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. Author manuscript; available in PMC: 2010 Jan 1.
Published in final edited form as: Infant Behav Dev. 2008 Nov 11;32(1):10–16. doi: 10.1016/j.infbeh.2008.09.005

Depressed Pregnant Black Women Have a Greater Incidence of Prematurity and Low Birthweight Outcomes

Tiffany Field 1,2, Miguel Diego 1, Maria Hernandez-Reif 3, Osvelia Deeds 1, Vitillius Holder, Saul Schanberg 4, Cynthia Kuhn 4
PMCID: PMC2652730  NIHMSID: NIHMS92381  PMID: 19004502

Abstract

Pregnant black depressed women were compared to pregnant black non-depressed women on self-report stress measures and cortisol levels at mid and late pregnancy and on neonatal outcomes. The depressed women had higher anxiety, anger, daily hassles, sleep disturbance scores and cortisol levels at both prenatal visits. These higher stress levels may have contributed to the greater incidence of prematurity and low birthweight neonatal outcomes noted in the depressed group, and they may partially explain the higher rate of prematurity and low birthweight among black women.

In several U.S. population-based cohort studies, black women have experienced higher incidence of preterm births. For example, in a study by the Missouri Department of Health maternally linked database of births in Missouri between 1989 and 1997, an over-representation of preterm births occurred for black women. This was true independent of maternal, medical and associated economic factors (Kistka, Palomar, Lee, Boslaugh, Wangler, Cole, DeBaum & Muglia, 2007). Preterm births for black women also occurred at an increased frequency (adjusted odds ratio 4.11) on earlier gestations (31 to 33 weeks gestational age). In a Chicago-area hospital sample of 13,010 black and 19,007 white mother-infant pairs, black women were nearly twice as likely as white women to experience preterm (before 37 weeks’ gestation) and very preterm (before 32 weeks’ gestation) delivery that was associated with premature rupture of the membranes or was classified as idiopathic (Schieve & Handler, 1996).

In a meta-analysis of a larger database, preterm births occurred in 9.7% of U.S. singleton births (Reagan & Salsberry, 2005). The rate for black women was double that of white women, and the rate was 25% higher for black than for Hispanic women. These authors suggested that while a number of individual correlates with preterm birth have been identified, race and ethnic differences have not been fully explained. Thus, the negative birth outcomes of low birthweight and preterm delivery have been disproportionately reported for black women, and these ethnic disparities in negative pregnancy outcomes have been relatively unchanged for decades (Zayas, Cunningham, McKee& Janakowski, 2002). However, very little information exists to explain these disparities (Stewart, Dean, Gregorich, Brawarsky & Hass, 2007).

Preterm birth remains the leading cause of perinatal mortality and morbidity and one of the most significant problems in maternal and infant health. In the U.S. it is estimated that 14% of infants are born preterm (National Center for Health Statistics, 2006). Significant morbidity, long-term health consequences, delays in growth and development and the impact on the quality of life of the parents following preterm birth highlight the need for research to explore the mechanisms contributing to preterm birth and the need to develop effective interventions for the management of prenatal depression (Wen, Smith, Yang & Walk, 2004).

The research literature has not only established that black women have an increased risk of preterm birth compared with white women, but also that maternal depressive symptoms are associated with increased risk for preterm birth, particularly among black women. Race-related differences in prenatal depression could help explain racial disparities in preterm births. In a sample of 1,163 women, the mean CES-D (Center for Epidemiological Studies-Depression) scores were significantly higher among black (17.4) than white (13.7) women (Orr, Blazer & James, 2006). Of black women, 49% had CES-D scores higher than 15 compared with 34% of white women. Also, 28% of black women had scores higher than 22 compared with 16% of white women. After adjustment for maternal age, marital status and education, odds ratios for race for both CES-D cut-off scores were approximately 1.5.

Black women reported more symptoms of depression than any other ethnic group in an even larger database of 5,200 cases from the National Maternal and Infant Health Survey of the National Center for Health Statistics (Branch, 2002). In at least one other study, black women were significantly more likely to report depressed mood than Hispanic women even when the contextual variables of age, marital status, income and educational levels were controlled (Segre, O’Hara & Losch, 2006).

