HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by MCKEE, M. D. Articles by ZAYAS, L. Search for Related Content PubMed PubMed Citation Articles by MCKEE, M. D. Articles by ZAYAS, L.

Health-Related Functional Status in Pregnancy: Relationship to Depression and Social Support in a Multi-Ethnic Population

From the Department of Family Medicine, Albert Einstein College of Medicine, Bronx, New York, and the Center for Hispanic Mental Health Research, Graduate School of Social Service, Fordham University, New York, New York.

Address reprint requests to: M. Diane McKee, MD, MS Department of Family Medicine Albert Einstein College of Medicine 1300 Morris Park Avenue Bronx, NY 10461 E-mail: mckee{at}aecom.yu.edu

	Abstract

Top Abstract Materials and Methods Results Discussion References

 
Objective: To describe perceived well-being and functional status during uncomplicated late pregnancy among low-income minority women, and to examine the relationship of functional status to depression and social support.

Methods: Hispanic and black women with low-risk pregnancies completed an interview consisting of demographics, the Medical Outcomes Study Short Form 36 (SF-36), Beck Depression Inventory-II (BDI-II), and the Norbeck Social Support Questionnaire.

Results: Of the 155 women who were eligible and asked to participate, 41 refused for a participation rate of 74%. Results of the SF-36 showed lowest perceived well-being in the vitality and physical role dimensions. Depressive symptomatology was high, with a mean BDI score of 15 (standard deviation 8.6). Using a BDI score of 14 as the cutoff point, over half of the sample was categorized as having significant depressive symptoms. Significantly lower functional status was seen for depressed subjects in all subscales of the SF-36 compared with nondepressed subjects. Although functional status was negatively correlated with BDI score in all dimensions (r = .23–.69), correlation of SF-36 scores with social support was much weaker (r = .06–.24).

Conclusion: Elevated levels of depressive symptomatology are strongly correlated with lowered health-related functioning and perceived well-being. Social support is not associated with increased physical or emotional well-being but is weakly associated with mental health as measured by the SF-36.

Though a joyful event for most women, pregnancy is often a stressful period both physically and mentally.¹ Even in normal pregnancies, physical and emotional changes can alter the ability of women to carry out their usual roles.² The primary goal of health care during pregnancy is the achievement of the best possible maternal and fetal outcome. There is evidence that perceived well-being during pregnancy positively predicts the mother’s early postnatal role adjustment.^3,4 Prior studies have shown that the changes of pregnancy may detract from overall quality of life.² Hueston and Kasik-Miller,⁵ in a cohort of white women with normal pregnancies, found health-related functional status changes for physical but not emotional aspects of health as measured by the Medical Outcomes Study-Short Form 36 (SF-36). This study found that sociodemographic factors such as employment, level of income, and presence of spouse or partner support had only a small influence on quality of life. Assessments of quality of life in other pregnant populations are limited.⁶

Depression is common among women of childbearing age, and is more common among low-income ethnoracial minority groups.^7–9 Rates of depression in pregnancy have ranged from 10–30% depending on the diagnostic criteria used and population studied.^10,11 Depressed mood during pregnancy places women at risk for postpartum depression,¹¹ is associated with adverse obstetric outcomes including low birth weight¹² and preeclampsia,¹⁰ and increases the likelihood that women will engage in adverse health behaviors such as smoking.¹³ Undiagnosed and untreated depression is especially serious because of its potential to affect parenting behavior and indirectly affect the offspring.^14,15

Wells et al¹⁶ found that depressive disorder and depressive symptoms in the absence of disorder are associated with limitations in multiple dimensions of patient well-being. Thus, it may be important to direct treatment during pregnancy toward improvement in emotional and physical function and quality of life. The purpose of this study was to describe well-being (perceived quality of life and functional status) among low-income minority women in late pregnancy, and to assess the relationship of functional status to social support and depression in this population.

