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[其他话题] 【小夏的论文笔记】中国女性孕期焦虑和抑郁症状与低出生体重的关联:巢式病例对照研究

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夏鹏飞 发表于 2017-4-28 23:38:25 | 显示全部楼层 |阅读模式

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本帖最后由 夏鹏飞 于 2017-4-28 23:40 编辑

Symptoms of anxiety and depression during pregnancy and their association with low birth weight in Chinese women: a nested case control study

中国女性孕期焦虑和抑郁症状与低出生体重的关联:巢式病例对照研究
原文链接:http://link.springer.com/article/10.1007%2Fs00737-016-0697-2

【Abstract】

This study is a nested case control study from a population-based cohort study conducted in Wuhan, China. The aim is to estimate the association between symptoms of depression during pregnancy (DDP), anxiety during pregnancy(ADP), and depression with anxiety during pregnancy (DADP) and low birth weight (LBW) and to examine the extent to which preterm birth (PTB) moderates these associations. Logistic regression analyses were used to model associations between DDP, ADP, and DADP and LBW. Models were stratified by the presence or absence of PTB to examine moderating effects. From the cohort study, 2853 had a LBW baby (cases); 5457 pregnant women served as controls. Women with DDP or ADP only were not at higher risk of having a LBW baby, but DADP was associated with increased risk of LBW (crude OR 1.41, 95% CI 1.17–1.70; adjusted OR 1.29, 95% CI 1.07–1.57), and the significant association was particularly evident between DADP and LBW in PTB, but not in full-term births. Our data suggests that DADP is related to an increased risk of LBW and that this association is most present in PTBs.

【Keywords】

Low birth weight Depression during pregnancy Anxiety during pregnancy Preterm birth
Shaoping Yang and Rong Yang contributed equally to this work.



这是一项武汉队列研究基础上设计和实施的巢式病例对照研究(nested case control study,NCCS),也称为嵌入式病例对照研究。主要通过 Logistic回归

分析孕期的抑郁、焦虑及抑郁伴焦虑与低出生体重之间的关系,并以早产因素调整关联。结果发现孕期抑郁伴焦虑与低出生体重风险增加有关,尤见于早产。


关于巢式病例对照研究这里有一篇很好的介绍:
http://www.medsci.cn/article/show_article.do?id=0aaf9310d9

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 楼主| 夏鹏飞 发表于 2017-4-28 23:39:02 | 显示全部楼层
这两段分别介绍了

1.低出生体重的定义以及低出生体重和早产的社会影响。

2.孕期抑郁和焦虑对母婴健康的不良影响及中国的高发现状。


【Introduction】

A low birth weight (LBW) baby is defined as a live newborn weighing less than 2500 g regardless of gestational age (World Health Organization 1993). Preterm birth (PTB) and small for gestational age (SGA) are the primary risk factors for LBW, which is associated with many multifaceted health problems across the life span (Stevens-Simon and Orleans 1999). Due to associated health problems such as failure to thrive and developmental delays, LBW babies require substantial health care services which places a financial burden on families and the medical system (Stevens-Simon and Orleans 1999). Reducing the rates of LBW is a major public health concern. It is estimated that about 30 million babies are born with LBW each year around the world, and 23.8% of these babies often face severe short-term and long-term health sequelae (Biswas et al. 2008). In 2012, the World Health Organization (WHO) reported that LBW and PTB are the leading causes of neonatal deaths (http://www.who.int/mediacentre/factsheets/fs363/en/). In developing countries, deaths from LBW contribute 60–80% to all neonatal deaths (Lawn Lawn et al. 2005). While the survival of babies with LBW and PTB has greatly increased, largely due to improvement in neonatal intensive care unit services, multiple interventions with comprehensive, multicomponent prenatal care components have failed to demonstrate effects. In part, these intervention studies have been limited by methodological considerations such as selection bias, but there has also been a lack of attention to relevant risk factors (Stevens-Simon and Orleans 1999). In order to make substantial gains in the global threat of infant mortality, risk factors and their determinants must be better understood and addressed by public health programs, particularly in developing countries.