Depression is prevalent during pregnancy, affecting 10% to 40% of women (de Tychey, Splitz, Briancon, Lighezzolo, Girvan, Rosati, Thockler, Vicent, 2005; Stowe, Hostetter, & Newport, 2005). Prenatal and perinatal complications associated with depression include higher rates of placental abnormalities (Jablensky, Morgan, Zubrick, Bower & Yellachich, 2005), preeclampsia (Kurki, Hiilesmaa, Raitasalo, Mattila & Ylikorkala, 2000) and spontaneous abortion (Nakano, Oshima, Sugiura-Ogasawara, Aoki, Kitamura & Furukawa, 2004). Depressed women are also more likely to deliver prematurely (Jesse, Seaver, Wallace, 2003; Moncuso, Schetter, Rini, Roesch & Hobel, 2004; Orr, James & Prince 2002), and they often have neonates who require intensive care for postnatal complications including bronchopulmonary dysplasia and intraventricular hemorrhage (Chung, Lau, Yip, Chlu & Lee, 2001).

Neonates of depressed mothers are also at greater risk for being low birthweight (<2500 grams) (Field, Diego, Hernandez-Reif, Schanberg & Kuhn., 2004; Hoffman & Hatch, 2000), with low birthweight being one of the leading causes of neonatal morbidity and mortality (National Center for Health Statistics, 2006). As many as 20% of low birthweight infants experience fetal growth retardation, which continues across the first year of life (Patel, Rodrigues, DeSouza, 2002; Rahman, Iqbal, Bunn, Lovel, Harrington, 2004).

The fetuses and neonates of depressed mothers also differ behaviorally, biochemically and physiologically. Fetuses of depressed women show elevated heart rates (Allister, Lester, Carr & Liu, 2001), greater activity levels (Dieter, Field, Hernandez-Reif, Jones, Lecanuet, Salman & Redzepi, 2001) and increased physiological reactivity (Monk, Sloan, Myers, Ellman, Werner, Jeon, Tager & Fifer, 2004). Newborns of depressed mothers perform less optimally on the Brazelton Neonatal Behavior Assessment Scale, and they show less positive affect (Abrams, Field, Scafidi & Prodromidis, 1995; Field, Diego, Hernandez-Reif, Schanberg, Kuhn, Yando & Bendell, 2004; Lundy, Field & Pickens, 1997; Lundy, Jones, Field, Nearing, Davalos, Pietrro, Schanberg & Kuhn, 1999). Their negative affect continues into later infancy (Huot, Brennan, Stowe, Plotsky, & Walker, 2004), and their cortisol responses to mild stressors are predictive of negative affect even at the toddler stage. Infants of depressed mothers also show inferior mental, motor and emotional development (Patel, et al, 2002; Sondergaard, Olsen, Friss-Hasche, Dirdal, Thrane & Sorensen, 2003) and later social and emotional problems during childhood including less emotional well-being as well as internalizing and externalizing problems (Luoma, Kaukonen, Matymaa, Puura, Tamminen & Salmelin, 2004; O’Connor, Heron, Glover, Golding & ALSPAC Study Team, 2003).

In two studies by our group, we reported associations between prenatal depression, elevated maternal prenatal cortisol and preterm delivery (Field Diego, Hernandez-Reif, Schanberg, Kuhn, Yando & Bendell, 2003, Field et al, 2004). In one of these studies, cortisol levels at 20 weeks gestation was the strongest predictor of premature delivery (Field et al, 2004). Sandman et al (Sandman, Glynn, Schetter, Waolhwa, Garite, Chicz-DeMet, & Hobel, 2006) also reported that women who delivered preterm infants exhibited higher corticotrophin releasing hormone levels and higher cortisol levels during the second trimester.

Other studies have shown that maternal and fetal cortisol levels are significantly correlated, suggesting that maternal cortisol crosses the placenta (Gitau, Fisk, Teixeira, Cameron & Glover, 2001). In the Gitau et al. (2001) study, 34% of the variance in fetal cortisol was attributable to maternal levels. These fetal studies revealed that a significant amount of stressed mothers’ cortisol crosses the placenta, perhaps explaining the correlation between maternal and fetal cortisol (Giannakoulopoulos, Teixeira, Fisk & Glover, 1999; Gitau, et al., 2001).

The purpose of the present study was to determine whether black depressed pregnant women versus black non-depressed pregnant women were more stressed as manifested by higher self-report scores on anxiety, anger, daily hassles and sleep disturbances and higher cortisol levels. The higher stress levels predicted for the depressed women were expected to lead, in turn, to a greater incidence of prematurity and low birthweight.

