Implications of Antenatal Depression and Anxiety for

Obstetric Outcome
Liselott Andersson, MD, Inger Sundstrom-Poromaa, MD, PhD, Marianne Wulff, MD, PhD,
Monica strom, MD, PhD, and Marie Bixo, MD, PhD
OBJECTIVE: To investigate the obstetric outcome and health
care consumption during pregnancy, delivery, and the
early postpartum period in an unselected populationbased sample of pregnant women diagnosed with antenatal depressive and/or anxiety disorders, compared with
healthy subjects.
METHODS: Participants were 1,495 women attending 2 obstetric clinics in Northern Sweden. The Primary Care Evaluation of Mental Disorders was used to evaluate depressive
and anxiety disorders in the second trimester of pregnancy.
To assess demographic characteristics, obstetric outcome,
and complications, the medical records of the included
women were reviewed.
RESULTS: Significant associations were found between depression and/or anxiety and increased nausea and vomiting, prolonged sick leave during pregnancy and increased
number of visits to the obstetrician, specifically, visits related to fear of childbirth and those related to contractions.
Planned cesarean delivery and epidural analgesia during
labor were also significantly more common in women with
antenatal depression and/or anxiety.
CONCLUSION: There is an association between antenatal depressive and/or anxiety disorders and increased health care
use (including cesarean deliveries) during pregnancy and
delivery. (Obstet Gynecol 2004;104:46776. 2004 by
The American College of Obstetricians and Gynecologists.)
LEVEL OF EVIDENCE: II-2

Depression and anxiety disorders are common health problems that affect women more often than men.1 The World
Health Organizations Global Burden of Disease Study2
has estimated unipolar major depression to be the leading
cause of disease-related disability among women in the
world today. Reproductive events have been suggested to
be involved in the onset and course of depression and
From the Department of Clinical Sciences, Obstetrics and Gynecology, Ume
University, Ume, Sweden; Department of Obstetrics and Gynecology, Sunderby
Hospital, Lule, Sweden; Department of Womens and Childrens Health,
University Hospital, Uppsala, Sweden; and Department of Clinical Sciences,
Psychiatry, Ume University, Ume, Sweden.
The authors thank all personnel involved in the ultrasound screening procedures at
the 2 sites and especially Mrs. Marie Wallgren and Mrs. Yvonne Hoff.
VOL. 104, NO. 3, SEPTEMBER 2004
2004 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.

anxiety,3,4 in which context, postpartum depression5 is

probably the most studied. Prior research has found associations between antenatal depression and/or anxiety and
deteriorated neonatal outcome in terms of preterm delivery
and small-for-gestational-age births.6,7 Although a number
of studies have assessed the prevalence of antenatal depression and anxiety,8,9 few studies have investigated the impact of these disorders on obstetric outcome. Perkins and
colleagues10 found a weak relationship between anxiety
and use of analgesia/anesthesia in the second stage of labor,
but no other obstetric complications. Likewise, a recent
study of Chung and coworkers11 indicated an increased
risk for use of epidural analgesia and operative deliveries in
women with antenatal depressive symptoms. On the other
hand, Wu and colleagues12 did not reveal any associations
between antenatal depressive symptoms and mode of delivery. Validation and comparison of results between studies is, however, difficult, because most studies have used
different rating scales and/or criteria for diagnosing depression and anxiety. For example, none of the 3 last-mentioned
studies has used modern psychiatric criteria that adhere to
Diagnostic and Statistical Manual of Mental Disorders-4th edition
guidelines. Another more general problem when addressing the impact of antenatal depression and/or anxiety on
obstetric outcome is that few studies have been performed
in population-based samples.
The aim of this study was to investigate obstetric
outcome and health care consumption during pregnancy, delivery, and the early postpartum period in an
unselected population-based sample of pregnant women
diagnosed with antenatal depressive and/or anxiety disorders, compared with healthy subjects.

Financial Disclosure
This study was supported by research grants from Pfizer AB,
Stockholm, Sweden, Visare Norr, Ume University Insamlingsstiftelsen, and by grants to Inger Sundstrom-Poromaa from the Swedish
Society for Medical Research.

