychological response can affect gestational age. Most studies found a significant positive relationship between psychological disorders and the incidence of preterm delivery (24, 25). This could be due to the higher prevalence of cigarette, alcohol and drug use among women with psychological disorders, which affects the age of delivery. In this study, 1 - 2% of women with spontaneous preterm delivery had impairment in four categories of psychosis, paranoia, obsessive-compulsive, and interpersonal sensitivity. Other categories had normal scores similar to women with term delivery. Most of the studies evaluated psychological disorders by means of history taking and based on patients’ explanation. In this study, we used SCL-70-R questionnaire, which is an accurate scale that evaluates psychological disorders in nine different categories. These findings suggest that by reducing stress and psychological distress and through improving social support, it may be possible to enhance the quality of life of these patients.

4.1. Conclusion

Psychological disorders in pregnancy are associated with an increased risk of preterm delivery. Future studies should focus on finding ways to lower psychological disorders in late pregnancy. In addition, psychological disorders were higher in women with spontaneous preterm delivery at any level compared to those with term delivery. Therefore, to prevent adverse outcomes, special care should be provided to those women with psychological disorders. Moreover, proper screening programs and treatment regimens should be designed and implemented to decrease the risk of preterm labor.

References

  • 1.

    Yoon BH, Romero R, Moon JB, Shim SS, Kim M, Kim G, et al. Clinical significance of intra-amniotic inflammation in patients with preterm labor and intact membranes. Am J Obstet Gynecol. 2001;185(5):1130-6. [PubMed ID: 11717646]. https://doi.org/10.1067/mob.2001.117680.

  • 2.

    Afrakhteh M, Ebrahimi S, Valaie N. Prevalence of preterm delivery and its related factors in females referring to Shohada Tajrish Hospital [ in Persian ]. Pejouhandeh quartery research J. 2003;30(7):343-1.

  • 3.

    Eliyahu S, Weiner E, Nachum Z, Shalev E. Epidemiologic risk factors for preterm delivery. Isr Med Assoc J. 2002;4(12):1115-7. [PubMed ID: 12516903].

  • 4.

    Kaufman JS, Alonso FT, Pino P. Multi-level modeling of social factors and preterm delivery in Santiago de Chile. BMC Pregnancy Childbirth. 2008;8:46. [PubMed ID: 18842145]. https://doi.org/10.1186/1471-2393-8-46.

  • 5.

    Asnafi N, Sharifi F, Haian K, Yousefian G. Comparison of early pregnancy outcome with and without premature rupture of memberance. J Babol univ med sci (JBUMS). 2006;8(4 (32)):38-42.

  • 6.

    Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller A, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. The Lancet. 2012;379(9832):2162-72. https://doi.org/10.1016/s0140-6736(12)60820-4.

  • 7.

    Littleton HL, Bye K, Buck K, Amacker A. Psychosocial stress during pregnancy and perinatal outcomes: a meta-analytic review. J Psychosom Obstet Gynaecol. 2010;31(4):219-28. [PubMed ID: 21039328]. https://doi.org/10.3109/0167482X.2010.518776.

  • 8.

    Da Costa D, Dritsa M, Larouche J, Brender W. Psychosocial predictors of labor/delivery complications and infant birth weight: a prospective multivariate study. J Psychosom Obstet Gynaecol. 2000;21(3):137-48. [PubMed ID: 11076335].

  • 9.

    Paarlberg KM, Vingerhoets AJJM, Passchier J, Dekker GA, Van Geijn HP. Psychosocial factors and pregnancy outcome: A review with emphasis on methodological issues. J Psychosomatic Res. 1995;39(5):563-95. https://doi.org/10.1016/0022-3999(95)00018-6.

  • 10.

    Goodman JH, Chenausky KL, Freeman MP. Anxiety disorders during pregnancy: a systematic review. J Clin Psychiatry. 2014;75(10):1153-84. [PubMed ID: 25373126]. https://doi.org/10.4088/JCP.14r09035.

  • 11.

