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Pregnancy, somatic complaints and depression: a Frenchpopulation-based study

Gisele Apter a, Emmanuel Devouche a,*, Valerie Garez a, Marina Valente b,Marie-Camille Genet a, Maya Gratier c, Joelle Belaisch-Allart d

a Erasme Hospital, Psychiatry and Psychopathology Research Institute, Franceb Beclere General Hospital Maternity Ward, Francec University Paris Ouest, Franced Sevres General Hospital Maternity Ward, France

A R T I C L E I N F O

Article history:

Received 23 February 2013

Received in revised form 3 July 2013

Accepted 3 August 2013

Keywords:

Depression during pregnancy

Somatic complaints

Antenatal OB/GYN screening

Early intervention

Public Mental Health

A B S T R A C T

Objective: Depression during pregnancy is today one of the greatest medical risks for expectant mothers

and newborns. It is associated with numerous morbid conditions and with postnatal depression.

Identifying depression during pregnancy is therefore a major public health concern, but screening for

depression is not routinely carried out in somatic settings. We hypothesized that the presence of

numerous somatic complaints contributes to the detection of an increased risk of depression during

pregnancy.

Study design: A cross-sectional study was conducted on 1000 consecutive pregnant women approached

during OB/GYN visits at a general maternity hospital. They were asked to fill out a questionnaire, which

contained the Edinburgh Postnatal Depression Scale (EPDS) and a checklist of 18 somatic complaints.

Results: The median number of somatic complaints was 5 (interquartile range 3–7). The risk of

depression during the 2nd and 3rd trimesters was 18.3% (EPDS score > 10.5). Logistic regression

revealed that when the somatic complaints total score moved from 3 to 7, the odds of moving from not-

at-risk to at-risk for antenatal depression were multiplied by 2.91.

Conclusion: Our results call for further research exploring somatic complaints and their link to

depression during pregnancy. Until more knowledge is available, we suggest considering that women

with a high number of somatic complaints during pregnancy are at high risk for depression and should be

referred for further diagnostic clinical assessment and care.

� 2013 Published by Elsevier Ireland Ltd.

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology andReproductive Biology

jou r nal h o mep ag e: w ww .e lsev ier . co m / loc ate /e jo g rb

1. Introduction

Depression during pregnancy is today one of the greatestmedical risks both for expectant mothers and newborns. It isassociated with a higher risk of numerous medical morbidconditions for both mother and child. It has been positivelycorrelated with pre-eclampsia and premature onset of labor [1,2].In addition, mental disorders during pregnancy are associated withpoor prenatal health care [3,4]. Kelly et al. [4] examined 1 millionconsecutive deliveries in the US, controlling for socioeconomicstatus and parity. Women with psychiatric disorders delayed care,and less than 50% of them attended prenatal clinics. Lack of health

Abbreviations: OB/GYN, obstetrics and gynecology; EPDS, Edinburgh Postnatal

Depression Scale; OR, odds ratio; CI, confidence interval.

* Corresponding author at: University Paris Descartes, 71, Avenue Edouard

Vaillant, 92100 Boulogne Billancourt, France. Tel.: +33 0155205933.

E-mail address: emmanuel.devouche@parisdescartes.fr (E. Devouche).

Please cite this article in press as: Apter G, et al. Pregnancy, somatic coObstet Gynecol (2013), http://dx.doi.org/10.1016/j.ejogrb.2013.08.01

0301-2115/$ – see front matter � 2013 Published by Elsevier Ireland Ltd.

http://dx.doi.org/10.1016/j.ejogrb.2013.08.013

care heightens the risk of non-detection of major medical issuessuch as hypertension or gestational diabetes in women, and fetalgrowth retardation. This, in turn, increases the risk of prematurebirth, low birth weight for gestational age, and their chain ofcomplications. As for mental health issues, mood disorders such asdepression are directly responsible for poor attendance for caredue to feelings of worthlessness and increased fatigue. Thereforemental health disorders directly contribute to an increased risk ofmajor peripartum public health issues.

Depression during pregnancy is strongly correlated withpostnatal depression and with subsequent non-perinatal depres-sion [5]. When associated with a history of abuse and neglect,peripartum depression has been strongly related to impairment ofthe mother–infant relationship and with negative impact on infantemotional and cognitive development [6]. The association ofdepression during pregnancy with prematurity and low birthweight, in itself a possible consequence of depressive mood duringpregnancy, also puts the infant at high risk of parent–infantinteractive dysregulation with an increase in negative emotional

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development of premature infants and risk of abuse and neglect[7,8].