Mental health has been increasingly investigated as a risk factor for LBW. Some studies have found that pregnant women have a prevalence of mental disorders similar to non-pregnant women at the same age, while others have observed that pregnant women are at higher risk of mental disorders (Anderson et al. 2003). Specifically, it is estimated that 10–30% of pregnant women suffer from depression symptoms while 5 to 54% experience anxiety disorders (Fisher et al. 2010; Niemi et al. 2013), making anxiety and depression the most common emotional disturbances during the perinatal period. These mental health disorders often co-occur; of patients with major depressive disorder, 30 to 58% also suffered with anxiety (Nasreen et al. 2011). Due to the numerous physiological and hormonal changes the body undergoes as well as the stressors that can occur during pregnancy, medical and public health professionals have long been concerned with the adverse effects of DDP and ADP on the mother and babies’ health following delivery. However, due to inconsistent results from previous studies, drawing conclusions about the specific role of maternal mental health on adverse pregnancy outcomes has been challenging (Lamers et al. 2011a). Steer et al. found DDP was significantly associated with LBW (Steer et al. 1992), but Chung and associates showed that DDP did not have any influence on LBW (Chung et al. 2001). In another study, Field et al. found that ADP was associated with an increased risk of LBW (Field et al. 2003), but Berle and his colleagues reported that they did not find a significant association between ADP and LBW (Berle et al. 2005). To date, there have been few studies on DADP. Field and colleagues studied the effect of DADP on birth outcomes and reported that the comorbid group, suffering from both depression and anxiety, experienced a greater incidence of LBW than that of either the non-depressed or depressed groups (Field et al. 2010). Further, the prevalence rate of depression and anxiety symptoms in pregnant women may vary across ethnic groups (Lamers et al. 2011a; Field et al. 2010), making it important to study the cultural context of the association of mental health and birth outcomes. Some studies have demonstrated that depression and anxiety during the perinatal period are more common among women in low- and middle-income countries (Faisal-Cury and Rossi Menezes 2007). A study reported that the prevalence of DDP in Chinese women is 19.8% and that the prevalence of ADP increased from 5.5 to 25.5% over the past 10 years (Zhao et al. 2006). In Wuhan, China, with seven inner city districts and six remote city districts, due to the rapid development of the economy, stress-related illnesses have become increasingly common. The purpose of the present study was to determine the relationship between DDP, ADP, and DADP and the presence of LBW and to identify important covariates that modify these associations.
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 楼主| 夏鹏飞 发表于 2017-4-28 23:42:34 | 显示全部楼层
方法部分介绍了

1.研究对象的基本信息及纳入标准:武汉市内居住至少两年;市内医院分娩并在市内休养;怀孕前无精神障碍史;无出生缺陷的单胎活产。

2.数据收集方式:武汉市妇幼保健中心电子围产期保健信息系统(EPHCIS);社区卫生服务中心(CHSC)调查问卷;抑郁和焦虑的暴露由孕妇自我感觉。

3.统计分析:描述性统计;卡方检验低出生体重与抑郁、焦虑之间关联;二元Logistic回归分析模拟抑郁、焦虑与低出生体重之间管理;分层分析检查早产的影响;选择的混杂因素:母亲年龄,受教育程度,家庭收入,新生儿性别,妊娠史,既往流产史,体重增加量,被动吸烟史,阴道出血,尿液或阴道感染和妊娠并发症(心脏病或肝脏疾病或高血压)。


【Methods】

Study design and study population

The present study is a nested case control study from a population-based birth cohort study that was designed to evaluate adverse birth outcomes including PTB and LBW. The study was conducted in the seven inner city districts of Wuhan, China, from June 10, 2011, to June 9, 2013. For the purpose of this analysis, cases consist of every pregnant woman in the cohort who had a newborn with LBW. The control group was comprised of mothers from a previous case control study of this cohort, which was a random sample from the cohort of women who had either a PTB or a LBW baby. The cases and controls were required to meet the following criteria: (1) to have lived in the seven inner city districts of Wuhan for at least 2 years, (2) to have given birth in a hospital located in the inner city and rested in the inner city following delivery, (3) to not have a history of mental disorders prior to pregnancy, and (4) to have a singleton live birth without any birth defects.

