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Prevalence and Factors Associated With Depressive Symptomatology Among Women Before Termination of Pregnancy for Fetal Anomaly

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Fetal anomalies, also known as birth defects, can be defined as structural or functional anomalies that occur during intrauterine life. Over the past few decades, improvements in prenatal screening and prenatal diagnosis have increased the detection rate of fetal anomalies diagnosed in early pregnancy (Carlson & Vora, 2017). According to the World Health Organization (2016), every year an estimated 303,000 newborns die from congenital abnormalities within 4 weeks after birth. The incidence of birth defects in China is high at 5.6% of total births per year (Ministry of Health of the People’s Republic of China, 2012). When a severe fetal anomaly is diagnosed, the majority of women decide to terminate their pregnancy (Jeon et al., 2012). However, women go through a complicated period and have serious psychological issues before termination (Qin et al., 2019).

Following a prenatal diagnosis of fetal anomaly and before termination of pregnancy, women experience emotional shock and decision-making difficulties. Their reactions have been described as intense sadness and negative emotions, such as depression, anxiety, grief, hopelessness, and guilt (Benute et al., 2012; Kaasen et al., 2017). Following the diagnosis, they are confronted with a difficult decision: either to continue the pregnancy, which may cause pain to the expected child, or to terminate the pregnancy (Carlsson et al., 2016). The considerations involved in the decision-making process are difficult and complex. Expectant mothers are less sure of having made the correct choice. Women subsequently experience guilt, self-blame, and even severe anxiety and depression (Carlsson et al., 2016; Brondino et al., 2013). Previous studies have also shown that women are prone to mental problems during particularly difficult decision making (van Ditzhuijzen et al., 2015). Women had higher levels of psychological distress before termination than after termination (Steinberg et al., 2016). In addition, the results of a longitudinal study indicated that adverse psychological reactions at the initial time-point have a long-term effect on future psychological outcomes (Korenromp et al., 2009). Many qualitative studies have described the mental state of women before termination of pregnancy (Carlsson et al., 2016; Lotto et al., 2016); however, few quantitative studies have been performed.

Depressive symptomatology associated with termination of pregnancy for fetal anomaly (TOPFA) deserves special attention, as depression is the most common psychiatric disorder among women during pregnancy (Kent, 2011). A study in Hong Kong reported that the incidence of depressive symptomatology after a miscarriage in women is significantly higher than other psychological disorders such as anxiety, obsessive-compulsive disorder, and posttraumatic stress disorder (Sham et al., 2010). Depressive symptomatology after termination has been widely studied and reported (Gold et al., 2016; Kersting et al., 2009), whereas depressive symptomatology before termination has received little attention. It is important to note that women had higher levels of depressive symptomatology during the decision-making period than after TOPFA (Brondino et al., 2013). In other words, depressive symptomatology before termination may be worse than depressive symptomatology after termination. It is reported that most people who experience their first depressive symptomatology will experience at least one more in their lifetime (American Psychiatric Association, 2013). Depressive symptomatology also has an effect on subsequent pregnancies (Mutiso et al., 2018). Thus, women’s risk of depression should be taken seriously at all times. As there is no previous work aimed specifically at depressive symptomatology in women before TOPFA, there is a need to investigate the prevalence of depressive symptomatology before termination.

Several risk factors related to adverse psychological outcomes in women diagnosed with fetal anomaly have been investigated, including sociodemographic characteristics (e.g., education, religion), obstetric factors (e.g., gestational week), social support, and self-efficacy (Korenromp et al., 2009; Korenromp et al., 2007; Norman-Whitaker, 2014). In addition, sleep disturbance and fatigue have been shown to be strongly associated with pregnancy-related depressive symptomatology (Shelton & Cormier, 2018).

Although many studies concern depressive symptomatology after TOPFA, there is little evidence of prevalence and associated risk factors for depressive symptomatology before termination of pregnancy. Therefore, the purpose of the current study was to investigate the prevalence and related risk factors of depressive symptomatology in women before TOPFA.