	Materials and Methods

Top Abstract Materials and Methods Results Discussion References

 
This study was approved by the institutional review boards of Fordham University, Albert Einstein College of Medicine, and Montefiore Medical Center. Between November 1998 and July 2000, we conducted chart reviews of women over the age of 18 receiving prenatal care at three community health centers serving low-income populations in the Bronx, New York. Women were excluded if greater than 32 weeks’ gestation at the time of review, other than black or Hispanic, found to have a major mental illness, active substance abuse, or significant medical or obstetric complications of pregnancy, including any condition requiring referral to a high-risk obstetric provider. Eligible subjects were invited to participate in a randomized trial of a social work intervention during pregnancy. Subjects were informed that they might receive services to help decrease the stresses they encounter in their lives which sometimes lead to depression.

Subjects who consented to participate in the randomized trial completed a baseline interview, in English or Spanish, consisting of demographic data and multiple questionnaires assessing depression, social support, functional status, life events, and perceived parenting competency. The initial interview was administered by black or Hispanic female research assistants in the late second or early third trimester (mean 28.3 weeks, standard deviation [SD] = 2.7). Initial data were collected at this point in pregnancy because 1) depressive symptomatology peaks in late pregnancy,¹¹ 2) most exclusion criteria have been identified, and 3) we sought inclusion of as many women as possible (including late care seekers). This analysis uses data from the baseline interviews and questionnaires, completed before randomization, of all study participants.

Health-related functional status was measured using the SF-36,^17–19 which obtains subject perceptions of general health, bodily pain, physical role, emotional role, social functioning, mental health, vitality, and physical functioning. This measure has been used extensively to evaluate health-related functional status in a variety of populations. It has been used to assess the effects of physical and psychiatric problems on that status.^16,20 These dimensions are described in Table 1. An absolute score for each dimension of health in the SF-36 was transformed into a score of 0–100, indicating the percentage of the possible score, with a score of 100 representing optimal health.

Social support was assessed using the 1995 Norbeck Social Support Questionnaire^30,31 (NSSQ), an instrument developed for use in pregnancy. This measure allows subjects to list and rate their own social support network, first by naming all the persons available to them for support and then indicating how much support is available from these people in certain everyday situations. There are three summary variables derived from the NSSQ: total functional support (ie, affect, affirmation, and aid), total network (total number in network, frequency of contact, duration of relationships), and total loss (number of different types of persons and amount of support lost).

Data were analyzed using the SPSS 9.0 (SPSS Inc., Chicago, IL) statistical program. Because of the ordinal nature of the data from the BDI, NSSQ, and SF-36, nonparametric statistics were used. Depressive symptoms as measured by the BDI were also treated as dichotomous variables to compare depressed and non-depressed subjects with regard to social support and functional status. Kruskal-Wallis one-way analyses of variance were used to examine these group differences. The relationships of health-related functional status, depression, and social support were evaluated using a Spearman correlation matrix to examine the scores.

	Results

Top Abstract Materials and Methods Results Discussion References

 
From the potential sample of women who initiated prenatal care at the health centers during this period (n = 491), 230 were not eligible to participate. Nonmutually exclusive reasons for ineligibility included: age less than 18 years (n = 43), prior stillbirth or neonatal death (n = 13), human immunodeficiency virus infection (n = 5), major mental illness (n = 8), high-risk pregnancies (n = 41), and/or gestational age greater than 32 weeks at the time of review (n = 66). Some eligible women (n = 106) could not be contacted to be recruited. Of the 155 women who were eligible and asked to participate, 41 refused and 114 agreed, for a participation rate of 74%. Of the 114 women who participated, one had responses very different from the average. This 38-year-old black subject had scores greater than 4 SDs above the mean on several of the measures. It was determined that she was an outlier and her responses were excluded from data analysis. Finally, eight subjects had missing data and were therefore not included in data analysis. This resulted in a total of 105 participants.

