Mental health conditions associated with adverse maternal outcomes: AJOG Study
Mental health conditions, including depressive and anxiety disorders, are common among pregnant and postpartum women. Moreover, bipolar and schizophrenia disorders may affect a small but significant proportion of the obstetrical population. Maternal mental health conditions are associated with a range of adverse outcomes, including preterm birth, preeclampsia, cesarean delivery, and maternal mortality. In addition, maternal mental health conditions are associated with severe morbidity. In the general population, mental health conditions are often comorbid with chronic medical conditions and are increasing among younger adults.
Logue TC and team conducted a serial cross-sectional analysis of a national database to (1) describe trends in the prevalence of depressive disorders, anxiety disorder, bipolar spectrum disorder, and schizophrenia spectrum disorder diagnoses during delivery hospitalizations; (2) to determine to what degree other chronic health conditions, such as diabetes mellitus and chronic hypertension, are present with mental health conditions; and (3) to evaluate whether mental health is associated with increased risk of adverse outcomes.
The 2000 to 2018 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of women aged 15 to 54 years with and without mental health condition diagnoses, including depressive disorder, anxiety disorder, bipolar spectrum disorder, and schizophrenia spectrum disorder, were identified. The association between mental health conditions and the following adverse outcomes was determined: (1) severe maternal morbidity, (2) preeclampsia or gestational hypertension, (3) preterm delivery, (4) postpartum hemorrhage, (5) cesarean delivery, and (6) maternal mortality.
Of 73,109,791 delivery hospitalizations, 2,316,963 (3.2%) had ≥1 associated mental health condition diagnosis. The proportion of delivery hospitalizations with a mental health condition increased from 0.6% in 2000 to 7.3% in 2018. Among deliveries in women with a mental health condition diagnosis, chronic health conditions, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, increased from 14.9% in 2000 to 38.5% in 2018.
Deliveries to women with a mental health condition diagnosis were associated with severe maternal morbidity preeclampsia and gestational hypertension, preterm delivery, postpartum hemorrhage, cesarean delivery, and maternal death.
In this serial cross-sectional study, there were 4 main findings. The first main finding was that the proportion of delivery hospitalizations with ≥1 mental health condition diagnosis increased >10-fold throughout the study period from 2000 to 2018. Although most of this increase was because of increased diagnoses of anxiety disorder and depressive disorder; bipolar and schizophrenia spectrum disorder diagnoses also increased significantly throughout the study period.
The second main finding was that mental health condition diagnoses were associated with a modestly increased risk of a range of adverse maternal and obstetrical outcomes.
The third main finding was that mental health conditions were increasingly associated with underlying chronic health conditions, such that nearly 40% of hospitalizations with a mental health condition diagnosis had a diagnosis of pregestational diabetes mellitus, obesity, chronic hypertension, asthma, or substance abuse by the end of the study period.
The fourth main finding was that in the setting of mental health condition diagnoses, underlying health conditions were associated with a greater magnitude of risk of severe maternal morbidity.
Findings from this analysis supported that mental health conditions are of increasing clinical significance in the obstetrical population as they are becoming more prevalent in absolute terms and in relation to other chronic conditions. The increased risk from conditions such as chronic hypertension, pregestational diabetes mellitus, obesity, substance abuse, and asthma that was seen in the setting of mental health condition diagnoses may be a consequence of mental health conditions functioning as an obstacle to disease-specific optimal care, which may indicate a need for more intensive surveillance and management during pregnancy. Moreover, mental health conditions may be associated with poorer preconceptional healthcare as patients with these diagnoses may be less likely to access optimal nonobstetrical medical care. Finally, it is possible that untreated or inadequately treated mental health disorders contribute to chronic health conditions through multisystem dysregulation (via the hypothalamic-pituitary-adrenal axis and immune functioning) and compromised lifestyle factors (including diet, sleep, and physical exercise). Further research is needed to determine to what degree the prevalence of and risk associated with mental health condition conditions are associated with social determinants of health and other complicated exposures.
This study found that the proportion of delivery hospitalizations of women with mental health condition diagnoses has increased significantly. Mental health condition diagnoses were associated with other underlying chronic health conditions and a modestly increased risk of a range of adverse outcomes. In the setting of mental health condition diagnoses, underlying health conditions were associated with a greater magnitude of risk of severe maternal morbidity. These findings suggested that mental health conditions are an increasingly important risk factor in adverse maternal and obstetrical outcomes.
Source: Logue TC, Wen T, Monk C, et al. Trends in and complications associated with delivery with mental health condition diagnoses. Am J Obstet Gynecol 2022;226:405.e1-16.
