Prevalence of depression during pregnancy in spanish women: trajectory and risk factors in each trimester

International Journal of Environmental Research and Public Health Article Prevalence of Depression during Pregnancy in Spanish Women: Trajectory and Risk Factors in Each Trimester M. Carmen Míguez * and M. Belén Vázquez   Citation: Míguez, M.C.; Vázquez, M.B. Prevalence of Depression during Pregnancy in Spanish Women: Trajectory and Risk Factors in Each Trimester. Int. J. Environ. Res. Public Health 2021,18, 6789. https:// doi.org/10.3390/ijerph18136789 Academic Editor: Paul B. Tchounwou Received: 20 May 2021 Accepted: 21 June 2021 Published: 24 June 2021 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain; [email protected] *Correspondence: [email protected]; Tel.: +34-881-81-3740 Abstract: The aims of this research were to determine the trajectories of probable depression and major depression during pregnancy and to identify the associated and predictor variables (sociodemographic, pregnancy-related, and psychological) for both conditions in each trimester of pregnancy. A longitudinal study was carried out with 569 pregnant Spanish women who were assessed in the first, second, and third trimesters of pregnancy. Depression was assessed using the Edinburgh Postnatal Depression Scale and a clinical interview. Measures of anxiety and stress were also included. The prevalence of probable depression in the first, second, and third trimesters was 23.4%, 17.0%, and 21.4%, respectively, and that of major depression was 5.1%, 4.0%, and 4.7%. Thus, the prevalence of both conditions was the highest in the first and third trimesters. The trajectories of probable depression and major depression followed the same pattern throughout pregnancy. All of the psychological variables studied were associated with both conditions in all three trimesters, with perceived stress being a predictor at all times. The association between the other variables and both conditions of depression was similar. Two exceptions stand out: having had previous miscarriages, which was only associated with probable depression and was also a predictor, in the first trimester; and complications during pregnancy, which was only associated with probable and major depression in the third trimester. These findings should be taken into account in routine pregnancy follow-ups, and necessary interventions should be started in the first trimester. Keywords: pregnancy; antenatal depression; prevalence; trajectory; risk factors 1. Introduction Depression is one of the most prevalent psychological disorders, affecting women at twice the rate of men [ 1 ]. In women, vulnerability to depression is particularly high during pregnancy and in the postpartum period [ 2 ], as the birth of a child is a life event associated with numerous biological, hormonal, psychological, familial, and social changes. Antenatal depression has received less attention than postpartum depression [ 3 ], as pregnancy was traditionally thought to protect women against the onset or relapse of depressive disorders. Depression during pregnancy has important consequences, both for mothers and their children. In particular, the main consequence of antenatal depression for mothers is a continuation of the state into the postpartum period, as depression in pregnancy is the main risk factor for postpartum depression [ 4 – 6 ]. Children of mothers with antenatal depression have been found to be more likely to have intrauterine growth retardation [ 7 ], be born preterm [ 7 – 10 ], and be small for gestational age [ 9 , 10 ], all of which are major causes of neonatal and infant morbidity and mortality. On the other hand, there is a lack of longitudinal research addressing the prevalence of antenatal depression in each trimester of pregnancy, as most studies are cross-sectional, which makes it impossible to determine the trajectory of depression throughout pregnancy. This can lead to an inaccurate picture of the actual situation, as the prevalence of depression often varies throughout pregnancy [ 11 – 13 ]. The analysis of the trajectory of depression in the same sample of pregnant women is important because it enables the identification of Int. J. Environ. Res. Public Health 2021,18, 6789. https://doi.org/10.3390/ijerph18136789 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021,18, 6789 