0029-7844/04/$30.00
doi:10.1097/01.AOG.0000135277.04565.e9

467

MATERIALS AND METHODS

All women attending the second trimester routine ultrasound screening at Ume University Hospital and at
Sunderby Central Hospital were approached for study
participation. The inclusion period was from October 2,
2000, to October 1, 2001. The Swedish antenatal health
care system includes almost 100% of the Swedish pregnant population.13 Furthermore, approximately 97% of
the Swedish pregnant population participate in the ultrasound examination, which is performed at 16 18 weeks
of gestation, mainly for estimation of the expected date of
delivery and detection of multiples.14 During the study
period, Ume University Hospital served a population
of 134,428 people, of which 27,063 were women of
reproductive age. The corresponding figures for Sunderby Central Hospital were 115,600 and 19,277, respectively. Most importantly, there were no other available ultrasound screening facilities or delivery units in
these 2 cities.
Exclusion criteria for the study were 1) detection of
malformation or missed abortion at the ultrasound examination, 2) inability to read and understand the questionnaire because of language difficulties, and 3) not
providing informed consent. Moreover, only cases with
complete medical records for the entire pregnancy and
delivery were included in the study.
The Primary Care Evaluation of Mental Disorders
system was used for screening of depressive and anxiety
disorders. It has been validated for use in primary care
settings15 and conforms to the criteria of Diagnostic and
Statistical Manual of Mental Disorders-4th edition. The agreement between diagnoses of the Primary Care Evaluation
of Mental Disorders and those of independent mental
health professionals is excellent, with an overall accuracy
of 88%. Primary Care Evaluation of Mental Disorders
was considered to be a suitable tool for assessing the
prevalence of psychiatric disorders in an obstetric outpatient setting because of its utility and ease of use. Furthermore, a self-administered version of Primary Care Evaluation of Mental Disorders, the Primary Care
Evaluation of Mental Disorders Patient Health Questionnaire, has been validated for use in obstetric gynecologic patients.16 The Primary Care Evaluation of
Mental Disorders system consists of 2 components: a
1-page patient questionnaire and a 12-page clinician evaluation guide, which is a structured interview for the
clinician to follow when evaluating the responses on the
patient questionnaire. The instrument estimates the presence of 20 possible mental disorders, among which this
study focused on 13 diagnoses. Among these 13 diagnoses of interest, 8 correspond to the specific requirements of Diagnostic and Statistical Manual of Mental Disor-

468

Andersson et al

Depression, Anxiety, and Obstetric Outcome

ders-4th edition (major depressive disorder, dysthymia,

partial remission of major depressive disorder, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, social phobia, and bulimia nervosa). Additionally, 4 subthreshold diagnoses are included (minor
depressive disorder, anxiety not otherwise specified, eating disorder not otherwise specified, and binge-eating
disorder). Because fewer symptoms are required than for
a specific diagnosis from Diagnostic and Statistical Manual of
Mental Disorders-4th edition, these diagnoses are called
subthreshold. However, they are included because
they are associated with considerable impairment in
function.17 Finally, a rule-out diagnosis of bipolar disorder was included. For the present study, a modified form
of the patient questionnaire was used, which contained
25 questions evaluating somatoform disorder, mood disorders, anxiety disorders (including social phobia and
obsessive-compulsive disorder), and eating disorders.
Somatoform disorders and rule-out diagnoses of mood
and/or anxiety related to a physical disorder, medication, or drugs were not assessed.
Before attending the ultrasound examination, the
women completed the patient questionnaire. In doing so,
they were also asked to provide name, date of birth,
telephone number, and an informed consent allowing
for a telephone interview. If any key question for mental
disorders was indicated, the woman was considered to
be screen-positive, and a telephone interview was conducted within 12 weeks after the ultrasound examination using a computerized version of the clinician evaluation guide. Those who were asking for help and/or had
thoughts about committing suicide were immediately
referred to psychiatric specialist care. One research nurse
and 4 obstetricians performed the telephone interviews.
The results, fully described elsewhere,9 were as follows: A total of 2,263 women were examined by ultrasound screening during the inclusion period. After exclusion for refusal to participate (10 women), language
difficulties (82 women), too intense patient flow (362
women), and other reasons (14 women), 1,795 women
received the patient questionnaire. Sixty-four women did
not answer the questionnaire, and 105 women did not
sign the informed consent. Furthermore, 22 women
were excluded because of missed abortion or malformation, and 49 women were not reached within the stipulated 14 days. Incomplete medical records were present
in 60 women. Thus, the study population consisted of
1,495 women.
Three months after delivery, the medical records of
the women were thoroughly reviewed. Demographic
and behavioral characteristics, such as maternal age,
parity, body mass index (BMI) in the first trimester,
marital status, socioeconomic status, smoking and to-