Demographics of participants are described in Table 2. Women had a mean age of 24 years (standard deviation = 5.0). Subjects identified themselves as Puerto Rican (43%), black (39%), Dominican (11%), and other (7%). The majority reported that they grew up in the United States. The majority of the subjects’ parents were born in the United States, with the second largest birth-place being Puerto Rico (30% of fathers and 27% of mothers). Most subjects completed 12 years of schooling. Twenty-three percent of women were full-time homemakers, 12% worked full time, 8% worked part-time, and the remainder were unemployed. Single mothers made up just over half of subjects (52%). Subjects began prenatal care at a mean of 13 weeks’ gestation with a range of 5 to 27 weeks. A substantial minority of subjects were nulliparous (37%).

	Discussion

Top Abstract Materials and Methods Results Discussion References

Over half of the healthy pregnant women in our study showed elevated levels of depressive symptoms. Our results are similar to Wells et al¹⁶ in that depression is strongly related to a global reduction in the dimensions of perceived well-being. The number of depressive symptoms is strongly correlated with all measures of physical and mental well-being as measured by the SF-36. Of note, the decrease in functional status is not limited to emotional dimensions, but is pronounced as well in the physical subscales measured by the SF-36 instrument.

Prior studies have demonstrated that maternal depression may have a deleterious effect on childbearing practices, and ultimately, infant behavioral outcomes.^15,32 It is not known if the pronounced decrease in multiple dimensions of health-related functional status and perceived well-being may also indirectly effect the offspring. Substantial alterations in functional status for many women may potentially affect health utilization in important ways such as adherence to treatment recommendations and appointment keeping for mothers and their children. The increase in depressive symptoms and decrease in multiple dimensions of functional status seen in our sample suggest that low-income ethnoracial minority women may experience greater levels of distress during pregnancy than other women. Of note, the number of supports available was unrelated to functional status, ie, having more supports did not help to reduce the impact of depression on functional status. This suggests not only a need for health care providers to be sensitive to cultural factors, but that case management services for these low-income women may reduce the deleterious impact of depression during pregnancy.

Some limitations of this research should be considered. Despite substantial experience with the BDI in pregnancy, there is no consensus on the appropriate cutoff point to identify depression during pregnancy. Holcomb et al²⁵ found that a cutoff of greater than 16 in their population (with a mean BDI score of 11) resulted in a positive predictive value of 0.5 and a negative predictive value of 0.98. We chose to use 14 or higher, increasing sensitivity at the expense of specificity. Nevertheless, the average score in our sample is substantially higher than previous studies with pregnant women^24–29 suggesting that there is more distress in this population. Similarly, the global decreases in functional status seen among those who scored in the depressive range on the BDI suggest that these symptoms have clinical significance.

Because our sample was limited to low-income minority women, it is not possible to untangle the relative contribution of ethnicity, environment, and poverty. Thus, comparison of our findings to the Hueston and Kasik-Miller sample⁵ is limited by population differences other than ethnicity. Future studies should compare functional status in pregnancy across socioeconomic class within the same ethnic group as well as across various ethnic groups within the same socioeconomic class. We measured functional status at only one point in pregnancy, though Hueston and Kasik-Miller⁵ demonstrated that the SF-36 scores are not static as pregnancy progresses. Thus, our comparison is to the average of the scores in the Hueston study though our measurement was in the early third trimester. Future research should evaluate the relationship between functional status and depression at multiple points throughout pregnancy. Finally, subjects who entered prenatal care in the third trimester may be a very different population, not represented in our sample. Similarly, we do not know whether those women who refused participation had better, worse, or equal profiles.

	Footnotes

 
This work was supported by grant R24 MH57936 from the National Institute of Mental Health.

PII S0029-7844(01)01377-1

Received September 25, 2000. Received in revised form January 24, 2001. Accepted February 15, 2001.