2 of 17 the times of the greatest vulnerability since cross-sectional studies provide very different results, as they use different assessment instruments. The few existing longitudinal studies have provided mixed results regarding the trajectory of depression. In particular, some studies found that the first and third trimesters of pregnancy are the times of the highest prevalence of probable depression [ 13 – 16 ] and major depression [ 13 ], although the values in the third trimester did not reach those observed in the first trimester. However, in a study conducted in China [ 17 ], although probable depression was also the most prevalent in the first and third trimesters, the prevalence rate was higher in the latter than in the former. The same pattern was observed in Italy for major depression [ 18 ]. In all cases, the trajectory of depression is V-shaped. By contrast, a study in India [ 19 ] reported the opposite trajectory (/ \ ), with the highest prevalence occurring in the second trimester and the lowest prevalence in the third trimester. On the other hand, a study conducted in Korea [ 20 ] found that the presence of probable depression followed an ascending path (/) between the first and the third trimester. As longitudinal studies on the prevalence of antenatal depression by trimester are scarce, there is also a lack of knowledge regarding the associated variables at each point. Specifically, we did not find any studies in the existing literature that have analysed the variables associated with antenatal depression in each trimester. Thus, it is not possible to know whether there are variables associated with depression that remain stable throughout the pregnancy, or whether there are others that are specific to a particular trimester and then disappear in the rest of the pregnancy. Identifying such associations would enable the implementation of prevention and intervention measures adjusted to each phase. In this respect, the variables that are the most frequently associated with depression in pregnancy are sociodemographic, obstetric, and psychological variables [ 21 ]. In particular, antenatal depression has been associated with low educational level [ 15 , 22 – 25 ] and low socio-economic level [ 17 , 22 , 24 , 26 – 29 ], being unemployed [ 22 , 30 , 31 ], and not having planned the pregnancy [ 15 , 17 , 19 , 25 , 27 , 29 – 34 ]. Regarding psychological variables, having a history of depression [ 17 , 23 , 26 , 31 ], as well as anxiety [ 26 , 33 – 36 ] or stress [ 33 , 34 , 36 ] are the variables that are the most frequently associated with antenatal depression. On the other hand, in regard to variables such as age and parity, the studies’ findings are contradictory. Specifically, different studies have reported a relationship with younger age [ 18 , 37 ], while in others, it is related to older age [ 23 , 29 ]. Likewise, with respect to parity, both primiparity [ 36 ] and multiparity [ 19 , 23 , 26 , 31 , 32 ] have been associated with the presence of antenatal depression. Monitoring women for depression throughout pregnancy will enable the identification of the most vulnerable phases and the variables associated with the presence of depression in each trimester. This would lead to more efficient help being offered in accordance with the real needs of future mothers and will prevent the depressive state and its associated consequences from extending to the postpartum period. Therefore, the aims of the present research were first, to assess the trajectory of probable depression, assessed with a self-report instrument (EPDS), and of major depression, assessed with a clinical interview (SCID), during pregnancy; and second, to identify the associated and predictor variables (sociodemographic, pregnancy-related, and psychological) of both probable depression and major depression in each trimester of pregnancy. The study aimed to answer the following specific questions: 1. Is the trajectory of depression throughout pregnancy the same regardless of its severity? 2. Do the same variables predict the presence of probable depression and of major depression? 3. Which variables are the most closely associated with depression in each trimester? Are they the same, or are there trimester-specific predictors? 