OBSTETRICS & GYNECOLOGY

bacco habits, alcohol consumption, prevalence of

chronic disease, and history of psychiatric disorders,
were extracted from the medical records. Furthermore,
data on previous miscarriage and infertility treatment
(ovulation stimulation and in vitro fertilization) in the
actual pregnancy were assessed. Data on drug abuse
other than tobacco and alcohol were not assessed because no routine screening is made for these drugs in the
antenatal health care program since the prevalence during pregnancy generally is considered to be very low in
Sweden.
Pregnancy data obtained from the medical charts included number of midwife visits, nausea and vomiting
(defined as doctors visits and/or disability days because
of nausea and vomiting), incidence of sick leave during
first trimester, total amount of sick leave before 36 weeks
of gestation, number of ultrasound examinations, total
number of visits to the obstetrician, and specific visits for
amniocentesis or chorion villi sampling, pain, fear of
childbirth, and premature contractions. Pregnancy complications assessed were hypertensive disorder, including preeclampsia, postterm labor, oligohydramnios,
bleeding in late gestation (including placenta previa and
abruption placenta), intrauterine growth restriction, fetal
hypoxia, and preterm delivery.
Delivery data were obtained on induced labor,
planned or acute cesarean delivery, instrumental delivery, use of oxytocin and epidural analgesia during labor,
time from self-experienced start of labor to delivery, and
time from arrival in the delivery unit to delivery. Data on
poor progress in labor, postpartum bleeding, fetal distress, and rupture of the anal sphincter were recorded for
assessment of delivery complications. Finally, data were
recorded on early postpartum complications, such as
postpartum infection, postpartum readmission, mastitis,
other postpartum complications, and stay at the maternity ward.
The study was approved by the Ethics Committee,
Ume University, Sweden.
The study population and the group of eligible, but
not included, women were compared with regard to age,
parity, marital status, socioeconomic status, smoking,
snuff taking, and history of psychiatric disorder.
Hospital-to-hospital variation was evaluated regarding the distribution of diagnoses from the Primary Care
Evaluation of Mental Disorders. Continuous variables
were compared with the t test and are displayed as mean
standard deviation. Frequencies were compared between groups by 2 test.
Multiple logistic regression analysis was used to calculate adjusted odds ratios for obstetric outcome. For adjustment, the following maternal factors were included:
maternal age as completed years at the time of the

VOL. 104, NO. 3, SEPTEMBER 2004

psychiatric investigation, parity as primipara or not,

marital status as married/cohabiting with a partner and
single parents, and socioeconomic status according to
Swedish socioeconomic indices as professional employees or laborers. Smoking, recorded at the first visit to
antenatal care, was categorized into nonsmoking (not
daily smoking) and smoking (one or more cigarettes per
day). Likewise, snuff taking was classified into no snuff
taking and snuff taking. The first trimester BMI, kg/m2,
was categorized according to recommendation by the
World Health Organization: underweight (BMI 18.5),
normal (BMI 18.524.9), overweight (BMI 25.0 29.9),
and obese (BMI 30). A history of heart disease,
diabetes mellitus, hypertension, or renal disease was
used to indicate chronic disease. Data on previous miscarriage and infertility treatment in the actual pregnancy
were also categorized.
Pregnancy and delivery data were categorized according to group means as follows: number of midwife visits,
duration of sick leave, number of ultrasound examinations, visits to the obstetrician, time from start of labor to
delivery, and time from arrival in the delivery unit to
delivery. Preterm delivery was defined as less than 37
weeks of completed gestation. The gestational age was
estimated according to the result of the second-trimester
ultrasound screening. No other methods were used in
spontaneous pregnancies. The gestational age in pregnancies resulting from in vitro fertilization was estimated
according to the day of embryo transfer. Stay at the
maternity ward postpartum was categorized to fit the
Swedish definition of early discharge, which is less than
72 hours. Women who delivered by planned cesarean
delivery were excluded in the statistical analyses on
variables concerning only spontaneous and induced labor, such as use of oxytocin, epidural analgesia, time
from start of labor to delivery, time from arrival in
delivery department to delivery, poor progress in labor,
and rupture of the anal sphincter.
A 2-sided P value .05 was considered significant.
All statistical analyses, with one exception, were performed using SPSS 10.0 (SPSS Inc, Chicago, IL). Confidence intervals for proportions were calculated using
EpiCalc 2000 (Brixton Health, www.brixtonhealth.com).

