OBJECTIVE. The purpose of the study was to assess the relationship between multiple births and maternal depressive symptoms measured 9 months after delivery.
METHODS. Data were derived from the Early Childhood Longitudinal Study-Birth Cohort, a longitudinal study of a nationally representative sample of children born in 2001. Depressive symptoms were measured at 9 months by using an abbreviated version of the Center for Epidemiologic Studies Depression Scale. Logistic regression analyses were conducted to study the association between multiple births and maternal depressive symptoms, with adjustment for demographic and household socioeconomic characteristics and maternal history of mental health problems. A total of 8069 mothers were included for analyses.
RESULTS. The prevalence of moderate/severe depressive symptoms at 9 months after delivery was estimated to be 16.0% and 19.0% among mothers of singletons and multiple births, respectively. Only 27.0% of women who had moderate/severe depressive symptoms reported talking about emotional or psychological problems with a mental health specialist or a general medical provider within the 12 months before the interview. The proportions of women with depressive symptoms who were receiving mental health services did not vary according to plurality status.
CONCLUSIONS. Mothers of multiple births had 43% greater odds of having moderate/severe, 9-month postpartum, depressive symptoms, compared with mothers of singletons. Greater attention is needed in pediatric settings to address maternal depression in families with multiple births.
Approximately 139 000 multiple births occurred in the United States in 2004, accounting for 3.4% of all live births. The multiple birth rate (ie, the proportion of live multiple births among all live births) has increased over the past 2 decades, reaching a record high in 2004 (33.9 multiple births per 1000 live births) that was 76% higher than the rate in 1980 (19.3 multiple births per 1000 live births).1 Although increases in multiple birth rates have been greatest among non-Hispanic white women and among women ≥35 years of age, the increasing trend has been observed for all races and age groups.1 Risks associated with multiple births, such as preterm labor, low birth weight, and prematurity, have been well documented.1–3 The infant mortality rate among multiple births was estimated to be 30.5 deaths per 1000 live births in 2004, which was 5 times higher than the rate among singleton births of 5.9 deaths per 1000 live births,4 and the impact of increasing numbers of multiple births on overall infant mortality trends has been identified.5
The impact of multiple births on maternal mental health, particularly postpartum depression, has been understudied.6 Undergoing a high-risk pregnancy and delivering multiple births are stressful life events, and the unique demands of parenting multiple infants can result in high levels of parental stress, fatigue, and social isolation.7 In a prospective study of 175 women who conceived after in vitro fertilization (IVF) treatment, mothers of multiple births were 3 times more likely to show clinically significant depressive symptoms 6 weeks after delivery, compared with mothers of singletons.8 Another study reported that mothers of multiple births conceived through IVF had higher levels of parental stress and anxiety 1 year after delivery, compared with mothers of singletons conceived through IVF or naturally, whereas there was no significant difference among mothers of singletons according to conception mode.9 Greater parental stress and more-prevalent maternal depressive symptoms were still reported 2 to 5 years after delivery among mothers of multiple births conceived through IVF, compared with mothers of singletons conceived through IVF.10
Drawing inferences about the effects of multiple gestation on maternal depression is complicated, however, because known risk factors for depression, such as prematurity,11 use of assisted reproductive technologies,6,12 and cesarean delivery,13 are more common among mothers of multiple births than among mothers of singletons. Little is known about the population prevalence of postpartum depression among mothers of multiple births. Only a few small, facility-based studies examined the different effects on maternal depression and parental stress of multiple births, compared with singleton births, controlling for infertility,8,9,12 and the results were limited by potential selection bias in the samples. One population-based study reported a higher prevalence of emotional disturbance indicative of depression among mothers of multiple births 5 years after delivery, but the analysis was limited by the small number of multiple births sampled.14 The primary purpose of the study was to assess the relationship between multiple births and maternal depressive symptoms, by using a nationally representative, population-based survey, the Early Childhood Longitudinal Study-Birth Cohort (ECLS-B).
The ECLS-B monitors a nationally representative sample of children born in 2001, with oversampling of selected ethnic minority groups, low birth weight infants, and twins. Births were sampled within primary sampling units from the National Center for Health Statistics vital statistics system, and primary sampling units were stratified on the basis of geographical region, median household income, proportion minority population, and metropolitan versus nonmetropolitan area. Children who died or were adopted before 9 months of age and children born to women <15 years of age were excluded.15
Three data sources were used for the analyses, that is, a parental self-administered questionnaire and a parental interview at 9 months and the birth certificate. The self-administered questionnaire included items regarding depressive symptoms during the previous week and lifetime episodes of alcohol or drug abuse problems or hospitalization attributable to mental health problems. The interview reported demographic and socioeconomic characteristics, maternal health care utilization before and during pregnancy, and consultation with health care providers regarding mental health problems in the preceding 12 months. Interviews were conducted in English or Spanish.15 Birth certificates provided information on obstetric and neonatal characteristics.
