A Life Course Perspective on Depressive Symptoms in Mid-Pregnancy

  • Claudia HolzmanEmail author
  • Janet Eyster
  • Linda Beth Tiedje
  • Lee Anne Roman
  • Elizabeth Seagull
  • Mohammad Hossein Rahbar
Original Article

Objective: To examine the prevalence of depressive symptoms in mid-pregnancy and their relation to life circumstances across the life course in a community-based sample. Methods: The Pregnancy Outcomes and Community Health (POUCH) Study enrolled women at 16–26 weeks' gestation from 52 clinics in five Michigan communities. At enrollment women completed a screening instrument for depressive symptoms (CES-D) and questions about life circumstances covering three “periods,” i.e. previous 6 months, adulthood, and childhood. Questions were grouped into sub-constructs (e.g., abuse, economic, substance use, loss, and legal) for each “period” and evaluated in relation to CES-D scores. Analyses included 1321 POUCH participants divided into three subgroups: teens; women ≥20 years insured by Medicaid (disadvantaged); and women ≥20 years not insured by Medicaid (advantaged). Results: A positive CES-D screen (≥16) was more common in teens (46%) and disadvantaged women (47%) than in advantaged women (23%). Recent problems (previous 6 months) with abuse, economics, and substance use in someone close were each associated with higher adjusted mean CES-D scores (2.3–7.5 increase) in the three subgroups of women. In life course analyses, abuse and substance use in teens, and abuse and economic problems in disadvantaged and advantaged women were strongly linked to higher adjusted mean CES-D scores when these problems occurred both in childhood and adulthood (range 2.2–7.1 increase), whereas the associations were more modest when problems were confined to childhood. Conclusions: Strategies for addressing the public health problem of depressive symptoms in mid-pregnancy will benefit from a life course perspective.


depression pregnancy life course life events. 



This study was supported by the National Institute of Child Health and Human Development grant numbers R01 HD34543-01 and R01 HD034543-07 and National Institute of Nursing Research and the March of Dimes Perinatal Epidemiological Research Initiative Program grants 20-FY98-0697 through 20-FY04-37. The contributions of the other members of the Prematurity Study Group, Nigel Paneth, Rachel Fisher, Lynn Reuss, Bertha Bullen, David Kallen, Eric Devos, Joseph Marshall, Karen Friderici, Renee Canady, and Pat Senagore, are greatly acknowledged. The authors thank POUCH study participants, the participating clinics for their assistance and cooperation, and Sean Zhou for data management.