METHODS

Participants

Three-hundred thirty six pregnant black women were screened for depression on the SCID during their second trimester between 18 and 22 weeks (M=20 weeks) gestation at two Prenatal Ultrasound Clinics at a large university hospital in the U.S. Eligibility criteria were as follows: 1) age greater than 18 years; 2) singleton pregnancy; 3) uncomplicated pregnancy; and 4) a diagnosis of depression based on the SCID (Structured Clinical Interview for DSM IV Diagnosis). Exclusion criteria included: 1) medical illness (diabetes, HIV); 2) other psychiatric conditions (e.g., bipolar disorder); 3) self-reported drug use or medications that might affect cortisol levels including antidepressants and steroids (only 2–5% in our previous samples); and 4) a positive screen for illicit drugs. Power analyses were based on data from our previous study on prenatally depressed women (Field, et al., 2004).

Of the 336 pregnant black women screened, 205 were non-depressed and 131 (39%) were depressed (major depressive disorder). It is not clear if the depression at the 20 week and 32 week periods were current episodes due to the stress of pregnancy or chronic depression. The black pregnant women were distributed as follows: 56% African-American, 26% Haitian and 18% Caribbean black, and same 44% of the black women were immigrants. The women were of low socioeconomic status (M=4.0 on the Hollingshead Index), and 70% of the women had a high school education or less. Marital status was distributed 42% living with partner, 31% single, 22% married and 5% divorced. The women averaged 24.9 years of age, and they had 1.5 children on average. The infants were evenly distributed on gender (50% female). The two groups did not differ on these demographic variables.

Procedures and Measures

The women were recruited at their first ultrasound assessment (M=20 weeks gestation). Following an informed consent, a Research Associate accompanied the mother to a private room where a Structured Clinical Interview for DSM-IV Diagnosis (SCID) was conducted to diagnose depression, and the self-report measures were completed. These included a demographic questionnaire, the CES-D, STAI and STAXI scales and the Daily Hassles scale. In addition, a urine sample was collected for cortisol levels.

The same assessments were made 12 weeks later at a follow-up assessment (M=32 weeks gestation) except that the Daily Hassels Scale was replaced by the Sleep Disturbances Scale because of the significant sleep disturbances noted in later pregnancy. After that assessment, from 32 weeks until delivery, the women were called at weekly intervals to check on their progress and to ensure their compliance in notifying us about their delivery so we could conduct the neonatal assessments. At the neonatal period, the mothers contacted us, and we repeated the assessments made at the prenatal period on the mothers and recorded neonatal outcomes. The birth measures were determined from the medical charts post-delivery (gestational age and birthweight). All assessments were conducted by the trained research associates who were blind to the study’s hypotheses and to the group assignment.

Structured Clinical Interview for DSM-IV Diagnosis

All women in the study were administered the SCID-I (Non-patient edition: research version) to determine a Major Depression Disorder diagnosis and to screen out other disorders including bipolar disorder, schizophrenia and other psychotic disorders. Women with bipolar disorder were omitted because they are likely to be on medications, and they are likely to have manic episodes. The SCID was administered by psychology graduate student research associates following training and with continuing supervision by our clinical psychologist.

Self-Report Measures

The mothers were given the same self-report measures at the prenatal and the neonatal periods: a) Sociodemographic/Social Support Questionnaire; b) Center for Epidemiological Studies – Depression scale (CES-D); c) Sate Anxiety Inventory (STAI); d) State Anger Inventory (STAXI); e) Daily Hassles Scale; and f) Sleep Disturbances Scale.

Sociodemographic/Social Support Questionnaire (Field, 2002)

The Sociodemographic/Social Support Questionnaire is comprised of items concerning age, education, occupation, income, marital status, number of children in the family, ethnicity and social support. Other questions include the use of any drugs, medications (including antidepressants and steroids) and therapies.

Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977)

This 20-item scale was included to assess symptoms of depression. The woman is asked to report on her feelings during the preceding week. The scale has adequate test/retest reliability (.60 over several weeks), internal consistency (.80–.90) and concurrent validity (Wells, Klerman & Deykin, 1987). Test-retest reliability over a one-month period on this sample was .79, suggesting some short-term stability of depressive symptoms. A score of 16 on the CES-D is considered the cutpoint for depression (Radloff, 1991).