The study extracted cases and controls from the Electronic Perinatal Health Care Information System (EPHCIS) of the Wuhan Medical and Health Center for Women and Children (WMHCWC). The EPHCIS has been running as a three-level service network for the health of women and children for more than 10 years. It collects electronically all clinical perinatal information from all pregnant women in Wuhan including data from antepartum examinations, intrapartum condition, and postpartum visits for both the mother and the child. Cases and controls were sampled three times per month. All births from the 1st day to the 10th day of the month were sampled on the 20th day of that month, all births from the 11th day to the 20th day of the month were sampled on the last day of that month, and all births from the 21st day to the last day of month were sampled on the 10th day of the next month.

Birth-related data

The main outcome, LBW, was defined as a newborn weight below 2500 g. The newborn weight was weighed by obstetric nurses in the delivery room and was recorded into EPHCIS within 24 h of the baby’s birth. Gestational age was calculated from prenatal care records, which is determined by the date of the last menstrual period (LMP) and/or ultrasound during the first trimester. Other conditions including methods of delivery, newborn height, vaginal bleeding, and other data related to the mother and the newborn during delivery were entered into EPHCIS.

Main exposure and other covariates

The primary exposure variable and covariates were collected by questionnaires administered by doctors or nurses of the community health service centers (CHSCs) during their routine prenatal care and postpartum home visits with pregnant mothers. The questionnaires were developed by a study group consisting of trained and certified nurses and physicians and were completed within 3 months of delivery. The information collected included maternal demographics, socioeconomic status, gravidity, parity, miscarriage, abortion history, age at first birth, history of stillbirth or birth defects, weight before pregnancy, weight at birth, history of maternal medical conditions, family disease history, working status, smoking and passive smoking, alcohol consumption, nutrition, level and nature of physical activity, medicine use history, stressors, anxiety, depression, social support, and others.

The exposure for this study was self-reported symptoms of depression and anxiety during pregnancy. Mothers responded with “yes” or “no” on two questions about how they felt during their pregnancy: one that asked if they felt depressed and a second that asked if they felt anxious. They were coded as positive for depression or anxiety if they said yes to either item or positive for depression comorbid anxiety if they said yes to both items.

The WMHCWC was responsible for setting up the database, managing programs, controlling quality, and gathering data. Researchers from the DWCHCHs obtained questionnaire data from their governed CHSCs, entered this information into the database, and then uploaded it to the WMHCWC.

Statistical analysis

Descriptive analyses were used to characterize the participants and their exposures. Chi-squared analysis was used to test possible bivariate associations between the variables and LBW as well as depression or/and anxiety during pregnancy. A binary logistic regression analysis was used to model the relationship of depression or/and anxiety during pregnancy and LBW. In order to examine the moderating effects of PTB, stratified analyses were conducted. In all analyses, odd ratios (ORs) with 95% confidence intervals (CIs) were calculated. All t tests were two tailed and p values below 0.05 were considered statistically significant. Epidata 3.02 was used to enter the data from the questionnaires and SAS version 9.2 (SAS Statistical Institute, Inc., Cary, NC) was used for statistical analysis.

Data were also collected on factors hypothesized to confound the association between mental disorders and LBW. Based on our previous study and the published literatures, we selected the following factors to investigate as potential confounding variables: maternal age, educational attainment, household income, newborn sex, gravidity, previous miscarriage, weight gain, passive smoking, vaginal bleeding, urinary or vaginal infection, and pregnancy complications (heart disease or liver disease or hypertension). The weight gain data was determined by measuring actual height and weight gain during pregnancy and then categorizing weight gain based on pre-pregnancy BMI and the IOM’s 2009 gestational weight gain by BMI category guidelines (Haugen et al. 2014).
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 楼主| 夏鹏飞 发表于 2017-4-28 23:43:03 | 显示全部楼层
结果部分介绍了

1.样本基本信息:样本量;问卷应答率;病例组和对照组混杂因素的差异。抑郁、焦虑患病率

2.控制协变量前,抑郁、焦虑、抑郁伴焦虑患病率均高于对照组(具有统计学意义)。

3.单纯抑郁、单纯焦虑不增加低出生体重风险,抑郁伴焦虑与低出生体重有关,控制协变量后差异仍具有统计学意义。

4.按照早产与否分层,多项回归分析模拟各层之间抑郁、焦虑、抑郁伴焦虑与低出生体重之间联系,结果显示抑郁、焦虑、抑郁伴焦虑并不增加足月产低出生体重风险,但出现低出生体重的早产产妇有1.52倍的风险患有抑郁伴焦虑 ,调整协变量后关系仍然存在。