Method

Study Design and Participants

A cross-sectional study was performed from May to December 2017 in the obstetric departments of six hospitals in Changsha, Hunan province. After a woman was diagnosed with a fetal anomaly and decided to be hospitalized to terminate the pregnancy, a gynecologist referred her to the researchers. We collected data after she was hospitalized but before the pregnancy was terminated. Women were eligible if they were 11 to 24 gestational weeks, able to write and speak Chinese, and willing to participate in the study. Women with severe complications (e.g., heart failure, severe pre-eclampsia, eclampsia, massive hemorrhage) or with a diagnosis of severe mental illness (e.g., psychosis, schizophrenia) were excluded.

Ethical Considerations

Ethical approval for this study was obtained from the Central South University Institutional Review Board (2017-S205). Pregnant women who met the inclusion criteria and were interested in participating in the study met with research staff to discuss the study further. After research staff explained the study, verbal consent was obtained from all participants.

Measures

General Information Questionnaire. This questionnaire was self-compiled on the basis of a large number of documents, and relevant experts were invited to review, modify, and supplement it. The questionnaire included: age, gestational week, residence (urban, rural), whether a woman was from a one-child family, educational level (Associate’s degree or lower, Bachelor’s degree, Master’s degree or higher), monthly family income (≤5,000 or >5,000 Chinese yuan), religion, whether it was a second pregnancy, whether there was a history of adverse pregnancy outcomes (including spontaneous abortion, stillbirth, premature birth, dystocia, and ectopic pregnancy), any negative emotional experiences (e.g., tension, pain, distress), and whether a woman was seeing her health care provider for regular check-ups.

Edinburgh Postnatal Depression Scale (EPDS). The Chinese version of the EPDS was used to screen for depressive symptomatology before termination. The original version of the EPDS is a 10-item self-report questionnaire, with each question scored from 0 to 3, and the total score ranging from 0 to 30 (Cox et al., 1987). The EPDS is a common tool to screen for postnatal as well as antenatal depressive symptomatology (Gibson et al., 2009). The Chinese version of the EPDS has satisfactory psychometric properties. A cutoff score of 9/10 is recommended for screening for depressive symptomatology in Chinese populations, which has a sensitivity of 82% and specificity of 86% (Lee et al., 1998). In the current study, participants with an EPDS score ≥10 were considered at risk for depression before termination, indicating the need for further evaluation.

Engagement With Health Care Provider (EHCP). The EHCP scale is a 13-item instrument, in which items are rated on a 4-point scale, with lower scores indicating better engagement by patients (Bakken et al., 2000). A Chinese version was translated and revised by Chen et al. (2018), with a Cronbach’s alpha of 0.94. In the Chinese version, the lower the score, the better the patient’s engagement.

Perceived Social Support Scale (PSSS). The PSSS contains 12 items in three dimensions—family, friends, and significant others—rated on a 7-point scale (Zimet et al., 1988). Higher scores indicate better perceived social support. The PSSS has good reliability and validity (Zimet et al., 1988). The Chinese version of the PSSS also demonstrated good psychometric properties with a Cronbach’s alpha of 0.89 (Chou, 2000).

General Self-Efficacy Scale (GSES). Schwarzer et al. (1981) developed a 20-item scale to measure an individual’s judgment of their ability to accomplish something successfully. The scale was revised into 10 items and translated into 28 languages, with Cronbach’s alpha ranging from 0.75 to 0.91 (Scholz et al., 2002). Wang et al. (2001) translated the GSES into a Chinese version with a Cronbach’s alpha of 0.87. Items are graded on a 4-point scale, with higher scores suggesting higher self-efficacy.

General Sleep Disturbance Scale (GSDS). The GSDS, created by Lee (1992), contains 21 items related to frequency in the past 1 week of difficulty getting to sleep, waking during sleep, waking too early from sleep, sleep quality, sleep quantity, daytime sleepiness, and use of substances to help induce sleep, with scores ranging from 0 (no days in the past 1 week) to 7 (every day in the past 1 week). The higher the score, the higher the degree of sleep disturbance. Cronbach’s alpha was 0.82. Lu et al. (2016) translated the GSDS into a Chinese version with a Cronbach’s alpha of 0.8.

Numerical Rating Scale–Fatigue (NRSF). The original fatigue scale, which included 13 items, was developed by Lee in 1991. To reduce the burden on participants, it was converted to a short form numerical rating scale for fatigue that only contained seven items (Lee & Lee, 2007). The severity of fatigue is measured on a scale ranging from 0 (not at all) to 10 (extremely). The Chinese version, comprising seven items, was revised in 2014, with a Cronbach’s alpha of 0.97 to 0.99 (Tsai et al., 2014).