State Anxiety Inventory (STAI) (Spielberger, 1988)

This scale was included because many depressed women have comorbid anxiety which also negatively affects prenatal development (Field et al, 2003; Glover, Teixeira, Gitau & Fisk, 1999). This scale was also included because of its relationship to cortisol in our previous studies. The State Anxiety Inventory is comprised of 20 items and is summarized by a score ranging from 20 to 80 and assesses how the woman feels in terms of severity (“not at all” to “very much so”). Characteristic items include “I feel nervous” and “I feel calm.” Research has demonstrated that the State Anxiety Inventory has adequate concurrent validity and internal consistency (r=.83).

State Anger Inventory (STAXI) (Forgays, Forgays, & Spielberger, 1997)

The STAXI provides relatively brief, objectively scored measures of the experience, expression, and control of anger. This scale was included because anger has been associated with depression in our previous studies on pregnant women (Field et al, 2003). The STAXI consists of 22 items on general angry reactions. Four point ratings range from “not at all” (1) to “very much so” (4). Examples of the items are “I am furious”, “I feel like screaming”, “I am quick tempered”, “When I get frustrated, I feel like hitting someone”, “When angry or furious, I control my temper”; “I try to simmer down”. The cut-off score for high anger is 52.

Daily Hassles Scale (Field, Diego, Hernandez-Reif, Schanberg, Kuhn, Yando, & Bendell, 2003)

This scale was developed to assess the degree of hassle being experienced by expectant mothers. The 16 items on a 4-point Likert scale include questions on the hassles associated with people including family members, landlord and friends, and with finances.

Sleep Disturbances Scale (Verran & Snyder-Halperin, 1988)

Questions on this 15-item scale are rated on a visual analogue anchored at one end with effective sleep responses (e.g., “Did not awaken,” “Had no trouble sleeping”) and at the opposite end with ineffective responses (e.g., “Was awake 10 hours,” “Had a lot of trouble falling asleep”). The participants place a mark across the answer line at the point that best reflects their last night’s sleep. A reliability coefficient of .82 has been reported for this scale. The sleep disturbances subscale was used in this study because of its association with depression in other pregnant women samples (Field, Diego, Hernandez-Reif, Figueiredo, Schanberg, & Kuhn, 2007).

Cortisol Assays

In order to measure the excretion of urinary free cortisol, first morning urine samples were collected on the assessment days (20 and 32 weeks gestation). They were then frozen and sent to the lab of Drs. Schanberg and Kuhn for assays. Total excretion of cortisol in urine was determined using HPLC with UV detection at 254nm. Cortisol from the urine was extracted with methylene chloride using methylprednisolone as an internal standard. Assays were then done on a reverse phase chromatographic system. With the HPLC procedure the lower limit of detection for cortisol is about 5mg/ml. of urine.

Birth Measures

These included gestational age at delivery and birthweight. Gestational age was determined by best obstetric estimate with a combination of last menstrual period and early uterine size and was confirmed by obstetric ultrasonographic biometry.

RESULTS

ANOVAs were conducted on the measures taken at the first and second prenatal visits and the postnatal visit. As can be seen in table 1, the depressed versus non-depressed black women had: 1) higher depression, anxiety, anger and daily hassles scores at the first prenatal visit; 2) higher depression, anxiety, anger and sleep disturbances scores at the second prenatal visit (M=32 weeks) as well as higher cortisol levels; and 3) higher depression, anxiety, anger and sleep disturbances scores at the postnatal visit. Also, at the first prenatal visit, a greater percentage of the depressed mothers answered positively to: 1) having a stressful situation during pregnancy (45% of the depressed mothers versus 28% of non-depressed mothers, χ2=8.62, p=.003); 2) not being “happy when they found out they were pregnant” (40% versus 25%, χ2=6.86, p=.009); and 3) their partners not being “happy when they found out they were pregnant” (21% versus 9%, χ2=7.60, p=.006). As can be seen in table 2, the depressed versus non-depressed black women had less optimal neonatal outcomes including: 1) lower gestational age; 2) a greater incidence of prematurity; 3) lower birthweight; and 4) a lower birthweight percentage for gestational age.

Table 1.

Means for prenatal self-report measures for depressed versus non-depressed black pregnant women after controlling for socioeconomic status, marital status and education.