RESULTS
In the study population of 1,495 women, 211 (14.1%;
95% confidence interval CI 12.40 15.99%) had one or
more psychiatric diagnoses. Depressive disorders were
most common, with a prevalence of 174 (11.6%; 95% CI
10.04 13.36%) subjects. Major depression was present

Andersson et al

Depression, Anxiety, and Obstetric Outcome

469

Table 1. Characteristics of Study Population Versus Group of Women Not Included in Study

Age (y)
Marital status
Married or cohabiting
Not married or cohabiting
Socioeconomic status
Professional employee
Laborer
Smoking status
Nonsmoker
Smoker
Snuff taking status
Not snuff taker
Snuff taker
Parity
Nullipara
Multipara
Previous psychiatric disorder
No
Yes

Study population
(n 1,495)*

Not-included women
(n 768)*

29.6 4.6

29.7 5.2

1,433 (96.6)
51 (3.4)

650 (95.4)
31 (4.6)

687 (46.5)
791 (53.5)

265 (38.9)
416 (61.1)

1,374 (92.8)
106 (7.2)

615 (91.1)
60 (8.9)

1,392 (94.1)
88 (5.9)

654 (96.9)
21 (3.1)

649 (43.5)
844 (56.5)

308 (44.3)
388 (55.7)

1,424 (95.8)
63 (4.2)

656 (95.1)
34 (4.9)

P
.42
.22
.01
.16
.01
.75
.50

Data are presented as mean standard deviation or n (%).

* For all variables, missing data was prevalent in 1.9 4.8%.

in 48 (3.2%; 95% CI 2.39 4.26%) women, and 106

(7.1%; 95% CI 5.87 8.55%) had a minor depressive
disorder. Anxiety disorders were present in 92 (6.2%;
95% CI 5.06 7.57%) women, and anxiety not otherwise
specified was most common, found in 63 (4.2%; 95% CI
3.275.38%) subjects. A total number of 11 (5.2%; 95%
CI 2.759.37%) of the 211 women with a psychiatric
diagnosis had some sort of treatment for their psychiatric
condition. Only one of them used any antidepressant
therapy at the time for second-trimester ultrasound
screening. One additional woman was prescribed antidepressant therapy later in pregnancy. In both of these
cases, the drug was a selective serotonin reuptake inhibitor. None of the women without any psychiatric diagnosis were noted to use psychoactive medication.
Comparisons between the original study group and
the group of women not included in the study are given
in Table 1. The excluded subjects had a significantly
lower socioeconomic status than the study population
and were more seldom snuff taking.
Multiple pregnancies were exclusively twins, and the
distribution of twins between women with a psychiatric
diagnosis and those without did not differ significantly
(17 1.3% in healthy subjects and 4 1.9% among
women with a psychiatric diagnosis). Also, the distribution of stillbirths was not significantly different between
groups (4 0.3% stillbirths in women without a psychiatric diagnosis and 2 0.9% in women with antenatal
depressive and/or anxiety disorders).

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Depression, Anxiety, and Obstetric Outcome

Regarding the distribution of psychiatric diagnoses,

there was no significant difference between the 2 hospitals (not in table).
Maternal factors associated with depressive and/or
anxiety disorders are presented in Table 2. Not being
married or cohabiting with a partner, low socioeconomic
status, smoking, multiparity, and BMI more than 30
kg/m2 were significantly and independently associated
with the presence of a diagnosis of depression and/or
anxiety in the second trimester of pregnancy.
Women with antenatal depressive and/or anxiety disorder more often suffered from nausea and vomiting
(Table 3). They more often had their first sick leave
already during the first trimester, and they had a significantly higher number of disability days throughout the
entire pregnancy, compared with the group without a
diagnosis (Table 3). Thirty-seven percent of all women
had disability days at some time during pregnancy (not
presented in table). Furthermore, women with an antenatal psychiatric diagnosis visited their obstetrician more
often than healthy subjects, and specifically, they more
frequently attended the obstetrics gynecology clinic because of fear of childbirth and premature contractions
(Table 3). Also, they were more commonly delivered by
planned cesarean, had an increased use of epidural
analgesia, and reported a longer self-experienced time
of labor (Table 4). Severe complications of pregnancy,
delivery, and the early postpartum period were not