As many as 18.4% of pregnant women are depressed duringtheir pregnancy, with 12.7% developing major depression [9,10].Bennett et al. [9] found prevalence rates of 7.4%, 12.8% and 12.0% inthe first, second and third trimesters while Gavin et al. [10]determined point prevalence to be 11.0%, 8.5% and 8.5%.Considering how common a condition depression during pregnan-cy appears to be and how strongly linked it is to medical risk anddevelopmental issues for mother and infant, identifying it ought tobe a major public health concern [11]. Yet practitioners still lacksimple and reliable ways of doing so for routine use.

OB/GYN visits provide a unique opportunity for pregnantwomen to talk about their feelings and express somatic complaints[12]. Various attempts have been made at quick screening fordepression during pregnancy. The Edinburgh Postpartum Depres-sion Scale (EPDS) has been used to identify pregnant womenpotentially at-risk for depression [13,14]. This scale, however, isnot a part of routine medical OB/GYN visits even though it has beenshown to be fully valid for screening for major depression duringpregnancy [15]. It is not a diagnostic tool per se but has shownexcellent validity in screening for at-risk populations. Screening fordepression during pregnancy can be difficult, as somatic symptomssuch as changes in sleep, appetite and energy are generallyattributed by clinicians to pregnancy itself. It has therefore beenassumed that asking about somatic symptoms will increase falsepositives in the screening and assessment of depression duringpregnancy. This assumption has led to underdiagnosis for mooddisorder during the peripartum period as shown in the study byKelly et al. [4]: Women with a diagnosis of depression reportedmore physical complaints than their non-depressed counterparts.As suggested by Klainin and Arthur [16] in their literature review, astudy systematically exploring depression in OB/GYN patientsusing expressed somatic complaints as a screening tool still needsto be implemented.

1.1. Aims of the study

We therefore aimed to address this issue in order to evaluatethe somatic complaints that women usually cite during theirprimary care visits, based on a list of somatic symptoms expressedduring the 2nd and 3rd trimesters and often noted in OB/GYNsettings as an indicator of depressive risk during pregnancy.

2. Materials and methods

2.1. Participants

A cross-sectional study was undertaken in a general hospitalmaternity ward (1700 births per year), which is part of a networkof maternity wards in a suburban area of Paris. We enrolled 1000consecutive pregnant women, who were approached during theirregular OB/GYN visits, regardless of mothers’ age, ethnicity andtrimester of pregnancy. Recruitment began in April 2009 and wascompleted in September 2009. All mothers signed an informedconsent form, guaranteeing general anonymous treatment ofinformation and allowing right of access to their medical files.

2.2. Procedure

A questionnaire was routinely handed out to be filled out in thewaiting room for the OB/GYN visits at the maternity ward. Eachmother was asked by the medical secretary to complete thequestionnaire, and to leave it in a ballot box dedicated to the study.The questionnaire took 5–10 min to complete; this is well adaptedto the usual wait that precedes an OB/GYN visit. The questionnaire

Please cite this article in press as: Apter G, et al. Pregnancy, somatic coObstet Gynecol (2013), http://dx.doi.org/10.1016/j.ejogrb.2013.08.01

was offered by the OB/GYN team and presented in this way:‘‘During your wait, we would be grateful if you would agree to fillout this questionnaire. It will help us to know about you duringyour pregnancy. If you accept, you may be contacted again by amember of our team. All your answers are strictly confidential andwill only be included in your medical file’’. The questionnaire wasaimed at collecting demographic data and contained generalquestions, a checklist of 18 somatic complaints and the EdinburghPostnatal Depression Scale (EPDS). The checklist was established ina series of meetings with obstetricians, midwives and headmidwives of the maternity network comprising a catchment areaof 5 maternity wards delivering approximately 13,700 births peryear. Three multidisciplinary meetings took place during the yearprior to the study where practitioners from the five maternitywards listed the kinds of somatic symptoms most routinelyreported in the last year of activity.

Somatic complaints covered the following areas: sleep dis-orders (nightmares, insomnia), eating disorders (bulimia, loss ofappetite, nausea, vomiting, and abdominal pain), OB/GYN com-plaints (uterine contractions, bleeding, pelvic pain), digestivesystem complaints (gastric pain, constipation, and diarrhea),general complaints (asthenia, dizziness, swollen legs, varicoseveins, back pain). Each complaint was attributed a score of 1 ifticked. We examined the total number of somatic symptomsreported by each woman (ranging from 0 to 18).