    Siegel RS, Brandon AR. Adolescents, pregnancy, and mental health. J Pediatr Adolesc Gynecol. 2014;27(3):138-50. [PubMed ID: 24559618]. https://doi.org/10.1016/j.jpag.2013.09.008.

  • 12.

    Darvill R, Skirton H, Farrand P. Psychological factors that impact on women's experiences of first-time motherhood: a qualitative study of the transition. Midwifery. 2010;26(3):357-66. [PubMed ID: 18783860]. https://doi.org/10.1016/j.midw.2008.07.006.

  • 13.

    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 Pt 1):1071-83. [PubMed ID: 16260528]. https://doi.org/10.1097/01.AOG.0000183597.31630.db.

  • 14.

    Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR. Prevalence of depression during pregnancy: systematic review. Obstet Gynecol. 2004;103(4):698-709. [PubMed ID: 15051562]. https://doi.org/10.1097/01.AOG.0000116689.75396.5f.

  • 15.

    Bjelanovic V, Babic D, Oreskovic S, Tomic V, Martinac M, Juras J. Pathological pregnancy and psychological symptoms in women. Coll Antropol. 2012;36(3):847-52. [PubMed ID: 23213943].

  • 16.

    Berkowitz GS, Kasl SV. The role of psychosocial factors in spontaneous preterm delivery. J Psychosom Res. 1983;27(4):283-90. https://doi.org/10.1016/0022-3999(83)90050-8.

  • 17.

    Hedegaard M, Henriksen TB, Sabroe S, Secher NJ. Psychological distress in pregnancy and preterm delivery. BMJ. 1993;307(6898):234-9. [PubMed ID: 8369684].

  • 18.

    Copper RL, Goldenberg RL, Das A, Elder N, Swain M, Norman G, et al. The preterm prediction study: Maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks' gestation. AmericaJ Obst Gynecol. 1996;175(5):1286-92. https://doi.org/10.1016/s0002-9378(96)70042-x.

  • 19.

    Perkin MR, Bland JM, Peacock JL, Anderson HR. The effect of anxiety and depression during pregnancy on obstetric complications. BJOG: Int J Obs Gynaecol. 1993;100(7):629-34. https://doi.org/10.1111/j.1471-0528.1993.tb14228.x.

  • 20.

    Gorsuch RL, Key MK. Abnormalities of Pregnancy as a Function of Anxiety and Life Stress. Psychosomatic Med. 1974;36(4):352-62. https://doi.org/10.1097/00006842-197407000-00009.

  • 21.

    Molfese VJ, Bricker MC, Manion LG, Beadnell B, Yaple K, Moires KA. Review Article: Anxiety, depression and stress in pregnancy: A multivariate model of intra-partum risks and pregnancy outcomes. J Psychosom Obst Gynecol. 2009;7(2):77-92. https://doi.org/10.3109/01674828709019593.

  • 22.

    Peacock JL, Bland JM, Anderson HR. Preterm delivery: effects of socioeconomic factors, psychological stress, smoking, alcohol, and caffeine. BMJ. 1995;311(7004):531-5. [PubMed ID: 7663207].

  • 23.

    Wadhwa PD, Sandman CA, Porto M, Dunkel-Schetter C, Garite TJ. The association between prenatal stress and infant birth weight and gestational age at birth: a prospective investigation. Am J Obstet Gynecol. 1993;169(4):858-65. [PubMed ID: 8238139].

  • 24.

    Messer LC, Dole N, Kaufman JS, Savitz DA. Pregnancy intendedness, maternal psychosocial factors and preterm birth. Matern Child Health J. 2005;9(4):403-12. [PubMed ID: 16249944]. https://doi.org/10.1007/s10995-005-0021-7.

  • 25.

    Vigod SN, Villegas L, Dennis CL, Ross LE. Prevalence and risk factors for postpartum depression among women with preterm and low-birth-weight infants: a systematic review. BJOG. 2010;117(5):540-50. [PubMed ID: 20121831]. https://doi.org/10.1111/j.1471-0528.2009.02493.x.