Small for gestational age babies and depressive symptoms of mothers during pregnancy: Results from a birth cohort in India

Babu, Giridhara R.; Murthy, G.V.S.; Reddy, Yogesh; Deepa, R.; Yamuna, A.; Prafulla, S.; Krishnan, Anjaly; Lobo, Eunice; Rathnaiah, Mohanbabu; Kinra, Sanjay

Abstract

Background: Annually, more than a million Low birthweight (LBW) are born in India, often afflicting disadvantaged families. Several studies have undertaken association of poverty, nutritional status, and obstetric factors with LBW. Through our study, we aimed to examine the possibility of any relation between Edinburgh Postnatal Depression Scale (EPDS) score measured during pregnancy with incidence of babies born Small for Gestational Age (SGA). Moreover, we explored if there is any utility for identifying a cut-off point of EPDS for predicting SGA.

Methods: Pregnant women attending the antenatal clinic at a public hospital between 14 to 32 weeks were recruited from April 2016 to Oct 2017. The EPDS was administered to assess depression through face-to-face interviews. Newborn anthropometry was performed post-delivery. For analysis, birth weight 90th percentile as Large for Gestational Age (LGA).
Results: Prevalence of depressive symptoms (EPDS score >11) was 16.5% (n=108/654) in antenatal mothers. These women delivered a higher proportion of SGA babies (21.3 v/s 15.8) and LGA (9.3 v/s 3.3) compared to women with no symptoms. The odds of women giving birth to a child with SGA were twice as high for women with EPDS scores >11 (adjusted OR = 2.03; 95% CI = 1.12 – 3.70) compared to the women with EPDS scores of ≤11. In terms of Area under curve (AUC), EPDS 11 cut off (AUC: 0.757, CI 0.707- 0.806) was same as EPDS 12 cut-off (AUC: 0.757, CI 0.708- 0.807), which was slightly lower than EPDS 13 cut off (AUC: 0.759 CI 0.709- 0.809).

Conclusions: We found a strong association of antenatal depressive symptoms during pregnancy with SGA measured by EPDS. Thus, we recommend implementation of timely and effective screening, diagnostic services, and evidence-based antenatal mental health services in order to combat SGA, and further associated-metabolic syndromes.

Citation

Babu, G. R., Murthy, G., Reddy, Y., Deepa, R., Yamuna, A., Prafulla, S., Krishnan, A., Lobo, E., Rathnaiah, M., & Kinra, S. (2019). Small for gestational age babies and depressive symptoms of mothers during pregnancy: Results from a birth cohort in India. Wellcome Open Research, 3, Article 76. https://doi.org/10.12688/wellcomeopenres.14618.2