2.3. Measures

Risk for antenatal depression was assessed using the EPDS, a 10-item self-rating scale that was designed to screen a broadpopulation for risk of having perinatal depression [17]. This scalecovers the symptomatology commonly associated with depres-sion, excluding somatic dimensions such as fatigue and appetitevariations, which are normal during the ante- and postnatalperiods. Each item is scored on a 4-point scale (0–3), giving aminimum total score of 0 and a maximum of 30. It can becompleted and scored quickly and has a high level of acceptability[17]. Following the study of Matthey et al. on the variability of cut-off scores [18], we decided to test both a cut-off score of 11 or moreand a cut-off score of 13 or more for antenatal screening fordepressive disorders.

2.4. Socio-demographic and OB/GYN data collection

Socio-demographic and OB/GYN data were obtained frommedical files. Each questionnaire was assigned a number and eachnumber was associated with a medical file. This procedure ensuredaccess to socio-demographic and relevant OB/GYN information inaddition to self-report answers by women. This also allowed us tocollect information about women who did not return thequestionnaire. Socio-demographic variables included maternalage (18–34 years vs. �35 years), geographic origin (Europe vs.other), currently living with a partner (yes/no), employment status(employed vs. unemployed), pre-gestational body mass index(BMI; normal weight (18–25 kg/m2) vs. overweight (�25 kg/m2)),and tobacco use (yes/no). OB/GYN variables included: trimester ofpregnancy at the moment of the survey (trimester 2 vs. trimester3), parity (nulliparous or not), type of pregnancy (single ormultiple), pregnancy resulting from an assisted reproductivetechnique (ART) process (yes/no), and OB/GYN hospitalizationduring ongoing pregnancy before the survey (yes/no).

2.5. Statistical analysis

Analysis was done with Stata for Windows (version 10). Logisticregression was used to estimate odds ratios (ORs) and Wald 95%

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Table 1Somatic complaint during pregnancy.

Number of women (n = 706)

Sleep disorder complaints

Insomnia 136 (19.3%, 16.5–22.3)

Nightmares 262 (37.1%, 33.6–40.7)

Eating disorder complaints

Nausea 424 (60.1%, 56.4–63.6)

Abdominal pain 242 (34.3%, 30.9–37.9)

Vomiting 232 (32.9%, 29.5–36.41)

Loss of appetite 137 (19.4%, 16.7–22.5)

Bulimia 54 (7.6%, 5.9–9.9)

Ob/Gyn complaints

Uterine contractions 275 (39%, 35.4–42.6)

Pelvic pain 159 (22.5%, 19.6–25.8)

Bleeding 78 (11%, 8.9–13.6)

Digestive system complaints

Constipation 327 (46.3%, 42.7–50)

Heartburn 274 (38.8%, 35.3–42.5)

Diarrhea 95 (13.5%, 11.1–16.2)

General complaints

Asthenia 393 (55.7%, 52–59.3)

Back pain 352 (49.9%, 46.2–53.5)

Swollen legs 260 (36.8%, 33.4–40.5)

Dizziness 210 (29.7%, 26.5–33.2)

Varicose veins 70 (9.9%, 7.9–12.4)

Data are number (%, 95% CI).

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CIs of the association of postnatal depression with somaticcomplaints during pregnancy and with socio-demographic andOB/GYN characteristics of women.

3. Results

Among the 1000 consecutive women who were solicited, 759(75.9%) spontaneously completed and returned the questionnaire.Of these, 726 (95.7%) returned a fully filled questionnaire. Medicalfiles were unavailable for 11 women due to medical transfers toanother maternity ward and were incomplete for 9 women.Complete data were thus collected for 706 women (Fig. 1). The 706women who returned the questionnaire did not differ significantlyfrom the 241 women who did not, in terms of sociodemographicand OB/GYN characteristics.

All but 14 women (2%) reported at least one somatic complaint.Three, 5 and 7 are the values of the boundary at the 25th, 50th, or75th percentiles. Three complaints were reported by half or moreof the women: nausea (60.1%), asthenia (55.7%) and back pain(49.9%) (Table 1). Bulimia and varicose veins were reported by lessthan 10% of the cohort.