At 9 months, 9878 parents or guardians of 10 688 children completed parental interviews, among whom were 9747 biological mothers living with the sampled child; 9672 of those women reported whether they had singleton or multiple births. We included the 8069 mothers (83.4%) who completed all of the depressive symptom questions. Rates of completion of the questions did not vary according to plurality.
Maternal depressive symptoms at 9 months after delivery were measured by using an abbreviated form of the Center for Epidemiologic Studies Depression Scale (CES-D).16 A high CES-D score does not constitute a clinical diagnosis of depression, but higher scores are more common among patients with clinical depression, and the CES-D correlates strongly with other depression rating scales.17 The original 20-item form and various abbreviated forms of the CES-D have been used widely to screen for depression in general populations.18–22 The abbreviated form used in the ECLS-B includes 12 symptoms, with each item coded on a 4-point scale between 0 (never) and 3 (often). The range of total scores is 0 to 36, and Cronbach's α for the study sample was .88, comparable to that in previous studies.20,23 Total scores between 10 and 14 and ≥15 represent moderate and severe depressive symptoms, respectively.20
The main independent variable of the study was multiple birth. We also included variables associated with postnatal maternal stress and/or depression, such as neonatal and obstetric characteristics at birth (prematurity,11 cesarean section,13 and complications during labor and delivery24), demographic and socioeconomic characteristics (age,25,26 parity,24 race,24 marital status,24,27 household income,24,27 and education24,28,29), and history of mental illness.24,27,30 Gestational age at delivery was examined as a categorical variable, that is, ≥37 weeks (term), 33 to 36 weeks (moderately preterm), or <33 weeks (severely preterm). Mode of delivery was coded as vaginal delivery or cesarean section. A single binary variable was constructed to indicate whether a mother had ≥1 of the 14 obstetric complications specified on the birth certificate (Table 1).
We examined maternal age at the time of the interview as a continuous variable, because we found minimal nonlinear age effects with categorical transformation of maternal age. Maternal parity was coded as primapara or multipara. Current marital status was categorized as currently married or currently not married (divorced, separated, widowed, or never married). Models in which the separate categories of nonmarriage were assessed independently did not alter the principal findings regarding the effects of multiple births on depression. Maternal race/ethnicity was categorized as non-Hispanic white, non-Hispanic black, Hispanic, or other. We also used a household socioeconomic status (SES) index variable defined in the ECLS-B, which included household income, parental education, and occupation.31,32 This variable was coded into 3 groups, that is, low, middle, and high SES (for household SES index scores in the lowest quintile, the middle 3 quintiles, and the highest quintile among all sampled households, respectively). Finally, 2 binary variables for maternal lifetime history of mental health problems were constructed, that is, history of hospitalization attributable to mental health problems and history of alcohol and/or drug abuse problems. Mothers also reported whether they had talked to a mental health specialist or a general medical provider (ie, a psychiatrist, psychologist, doctor, or counselor) regarding any emotional or psychological problem in the preceding 12 months, and a binary variable was measured (ie, talking once or more versus never).
The unit of analysis was a biological mother living with the sampled child. Logistic regression analysis was conducted to study associations between moderate/severe depressive symptoms (CES-D scores of ≥10) and covariates. Only covariates that had P values of <.2 in unadjusted models were included in multivariate modeling. In adjusted models, we started with the initial model with only the multiple birth variable and then introduced other covariates, in the following order: prematurity, obstetric variables, maternal demographic variables, household socioeconomic characteristics, and maternal history of mental health problems. Any changes in the coefficient of the multiple birth variable with inclusion of an additional set of covariates suggested that any differences in outcomes according to plurality status were associated with the newly introduced covariates.
In addition, mental health consultation history was analyzed among all mothers, as well as among those with moderate/severe depressive symptoms. Proportions of mothers who had obtained mental health consultations were estimated according to maternal demographic, household socioeconomic, and maternal mental health history variables. All estimates of means, proportions, regression coefficients, and SEs were adjusted for sampling weights used in the survey. A P value of .05 was considered statistically significant. Stata 9.0 statistical software (Stata, College Station, TX) was used for all analyses. The study was declared exempt by the Committee on Human Research at Johns Hopkins Bloomberg School of Public Health.
Higher risks of obstetric and neonatal complications with multiple gestations were apparent (Table 1). Adjusted odds ratio of having moderate-to-severe depressive symptoms was 1.43 for mothers of multiple births compared to mothers of singletons. Maternal demographic and household socioeconomic characteristics varied significantly between mothers of singletons and mothers of multiple infants. Mothers of multiple births were more likely to be older, to be currently married, to be educated, and to have higher household SES. There was no significant difference in maternal history of mental health problems according to plurality status.
