Research paperThe role of social support in family socio-economic disparities in depressive symptoms during early pregnancy: Evidence from a Chinese birth cohort
Introduction
Antenatal depression is becoming one of the most common complications during pregnancy, affecting up to 10% of pregnant women (Vigod et al., 2016). Higher rates were reported in Chinese pregnant women (Lau et al., 2011, Li et al., 2012a). Depression during pregnancy may lead to adverse maternal outcomes, such as gestational diabetes mellitus, hypertension, preeclampsia (Becker et al., 2016), and postpartum depression(Silva et al., 2012), and subsequent adverse birth and postnatal outcomes, including low birth weight (Grigoriadis et al., 2013, Grote et al., 2010), premature birth (Grigoriadis et al., 2013, Grote et al., 2010), fetal growth restriction (Grote et al., 2010), and a higher risk of admission to a neonatal intensive care unit (Grigoriadis et al., 2013). Either singly or combined, these conditions may impact the quality of life of the mother and child.
Socio-demographic factors such as income and education may influence antenatal depression (Biaggi et al., 2016). Previous studies examining the associations of socio-economic factors with the risk of depression during pregnancy mainly focused on individual indicators (Biaggi et al., 2016). However, multiple socio-economic indicators reflect different interrelated components. For example, maternal occupation represents both social standing and material resources, which are strongly related to maternal income and education (Galobardes et al., 2006b). Therefore, a single indicator may not represent the multidimensionality of socio-economic position (SEP), which is commonly measured by education, income or wealth, occupation and living conditions, together (Adler et al., 1994, Vyas and Kumaranayake, 2006).
Few studies examined the association between family SEP and depressive symptoms among pregnant women using aggregative indicators of SEP, with largely inconsistent results (Goyal et al., 2010, Lancaster et al., 2010, Silva et al., 2012, Yohannes Dibaba and Hindin, 2013). Furthermore, it is unclear whether the relationship between risk factors and depressive symptoms is modified by parity. Depressive symptoms in nulliparous women may be more associated with changes related to pregnancy, while multiparous mothers may face the challenges of increased financial responsibilities (Figueiredo and Conde, 2011). However, such modification remains largely unexplored.
Depression is difficult to treat and identification of causes related to depression may lead to new modifiable targets for prevention. Numerous studies showed an inverse relation between social support and depression in pregnant women (Biaggi et al., 2016). However, some studies failed to identify an association between SEP and depression during pregnancy when social support was adjusted for in the models (Shakeel et al., 2015, Yohannes Dibaba and Hindin, 2013), which suggested social support may mediate the relation between SEP and depression (Lancaster et al., 2010). Existing literature on the mediating role of social support has only been demonstrated in a few studies restricted to non-pregnant (such as adolescents, postpartum populations) (Gjerdingen et al., 2014, Miller and Taylor, 2012, Wickham et al., 2014). However, it is unclear whether these findings apply to pregnant women where pregnant women may be vulnerable to developing mental health problems because of the changes in hormones during pregnancy, including higher estradiol, progesterone and cortisol (Kammerer et al., 2006), as well as the stress of the impending birth with all its implications (Carlo et al., 2014).
China is experiencing rapid economic development and urbanization, which may affect mental stress that changes physiological, psychological and behavioral factors (Li et al., 2012b). Furthermore, rural to urban migration is a major source of China's growth, and living conditions are one of main concerns among these migrants, with negative effects on women's physical and mental health (Hu et al., 2011). However, the association of SEP with antenatal depression among Chinese women is unclear given a lack of such studies in Chinese populations. In order to address these research gaps, we examined the association between SEP and depressive symptoms during early pregnancy, and if present, to assess whether this association was mediated by social support in a large birth cohort in Guangzhou, one of the most economically developed cities in China. We also assessed whether the relation between SEP and depressive symptoms and any mediation by social support were modified by parity.
Section snippets
Study population and design
For the present study, baseline information was obtained for all participants as part of the ongoing prospective Born in Guangzhou Cohort Study (BIGCS), conducted in Guangzhou Women and Children's Medical Center, China. Details of the BIGCS have been described previously (Qiu et al., 2017). In short, pregnant women were eligible if they: i) lived in and intended to remain in Guangzhou for at least three years after delivery, ii) attended their first antenatal care visit before the 20th week of
Results
We included 14,332 pregnant women who were recruited between January 2013 and April 2016, since the items of social support were only added to questionnaires after 2012. Those with invalid or missing data on depressive symptoms (n = 851) and/or SEP (n = 843) were excluded, as well as those with missing data on gestational week, or those who completed the baseline questionnaire after the 20th gestational week (n = 256). A total of 12,382 women (mean age 29.4 years [standard deviations 3.5]) were
Discussion
Consistent with several previous studies (Goyal et al., 2010, Raisanen et al., 2014, Silva et al., 2012), lower SEP was associated with a higher risk of depressive symptoms in early pregnancy. Our study also adds by showing that the association between SEP and depressive symptoms might be mediated by social support. Although some studies were unable to replicate the relation between SEP and depressive symptoms (Shakeel et al., 2015, Yohannes Dibaba and Hindin, 2013), these studies included
Declarations of interest
None.
Contributors
Hui-Min Xia and Xiu Qiu conceived and designed the study; Dong-Mei Wei and Shiu Lun Au Yeung conceived and designed the study, analysed and interpreted the data, and drafted the manuscript; Jian-Rong He, Wan-Qing Xiao and Jin-Hua Lu analysed and interpreted the data; Si Tu and Nian-Nian Chen collected and assembled the data; Kin Bong Hubert Lam, Kar-Keung Cheng, Gabriel M Leung and C Mary Schooling interpreted the data. All authors reviewed and revised the manuscript critically for important
Funding
This work was supported by the Guangzhou Science and Technology Bureau, China [grant number 201508030037]; National Natural Science Foundation of China [grant number 81673181]; and National Key Research and Development Program of China [grant number 2016YFC1000205]. The three funding providers had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Acknowledgements
The authors are grateful to all the participants in the Born in Guangzhou Cohort Study, all obstetric care providers who assisted in the implementation of the study, and to the whole study team. We also thank Dr. Zhiwei Gao for useful comments on the study and Deborah Malden for editing the language of the manuscript.
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