One hundred and twenty nine women were at risk fordepression (18.3%, 95% CI 15.6–21.3) with an EPDS cut-off scoreof 11 or more and 91 (12.9%, 95% CI 10.6–15.6) with an EPDS cut-offscore of 13 or more. Among the sociodemographic variablesexamined, two were associated with a risk for depression using anEPDS cut-off score of 11 or more (Table 2): the risk was increasedfor women living without a partner or those who smoked.Examination of OB/GYN variables only revealed a significantassociation with trimester of pregnancy: the risk for antenataldepression was increased for women interviewed during thesecond trimester of pregnancy. These three associations werestrongest with the use of an EPDS’s cut-off score of 13 or more, anda fourth association appeared: the risk for depression duringpregnancy was also increased for unemployed women (Table 2).

Fig. 1.

Please cite this article in press as: Apter G, et al. Pregnancy, somatic coObstet Gynecol (2013), http://dx.doi.org/10.1016/j.ejogrb.2013.08.01

Depression was associated with somatic complaints before andafter adjustment for all sociodemographic and OB/GYN variablesand whichever EPDS cut-off was used (unadjusted odds ratio(OR) = 1.28, 95% CI 1.19–1.38 and unadjusted OR = 1.28, 95% CI1.19–1.36 respectively, and adjusted OR = 1.31, 95% CI 1.22–1.40and adjusted OR = 1.34, 95% CI 1.23–1.45 respectively). We alsocomputed OR corresponding to an increase from the first to thethird quartile: when the somatic complaints total score movesfrom 3 to 7, while all of the other variables in the model holdconstant, the odds of moving from not at risk to at risk aremultiplied by 2.91 with an EPDS cut-off of 11 or more (adjustedOR = 2.91, 95% CI 2.19–3.86) and by 3.17 with an EPDS cut-off of 13or more (adjusted OR = 3.17, 95% CI 2.28–4.41).

4. Comments

The main result of this study is that pregnant women who havean elevated number of ‘‘subjective somatic complaints’’ are atgreater risk for depression during the peripartum period. In thisstudy, no single complaint appears to be pathognomonic ofdepression. Rather, it is the accumulation of different symptomsthat is directly correlated with the EPDS score. It is important tonote that the EPDS does not include questions about somaticcomplaints, therefore the direct association between somaticcomplaints and risk of depression can be considered even stronger.Another powerful indirect result of this study is the impressiveturnout. When asked about their feelings during pregnancy, amajority of women responded (more than 70%). This, in itself,shows the strong interest women have in exploring their physicaland mental health status during the peripartum period, andtherefore the impact one could have during this specific period ifscreening could be implemented more systematically in OB/GYNclinics. One possible confounder in our study is the inherentoverlap that exists between a number of somatic complaintsymptoms included in the checklist (Table 1). Indeed, some of thesymptoms can be subsumed under broader categories, and it ispossible that subjects appear to present numerous somatic

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Table 2Sociodemographic and OB/GYN characteristics of women and association of these characteristics with risk for antenatal depression. Two separate cut-off scores were

considered using the EPDS.

Number of

women (n = 706)

Women at risk for

AND (EPDS � 11 = 129)*

Adjust Wald

OR (95% Cl)**

Women at risk for AND

(EPDS � 13; n = 91)*

Adjusted Wald

OR (95% CI)**

Sociodemographic data

Age (years)

18–34 509 (72%) 94 (18.5%) 1.00 65 (12.8%) 1.00

�35 197 (28%) 35 (17.8%) 1.09 (0.67–1.76) 26 (13.2%) 1.22 (0.69–2.11)

Born in Europe

Yes 445 (63%) 72 (16.2%) 1.00 53 (11.9%) 1.00

No 261 (37%) 57 (21.8%) 1.4 (0.91–2.18) 38 (14.6%) 1.14 (0.68–1.93)

Living with partner

Yes 648 (92%) 107 (16.5%) 1.00 73 (11.3%) 1.00

No 58 (8.2%) 22 (37.9%) 2.57 (1.38–4.81) 18 (31%) 2.89 (1.46–5.69)

Employment status

Employed 651 (92%) 112 (17.2%) 1.00 77 (11.8%) 1.00

Unemployed 55 (7.8%) 17 (30.9%) 1.96 (0.97–3.97) 14 (25.5%) 2.71 (1.24–5.89)

Pregestational body mass index (kg/m2)

18–25 589 (83%) 102 (17.3%) 1.00 72 (12.2%) 1.00

�25 117 (17%) 27 (23.1%) 1.15 (0.68–1.96) 19 (16.2%) 1.03 (0.55–1.92)