2. Materials and Methods 2.1. Procedure and Participants The present research was conducted in accordance with the Helsinki Declaration and received previous approval from the ethics committees of all of the institutions involved. Int. J. Environ. Res. Public Health 2021,18, 6789 3 of 17 It was a longitudinal study with three assessment waves: the 1st trimester of pregnancy (M = 10.87 weeks; SD = 2.36), the 2nd trimester of pregnancy (M = 20.69 weeks; SD = 1.21) and the 3rd trimester of pregnancy (M = 33.28 weeks; SD = 2.05). Pregnant women attending the primary public healthcare service in northwest Spain were recruited in the 1st trimester of pregnancy (n= 620). Women were eligible to participate if they were at least 18 years of age, were in the first trimester of pregnancy, spoke Spanish, and were willing to participate in subsequent assessments throughout the pregnancy. The exclusion criteria were: being under 18 years of age, having a gestational age equal to or greater than 15 weeks, not reading or speaking Spanish, and not having participated in any of the evaluations. The aims and procedures were explained, and the pregnant women who were willing to participate provided written informed consent. The final sample consisted of 569 women. The procedure and sample tracking characteristics are shown in Figure 1. All women participated voluntarily in the study. The assessments were carried out personally and individually at the hospital prior to the women entering the protocolised pregnancy follow-up consultation. In each pregnancy trimester, all of the questionnaires and SCID interviews were administered personally by one psychologist who received SCID training and who was blind to the EPDS scores. The average duration of each interview was about 40 min. Figure 1. Flow diagram of recruitment and progress through the study. 2.2. Measures 2.2.1. Socio-Demographic and Pregnancy Information Three ad hoc questionnaires including questions on socio-demographic (e.g., age, marital status, educational level, occupational status, and personal monthly income), pregnancy-related (e.g., parity, previous abortions, planned pregnancy, pregnancy reaction, complications, attendance at maternal classes), and psychological variables were elaborated on specifically for the study. Int. J. Environ. Res. Public Health 2021,18, 6789 4 of 17 2.2.2. Depression The Edinburgh Postnatal Depression Scale (EPDS) [ 38 ] is a self-reported questionnaire consisting of 10 items with 4 response options. The scores range between 0 and 30, with higher scores indicating a greater severity of depression. The Spanish validation of the EPDS for use in pregnancy was used [ 13 ], which determined that the most appropriate cut-off point for screening for probable antenatal depression was ≥ 10. The reliability of the EPDS during pregnancy was 0.81 in the first trimester, 0.82 in the second trimester, and 0.85 in the third trimester in the present study. The Structured Clinical Interview for DSM-IV (SCID) [ 39 ] is a semi-structured interview that determines a formal diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The use of such interviews improves diagnostic reliability by standardising the assessment process and increases the diagnostic validity by facilitating the application of DSM diagnostic criteria and the systematic enquiry of symptoms that might otherwise go unnoticed. 2.2.3. Stress The Spanish validation [ 40 ] of the Perceived Stress Scale (PSS) [ 41 ] was used. The PSS is a self-administered scale that measures the degree to which life situations in the previous month are rated as stressful. It consists of 14 items, with 5 response options. The scale ranges from 0 to 56, with higher scores indicating a higher level of perceived stress. With this sample, the reliability of the PSS during pregnancy was 0.86 in the first trimester, 0.88 in the second trimester, and 0.87 in the third trimester. 2.2.4. Anxiety The State-Trait Anxiety Inventory (STAI) [ 42 ] assesses both the current level of anxiety and the individual’s predisposition to suffering from anxiety. It consists of 40 items, 20 of which refer to the state subscale (STAI-E), with other 20 referring to the trait subscale (STAI-R). The score for each subscale ranges from 0 to 60, with higher scores indicating higher levels of anxiety. For the state subscale, the recommended cut-off point for women is greater than 31, and for trait anxiety, the cut-off point for woman is greater than 32 (75th percentile). In our sample, the reliability of the trait anxiety subscale in the first trimester of pregnancy was 0.88, and the reliability of the state subscale, 0.91. In the second and third trimesters, the reliability of the state anxiety subscale was 0.92. 