Prevalence and predictors of antenatal depressive symptoms among Chinese women in their third trimester: a cross-sectional survey

Antenatal depression has been identified as a serious health problem, but is a neglected component of care for women in the third trimester of pregnancy [1,2]. While postnatal depression is now well recognised [3], antenatal depression has not been studied extensively [4]. Antenatal depression is a depressive episode that begins in pregnancy, and is often a predictor of postnatal depression [5]. Research in the U.S. reported that 33% of postnatal depression begins in pregnancy [6]. In addition, some evidence indicates there could be a higher prevalence of depressive symptoms during pregnancy than in the postnatal period [7], as diagnosis of antenatal depression is difficult because the physiological signs of pregnancy overlap with the symptoms of antenatal depression [5]; and healthcare providers mainly focus on the physical health aspects of pregnancy [8].

The prevalence rate of antenatal depression has been reported at up to 42.7% [9]. Symptoms of antenatal depression include sadness during most of the day, hopelessness, lack of interest and fatigue, trouble sleeping and eating, along with extreme irritability and an inability to feel happiness or joy [10]. There is evidence that antenatal depression can have adverse effects on the mother, her child, and the family as a whole [2,11]. First, adverse effects for mothers include noncompliance with prenatal care; reduced sleep; clinical implications such as increased uterine irritability, pre-eclampsia, postpartum bleeding, preterm delivery and even suicide [1,10]. Second, negative outcomes associated with their babies include low birth weight, smaller head circumference, lower Apgar scores, and unhealthy behaviours; while among children they include smoking and alcohol consumption [1,12]. Children of depressed mothers have a high risk of emotional and behavioural problems and cognitive development delay [13]. Third, antenatal depression also has negative impacts on families. The most significant consequences of antenatal depression may negatively influence social and personal adjustment, marital relationships, and mother-infant interactions [14].

Risk factors for depression during pregnancy are largely similar to those for depression at other times, although treatment considerations for antenatal depression differ [2,10]. Research has indicated that some of the most common risk factors for antenatal depression include social support, life satisfaction and perceived stress [1]. A review of 57 studies indicated that some of the most important risk factors for antenatal depression are life stress, a history of depression, lack of social support, unintended pregnancy, Medicaid insurance, domestic violence, lower income, lower education, smoking, and single status [11,15]. Other studies have identified previous pregnancy loss, pregnancy problems, unplanned pregnancy and fear of childbirth as risk factors for antenatal depression [16]. There appears to be a paucity of research examining risk factors for antenatal depression among Chinese women.

Given the high prevalence of antenatal depression and its serious consequences, efforts should be made to identify risk factors to assist in prevention, identification and treatment [16]. Research literature on antenatal depression is limited, especially in developing countries such as China. There is a lack of research regarding antenatal depression and its predicting factors. Knowledge of risk factors for antenatal depression in clinical settings can alert healthcare providers to the possibility of a depressive disorder [14]. This study, therefore, aims to identify the prevalence of third trimester antenatal depressive symptoms and its predictors among Chinese women.

A cross-sectional survey was used to identify the prevalence of antenatal depressive symptoms among Chinese pregnant women in their third trimester and its predicting factors.

This study provides a cross-sectional snapshot of the prevalence and relevant predictors of antenatal depressive symptoms among Chinese women in their third trimester. The prevalence of antenatal depressive symptoms found in the current study was 28.5%. A meta-analysis of 21 studies concluded the mean prevalence of depression across the antenatal period was 10.7% [29]. Hence, the prevalence of antenatal depressive symptoms in this study was higher than in those studies in both developed and developing countries. It is possible that poor identification and measurement of depression during pregnancy directly contributes to some depressive women being misclassified as postpartum onset [2].

For demographic risk factors, being in a younger age group was a statistically protective factor of antenatal depressive symptoms. This is consistent with previous research by Koleva, and colleagues [11], who found that an older age was a significant predictor of antenatal depression. Obviously, pregnancy at an older age, especially pregnancy higher than 35 years old, is usually categorized as high risk pregnancy, so older women are more likely to be vulnerable and feel depressed. In relation to the predictor factor of miscarriage history, Koleva, and colleagues [11], found that the number of previous pregnancies was significantly associated with antenatal depression. While previous research suggests the strongest risk factor for antenatal depressive symptoms was a history of depression [30], the present study lacked information on any past psychiatric episode, and whether there was a family history of depression.

In terms of the psychosocial predictors of antenatal depressive symptoms, both personality traits of psychoticism and neuroticism were significant risk factors (OR = 1.06 and 1.07, respectively). Consistent with other research [16,31], active coping and total social support were significant protective factors for antenatal depressive symptoms. Hence, active coping strategies and social support would be possible mediators between demographic and clinical risk factors and antenatal depressive symptoms among Chinese pregnant women. Findings in this study can inform healthcare providers to adjust antenatal care accordingly with a more psychological aspect for care, such as training pregnant women in more active coping strategies to obtain more social support.

Fostering social support could be carried out through community development strategies, including community participation. For example, community peer support group interventions could be useful strategies in helping women obtain adequate support as they enter motherhood. While the development of perinatal mental health services in China is still in its infancy, integrated models of perinatal mental health service delivery - including identification and prevention, which are in use in developed countries - could be used to guide Chinese perinatal mental health service development [2]. Furthermore, integrating perinatal mental health into routine maternity care should emphasise a primary health care approach. In cases of severe depression, antenatal care providers should refer patients to psychiatrists, in order to obtain specialist care. While some women will require referral to a psychiatrist, greater emphasis should still be placed on setting up community support systems that adequately support women.

Several study limitations should be taken into account. Study participants were restricted to women in their third trimester of pregnancy, therefore study findings cannot be generalised to the first and second trimesters. In addition, this study adopted a cross-sectional study design precluding causal conclusions. Longitudinal study designs are needed to monitor these depressive women and establish the causality of predictors for antenatal depressive symptoms. Another study limitation was the under-representation of women who were primiparous, married, and mainly coming from rural areas. Future research replicating this study with more multiparous urban pregnant women would be beneficial for the representativeness of the study population.

Despite these limitations, study findings have important implications. For practice, antenatal care providers should routinely screen all pregnant women for depressive symptoms, as a U.S. study has found that 33% of postnatal depression begins during pregnancy [6]. Additionally, antenatal care providers should refer women at high risk of depression to psychiatric services whenever necessary [1]. Targeted interventions for antenatal depression may reduce both symptom severity of depression and assist in the amelioration of pregnancy pressures. Implementation and empirical validation of targeted antenatal interventions are proposed for future research [16]. For education, relevant curricula for maternity care courses should include routine screening tools for antenatal depression, and incorporate evidence-based health care lectures on depression during pregnancy [1].

Depressive symptoms were relatively high in hospital antenatal attendees in a suburban city in South China. While active coping strategies and social support were significant protecting factors of depressive symptoms, significant risk factors include older age, a history of irregular menstruation and/or miscarriage, financial worries, and pregnancy pressure. Personality traits of psychoticism or neuroticism were also significant risk factors of depressive symptoms. Pregnancy brings major challenges for any women’s physical, social and psychological health. Due to the prevalence of depression during pregnancy and its negative impacts on both mother and infant, mental health should be made an integral part of routine obstetric care in China. Possible strategies could include close collaboration between psychiatry services and routine preventive obstetric services, and routinely conducting antenatal screening for depression and other psychiatric illness.