【Results】

A total of 95,911 pregnant women met the criteria in the Wuhan cohort study conducted from June 10, 2011, to June 9, 2013. Of the 95,911 newborns that were delivered, 2853 (3.0%) had LBW and were included as cases. The control group from a previous case control study of this cohort was used for the purpose of this analysis. Of the cohort, 4308 (4.5%) were PTB, of which 1704 were both PTB and had LBW; thus, the final number of PTB or LBW births was 5457. The control group for this analysis was 5457 women who were selected randomly from the 90,454 pregnant mothers who did not have PTB or LWB. Thus, the present study consisted of 2853 LBW newborns and 5457 controls. Questionnaires were mailed to all 8310 women, 71.0% of whom responded (n = 5903; 57.5% of cases and 78.1% of controls). As shown in Table 1, there were statistically significant differences between cases and controls in maternal age, household income, previous miscarriage, weight gain, pregnancy complications, urinaryor vaginal infection during pregnancy, and newborn sex. Differences in maternal educational attainment and passive smoking during pregnancy were not significant.

Overall, 18.6% (n = 1100) of the pregnant women had DDP symptoms, 13.0% (n = 769) had ADP symptoms, and 9.3% (n = 547) had DADP symptoms. The prevalence rate of either prenatal depression or anxiety was 22.4%. Before controlling for covariates, women with DDP, ADP, and DADP were more likely to have a LBW baby. The differences in the prevalence rates of DDP, ADP, and DADP between cases and controls were statistically significant (Table 2).

We categorized the exposure of depression or anxiety during pregnancy into three categories: only DDP (n = 553, 9.4%), only ADP (n = 222, 3.8%), and DADP (n = 547, 9.3%). DADP was associated with an increased risk of LBW. After adjusting for covariates, the odds of LBW decreased, but the significant association still existed. The risk of having a LBW baby was similar for women who had only DDP or ADP and those who did not have symptoms of DDP or ADP (Table 3).

In order to examine the moderating role of PTB, we stratified the analysis by the presence or absence of PTB. Among the 2853 LBW newborns, 1149 were PTB and the remaining 1704 were full-term births. Multinomial regression analysis was used to model the association between DDP, ADP, or DADP and LBW within each stratum of PTB. The further analyses showed that DDP, ADP, or DADP was not associated with an increased risk of LBW for full-term births, but participants had LBW with PTB had a 1.52 times increased risk of having DADP, after adjusting for covariates, this association remained (Table 4).
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 楼主| 夏鹏飞 发表于 2017-4-28 23:43:57 | 显示全部楼层
讨论部分列举了一些既往的研究结果。说明了本研究是研究抑郁焦虑与低出生体重的首例基于人群的病例对照研究,并且具有代表性;以及发现抑郁伴焦虑为低出生体重的风险因素。

另外也表示研究的局限性:使用的是自我报告而不是详细的心理或精神病学评估;病例的回应率较低;对照是从没有早产和低出生体重的母亲中随机抽取,而不是从仅仅没有低出生体重的母亲。


【Discussion】

The present study analyzed the associations between low birth weight and DDP, ADP, and DADP in a cohort of Chinese women and explored the moderating effects of preterm birth. It is well known that LBW not only leads to increased infant mortality but also places the infant at a greater risk of later adult chronic medical conditions such as diabetes, hypertension, and heart disease (Goldenberge and Culhane 2007). Mental disorders during pregnancy have been shown to be a risk factor for LBW (Weck et al. 2008) and thus have received significant attention over the past several decades. DDP and ADP symptoms have been studied separately in some studies. For instance, previous research has reported that DDP is associated with increased odds of LBW (Steer et al. 1992; Rondó et al. 2003; Rahman et al. 2004; Neggers et al. 2006), a finding supported by a subsequent study (Lawn Lawn et al. 2005), whereas some studies failed to demonstrate significant associations between DDP and LBW (Elsenbruch et al. 2007; Andersson et al. 2004; Larsson et al. 2004; Tony et al. 2001). Andersson et al. reported that a high-depressive symptom score during pregnancy increased the risk of LBW at full-term birth, but the significant association disappeared after adjusting for confounders (Andersson et al. 2014).The few papers that studied the effect of ADP only on LBW have shown a relatively inconsistent picture. For example, some studies reported that there was no association between ADP and LBW (Martini et al. 2010), while others have suggested that ADP was significantly associated with LBW (Field et al. 2003; Nasreen et al. 2010); a meta-analysis supported the finding of a significant association between ADP and LBW (Ding et al. 2014). Inconclusive findings indicate a need to further examine methodological factors related to the previous research. For instance, sample size, the inclusion of confounding factors, and the exposure assessment vary across previous research. Further, previous research in this area has included women of different socioeconomic statuses and ethnicities. Results from meta-analyses support the conclusion that the risk of LBW was significantly associated with DDP or ADP during pregnancy, but this association was larger in developing countries (Grigoriadis et al. 2013).