• Journal Article Type: Article
• Acceptance Date: Apr 16, 2019
• Online Publication Date: Apr 16, 2019
• Publication Date: Apr 16, 2019
• Deposit Date: May 7, 2019
• Publicly Available Date: May 7, 2019
• Journal: Wellcome Open Research
• Electronic ISSN: 2398-502X
• Publisher: F1000Research
• Peer Reviewed: Peer Reviewed
• Volume: 3
• Article Number: 76
• DOI: https://doi.org/10.12688/wellcomeopenres.14618.2
• Keywords: Small for Gestational age; Low birth weight; Prenatal depression; Screening; Pregnancy; Birth cohort; Public hospital; Low and Middle Income Country
• Public URL: https://nottingham-repository.worktribe.com/output/2026911
• Publisher URL: https://wellcomeopenresearch.org/articles/3-76/v2
• Additional Information: Referee status: Approved, Approved with reservations, Not Approved; Referee Report: 10.21956/wellcomeopenres.15915.r33687, Geetha Desai, Department of Psychiatry , National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India, 03 Sep 2018, version 1, 1 approved, 1 approved with reservations, 1 not approved; Referee Comment: Giridhara R Babu; ; Posted: 12 Feb 2019; 1.It is a well-written report. Few clarifications may be added to methods. Many thanks for the encouraging review. 2. EPDS is a self-rated instrument, how was it administered to women who could not rate the tool due to illiteracy. How was the tool translated? EPDS tool was translated into the local language (Kannada) and then back-translated to English for accuracy. Through this, efforts were made to ensure a clear and conceptually accurate translation that was easily understood by the local population. The Questionnaire was then administered to the respondents by trained Research Assistants who would interview without altering the actual meaning. The response score is quantified by asking the frequency of occurrence of depressive symptoms for the number of days. 3. Please mention that there are different cutoffs that have been established for different samples (Shrestha et al. 2016; 1)Thank you for this comment. We have included this in the manuscript now. (Page 5, Line 32) 4. In the flow chart, can you make it clear on how many had delivered when this report was written (was it 763?) or were there any exclusions due to fetal loss or twins? Five cases were excluded as it was a twin delivery and there were four stillbirths. We have updated the flow chart. 5. Since there is a mention of women being referred to a psychiatrist if the score was more than > 13, is there a possibility that they took treatment and hence there was no link to SGA? Can you describe the public hospital, was it just one or many centres? We have referred the women with a higher score to the psychiatrist, but we have not tracked them to ascertain the treatment that they may have received. There may be a chance that they have approached a specialist and have taken treatment. Jayanagar General Hospital; a secondary level public hospital was chosen to conduct this study. 6. Was violence assessed? As it is considered a risk factor. No, violence was not assessed as part of this study. We have mentioned this under the limitations now. 7. Since many of the public hospitals do not have adequate space, how was privacy ensured? We thank the reviewer for this rightful concern. The research team is allotted a separate room for administering the interview and carrying out other research activities at the hospital. Thereby, efforts are consciously made to ensure that the privacy of the respondents is assured during the interviews. 8. Did any of the women have hyperemesis? Seven women had hyperemesis in the study sample.; Referee Report: 10.21956/wellcomeopenres.16498.r35333, Howard Cabral, Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA, 24 Apr 2019, version 2, 1 approved, 1 approved with reservations, 1 not approved; Referee Report: 10.21956/wellcomeopenres.15915.r33919, Nisreen A. Alwan, Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, Southampton General Hospital, University of Southampton, Southampton, UK, 14 Nov 2018, version 1, 1 approved, 1 approved with reservations, 1 not approved; Referee Comment: Giridhara R Babu; ; Posted: 12 Feb 2019; ; 1. The stated study aim in the manuscript is to “replicate the association between antepartum depression and SGA in the setting of a public hospital in India”, ; however; the abstract conclusion seems to comment on the validity of using EPDS as a screening tool for antenatal depression. The study does not explicitly state the aim of examining the validity of EPDS as a screening tool. The abstract also reports values for the AUC using different cut-offs of EPDS for the diagnosis of antenatal depression. These values are only in relation to the SGA outcome examined in this study and does not compare EPDS to a ‘gold standard’ or another screening test for antenatal depression. Therefore, it is not accurate to comment ; of; the “usefulness of using 10-item EPDS screening tool” in relation to other outcomes other than SGA, or for use as a screening tool in general. Thank you for the comments. We have modified the abstract conclusion and result section as per the suggestion. ; 2. The manuscript needs to be clear about this, and if the authors would like to keep the ‘prediction’ element of EPDS in relation to SGA as an outcome, they need to be clear about this in the aims and methods. We have used antenatal depression as the exposure and SGA as an outcome. We have mentioned it clearly in the aims and methods. ; 3. Under the Methods section-Measurement, the authors state that they “aimed to assess the exact EPDS score cut-off value (11,12 or 13) as a better predictor of association between antenatal depression and SGA”. Firstly, this statement needs to move to the aims section at the end of the Introduction section, and also needs to be clearly stated in the abstract. Secondly, this aim is not interchangeable with testing if EDPS is a valid screening tool for antenatal depression in the population the study is trying to generalise results ; to; . We sincerely thank the reviewer for the comment. The aim of the study is now modified as per the suggestion of the reviewer. We agree with the reviewer that the aim is not interchangeable with testing if EDPS as a valid screening tool for antenatal depression in the population. Clearly, we do not have the intent of doing so. There is no external validity (generalization) without meeting the internal validity. Since our study not immune to the source of systematic error similar to all other observational studies, we are not providing any causal inference regarding the association between EPDS and SGA. We have included this limitation in the revised manuscript. ; 4. Under the Statistical Analysis section, it is not clear whether the association with SGA was examined using the continuous EPDS score or the 3 categorical variables based on the cut-off scores of 11, 12 and 13, or both. The legends of tables contain the categorical classification of EPDS score as per the cut-offs as 11, 12 and 13 Association with SGA was examined using EPDS score as categorical variable based on the cut off values. We have updated the details in the Statistical Analysis section as well; .(Page 9 Line 6) ; 5. Was maternal body mass index taken into account as a confounder? As we have no data on pre-pregnancy BMI we have not considered the body mass index obtained during different trimester of pregnancy as a confounder, but we have taken sum of skinfold thickness into account. (1) ; 6. Under the Results section, second paragraph: "among mothers with depressive symptoms….” using what EPDS cut-off? This applies to all the descriptive findings. Here depressive symptom is defined as EPDS score >11 as we have mentioned in Table 1 and it applies for all descriptive findings. In the present study the cutoff score 13 showed highest OR compared to rest two categories, however, we have shown the descriptive statistics with cutoff of 11 since it is the minimum value at which we got statistically significant results. ; 7. It is strange that the direction of effect is so different between using a cut-off of 11 versus 12 or 13 of the same scale (aOR 2.18 versus 0.46 and 0.41). Please check your categories and what you have assigned as a reference in your models. We sincerely thank the reviewer for this input. Please note that there was a mistake in coding the variable (EPDS score cut off 11, 12, 13). We recoded the entire data set and have thoroughly checked the entire analysis after redoing it. The resulted OR changes gradually from one cut off category to another. (OR : 2.03 ,1.96, 2.42 respectively) ; 8. Last paragraph of the results section, ‘accuracy of EPDS scale’ in relation to what? Are you saying that the strength of association with one outcome (SGA) a measure of ; accuracy; of the screening test? Please clarify. If you are trying to predict the outcome then that is a function of other factors accounted for in the prediction model (if it is adjusted), not just the EPDS cut-off. In our study, the use of EPDS score without adjusting for its confounders resulted in very low specificity in predicting SGA. The area under ROC curve using EPDS score alone in predicting SGA was 0.515. EPDS is a screening tool and hence may not fare well as a diagnostic test. However, after adjusting for confounders, the accuracy improved. Therefore, we meant that accuracy in predicting SGA by using EPDS scale improves after accounting for other variables confounders. This section is modified. (Page 18 Line 1) 1. Piers L, Soares M, Frandsen S, O'dea K. Indirect estimates of body composition are useful for groups but unreliable in individuals. International journal of obesity. 2000;24(9):1145.; Grant Information: This research is funded by Intermediate Fellowship in Public Health and Clinical medicine by Wellcome Trust DBT India Alliance to Dr Giridhara R Babu (grant no: IA/CPHI/14/1/501499). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.; Copyright: This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
• Contract Date: May 7, 2019