Professor, Chair, and Associate Dean of Research, College of Public Health, Division of Epidemiology, The Ohio State University, Columbus
SYNOPSIS: Reporting symptoms of having major depression one month after treatment for early pregnancy loss was about twice as common among Black women compared to non-Black women.
SOURCE: Shorter JM, Koelper N, Sonalkar S, et al. Racial disparities in mental health outcomes among women with early pregnancy loss. Obstet Gynecol 2021;137:156-163.
Early pregnancy loss (EPL) is common and can lead to psychological sequelae. Black women in the United States experience higher rates of pregnancy loss and perinatal depression than women of other racial groups. In a recent secondary analysis, Shorter et al evaluated whether Black women have more symptoms of major depression one month after being treated for EPL compared to non-Black women. To do this, they compared 120 women who self-identified as Black and 155 women who self-identified as non-Black. The latter group was comprised mostly of Hispanic (n = 72) women, followed by other (n = 36), white (n = 27), and Asian (n = 20) women. Participants in the parent trial (n = 300) were adults diagnosed with a nonviable intrauterine pregnancy at five to 12 weeks of gestation who were enrolled in a randomized trial in 2014-2017 to study the medical management of EPL.
For the present analysis, researchers diagnosed women as having symptoms of no, mild-moderate, or major depression one month after treatment using a common screening instrument, the Center for Epidemiological Studies-Depression scale (CES-D). This tool consists of 20 items that produce six subscales for the major dimensions of depression: depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep disturbance.
Participants also completed two other validated scales: the Perceived Stress Scale and the Adverse Childhood Experience (ACE) scale. The Perceived Stress Scale is a psychological tool for measuring perception of stress in the past month. Shorter et al included in their analysis participants from the parent study who completed the CES-D and Perceived Stress Scale. Missing scale data seemed to be more common among white participants than those of other races.
Overall, 24% (65/275) of participants were classified as having symptoms of major depression one month after treatment for EPL. The fraction with symptoms of major depression was higher among Black women (31%; 37/120) compared to non-Black women (18%; 28/155). Black women had odds of having major depression symptoms 2.02 times than that of non-Black women (95% confidence interval [CI], 1.15-3.55). This difference persisted after the authors adjusted for parity, baseline depression, and ACE score; the adjusted odds ratio (OR) was 2.48 (95% CI, 1.28-4.81). The proportion of women who reported high perceived stress one month after EPL treatment did not differ between Black women (8%; 10/120) and non-Black women (5%; 8/155). The unadjusted OR was 1.67 (95% CI, 0.64-4.37), and the OR adjusted for parity, baseline depression, and ACE score was 1.09 (95% CI, 0.36-3.26).
Having had at least two adverse childhood experiences (classified as having a “high” ACE score) was more common among Black women (53%; 64/120) compared to non-Black women (40%; 62/155). Black women had an odds 1.71 times that of non-Black women (95% CI, 1.06-2.77) of having a high ACE score. Specifically, having experienced parental separation or divorce and criminal behavior in the household was more commonly reported by Black women compared to non-Black women. Having a high ACE score was associated with symptoms of major depression (OR, 2.51; 95% CI, 1.41-4.46) and high perceived stress (OR, 4.53; 95% CI, 1.45-14.1) one month after treatment. After adjusting for race, baseline depression, and parity, the association between a high ACE score and major depression did not hold (adjusted OR, 1.71; 95% CI, 0.89-3.27), but high ACE score did remain associated with high perceived stress (adjusted OR, 3.90; 95% CI, 1.08-14.0).
EPL, defined as a nonviable intrauterine pregnancy in the first trimester, sometimes is referred to as miscarriage or spontaneous abortion. EPL is a common occurrence, often taking place without the person even being aware of the pregnancy. EPL occurs in about 31% of pregnancies overall but only in 10% of pregnancies that are clinically recognized.1 Shorter et al found that reporting symptoms of major depression was twice as common among Black women compared to non-Black women one month after receiving treatment for EPL. The non-Black category was heterogeneous in that it included women of Hispanic ethnicity, Asian race, and undefined “others.” (Note: The authors did not explain how Hispanic Black women were categorized.) It is possible that the strength of the association between Black race and depression following EPL might vary widely depending on the composition of the non-Black comparison group.
Almost one-quarter of participants in the study reported symptoms of major depression post-treatment; however, the study design is not suitable for estimating the prevalence of major depression following treatment for EPL. Because the study population was not selected to be representative of an external population (but instead consisted of women consenting to enroll in a randomized trial to test medical treatment of EPL), we cannot generalize the frequency of the outcome to a general population. The authors did not find differences by race in perceived stress one month after treatment for EPL. However, because only 18 participants reported high perceived stress, the authors likely did not have enough power to assess the adjusted association between race and perceived stress. A general rule of thumb is that 10 events are needed for each predictor variable to avoid overfitting the regression model.2 Thus, the authors would have needed at least 40 participants with high perceived stress for this analysis. As a result, we should consider the study findings to be uninformative as to the association between Black race and high perceived stress following EPL. However, because so few women in the study reported perceived stress, the study findings tell us that either the scale was not a valid measure for this population or perceived stress does not commonly follow EPL.
A limitation of secondary analysis of data collected for another purpose is that the choice of measures might be less than ideal and important covariates might not have been collected. As the authors acknowledged, the ACE scale may have failed to capture important adverse experiences related to childhood exposure to racism and environmental conditions. In contrast, the scale used for measuring depression symptoms (CES-D) has been validated across racial groups. Another limitation was the lack of data on pregnancy intention. Evidence suggests that women who obtain an induced abortion have less anxiety following the procedure compared to those who are unsuccessful in obtaining a desired abortion.3,4 Similarly, it is possible that women in the present study who had an unwanted pregnancy might have experienced relief at having the decision about continuing the pregnancy taken out of their hands. By not adjusting or otherwise controlling in the analysis for women’s feelings about the pregnancy, the relationship between race and mental health following EPL might be confounded.
Women might experience negative emotions after a pregnancy loss because they, or their partner or family, believe they are to blame.4 Clinicians can hold an important role in educating patients that EPL is common and might be accompanied by unfounded feelings of guilt or shame. Although the present study found an association between Black race and symptoms of major depression, this should not be used as an argument to target women for screening for depression based on their race. Given that major depression following EPL appears to be so common, and given that depression is a treatable condition, clinicians should be prepared to screen all patients with EPL, regardless of race or ethnicity, and, if necessary, to refer for timely mental health care.5
- Magnus MC, Wilcox AJ, Morken NH, et al. Role of maternal age and pregnancy history in risk of miscarriage: Prospective register based study. BMJ 2019;364:l869.
- Peduzzi P, Concato J, Kemper E, et al. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996;49:1373-1379.
- Biggs MA, Upadhyay UD, McCulloch CE, Foster DG. Women’s mental health and well-being 5 years after receiving or being denied an abortion: A prospective, longitudinal cohort study. JAMA Psychiatry 2017;74:169-178.
- Bardos J, Hercz D, Friedenthal J, et al. A national survey on public perceptions of miscarriage. Obstet Gynecol 2015;125:1313-1320.
- Farren J, Jalmbrant M, Falconieri N, et al. Posttraumatic stress, anxiety and depression following miscarriage and ectopic pregnancy: A multicenter, prospective, cohort study. Am J Obstet Gynecol 2020;222:367.e1-367.e22.