Group
Measure Depressed Non-depressed F p
First Prenatal Visit
Depression (CES-D) 24.7 (6.9) 9.0 (3.8) 529.15 .000
Anxiety (STAI) 43.0 (9.8) 33.7 (7.6) 74.09 .000
Anger (STAXI) 20.3 (6.2) 16.0 (4.4) 40.29 .000
Daily Hassles 26.7 (8.8) 21.6 (6.8) 18.97 .000
Second Prenatal Visit
Depression (CES-D) 17.31 (8.4) 11.2 (7.4) 7.59 .008
Anxiety (STAI) 43.9 (9.2) 35.1 (10.2) 9.15 .004
Anger (STAXI) 21.7 (9.1) 16.0 (6.0) 4.36 .05
Sleep Disturbances 52.7 (18.4) 36.6 (21.2) 8.68 .005
Cortisol level 71.7 10.5 6.69 .01
Postnatal Visit
Depression (CES-D) 20.6 (9.4) 12.2 (8.2) 46.86 .000
Anxiety (STAI) 40.4 (9.7) 33.6 (7.8) 25.58 .000
Anger (STAXI) 18.1 (5.4) 16.0 (5.0) 7.43 .007
Sleep Disturbances 57.7 (9.0) 43.4 (15.6) 4.47 .05
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Table 2.

Means for neonatal outcome measures for depressed versus non-depressed black pregnant women after controlling for socioeconomic status, marital status and education.

Group
Measure Depressed Non-depressed F p
Gestational Age 37.7 39.1 4.51 .05
Incidence Prematurity (%) 12.0 6.3 5.38 .05
Birthweight 3245.7 3310.2 5.27 .05
Birthweight Percentage for GA 39.9 45.5 4.22 .05
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DISCUSSION

As some have suggested, very little information exists to explain the disparities in negative pregnancy outcomes for black women that have existed for decades (Stewart et al, 2007). These disproportionately high rates of prematurity and low birthweight appear to have occurred independent of maternal medical and economic factors (Kistka et al, 2007).It should be noted that inasmuch as this sample was low SES, the data should not be generalized to all black women. The results of the current study suggest that prenatal depression and high stress levels may contribute to the negative pregnancy outcomes for black women. Across pregnancy, the depressed black women versus the non-depressed black women had higher rates not only of depressive symptoms but also higher scores on anxiety, anger, daily hassles and sleep disturbances, all of which have been associated with less optimal neonatal outcomes in previous studies (Field et al, 2003, 2004, 2005). A greater number of the depressed mothers also specifically reported having experienced “a stressful situation during pregnancy”, and a greater number reported “not being happy” as well as their “partner not being happy” with the pregnancy. Although the degree to which these stressors may contribute to elevated cortisol is unclear, the greater increase in cortisol levels in the depressed women is consistent with their self-reported depression and anxiety symptoms.

Cortisol, in turn, may have contributed to the lower gestational age and the greater incidence of prematurity in this group, as cortisol has been the strongest predictor of preterm delivery in at least two other pregnant women samples (Field et al, 2004; Sandman et al, 2006). Cortisol levels may be a cost-effective screening measure for identifying women at high-risk for prematurity and low birthweight outcomes.

Interventions that lower cortisol, such as massage therapy (Field, Diego, Hernandez-Reif, Schanberg, & Kuhn, 2004) and yoga (Kamei, Toriumi, Kimura, Ohno, Kumano, & Kimura, 2000), could then be provided to decrease this risk. Other interventions that could be explored include exercise, relaxation, stress management, coping skills, support groups and psychotherapy and combinations thereof including the recent study in which group psychotherapy combined with massage therapy led to decreased prenatal cortisol levels.

In conclusion, further research is needed on the effects of prenatal cortisol as well as other study hormones and neurotransmitters to identify those at risk for prematurity and low birth weight infant outcomes. Interventions that have been noted to lower cortisol in other samples can then be researched with prenatally depressed women.

Acknowledgments

We would like to thank the women who participated in this study. This research was supported by a Merit Award (MH46586), Senior Research Scientist Awards (MH00331 and AT001585) and a March of Dimes Grant (# 12-FYO3-48) to Tiffany Field and funding from Johnson and Johnson Pediatric Institute to the Touch Research Institutes.

Footnotes

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