Receipt of Spousal Support Items (RSSI). The RSSI scale, developed by Dorio (2009), comprises two parts: Provision of Spousal Support and Receipt of Spousal Support. Only Receipt of Spousal Support was used in the current study. The RSSI contains 20 items covering four dimensions—emotional concern, instrumental assistance, information support, and appraisal support—with items rated on a 5-point scale. Cronbach’s alpha of the entire scale is 0.92. Because there is no Chinese version of this scale, our research team translated and revised the scale according to the procedures of scale revision and cultural adjustment, and tested reliability and validity in this sample. The retest reliability of the entire scale and each dimension was 0.837, 0.812, 0.789, 0.824, and 0.799, respectively. Cronbach’s alpha of the entire scale and each dimension was 0.87, 0.83, 0.79, 0.93, and 0.85, respectively.

Data Analysis

Absolute (n) and relative (%) frequencies were calculated for categorical variables, whereas continuous variables are represented as mean (standard deviation). One-way analysis of variance was applied for the comparison of means between groups, and chi-square test was applied for the comparison of rates between groups. Using significant variables (p < 0.05) from the univariate analysis, a binary logistic regression model (likelihood ratio method) was used to identify the independent predictors of depressive symptomatology before termination. Odds ratio (OR) and 95% confidence interval (95% CI) were calculated. Significance was considered at p < 0.05. All statistical analysis was performed with SPSS v21.0.

Results

Demographic Characteristics

During the study period, a total of 291 women were admitted to the hospital for TOPFA. A total of 21 declined to participate due to personal reasons; therefore, 270 (92.8%) agreed to participate in the study. Mean maternal age was 30.29 years (SD = 5.04 years, range = 21 to 44 years), and mean gestational week was 21.15 weeks (SD = 4.54 weeks, range = 11 to 24 weeks).

Depressive Symptomatology

According to the EPDS, the prevalence of depressive symptomatology before termination (score ≥10) was 65.6% (177/270).

Analysis of Factors Associated With Depressive Symptomatology Before Termination

In the univariate analysis, the following characteristics were statistically associated with depressive symptomatology before termination: educational level, monthly family income, religion, history of adverse pregnancy outcomes, negative emotional experience, scores of various social support scales (including the PSSS, RSSI, and EHCP), GSES scores, and GSDS scores (Table 1).

Univariate Analysis of Differences Between Participants With and Without Depressive Symptomatology Before Termination (N = 270)

Table 1:

Univariate Analysis of Differences Between Participants With and Without Depressive Symptomatology Before Termination (N = 270)

Statistically significant variables were incorporated into a logistics regression model. Logistics regression analysis was conducted to identify the significant predictors for depressive symptomatology before termination. As shown in Table 2, the overall predictive model was statistically significant (p < 0.001). Results showed that participants who were religious had a higher risk of depressive symptomatology than those who were not religious (OR = 10.22; 95% CI [2.49, 42.01]); and women with a higher monthly family income had a lower risk of depressive symptomatology compared to women with a lower monthly family income (OR = 0.17; 95% CI [0.08, 0.35]). In addition, history of adverse pregnancy outcomes, self-efficacy, receipt of spousal support, and sleep disturbance were identified as risk factors for depressive symptomatology before termination. On the other hand, social support, engagement with health care providers, and high monthly family income were identified as protective factors for depressive symptomatology before termination.

Logistics Regression Analysis for Relative Factors of Depressive Symptomatology Before Termination of Pregnancy for Fetal Anomaly

Table 2:

Logistics Regression Analysis for Relative Factors of Depressive Symptomatology Before Termination of Pregnancy for Fetal Anomaly

Discussion

The current study is the first to investigate the prevalence of depressive symptomatology before TOPFA. Overall, 65.6% of participants experienced depressive symptoms before termination. We found that risk factors included receipt of spousal support, self-efficacy, religious belief, history of adverse pregnancy outcomes, and sleep disturbance, whereas protective factors included engagement with health care providers, social support, and high monthly family income.