Tobacco use

No 598 (85%) 101 (16.9%) 1.00 67 (11.2%) 1.00

Yes 108 (15%) 28 (25.9%) 1.69 (1.01–2.86) 24 (22.2%) 2.33 (1.31–4.13)

ObGyn data

Trimester of pregnancy

Trimester 3 564 (80%) 86 (15.2%) 1.00 56 (9.9%) 1.00

Trimester 2 142 (20%) 43 (30.3%) 1.64 (1.01–2.67) 35 (24.6%) 2.29 (1.32–3.98)

Parity before pregnancy

�1 437 (62%) 57 (13%) 1.00 37 (8.5%) 1.00

Nulliparous 269 (38%) 72 (26.8%) 1.01(0.65–1.57) 54 (20.1%) 1.21 (0.72–2.03)

ART process

No 619 (88%) 114 (18.4%) 1.00 79 (12.8%) 1.00

Yes 87 (12%) 15 (17.2%) 0.85 (0.43–1.69) 12 (13.8%) 0.92 (0.43–1.97)

Single pregnancy

Yes 682 (97%) 123 (18%) 1.00 86 (12.6%) 1.00

No 24 (3.4%) 6 (25%) 1.34 (0.44–4.08) 5 (20.8%) 1.25 (0.37–4.17)

ObGyn Hospitalisation during ongoing pregnancy***

No 681 (96%) 124 (18.2%) 1.00 87 (12.8%) 1.00

Yes 25 (3.5%) 5 (20%) 1.13 (0.39–3.26) 4 (16%) 1.42 (0.45–4.52)

Data are number (%).* Percentages are the proportion of the total number of women in each subgroup.** Adjusted for all other variables listed in the table.*** Before participation to the survey.

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symptoms when they in fact suffer from a single condition. Wesuggest, however, that the fact that some women choose to checknumerous symptoms, even ones that are partially redundant, ismore indicative of depression than the actual symptoms theyreport. Another point often underlined is that an increase insomatic discomfort is generally thought to be attributed topregnancy itself. Most pregnant women suffer from some somaticdiscomfort. Nevertheless, despite a widespread increase in numberof somatic complaints, our study clearly differentiates betweentwo groups of women based on their EPDS score. Women withhigher EPDS scores present a much greater number of somaticcomplaints. Due to the cross-sectional nature of the study,however, we do not know whether the somatic symptoms existedbefore pregnancy, were initiated by it or appeared in the course ofpregnancy.

It is important to note that it is not possible in our study toknow if somatic complaints are a tolerable means of expressionfor depression, i.e. a manner in which to signal an often guilt-ridden and hard-to-admit condition in most western societies,where pregnancy is thought of as a blissful state, or if a difficultand painful pregnancy has paved the way for a depressiveepisode. Therefore these results call for further researchexploring somatic complaints and their link to depressionduring the peripartum.

Until more knowledge is available, it could be interesting toconsider that women with a high number of somatic complaints

Please cite this article in press as: Apter G, et al. Pregnancy, somatic coObstet Gynecol (2013), http://dx.doi.org/10.1016/j.ejogrb.2013.08.01

during pregnancy need to be screened because of high risk fordepression. This could be performed by midwives and nursesduring routine OB/GYN visits during pregnancy. Women wouldthen be referred, if necessary, for further diagnostic clinicalassessment and care. Future studies in women’s health issueswould need to determine in what way somatic complaints are theexpression of depression and/or how they contribute to depressivemood and risk of depressive episodes.

No other medical condition with such dire consequences andsuch high prevalence as depression during pregnancy would gounscreened for and untreated. Should we not consider it time tosystematically address the issue of depression during pregnancywith the simple tools available to assess patients’ complaintstoday?

Authors’ contributions

G. Apter and E. Devouche are the investigators for the study andparticipated in all phases of the study, including the original idea,literature search, design, data analysis and interpretation, andwriting.

V. Garez, M. Valente and M.-C. Genet participated in the designof the study, acquisition of data and data interpretation.

M. Gratier participated in data interpretation and writing.J. Bellaish-Allart participated in the design of the study.All authors had critical input into the manuscript.

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Declaration of interest

The authors declare that they have no conflict of interest.

Role of the funding source

This study was made possible thanks to a grant from theMustela Foundation and by Erasme Hospital.

Acknowledgment

We are grateful to the Chairs and staff of the Ob-GynDepartments who facilitated access to the participants of ourstudy.

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