OBSTETRICS & GYNECOLOGY

Table 2. Selected Demographic, Behavioral, and Medical Characteristics Associated With Prevalence of Antenatal
Psychiatric Diagnosis
Psychiatric
diagnosis
(n 211)*
Age (y)
19
2029
3039
40
Marital status
Married or cohabiting
Not married or cohabiting
Socioeconomic status
Professional employee
Laborer
Smoking status
Nonsmoker
Smoker
Snuff taking status
Not snuff taker
Snuff taker
Parity
Nullipara
Multipara
Alcohol use
Rarely/never
Yes
Chronic disease
No
Yes
First-trimester BMI
18.5
18.524.9
25.029.9
30.0
Previous miscarriage
No
Yes
Infertility treatment
No
Yes

No psychiatric
diagnosis
(n 1,284)*

Odds ratio

95%
Confidence
interval

4 (1.9)
93 (44.1)
111 (52.6)
3 (1.4)

15 (1.2)
621 (48.4)
631 (49.1)
17 (1.3)

1.78
Referent
1.18
1.18

0.585.48

193 (91.5)
18 (8.5)

1,240 (97.4)
33 (2.6)

Referent
3.50

1.946.35

63 (29.9)
148 (70.1)

512 (40.4)
755 (59.6)

Referent
1.59

1.162.18

182 (86.7)
28 (13.3)

1,192 (93.9)
78 (6.1)

Referent
2.35

1.493.72

198 (94.3)
12 (5.7)

1,194 (94.0)
76 (6.0)

Referent
0.95

0.511.78

77 (36.5)
134 (63.5)

572 (44.6)
710 (55.4)

Referent
1.40

1.041.90

210 (99.5)
1 (0.5)

1,268 (99.9)
1 (0.1)

Referent
6.04

0.3896.91

198 (97.1)
6 (2.9)

1,229 (97.9)
27 (2.1)

Referent
1.36

0.553.32

4 (2.0)
108 (12.7)
54 (27.1)
33 (16.6)

22 (1.8)
744 (61.8)
328 (27.3)
109 (9.1)

1.25
Referent
1.13
2.09

169 (80.1)
42 (19.9)

1,045 (81.7)
234 (18.3)

Referent
1.11

0.771.60

207 (98.1)
4 (1.9)

1,237 (96.8)
41 (3.2)

Referent
0.58

0.211.64

0.871.58
0.344.10

0.423.70
0.801.61
1.343.23

BMI, body mass index.

Data are presented as n (%).
* Data for the BMI variable were missing in 93 (6.2%) women. For the variables marital status, socioeconomic status, smoking, tobacco users
(other than smoking), alcohol consumption, chronic disease, previous miscarriage, and infertility treatment, missing data was prevalent in 0.11.1%.

P .001.

P .05.

P .01.

affected by antenatal depression and/or anxiety (Tables 5 and 6).

DISCUSSION
The results of the present study suggest that antenatal
depressive and anxiety disorders are associated with
more negative events during pregnancy and delivery.
Severe obstetric complications, on the other hand, were
not affected by antenatal depression and/or anxiety.

VOL. 104, NO. 3, SEPTEMBER 2004

Our finding that more women with a psychiatric

diagnosis suffered from nausea and vomiting is supported in a study of Chou and colleagues,18 who noticed
an association between depression and nausea, vomiting, and fatigue in early pregnancy. Whether depression
preceded or resulted from the symptoms was considered
unclear, both in their study and in other investigations.19,20 However, in a study by Rodriguez and coworkers,21 frequent nausea was found to decrease from

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Depression, Anxiety, and Obstetric Outcome

471

Table 3. Pregnancy Data Associated With Presence of Antenatal Psychiatric Diagnosis

Psychiatric
diagnosis
(n 211)*
Midwife visits
10
10
Nausea and vomiting
No
Yes
Sick leave during first trimester
No
Yes
Sick leave before 36 weeks of gestation
7 wk
7 wk
Ultrasound examinations
2
2
Visits to the obstetrician
2
2
Amniocentesis or chorion villi sampling
No
Yes
Visits due to pain
No
Yes
Visits related to fear of childbirth
No
Yes
Visits related to premature contractions
No
Yes

No psychiatric
diagnosis
(n 1,284)*

Odds ratio

95%
Confidence
interval

114 (54.3)
96 (45.7)

671 (53.0)
596 (47.0)