The present study showed that having only DDP or ADP was not significantly associated with LBW in Chinese women. However, because more than 70% of individuals with depressive disorders also have anxiety symptoms (Lamers et al. 2011b), it is critical to examine the effect of these mental disorders when they occur together. Some reports have documented that anxiety and depression are common mental disorders and always co-occur in patients and that they can exacerbate their symptoms mutually (Kessler et al. 2007). There is limited research on the effect of DADP on LBW, although the research on DADP on other birth outcomes provides some insight. Field et al. reported that DADP could lead to a higher incidence of PTB (Field et al. 2010); Gladys et al. observed that DADP was not associated with birth weight (Ibanez et al. 2012). Vikrampatel and Prince found that maternal psychologyical morbidity was independently associated with birth weight (Vikrampatel and Prince 2006). Young (2004) and Dayan (2006) proposed that women with DADP were more likely to experience an excessive secretion of stress hormones, which can stimulate the synthesis and release of placental corticotrophin-releasing hormone (CRH), which could then lead to delivery. However, these studies seldom considered the related factor of preterm or full-term birth—clearly a risk for adverse birth outcomes.
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 楼主| 夏鹏飞 发表于 2017-4-28 23:44:31 | 显示全部楼层
结论:单纯抑郁与单纯焦虑与低出生体重无明显相关性,但抑郁伴焦虑孕妇出现低出生体重的风险较高。应更多关注孕产妇心理健康,今后研究需要更有效的诊断。


【Conclusion】

The analyses in the present study suggest that prenatal depression or anxiety are not significantly associated with LBW, but individuals with prenatal depression combined with anxiety are at a higher risk of having a LBW. Taking into account gestational age, this significant association is observed for preterm birth but not for full-term birth. Maternal mental health during pregnancy should be given more attention, and in a future study, a more effective methodological diagnosis for depression and anxiety during pregnancy is needed.


【Acknowledgments】

We appreciated the hard work of all the maternal and child health care staff in the seven District Maternal and Child Health Care Hospitals and 113 Community Health Service Centers in inner city, Wuhan, China.


【Compliance with ethical standards】

The study was approved by the institutional review board for human studies at our Saint Louis University, USA, and the Ethical Committee of WMHCWC. The study protocol complied with the principles outlined in the Declaration of Helsinki. All participants provided written informed consent prior to beginning data collection.


【Conflict of interest】

This study was sponsored by the HEI, US (4791-RFA09-2/10-5), and the Province Natural Science Foundation, Hubei Province, China (2010CDB08803). The authors declare that they have no competing interests.
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 楼主| 夏鹏飞 发表于 2017-4-28 23:48:58 | 显示全部楼层
本帖最后由 夏鹏飞 于 2017-4-28 23:51 编辑

看到方法部分的时候,我第一反应是,居然是直接问孕妇自己是否认为自己有抑郁或者焦虑,而不是使用量表进行测量。可能是问卷主要不是测这个,只是拿其中的两项出来分析了一下吧。看到最后,发现作者在讨论部分也坦陈了这个局限性。

PS:自己大创做的也是抑郁、焦虑相关的研究,看了这篇文章也有很大的收获,对自己论文的修改也很有参考价值。
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mmyrt 发表于 2017-4-29 00:22:32 触屏版 | 显示全部楼层
只想给楼主么么哒
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zhek 发表于 2017-5-5 06:44:33 | 显示全部楼层
假设还是有新意的,存在设计上的缺陷,如果是流行病学家审稿,可能就毙掉了。
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