	References

Top Abstract Materials and Methods Results Discussion References

 
1. Rofe Y, Blittner M, Lewin I. Emotional experiences during the three trimesters of pregnancy. J Clin Psychol 1993;49:3–12.[Medline]

2. Gjerdingen D, Froberg DG, Fontaine P. The effects of social support on women’s health during pregnancy, labor and delivery, and the postpartum period. Fam Med 1991;23:370–5.[Medline]

3. Paarlberg KM, Vingerhoets AJ, Passchier J, Dekker GA, Heinen AG, van Geijn HP. Psychosocial factors and pregnancy outcome: A review with emphasis on methodological issues. J Psychosom Res 1995;39:563–95.[Medline]

4. Mothander PR. Maternal adjustment during pregnancy and the infant’s first year. Scand J Psychol 1992;33:20–8.[Medline]

5. Hueston WJ, Kasik-Miller S. Changes in functional health status during normal pregnancy. J Fam Pract 1998;47:209–12.[Medline]

6. Larrabee KD, Monga M, Eriksen N, Helfgott A. Quality of life assessment in pregnant women with the human immunodeficiency virus. Obstet Gynecol 1996;88:1016–20.[Abstract]

7. Vera M, Alegria M, Freeman D, Robles R, Pescosolido B, Pena M. Depressive symptoms among Puerto Ricans: Island poor compared with residents of NYC area. Am J Epidemiol 1991;134:502–10.[Abstract/Free Full Text]

8. Dressler WW, Badger LW. Epidemiology of depressive symptoms in Black communities. J Nerv Ment Dis 1985;173:1–9.

9. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12 month prevalence of DSM-III-R psychiatric disorders in the US: Results from the National Comorbidity Survey. Arch Gen Psych 1994;52:8–19.

10. Kurki T, Hiilesmaa V, Raitasalo R, Mattila H, Ylikorkala O. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstet Gynecol 2000;95:487–90.[Abstract/Free Full Text]

11. Gotlib IH, Whiffen VE, Mount JH, Milne K, Cordy NI. Prevalence rates and demographic characteristics associated with pregnancy and the postpartum. J Consult Clin Psychol 1989;57:269–74.[Medline]

12. Paarlberg KM, Vingerhoets JJM, Passchier J, Dekker GA, Heinen AG, van Geijn HP, et al. Psychosocial predictors of low birth-weight: A prospective study. Br J Obstet Gynaecol 1999;106:834–41.[Medline]

13. Zuckerman B, Amorao H, Baucher H, Cabral H. Depressive symptoms during pregnancy: Relationships to poor health behaviors. Am J Obstet Gynaecol 1989;160:1107–11.[Medline]

14. Zayas LH. Family functioning and child rearing in an urban environment. J Dev Behav Pediatr 1995;16(Suppl):21–4.[Medline]

15. Field T. Maternal depression effects on infants and early interventions. Prev Med 1998;27:200–3.[Medline]

16. Wells KB, Stewart A, Hays RD, Burman A, Rogers W, Daniles M, et al. The functioning and well-being of depressed patients: Results from the Medical Outcomes Study. JAMA 1989;262:914–9.[Abstract]

17. Ware JE. Short form-36 health survey: Manual and interpretation guide. Boston, MA: The Health Institute, New England Medical Center, 1993.

18. Ware JE, Sherbourne CD. The Medical Outcomes Study 36-item short-form health survey (SF-36) I: Conceptual framework and item selection. Med Care 1992;30:473–83.[Medline]

19. Brazier JE, Harper R, Jones NMB, O’Cathain A, Thomas KJ, Usherwood T, et al. Validating the SF-36 health survey questionnaire: New outcome measure for primary care. BMJ 1992;305: 160–4.

20. Nelson E, Conger B, Douglass R, Gephart D, Kirk J, Page R, et al. The function and well-being of primary care patients. JAMA 1983;249:3331–8.[Abstract]

21. Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy of depression. New York: Guilford Press, 1979.

22. Perez-Stable EJ, Miranda J, Munoz RG, Ying Y. Depression in medical outpatients: Underrecognition and misdiagnosis. Arch Intern Med 1990;150:1083–8.[Abstract]

23. Coulehan JL, Schulberg HC, Block MR. The efficiency of depression questionnaires for case-finding in primary medical care. J Gen Intern Med 1989;4:541–7.[Medline]

24. Behrenz K, Monga M. Fatigue in pregnancy: A comparative study. Am J Perinatol 1999;16:185–8.[Medline]

25. Holcomb W, Stone L, Lustman P, Gavard JA, Mostello D. Screening for depression in pregnancy: Characteristics of the Beck Depression Inventory. Obstet Gynecol 1996;88:1021–5.[Abstract]