Referent
0.99

0.731.35

169 (81.3)
39 (18.8)

1,171 (92.2)
99 (7.8)

Referent
2.04

1.402.98

126 (68.9)
57 (31.3)

946 (84.3)
176 (15.7)

Referent
2.06

1.412.96

80 (44.2)
101 (55.8)

731 (66.0)
376 (34.0)

Referent
2.10

1.493.00

119 (56.4)
92 (43.6)

787 (61.4)
495 (38.6)

Referent
1.16

0.851.59

137 (64.9)
74 (35.1)

954 (74.5)
327 (25.5)

Referent
1.52

1.102.12

196 (92.9)
15 (7.1)

1,182 (92.3)
99 (7.7)

Referent
0.82

0.441.53

184 (87.2)
27 (12.8)

1,176 (91.8)
105 (8.2)

Referent
1.56

0.972.51

187 (88.6)
24 (11.4)

1,218 (95.1)
63 (4.9)

Referent
2.38

1.414.02

185 (87.7)
26 (12.3)

1,186 (92.6)
95 (7.4)

Referent
1.68

1.032.75

Data are presented as n (%).

* Data for the variable sick leave were missing in 207 (13.8%) women, and data for the variable sick leave during first trimester were missing in
190 (12.7%). For all other variables missing data was prevalent in 0.11.2%.

Odds ratio adjusted for age, marital status, socioeconomic status, smoking habits, parity, and body mass index.

P .001.

P .01.

P .05.

51% in gestational weeks 10 12 to 9% in week 20,

suggesting that the risk for overestimating psychiatric
disorders ought to be a minor problem at the later time
point. Furthermore, as previously mentioned, a selfadministered version of Primary Care Evaluation of
Mental Disorders, the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire, has been
validated for use in obstetric gynecologic patients.16
Depressive symptoms are not often recognized in clinical
gynecological practice, most likely because psychiatric
disorders in women often are disguised by somatic complaints, such as headache, chronic fatigue, pain, and
bleeding irregularities.22 Among patients with major depression seeking help at their general practitioner, the
majority presented with other symptoms or causes for
their consultation.22 Presumably, nausea and vomiting
could represent one such symptom of discomfort.

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Depression, Anxiety, and Obstetric Outcome

Our study suggests that women with antenatal depressive and/or anxiety disorder were on sick leave earlier in
the pregnancy and for a longer time period throughout
pregnancy than women without any diagnosis. Although not specifically concerned with a pregnant population, similar results were obtained in DEPRES (Depression Research in European Society), which was the
first pan-European study on depression in the community, performed by Lepine and coworkers.17 DEPRES
was performed on a large population (78,463 adults) in 6
countries and was not performed exclusively on pregnant women. The results of the DEPRES study revealed
more lost days of productivity in depressed subjects and
also a strong correlation between the severity of depression and number of sick-leave days. Those who suffered
from major depression lost 4 times as many working
days over a 6-month period as nonsufferers (13 versus 3

OBSTETRICS & GYNECOLOGY

Table 4. Delivery Data Associated With Presence of Antenatal Psychiatric Diagnosis

Induced labor
No
Yes
Planned cesarean delivery
No
Yes
Acute caesarean delivery
No
Yes
Instrumental delivery
No
Yes
Normal vaginal delivery without complications
Yes
No
Oxytocin during labor
No
Yes
Epidural analgesia
No
Yes
Time from start of labor to delivery
12 h
12 h
Time from arrival in delivery unit to delivery
12 h
12 h

Psychiatric
diagnosis
(n 211)*

No
psychiatric
diagnosis
(n 1,284)*

Odds ratio

95%
Confidence
interval

180 (85.3)
31 (14.7)

1,103 (86.0)
180 (14.0)

Referent
0.97

0.631.50

187 (88.6)
24 (11.4)

1,198 (93.3)
86 (6.7)

Referent
1.76

1.052.93

190 (90.9)
21 (10.0)

1,169 (91.0)
115 (9.0)

Referent
1.07

0.621.82

199 (94.3)
12 (5.7)

1,187 (92.4)
97 (7.6)

Referent
0.66

0.321.37

125 (59.2)
86 (40.8)

788 (61.4)
496 (38.6)

Referent
1.17

0.841.63

101 (56.1)
79 (43.9)

648 (55.6)
517 (44.4)

Referent
1.13

0.791.62

121 (65.1)
65 (34.9)

855 (72.0)
333 (28.0)

Referent
1.56

1.082.56

100 (58.1)
72 (48.9)

750 (69.3)
332 (30.7)

Referent
1.88

1.302.73

130 (72.6)
49 (27.4)

891 (78.1)
250 (21.9)

Referent
1.42

0.962.13

Data are presented as n (%).