The mean CES-D scores were 4.9 (95% confidence interval [CI]: 4.8–5.1) and 5.3 (95% CI: 4.8–5.7) among mothers of singletons and multiple births, respectively. The prevalence of moderate/severe depressive symptoms (CES-D score of ≥10) was 16.0% (95% CI: 15.0%–17.1%) among mothers of singletons and 19.0% (95% CI: 16.0%–21.9%) among mothers of multiple births. The prevalence of severe depressive symptoms (CES-D score of ≥15) was estimated to be 6.5% (95% CI: 5.8%–7.2%) and 6.7% (95% CI: 4.9%–8.6%) among mothers of singletons and mothers of multiple births, respectively.
The unadjusted odds of having moderate/severe depressive symptoms was 1.23 among mothers of multiple births, compared with mothers of singletons (Table 2). In bivariate models, severe preterm delivery (<33 weeks), age, race, marital status, SES, and history of mental illness were associated with the outcome (Table 2). With adjustment for preterm delivery, the odds ratio for multiple births was no longer significant; however, with controlling for additional demographic and socioeconomic covariates, multiple births showed a positive association with maternal depressive symptoms (Table 3). In the full model, the odds of depressive symptoms were 43% greater for mothers of multiple births, compared with mothers of singletons (Table 3). Non-Hispanic black mothers had 27% greater odds, compared with non-Hispanic white mothers. Mothers with a history of hospitalization attributable to mental health problems or alcohol/drug abuse also had significantly increased odds (odds ratios of 1.84 and 2.67, respectively). In contrast, currently married status, Hispanic ethnicity, and high household SES were negatively associated with the outcome. We examined interaction effects of multiple births on depressive symptoms according to marital status or Hispanic ethnicity, but we did not find statistical significance, possibly because of the small number of women in each of the interaction categories. We also conducted multivariate analyses excluding 70 mothers of triplets or higher-order multiple births from our sample, and estimated associations between multiple births and maternal depressive symptoms were comparable to those estimated by using the full sample of all mothers of multiple births.
Of the 8069 mothers included in this study, 7972 completed questions on mental health consultations (completion rate: 98.8%). The completion rate did not vary according to depressive symptom status. Overall, ∼11.4% (95% CI: 10.4%–12.3%) of mothers reported talking to a mental health specialist or a general medical provider regarding any emotional or psychological problem in the 12 months before the interview. The estimate was significantly higher among mothers with moderate/severe depressive symptoms (27.0% [95% CI: 23.8%–30.2%]) than among their counterparts (8.4% [95% CI: 7.5%–9.3%]). Among mothers with depressive symptoms, the rates of consulting were nearly twice as high among mothers who had a history of mental health problems and non-Hispanic white mothers, compared with their counterparts (Table 4). The rates of consulting did not vary according to plurality, age, parity, marital status, or household SES.
We examined associations between multiple births and maternal depressive symptoms, using nationally representative data. Our study suggested that 19% of mothers of multiple infants had moderate/severe depressive symptoms 9 months after delivery, compared with 16% of mothers of singletons. Mothers of multiple births were ∼40% more likely to have depressive symptoms, compared with their singleton counterparts, with adjustment for demographic and socioeconomic characteristics.
Parental stress in raising multiple infants has been suggested as a primary cause for maternal depression among mothers of multiple births.8,9 Although no direct causal relationship between postpartum depression and neurobiological factors has been documented, little information is available regarding the magnitude and duration of hormonal changes and dysregulation associated with multiple births.33 The adverse impact of maternal depression on child health and development has been well documented,34–38 and children of multiple births might have increased risk of developmental delay resulting from prematurity and low birth weight39–42 as well as suboptimal health service utilization associated with maternal depression.
Estimates of postpartum depression prevalence vary greatly because of the use of different diagnostic tools and different times of symptom assessment. Although the clinical definition of postpartum depression is limited to the onset of symptoms during the first 4 weeks after childbirth,43 many studies on maternal depression included women whose symptoms began 3 to 12 months after delivery.30 A meta-analysis reported that the prevalence of maternal depression 6 months after delivery was ∼10%, similar to that in the general population,44 but the prevalence in the first 5 weeks after birth was 3 times higher than the prevalence in the general population.45 Our results are limited to 9 months after delivery, and the prevalence of maternal depressive symptoms and the risk according to plurality in earlier postpartum months may differ from our estimates.