26. O’Hara M, Neunaber D, Zekoski E. Prospective study of postpartum depression: Prevalence, course, and predictive factors. J Abnorm Psychol 1984;93:158–71.[Medline]

27. Watson J, Elliott S, Rugg A, Brough D. Psychiatric disorder in pregnancy and the first post-partum year. Br J Psychiatry 1984;144: 453–62.[Abstract/Free Full Text]

28. Steer R, Scholl T, Beck A. Revised Beck Depression Inventory scores of inner-city adolescents: Pre and postpartum. Psychol Rep 1990;66:315–20.[Medline]

29. Pfost K, Stevens M. The relationship of demographic variables, antepartum depression, and stress to postpartum depression. J Clin Psychol 1990;46:588–92.[Medline]

30. Norbeck JS, Lindsey AM, Carrieri VL. Further development of the Norbeck Social Support Questionnaire: Normative data and validity testing. Nursing Res 1983;32:4–9.

31. Norbeck JS, Lindsey AM, Carrieri VL. The development of an instrument to measure social support. Nursing Res 1981;30:264–9.

32. Hart S, Jones NA, Field T, Lundy B. One-year old infants of intrusive and withdrawn depressed mothers. Child Psychiatry Hum Dev 1999;30:111–20.[Medline]

This article has been cited by other articles:

				C. Westdahl, S. Milan, U. Magriples, T. S. Kershaw, S. S. Rising, and J. R. Ickovics Social Support and Social Conflict as Predictors of Prenatal Depression Obstet. Gynecol., July 1, 2007; 110(1): 134 - 140. [Abstract] [Full Text] [PDF]

				W. K. Nicholson, R. Setse, F. Hill-Briggs, L. A. Cooper, D. Strobino, and N. R. Powe Depressive Symptoms and Health-Related Quality of Life in Early Pregnancy. Obstet. Gynecol., April 1, 2006; 107(4): 798 - 806. [Abstract] [Full Text] [PDF]

				F Forger, M Ostensen, A Schumacher, and P M Villiger Impact of pregnancy on health related quality of life evaluated prospectively in pregnant women with rheumatic diseases by the SF-36 health survey Ann Rheum Dis, October 1, 2005; 64(10): 1494 - 1499. [Abstract] [Full Text] [PDF]

				M. E. Coussons-Read, M. L. Okun, M. P. Schmitt, and S. Giese Prenatal Stress Alters Cytokine Levels in a Manner That May Endanger Human Pregnancy Psychosom Med, July 1, 2005; 67(4): 625 - 631. [Abstract] [Full Text] [PDF]

				E. A. Howell, P. A. Mora, C. R. Horowitz, and H. Leventhal Racial and Ethnic Differences in Factors Associated With Early Postpartum Depressive Symptoms Obstet. Gynecol., June 1, 2005; 105(6): 1442 - 1450. [Abstract] [Full Text] [PDF]

				M Ostensen, L Fuhrer, R Mathieu, M Seitz, and P M Villiger A prospective study of pregnant patients with rheumatoid arthritis and ankylosing spondylitis using validated clinical instruments Ann Rheum Dis, October 1, 2004; 63(10): 1212 - 1217. [Abstract] [Full Text] [PDF]

				L. H. Zayas, M. D. McKee, and K. R. B. Jankowski Adapting Psychosocial Intervention Research to Urban Primary Care Environments: A Case Example Ann. Fam. Med, September 1, 2004; 2(5): 504 - 508. [Abstract] [Full Text] [PDF]

				H. A. Bennett, A. Einarson, A. Taddio, G. Koren, and T. R. Einarson Prevalence of Depression During Pregnancy: Systematic Review Obstet. Gynecol., April 1, 2004; 103(4): 698 - 709. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by MCKEE, M. D. Articles by ZAYAS, L. Search for Related Content PubMed PubMed Citation Articles by MCKEE, M. D. Articles by ZAYAS, L.