RESUMO
BACKGROUND: Maternal stress has been identified as one of the most common clinical phenotypes associated with preterm birth. The American College of Obstetricians and Gynecologists recommends anxiety screening at least once in the perinatal period. The prevalence of perinatal anxiety is challenged by the absence of formalized screening protocols and underreporting in high-risk populations, such as those with a history of adverse pregnancy outcomes. OBJECTIVE: This study administered a validated anxiety screening tool in a cohort of patients with and without a previous spontaneous preterm birth and compared differences in score and rate of a positive screen between groups. Moreover, this study evaluated perinatal outcomes associated with a positive screen and described a referral protocol involving evaluation by a perinatal mental health counselor and clinical diagnoses. A hypothesis was made that patients with a previous history of spontaneous preterm birth would have higher self-reported anxiety symptoms than controls and that those with recurrent preterm delivery at <35 weeks of gestation would have the highest anxiety screening scores. STUDY DESIGN: This was a prospective observational cohort study administering the Generalized Anxiety Disorder 7-item screen to patients enrolled in 2 prenatal care clinics at our institution. The preterm birth cohort consisted of patients with a history of spontaneous preterm labor, premature rupture of membranes, or cervical insufficiency compared with the control cohort without this history. Screening was initiated at entry to prenatal care or referral to our high-risk obstetrical clinic. The inclusion criteria included English- or Spanish-speaking patients and singleton pregnancy, and the exclusion criteria included pregnancies complicated by a major congenital anomaly, enrollment after 34 weeks of gestation, delivery at <20 weeks of gestation, and incomplete delivery data. Referral to a mental health counselor was offered to those with a Generalized Anxiety Disorder 7-item screen score of ≥10. Perinatal outcomes as a comparison between the Generalized Anxiety Disorder 7-item screen-positive group and Generalized Anxiety Disorder 7-item screen-negative group were performed with statistical methods, including the Student t test, chi-square test, and Wilcoxon rank-sum test, with a P value of <.05 to determine significance. RESULTS: Between September 2020 and December 2021, 1349 participants were analyzed, with 143 patients (11%) in the previous preterm birth cohort and 1206 (89%) patients in the control cohort. Patients with a history of preterm birth and subsequent delivery at ≤35 weeks of gestation in the study pregnancy had significantly higher Generalized Anxiety Disorder 7-item screen scores than controls with delivery after 35 weeks of gestation (median score: 4 [interquartile range, 1-9] vs 2 [interquartile range, 0-6], respectively; P=.006). Overall, 187 participants (14%) screened positive with significantly higher rates in the previous preterm birth group than in the control group (20% vs 13%; P=.036). Of note, 117 patients (63%) accepted a referral, and 32 patients (17%) with a positive screen were diagnosed with a perinatal mood disorder. CONCLUSION: Patients with recurrent preterm birth have higher self-reported anxiety using the Generalized Anxiety Disorder 7-item screen than controls. Of those with a positive screen, 17% were diagnosed with a perinatal mood disorder.
RESUMO
BACKGROUND: Perinatal mood disorders have both short- and long-term negative consequences for mothers and their babies. National organizations recommend universal screening for postpartum depression. Little is known, however, about screening and referral among women living in underserved areas with limited access to care. OBJECTIVE: The objective of this report was to evaluate the utilization of mental health services in an urban, inner-city hospital following the implementation of colocated counseling services across 10 county-sponsored clinics that serve a medically underserved population. We further explored antecedents of a positive postpartum depression screen, factors associated with successful referral, and the rate of perinatal mood disorder diagnoses following universal screening. We hypothesized that integrated mental health services would improve referral rates following positive postpartum depression screening compared with historically separated services. STUDY DESIGN: This was a retrospective cohort study of women undergoing universal postpartum depression screening with deliveries from January 2017 to December 2019 who were compared with a historic cohort from the same population from June 2008 to March 2010. The Edinburgh Postnatal Depression Scale was used to evaluate women at their postpartum visit, and a mental health service referral was offered to women with a score of ≥13. The primary outcome was a comparison of completed referrals between cohorts with and without colocated mental health services following a positive postpartum depression screen. Statistical analysis included chi-square tests with a P value of <.05 being considered significant and adjusted multivariate analyses for perinatal outcomes associated with a positive postpartum screen. RESULTS: Between January 2017 to December 2019, 25,425 women completed a postpartum depression screen with 978 (4%) of those recording a positive screen. After implementation of colocated mental health counselors, completed perinatal mental health referrals significantly increased when compared with the historic cohort without colocated services (57%; 560 of 978 vs 22%; 238 of 1106; P<.001). Adverse neonatal outcomes, such as stillbirth (adjusted risk ratio, 9.5; 95% confidence interval, 6.35-14.26) and neonatal demise (adjusted risk ratio, 14.3; 95% confidence interval, 6.67-30.46), were most strongly associated with a positive depression screen. There were 122 (21%) women with a positive screen who were diagnosed with a depressive disorder in the peripartum period. There were no specific features associated with those who did or did not complete referral. One-fifth of women were referred for psychiatric evaluation following an initial evaluation, and the referral rate was associated with higher scores on the depression screen (P<.001). CONCLUSION: Utilization of mental health services following a positive depression screen more than doubled following the implementation of colocated services.