* Data for the variable time from start of labor to delivery were missing in 133 (9.6%) women, and data for the variable time from arrival in
delivery department to delivery were missing in 67 (4.8%) women. For the variables induced labor, oxytocin during labor, and epidural analgesia,
missing data was prevalent in 0.13.0%.

Odds ratio adjusted for age, marital status, socioeconomic status, smoking habits, parity, and body mass index.

P .01.

P .05.

days). In our study, 37% of women, at some time point

during pregnancy, had a sick-leave period. Although
missing data on disability days was prevalent in 207
subjects, thus opening up the possibility of some degree
of uncertainty in the results, the frequency is similar to
what previously has been reported from Swedish register
data. In 2002, 39% of pregnant Swedish women were on
sick leave during the last trimester of pregnancy.23
Another finding in the DEPRES17 study was that
sufferers from major depression imposed the greatest
demand on healthcare resources, making almost 3 times
as many visits to their general practitioner or family
doctor as nonsufferers. In our study we also found more
doctor visits among women with a diagnosis than among
women without.
Furthermore, consultation related to fear of childbirth
was significantly associated with a psychiatric diagnosis.
Supporting data are presented in a study by Sjogren and

VOL. 104, NO. 3, SEPTEMBER 2004

Thomassen,24 who found a higher frequency of psychological problems in women with severe anxiety over
childbirth compared with controls, and likewise, significant associations between antenatal depressive and/or
anxiety disorders and pronounced fear of childbirth
have been reported.9
Finally, we noted significant associations between antenatal depression and/or anxiety and consultations related to premature contractions, planned cesarean delivery, use of epidural analgesia during labor, and a selfexperienced longer time of labor. The higher incidence
of cesarean deliveries might be explained by a covariation between depression and/or anxiety and fear of childbirth, as already mentioned. Sjogren and Thomassen24
noted in their study that 68% of the women with severe
anxiety over childbirth initially requested cesarean delivery. In Sweden, the cesarean delivery rate has increased
from 10.6% in 1990 to 16.0% in 2001.13 Because there

Andersson et al

Depression, Anxiety, and Obstetric Outcome

473

Table 5. Complications of Pregnancy and Delivery Associated With Prevalence of Antenatal Psychiatric Diagnosis

Hypertensive disorder including preeclampsia

No
Yes
Postterm labor
No
Yes
Oligohydramnios
No
Yes
Bleeding in late gestation
No
Yes
Intrauterine growth restriction and hypoxia
No
Yes
Preterm delivery
No
Yes
Poor progress in labor
No
Yes
Postpartum bleeding
No
Yes
Fetal distress
No
Yes
Rupture of the anal sphincter
No
Yes

Psychiatric
diagnosis
(n 211)*

No
psychiatric
diagnosis
(n 1,284)*

Odds ratio

95%
Confidence
interval

203 (96.2)
8 (3.8)

1,251 (97.6)
31 (2.4)

Referent
1.37

0.573.27

197 (93.4)
14 (6.6)

1,181 (92.0)
103 (8.0)

Referent
0.78

0.431.44

205 (97.2)
6 (2.8)

1,249 (97.3)
35 (2.7)

Referent
0.91

0.352.37

209 (99.1)
2 (0.9)

1,268 (98.8)
16 (1.2)

Referent
0.75

0.163.45

208 (98.6)
3 (1.4)

1,269 (98.8)
15 (1.2)

Referent
1.43

0.405.14

194 (93.3)
14 (6.7)

1,210 (94.5)
70 (5.5)

Referent
1.20

0.642.25

161 (86.1)
26 (13.9)

995 (83.1)
202 (16.9)

Referent
0.83

0.501.36

209 (99.1)
2 (0.9)

1,268 (98.8)
16 (1.2)

Referent
0.75

0.163.45

193 (91.5)
18 (8.5)

1,198 (93.4)
85 (6.6)

Referent
1.36

0.762.42

180 (96.3)
7 (3.7)

1,169 (97.7)
28 (2.3)

Referent
2.03

0.854.86

Data are presented as n (%).