  1. 1.
    Ritter C, Hobfoll SE, Lavin J, Cameron RP, Hulsizer MR. Stress, psychosocial resources, and depressive symptomatology during pregnancy in low-income, inner-city women. Health Psychol 2000;19(6):576–85.PubMedCrossRefGoogle Scholar
  2. 2.
    Siefert K, Bowman PJ, Heflin CM, Danziger S, Williams DR. Social and environmental predictors of maternal depression in current and recent welfare recipients. Am J Orthopsychiatry 2000;70(4):510–22.PubMedCrossRefGoogle Scholar
  3. 3.
    Dayan J, Creveuil C, Herlicoviez M, Herbel C, Baranger E, Savoye C, et al. Role of anxiety and depression in the onset of spontaneous preterm labor. Am J Epidemiol 2002;155(4):293–301.PubMedCrossRefGoogle Scholar
  4. 4.
    Orr ST, James SA, Blackmore Prince C. Maternal prenatal depressive symptoms and spontaneous preterm births among African-American women in Baltimore, Maryland. Am J Epidemiol 2002;156(9):797–802.PubMedCrossRefGoogle Scholar
  5. 5.
    Seguin L, Potvin L, St-Denis M, Loiselle J. Chronic stressors, social support, and depression during pregnancy. Obstet Gynecol 1995;85(4):583–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Andersson L, Sundstrom-Poromaa I, Wulff M, Astrom M, Bixo M. Neonatal outcome following maternal antenatal depression and anxiety: A population-based study. Am J Epidemiol 2004;159(9):872–81.PubMedCrossRefGoogle Scholar
  7. 7.
    Dole N, Savitz DA, Hertz-Picciotto I, Siega-Riz AM, McMahon MJ, Buekens P. Maternal stress and preterm birth. Am J Epidemiol 2003;157(1):14–24.PubMedCrossRefGoogle Scholar
  8. 8.
    Barnet B, Joffe A, Duggan AK, Wilson MD, Repke JT. Depressive symptoms, stress, and social support in pregnant and postpartum adolescents. Arch Pediatr Adolesc Med 1996;150(1):64–9.PubMedGoogle Scholar
  9. 9.
    Evans J, Heron J, Francomb H, Oke S, Golding J. Cohort study of depressed mood during pregnancy and after childbirth. BMJ 2001;323(7307):257–60.PubMedCrossRefGoogle Scholar
  10. 10.
    Terry DJ, Mayocchi L, Hynes GJ. Depressive symptomatology in new mothers: A stress and coping perspective. J Abnorm Psychol 1996;105(2):220–31.PubMedCrossRefGoogle Scholar
  11. 11.
    Pruessner M, Hellhammer DH, Pruessner JC, Lupien SJ. Self-reported depressive symptoms and stress levels in healthy young men: Associations with the cortisol response to awakening. Psychosom Med 2003;65(1):92–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Grewen KM, Girdler SS, Hinderliter A, Light KC. Depressive symptoms are related to higher ambulatory blood pressure in people with a family history of hypertension. Psychosom Med 2004;66(1):9–16.PubMedCrossRefGoogle Scholar
  13. 13.
    Rajewska J, Rybakowski JK. Depression in premenopausal women: Gonadal hormones and serotonergic system assessed by D-fenfluramine challenge test. Prog Neuropsychopharmacol Biol Psychiatry 2003;27(4):705–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Heim C, Newport DJ, Wagner D, Wilcox MM, Miller AH, Nemeroff CB. The role of early adverse experience and adulthood stress in the prediction of neuroendocrine stress reactivity in women: A multiple regression analysis. Depress Anxiety 2002;15(3):117–25.PubMedCrossRefGoogle Scholar
  15. 15.
    Kessler RC, Price RH, Wortman CB. Social factors in psychopathology: Stress, social support, and coping processes. Annu Rev Psychol 1985;36:531–72.PubMedCrossRefGoogle Scholar
  16. 16.
    Kessler RC, Barber C, Birnbaum HG, Frank RG, Greenberg PE, Rose RM, et al. Depression in the workplace: effects on short-term disability. Health Aff (Millwood) 1999;18(5):163–71.CrossRefGoogle Scholar
  17. 17.
    Taylor SE, Repetti RL, Seeman T. Health psychology: What is an unhealthy environment and how does it get under the skin? Annu Rev Psychol 1997;48:411–47.PubMedCrossRefGoogle Scholar
  18. 18.
    Zuckerman B, Amaro H, Bauchner H, Cabral H. Depressive symptoms during pregnancy: Relationship to poor health behaviors. Am J Obstet Gynecol 1989;160(5 Pt 1):1107–11.PubMedGoogle Scholar
  19. 19.
    Fulkerson JA, Sherwood NE, Perry CL, Neumark-Sztainer D, Story M. Depressive symptoms and adolescent eating and health behaviors: A multifaceted view in a population-based sample. Prev Med 2004;38(6):865–75.PubMedCrossRefGoogle Scholar
  20. 20.
    Hutton HE, Lyketsos CG, Zenilman JM, Thompson RE, Erbelding EJ. Depression and HIV risk behaviors among patients in a sexually transmitted disease clinic. Am J Psychiatry 2004;161(5):912–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Suri R, Altshuler L, Hendrick V, Rasgon N, Lee E, Mintz J. The impact of depression and fluoxetine treatment on obstetrical outcome. Arch Women Ment Health 2004;7(3):193–200.Google Scholar
  22. 22.
    Hoffman S, Hatch MC. Depressive symptomatology during pregnancy: Evidence for an association with decreased fetal growth in pregnancies of lower social class women. Health Psychol 2000;19(6):535–43.PubMedCrossRefGoogle Scholar
  23. 23.
    Hobfoll SE, Ritter C, Lavin J, Hulsizer MR, Cameron RP. Depression prevalence and incidence among inner-city pregnant and postpartum women. J Consult Clin Psychol 1995;63(3):445–53.PubMedCrossRefGoogle Scholar
  24. 24.
    Rutter M. Pathways from childhood to adult life. J Child Psychol Psychiatry 1989;30(1):23–51.PubMedCrossRefGoogle Scholar
  25. 25.
    Lu MC, Halfon N. Racial and ethnic disparities in birth outcomes: A life-course perspective. Matern Child Health J 2003;7(1):13–30.PubMedCrossRefGoogle Scholar
  26. 26.
    Heim C, Newport DJ, Heit S, Graham YP, Wilcox M, Bonsall R, et al. Pituitary-adrenal and autonomic responses to stress in women after sexual and physical abuse in childhood. JAMA 2000;284(5):592–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Ainsworth M, Blehar MC, Waters E, Wall S. Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Lawrence Earlbaum, 1978.Google Scholar