2.3. Data Analysis Data were analyzed using SPSS Statistics, version 22 (PASW Statistics for Windows, SPSS Inc., Chicago, IL, USA), and a significance level of p< 0.05 was applied. To test the differences between the presence or absence of depression, a chi-square test for discrete variables and Student’s t-tests for continuous variables were performed. Cramers’s V coefficients and Cohen’s d were calculated in order to estimate the size of the effect. Binary forward stepwise logistic regression analysis was also used to determine the variables predicting depression in pregnancy, according to the EPDS, and/or major depression, according to the SCID, in each trimester of pregnancy. The dependent variable was probable depression status (EPDS ≥ 10, yes/EPDS < 10, no) or major depression status (yes depression/no depression), and the independent variables were those variables for which significant differences were found in the two-by-two analyses. Likewise, Cronbach’s alpha (α) was calculated in order to estimate the reliability of the scales. 3. Results 3.1. Characteristics of the Sample The study sample was composed of 569 women ranging in age from 18 to 45 years, with a mean age of 32.80 years (SD = 4.75). Most of the women were married or cohabiting (94.9%); 46.4% (n= 264) had university education, and 35.3% (n= 201) had secondary education. Regarding employment status, 75.2% (n= 428) were working. Regarding Int. J. Environ. Res. Public Health 2021,18, 6789 5 of 17 personal monthly income, 44.6% (n= 254) stated that they earned less than 1000 euros per month. Pregnancy was planned in 85.9% (n= 489) of cases, 59.4% (n= 338) of the women were primiparous, and 93.0% (n= 529) reported having reacted positively to confirmation of the pregnancy. Likewise, 63.3% (n= 360) reported attending maternal education classes, with the mean attendance being 4.45 classes (SD = 4.33) out of the 10 classes offered on a regular basis. 3.2. Trajectory of Depression throughout Pregnancy The prevalence of depression varied according to the time of the assessment and the assessment instrument used (Figure 2). The first trimester was the period during which the highest percentage of women had probable depression (23.4%) or major depression (5.1%). The prevalence of both probable depression (17.0%) and major depression (4.0%) was the lowest in the second trimester. In the third trimester, the prevalence of both probable depression (21.4%) and major depression (4.7%) was higher than in the second trimester but did not reach the values observed in the first trimester. Thus, the trajectories of probable depression and major depression followed the same pattern throughout pregnancy. Figure 2. Trajectory of the prevalence of probable depression and major depression during pregnancy. 3.3. Variables Associated with the Presence of Depression 3.3.1. Sociodemographic Variables Regarding the sociodemographic variables, the characteristics of the pregnant women experiencing probable depression or major depression in each trimester of pregnancy as well as the variables associated with both types of depression are shown in Table 1. Regarding the mean age, significant differences were found in the prevalence of probable depression in the first (31.99 vs. 33.05; t(569) = 2.254, p= 0.025, d Cohen = 0.25) and second trimesters (31.63 vs. 33.04; t(569) = 2.686, p= 0.007, d Cohen = 0.28), as these women were younger than the women who did not experience probable depression. For women experiencing major depression, the mean age was statistically significantly lower in the second (t(569) = 4.158, p< 0.001, d Cohen = 0.82; 28.83 vs. 32.97) and third trimesters (t(569) = 4.768, p< 0.001, d Cohen = 0.86; 28.63 vs. 33.01). Having a lower level of education was associated with both depression conditions in all three trimesters of pregnancy, while a lower level of income was only associated with probable depression in the 1st and 2nd trimesters. On the other hand, not having a partner, not cohabiting, or not being married was not associated with either condition at any time. 