* For the variables hypertensive disorder, preterm labor, and fetal asphyxia and growth retardation, missing data was prevalent in 0.1 0.5%.

Odds ratio adjusted for age, marital status, socioeconomic status, smoking habits, parity, and body mass index.

are no firm somatic explanations for this increase, psychological factors have been suggested to be involved.
The increased use of epidural analgesia found among
patients with depressive and/or anxiety disorders in our
study was also supported by Chung and colleagues.11
This finding, together with the experienced longer time
of labor, might be associated with more sensations of
pain. As previously mentioned,22 somatic complaints
seem to be associated with depressive and/or anxiety disorder, and pain especially has been noted to complicate the
diagnosing of depression.25 Likewise, McWilliams and colleagues26 found associations between chronic pain and
mood and anxiety disorders. In their study, anxiety disorders were more strongly associated with pain than were
mood disorders.
Other studies have noted associations between antenatal depressive symptoms and adverse events in pregnancy and/or delivery,6,11,27 including increased frequency of operative deliveries, preterm delivery, and

474

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Depression, Anxiety, and Obstetric Outcome

preeclampsia. The study on preeclampsia, performed by

Kurki and coworkers,27 revealed significant associations
between the disease and antenatal depressive and/or
anxiety symptoms. One suggested explanation was that
depression and anxiety might alter excretion of vasoactive hormones or other neuroendocrine transmitters,
leading to an increased risk for hypertension. Our study
did not reveal any correlations between antenatal depression and/or anxiety and complications of pregnancy
and delivery, such as hypertensive disorder including
preeclampsia, fetal growth restriction/hypoxia, and preterm delivery. Operative vaginal deliveries and acute
cesarean deliveries were also similarly distributed between women with a psychiatric diagnosis and healthy
subjects.
A limitation of the present investigation is the sample
size, which presumably is too small to detect adverse
events that normally are rare. For that reason, only a
limited number of relatively frequent obstetric complica-

OBSTETRICS & GYNECOLOGY

Table 6. Early Postpartum Complications Associated With Prevalence of Antenatal Psychiatric Diagnosis

Postpartum infection
No
Yes
Postpartum admission
No
Yes
Mastitis
No
Yes
Other postpartum complications
No
Yes
Hospital stay after delivery
3d
3d

Psychiatric
diagnosis
(n 211)*

No psychiatric
diagnosis
(n 1,284)*

Odds ratio

95%
Confidence
interval

208 (98.6)
3 (1.4)

1,234 (96.2)
49 (3.8)

Referent
0.38

0.121.24

211 (100)
0

1,271 (99.1)
11 (0.9)

Referent
0.02

Not calculated

206 (97.6)
5 (2.4)

1,248 (97.3)
35 (2.7)

Referent
0.96

0.342.37

207 (98.1)
4 (1.9)

1,264 (98.5)
19 (1.5)

Referent
0.73

0.362.53

153 (73.2)
56 (26.8)

917 (71.5)
366 (28.5)

Referent
1.12

0.811.65

Data are presented as n (%).

* For all variables, missing data was prevalent in 0.1%.

Odds ratio adjusted for age, marital status, socioeconomic status, smoking habits, parity, and body mass index.

tions have been studied. Another limitation is that the

assessment of psychiatric diagnoses were made at one
time point only during pregnancy, raising questions as to
whether symptoms remained unchanged, were transitory, or might have developed after the time of screening. For example, Evans and coworkers28 have noted a
significant increase in depression scores between 18 and
32 weeks of pregnancy. Finally, a third limitation is that
the excluded women, in fact, did differ from the study
population in that they had a lower socioeconomic status. Because low socioeconomic status was associated
with the presence of a psychiatric diagnosis, it can be
assumed that a number of women with antenatal depression and/or anxiety have been excluded from the study
group and that the prevalence of psychiatric disorder
during pregnancy would have been higher if these subjects had been included.
In conclusion, this study has pointed out that there is
an association between depressive and anxiety disorders
during pregnancy and lost productivity and increased
health care use. Besides the individual suffering, this also
generates increased costs for society.
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Address reprint requests to: Liselott Andersson, MD, Department of Obstetrics and Gynecology, Sunderby Hospital,
S-97180 Lule, Sweden; e-mail: liselott.andersson@nll.se and
lise-lott@bredband.net.
Received February 18, 2004. Received in revised form May 12, 2004.
Accepted May 21, 2004.

OBSTETRICS & GYNECOLOGY