Women who have lost a baby in a miscarriage or stillbirth can experience persistent depression during a later pregnancy that continues even after the birth of a healthy baby.
In a study of 13,133 women who gave birth in the early 1990s in southwest England and 21% had experienced miscarriages or stillbirths, “previous prenatal loss showed a persisting prediction of depressive and anxiety symptoms well after what would conventionally be defined as the postnatal period,” reported Emma Robertson Blackmore, Ph.D., of the University of Rochester Medical Center, New York, and her associates (Br. J. Psychiatry 2011 March 7 [doi:10.1192/bjp.bp.110.083105]).
The study builds on previous findings about increased anxiety and depression in pregnant women who had previously lost a baby in a miscarriage or stillbirth “by showing that the impact persists well past the subsequent pregnancy and despite the birth of a healthy child.” Because depression is very treatable, Dr. Blackmore emphasized in an interview the need for a heightened focus on identifying women with a previous prenatal loss and routinely screening them for depression.
The study, which drew its large sample from the Avon Longitudinal Study of Parents and Children (ALSPAC), measured data from six assessments, two prenatal (at 18 and 32 weeks) and four post partum (at 8 weeks and 8, 21, and 33 months). In the first assessment, the women self-reported any previous miscarriages and stillbirths. At each assessment stage, the women self-reported maternal anxiety using the Crown–Crisp Experiential Index (CCEI) and depression using the Edinburgh Postnatal Depression Scale (EPDS).
Covariates included “maternal age at initial interview, currently living with husband or partner, number of living children, education level, ethnicity, and use of tobacco and alcohol during the first 3 months of pregnancy,” previous depressive episodes, birth weight and gestational age, and a household crowding index. The investigators combined stillbirths and miscarriages after finding no significant difference in results.
Dr. Blackmore, who is in the department of psychiatry, said that she has done extensive work in postpartum depression, but she “was actually quite surprised by the findings” because it never crossed her mind before to ask women about previous loss. She had focused instead on factors such as any history of depression.
She explained how women who had a previous loss can “get incredibly anxious leading up to the gestational point” during which they lost the baby, which is when an ob.gyn. can step in and alleviate anxiety about physical symptoms.
The investigators did not report any relevant financial disclosures. The U.K. Medical Research Council, the Wellcome Trust, and the University of Bristol currently provide core support for ALSPAC. This particular study received funding from the National Institutes of Health.
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Miscarriages Require More Sensitivity
Dr. Nada Stotland sees this study as an important reminder for physicians not to trivialize miscarriages. “Sometimes medical professionals don't know what to say,” she said, and they may unintentionally hurt the patient by saying “You didn't even know the baby” or “Have another one.”
Because miscarriage is so common, Dr. Stotland thinks that physicians should be screening every woman for depression, whether or not she has risk factors.
The absence of cultural rituals for miscarriages can prevent the patient from getting closure in a time of grief. Dr. Stotland noted how Americans place importance on retrieving the bodies of fallen soldiers, but “we have nothing for miscarriage.” A physician's sensitivity to a patient's desire to name the child or hold a memorial service can help formalize this loss.
“It's just a matter of not saying something dismissive,” she said in an interview.
DR. STOTLAND is a professor of psychiatry and obstetrics and gynecology at Rush Medical College in Chicago. She did not report any relevant financial disclosures.