The small numbers of women receiving mental health counseling despite depressive symptoms highlight the need for better referral of patients with depressive symptoms. A high index of suspicion for depression should be maintained for mothers of multiple births, as well as for mothers with a history of mental health problems and unmarried mothers. Mothers of multiple births have more regular contact with health care providers throughout the prepregnancy, prenatal, and postpartum periods, which allows ample opportunities for health care providers to educate women about depression. In our study sample, 24.6% of mothers of multiple births underwent ovulation stimulation and/or artificial insemination for the pregnancy. Mothers of multiple births had an average of 20.7 prenatal visits (95% CI: 19.7–21.8 visits), compared with 14.2 visits (95% CI: 14.0–14.4 visits) for their counterparts. Parents of multiple births also are likely to obtain more-frequent pediatric care, because of the higher prevalence of neonatal complications among multiple births, compared with singleton births. In our study, however, we found that the level of mental health consultation was low among mothers with moderate/severe depressive symptoms, regardless of their plurality status.
The importance of providing education and screening for postpartum depression has been addressed previously.36–38,46–49 Because a routine postpartum visit is recommended only 4 to 6 weeks after delivery,50 routine pediatric visits, which are recommended ≥3 times during the first 2 months and ≥7 times during the first 12 months,51 may provide better opportunities for timely education, screening, referrals, and preventive interventions for postpartum depression. Maternal depression screening at well-child visits is accepted by mothers and is a feasible effective means of providing early detection and referral for postpartum depression.47,52 Pediatric practice guidelines recommend that pediatricians ask parents about stress and specific depressive symptoms.53 Such screening in pediatric practices also may increase health service seeking for mothers at risk of depression.19 Current guidelines for maternal depression screening identify risk factors for maternal depression, such as poverty, chronic maternal health conditions, domestic violence, substance abuse, and marital discord, but multiple births are not included.54
Our analysis was limited in identifying mechanisms for the increased risk of depressive symptoms among mothers of multiple births, because of the lack of data on potential key psychosocial covariates of maternal depression, including spousal/partner support and marital relationship6,24,27,29,49,55 and social support,24,27,30,49,55 which were independent of maternal depressive symptoms at the time of the interview. Multiple births have been associated with increased stress and anxiety levels for fathers as well,9 increased social isolation for mothers,7 and decreased marital adjustment.7 Any difference in the impact of multiple births according to the quantity and quality of spousal support should be further assessed. The lower risk of depressive symptoms among Hispanic mothers also needs to be examined further with family support variables, because Hispanic fathers show higher levels of engagement with their children56–59 and the extended family provides a primary social support network for Hispanic mothers.59,60 Finally, although the ECLS-B sample is nationally representative, mothers who completed all 12 depressive symptom questions were significantly more likely to be currently married and from higher household SES quintiles, compared with those who did not complete the questions (results not shown), which partially compromises the national representation of the sample.
In addition, maternal depressive symptoms are reported to be associated with a history of infertility6,61 and the use of assisted reproductive technology.6,12 However, few studies examined the association between maternal depressive symptoms and infertility treatment controlling for multiple births, because of the small number of multiple births sampled.12 We were also unable to study associations among maternal depressive symptoms, multiple births, and infertility, because infertility information was requested only from mothers of multiple infants in the ECLS-B. In our study sample, mothers of multiple births who received infertility counseling for the pregnancy had a depressive symptom prevalence of 13.9% (95% CI: 9.2%–18.5%; n = 234), compared with 21.1% (95% CI: 17.4%–24.8%; n = 540) among mothers of multiple births who never received infertility counseling. With adjustment for maternal education and household SES, however, the odds of having depressive symptoms did not vary according to infertility counseling status among mothers of multiple births. Additional studies are needed for better understanding of the associations among maternal depressive symptoms, multiple births, and infertility treatment, which might indicate clinical implications for counseling of infertility patients.
Mothers of multiple births had a 43% increased risk of having moderate/severe, 9-month postpartum, depressive symptoms, compared with mothers of singletons, in population-based data. Pediatric practices should make an additional effort to educate new and expecting parents of multiple infants regarding their increased risk for maternal postpartum depression. Furthermore, pediatric well-child visits are potentially valuable opportunities to provide education, screening, and referrals for postpartum depression for mothers of multiple births.
Dr Bishai was supported in part by a grant from the Maternal and Child Health Bureau (grant R40MC05475).
- Accepted August 12, 2008.
- Address correspondence to Yoonjoung Choi, DrPH, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe St, E8648, Baltimore, MD 21205. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
What's Known on This Subject
The multiple birth rate has increased steadily, and neonatal and obstetric risks associated with multiple births have been well documented. However, little is known about associations between multiple births and maternal mental health, particularly postpartum depression, at a population level.
What This Study Adds
Mothers of multiple births had 43% greater odds of having moderate/severe, 9-month postpartum, depressive symptoms, compared with mothers of singletons.
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