To our knowledge, many studies concern depressive symptomatology after termination, but less research is related to depressive symptomatology before termination. Previous studies have investigated the prevalence of depressive symptomatology after termination, reporting rates between 13% and 39% (Davies et al., 2005; Sullivan & de Faoite, 2017); however, there are differences in screening tools. Our results show that depressive symptomatology before termination was 65.6%, which is much higher than the rate of depressive symptomatology after termination reported in previous studies. One qualitative study found that women experienced two of the most emotional reaction stages before termination: a denial phase and a decision-making phase (Qin et al., 2019). Women were heartbroken and shocked during the denial phase. In the decision-making phase, women faced the pain of not being able to change the facts and the choice of giving up their child. Some women found they were “relieved” after taking a tablet to terminate the pregnancy (Lotto et al., 2016). Fetal anomaly brings a psychological burden to expectant mothers. We hypothesized that this psychological burden decreased after termination, which may explain why depressive symptomatology rates are higher before termination than after termination. Depression during and around the time of pregnancy is an important public health issue. Thus, it is necessary for researchers to be aware of the prevalence of depressive symptomatology before termination.

Interestingly, we found that the receipt of spousal support was a risk factor, and social support was a protective factor for depressive symptomatology before termination. These findings are different from previous studies, which have shown that support from partners, family, friends, and professionals has a positive psychological impact on women (Lafarge et al., 2013). One possible explanation is that the supportive response of the spouse may inadvertently reinforce the woman’s focus on the event. Another possibility is that solicitous spousal emotional support may cause more guilt in women. However, most women tend to seek help from their partner after diagnosis (Hanschmidt et al., 2018). Previous studies have confirmed the critical role of social support provided by partners in women’s depressive symptomatology (Davey-Rothwell et al., 2017). Therefore, the effect of spousal support on depressive symptomatology before termination should be studied more in the future.

We found that high self-efficacy scores were associated with a high risk of depressive symptomatology before termination, in contrast to results of previous studies (Korenromp et al., 2007). General self-efficacy refers to personal confidence in coping with various challenges in different environments or when facing new things. Charkhabi et al. (2013) found that people with high self-efficacy are less likely to give up when encountering problems, and they will try their best to find useful solutions to fix problems. However, fetal anomaly is an established fact. Individuals with high self-efficacy are unable to change this through positive coping mechanisms, consequently resulting in greater frustration and more depressive symptoms. Hence, health care providers must be reminded that it is important to pay attention to women with high self-efficacy before TOPFA.

Few studies have analyzed health care providers as a group closely related to social support. Our study explored the impact of engagement with health care providers on depressive symptomatology before termination, showing that it was a protective factor against depressive symptomatology before TOPFA. Many qualitative studies have reported that women with a fetal anomaly need professional help and emotional support from health care providers, and their support needs may become more obvious during pregnancy termination (Carlsson et al., 2016; Fisher & Lafarge, 2014). Women do not know how to choose (terminate or continue pregnancy) before termination. Their family and friends cannot provide them with professional information and support. Women believe that support from health care professionals is positive and can help them cope better with the negative emotions associated with a diagnosis (Lafarge et al., 2014). It is worth stressing that health care professionals provide information in appropriate ways and develop clear clinical guidelines for women to follow.

Sociodemographic factors are significantly correlated to depressive symptomatology in pregnant women. In the current study, religious belief and monthly family income were significantly associated with depressive symptomatology before termination in women diagnosed with a fetal anomaly. Being religious was associated with a high risk of depression, a result consistent with findings of another study (Korenromp et al., 2007). This result can be explained by the fact that women with religious beliefs had more feelings of guilt/shame. The difference is that in our study, only 10% had religious beliefs, whereas 86.7% of women in other studies had religious beliefs (Benute et al., 2012), which were related to their different sociocultural backgrounds. In addition, women from low-income families were more likely to develop depressive symptomatology before termination. Assessing sociodemographic factors for earlier identification and management of depression through active screening is important for the health of women and their families.

In the current study, women with sleep disturbances were more vulnerable to developing depressive symptomatology. A review has confirmed a strong positive association between sleep disturbance and postpartum depression (Bhati & Richards, 2015); however, the factors behind this association are not known or understood. Sleep disturbance may be a risk factor for depressive symptomatology before termination, but more research is needed to confirm this relationship. We recommend that health care providers further assess the sleep patterns and sleep quality of this population and provide information to women on good sleep hygiene.