  28. 28.
    Forest KB, Moen P, Dempster-McClain D. The effects of childhood family stress on women's depressive symptoms: A life course approach. Psychol Women Q 1996;20:81–100.CrossRefGoogle Scholar
  29. 29.
    Wise LA, Zierler S, Krieger N, Harlow BL. Adult onset of major depressive disorder in relation to early life violent victimisation: a case-control study. Lancet 2001;358(9285):881–7.PubMedCrossRefGoogle Scholar
  30. 30.
    van de Mheen HD, Stronks K, Mackenbach JP. A lifecourse perspective on socio-economic inequalities in health: The influence of childhood socio-economic conditions and selection processes. Sociol Health Illness 1998;20(5):754–77.CrossRefGoogle Scholar
  31. 31.
    Holland P, Berney L, Blane D, Smith GD, Gunnell DJ, Montgomery SM. Life course accumulation of disadvantage: Childhood health and hazard exposure during adulthood. Soc Sci Med 2000;50(9):1285–95.PubMedCrossRefGoogle Scholar
  32. 32.
    Alonzo AA. The experience of chronic illness and post-traumatic stress disorder: The consequences of cumulative adversity. Soc Sci Med 2000;50(10):1475–84.PubMedCrossRefGoogle Scholar
  33. 33.
    McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med 1998;338(3):171–9.PubMedCrossRefGoogle Scholar
  34. 34.
    Elder GH, Jr, George LK, Shanahan MJ. Psychosocial stress over the life course. In: Kaplan HB, editor. Psychosocial stress: Perspectives on structure, theory, life-course, and methods. New York: Academic Press; 1996:247–92.Google Scholar
  35. 35.
    Holzman C, Bullen B, Fisher R, Paneth N, Reuss L. Pregnancy outcomes and community health: The POUCH study of preterm delivery. Paediatr Perinat Epidemiol 2001;15(Suppl 2):136–58.PubMedCrossRefGoogle Scholar
  36. 36.
    Radloff L. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas 1977;I:385–401.CrossRefGoogle Scholar
  37. 37.
    Turner RJ, Wheaton B, Lloyd DA. The epidemiology of social stress. Am Sociol Rev 1995;60:104–5.CrossRefGoogle Scholar
  38. 38.
    Hatcher L. A step-by step approach to using the SAS system for factor analysis and structural equation modeling. SAS Institute Inc., 1994.Google Scholar
  39. 39.
    IVEware: Imputation and Variance Estimation Software. In: Raghunathan TE, Solenberger PW, Van Hoewyk J, Lepkowski JM, editors. A multivariate technique for multiply imputing missing values using a sequence of regression models. Ann Arbor: Survey Methodology Program, Survey Research Center, Institute for Social Research, University of Michigan, 1998.Google Scholar
  40. 40.
    Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al. The epidemiology of major depressive disorder: Results from the National Comorbidity Survey Replication (NCS-R). JAMA 2003;289(23):3095–105.PubMedCrossRefGoogle Scholar
  41. 41.
    Mazure CM, Keita GP, Glehar MC. Summit on women and depression: Proceedings and recommendations. Washington, DC: American Psychological Association, 2002.Google Scholar
  42. 42.
    Josefsson A, Berg G, Nordin C, Sydsjo G. Prevalence of depressive symptoms in late pregnancy and postpartum. Acta Obstet Gynecol Scand 2001;80(3):251–5.PubMedCrossRefGoogle Scholar
  43. 43.
    Kurki T, Hiilesmaa V, Raitasalo R, Mattila H, Ylikorkala O. Depression and anxiety in early pregnancy and risk for preeclampsia. Obstet Gynecol 2000;95(4):487–90.PubMedCrossRefGoogle Scholar
  44. 44.
    McKee MD, Cunningham M, Jankowski KR, Zayas L. Health-related functional status in pregnancy: Relationship to depression and social support in a multi-ethnic population. Obstet Gynecol 2001;97(6):988–93.PubMedCrossRefGoogle Scholar
  45. 45.
    Deal LW, Holt VL. Young maternal age and depressive symptoms: Results from the 1988 National Maternal and Infant Health Survey. Am J Public Health 1998;88(2):266–70.PubMedCrossRefGoogle Scholar
  46. 46.
    Roosa MW, Reinholtz C, Angelini PJ. The relation of child sexual abuse and depression in young women: Comparisons across four ethnic groups. J Abnorm Child Psychol 1999;27(1):65–76.PubMedGoogle Scholar
  47. 47.
    Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. JAMA 2001;286(5):572–9.PubMedCrossRefGoogle Scholar
  48. 48.
    Henderson DJ, Boyd C, Mieczkowski T. Gender, relationships, and crack cocaine: A content analysis. Res Nurs Health 1994;17(4):265–72.PubMedCrossRefGoogle Scholar
  49. 49.
    Turner RJ, Lloyd DA, Roszell P. Personal resources and the social distribution of depression. Am J Commun Psychol 1999;27(5):643–72.CrossRefGoogle Scholar
  50. 50.
    Turner RJ, Sorenson AM, Turner JB. Social contingencies in mental health: A seven-year follow-up study of teenage mothers. J Marriage Family 2000;62(3):777–91.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • Claudia Holzman
    • 1
    • 6
    Email author
  • Janet Eyster
    • 1
  • Linda Beth Tiedje
    • 1
  • Lee Anne Roman
    • 2
    • 4
  • Elizabeth Seagull
    • 5
  • Mohammad Hossein Rahbar
    • 1
    • 3
  1. 1.Department of EpidemiologyMichigan State UniversityEast LansingUSA
  2. 2.Department of Obstetrics, Gynecology, and Reproductive Biology and Institute for Health Care Studies, Michigan State UniversityEast LansingUSA
  3. 3.Data Coordinating CenterMichigan State UniversityEast LansingUSA
  4. 4.Grand Rapids Medical Education and Research CenterGrand RapidsUSA
  5. 5.Department of Pediatrics and Human DevelopmentMichigan State UniversityEast LansingUSA
  6. 6.Michigan State UniversityCollege of Human MedicineDepartment of EpidemiologyEast LansingUSA

Personalised recommendations