We found that women with a history of adverse pregnancy outcomes had higher rates of depressive symptomatology before termination than the general female population. One meta-analysis found that history of adverse pregnancy outcomes was associated with increased levels of depression during subsequent pregnancies (Hunter et al., 2017). In the current study, a total of 90 (33.3%) participants had a history of adverse pregnancy outcomes. Thus, health care providers should thoroughly inquire about a woman’s reproductive history, albeit a sensitive area for some women.

Limitations

Our study has a number of limitations, which need to be considered when interpreting the results. The first limitation is that this study only selected hospitals in Changsha, which could limit its representativeness. Second, the adopted cross-sectional design limits causal inference. Finally, we recommend that an investigation of spousal depressive symptomatology before termination be included in future studies.

Conclusion

Before TOPFA, women have a higher prevalence of depressive symptomatology. Our results add to existing studies. Although these findings need to be validated in prospective studies, they point to the need for depression screening in women before termination. Those who receive more support from their spouses and who have higher self-efficacy are at particular risk of depressive symptomatology before termination and should be frequently assessed. Risk factors could be compiled into a checklist, which could be used to identify women who require more clinical attention. Health care professionals should be aware of these factors early on to prevent the occurrence of depressive symptomatology, thereby improving maternal mental health.

References

Univariate Analysis of Differences Between Participants With and Without Depressive Symptomatology Before Termination (N = 270)

Items n (%) p Value
With Depressive Symptomatology (n = 177) Without Depressive Symptomatology (n = 93)
Residence 0.328
  Urban 120 (67.8) 69 (74.2)
  Rural 57 (32.2) 24 (25.8)
From one-child family 36 (20.3) 15 (16.1) 0.513
Educational level <0.001
  Associate’s degree or lower 94 (53.1) 25 (26.9)
  Bachelor’s degree 70 (39.5) 49 (52.7)
  Master’s degree or higher 13 (7.4) 19 (20.4)
Monthly family income (Chinese yuan) <0.001
  ≤5,000 112 (63.3) 31 (33.3)
  >5,000 65 (36.7) 62(66.7)
Religion 24 (13.6) 3 (3.2) 0.006
Second pregnancy 87 (49.2) 57 (61.3) 0.72
History of adverse pregnancy outcomes 69 (39) 21 (22.6) 0.007
Negative emotional experiences 81 (45.8) 30 (32.3) 0.037
Regular check-ups 165 (93.2) 87 (93.5) 0.57
Mean (SD) (Range)
Age (years) 30.42 (4.89) (21 to 44) 30.03 (5.33) (21 to 43) 0.545
Gestational week 21.12 (4.59) (11 to 28) 21.48 (4.44) (12 to 28) 0.537
EPDSa 14.22 (3.82) (10 to 22) 7.65 (1.18) (5 to 9) <0.001
PSSSb 71.34 (6.83) (59 to 84) 73.39 (7.03) (53 to 84) 0.021
RSSIc 3.81 (0.50) (2.45 to 4.7) 3.65 (0.38) (3.15 to 4.8) 0.006
EHCPd 29.63 (7.14) (7 to 44) 31.42 (6.79) (12 to 44) 0.047
GSESe 25.37 (4.67) (16 to 36) 23.45 (4.11) (16 to 32) 0.001
NRSFf 5.19 (1.35) (1.43 to 8.14) 4.96 (1.25) (2.43 to 7.71) 0.177
GSDSg 3.59 (0.93) (1.33 to 5.6) 3.00 (0.76) (1.33 to 4.4) <0.001

Logistics Regression Analysis for Relative Factors of Depressive Symptomatology Before Termination of Pregnancy for Fetal Anomaly

Item OR [95% CI] p Value
Monthly family income 0.17 [0.08, 0.35] <0.001
Religion 10.22 [2.49, 42.01] 0.001
History of adverse pregnancy outcomes 2.78 [1.33, 5.84] 0.007
PSSS 0.94 [0.89, 0.99] 0.017
GSES 1.23 [1.13, 1.35] <0.001
EHCP 0.95 [0.90, 0.99] 0.021
RSSI 4.42 [2.09, 9.32] <0.001
GSDS 2.02 [1.40, 2.92] <0.001

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