3.3.2. Pregnancy-Related Variables In terms of pregnancy-related variables, the characteristics of pregnant women with probable depression and major depression in each trimester of pregnancy as well as the variables associated with both conditions are shown in Table 2. Int. J. Environ. Res. Public Health 2021,18, 6789 6 of 17 Having reacted negatively to the confirmation of pregnancy was associated with both probable and major depression at all time points. On the other hand, having had previous miscarriages was only associated with probable depression in the first trimester, while having had complications at some time during pregnancy was only associated with the presence of major depression in the third trimester. 3.3.3. Psychological Variables Regarding the psychological variables, the characteristics of pregnant women with probable depression and major depression in each trimester of pregnancy as well as the variables associated with both types of depression are shown in Table 3. Regarding perceived stress, significantly higher mean scores were found among women experiencing probable depression and women experiencing major depression. Specifically, women with probable depression had higher mean scores for perceived stress in the first (t(569) = − 14.332, p<0.001, d Cohen = − 1.63; 25.44 vs. 16.17), second (t(569) = − 15.11, p< 0.001, d Cohen = − 1.81; 25.69 vs. 14.55) and third trimesters (t(569) = − 14.946, p< 0.001, d Cohen = − 1.59; 25.33 vs. 15.08). In addition, the mean scores were significantly higher among women with major depression in the first (t(569) = − 6.234, p< 0.001, d Cohen = − 1.30; 26.66 vs. 17.89), second (t(569) = − 7.953, p< 0.001, d Cohen = − 1.82; 28.52 vs. 15.94) and third trimesters (t(569) = − 8.343, p< 0.001, d Cohen = − 1.74; 29.00 vs. 16.69). All of the psychological variables studied were associated with both probable and major depression at all times. Thus, having a prior history of depression, having experienced a worsening of mood in previous pregnancies, having elevated state and trait anxiety as well as a higher level of stress were significantly associated with both probable depression and major depression. Table 1. Characteristics of women with probable depression and major depression as a function of sociodemographic variables. Probable Depression Major Depression First Trimester No (n= 436) Yes (n= 133) No (n= 540) Yes (n= 29) n%n%χ2Vn%n%χ2V Age 8.825 ** 0.13 0.180 ≤30 121 27.8 55 41.4 166 30.7 10 34.5 >30 315 72.2 78 58.6 374 69.3 19 65.5 Marital Status 1.001 4.778 Unmarried 20 4.6 9 6.8 25 4.6 4 13.8 Married/Cohabiting 416 95.4 124 93.2 515 95.4 25 86.2 Level of Education 13.809 *** 0.16 4.348 *0.09 Primary/Secondary 215 49.3 90 67.7 284 52.6 21 72.4 University 221 50.7 43 32.3 256 47.4 8 27.6 Employment Status 6.419 *0.11 2.835 Working 339 77.8 89 66.9 410 75.9 18 62.1 Not Working 97 22.2 44 33.1 130 24.1 11 37.9 Pregnancy Influenced Employment 14.979 *** 0.16 8.892 ** 0.13 No 365 83.7 91 68.4 439 81.3 17 58.6 Yes 71 16.3 42 31.6 101 18.7 12 41.4 Monthly Income (Euros) 9.783 ** 0.14 0.413 ≤1000 183 48.2 71 65.1 240 51.6 14 58.3 >1000 197 51.8 38 34.9 225 48.4 10 41.7 Second Trimester No (n= 472) Yes (n= 97) No (n= 546) Yes (n= 23) Age 8.372 ** 0.12 20.727 *** 0.19 ≤30 134 28.4 42 43.3 159 29.1 17 73.9 >30 338 71.6 55 56.7 387 70.9 6 26.1 Int. J. Environ. Res. Public Health 2021,18, 6789 7 of 17 Table 1. Cont. Marital Status 0.287 0.642 Unmarried 23 4.9 6 6.2 27 4.9 2 8.7 Married/Cohabiting 449 95.1 91 93.8 519 95.1 21 91.3 Level of Education 16.200 *** 0.17 8.108 ** 0.12 Primary/Secondary 235 49.8 70 72.2 286 52.4 19 82.6 University 237 50.2 27 27.8 260 47.6 4 17.4 Employment Status 1.642 12.956 *** 0.15 Working 360 76.3 68 70.1 418 76.6 10 43.5 Not Working 112 23.7 29 29.9 128 23.4 13 56.5 Pregnancy Influenced Employment 24.166 *** 0.21 11.231 ** 0.14 No 367 77.8 52 53.6 409 74.9 10 43.5 Yes 105 22.2 45 46.4 137 25.1 13 56.5 Monthly Income (euros) 7.442 ** 0.12 1.872 ≤1000 199 49.1 55 65.5 243 51.4 11 68.8 >1000 206 50.9 29 34.5 230 48.6 5 31.3 Third trimester No (n= 447) Yes (n= 122) No (n= 542) Yes (n= 27) Age 3.335 20.637 *** 0.19 ≤30 130 29.1 46 37.7 157 29.0 19 70.4 >30 317 70.9 76 62.3 385 71.0 8 29.6 Marital Status 0.132 0.313 Unmarried 22 4.9 7 5.7 27 5.0 2 7.4 Married/Cohabiting 425 95.1 115 94.3 515 95.0 25 92.6 Level of Education 8.948 ** 0.13 6.661 *0.11 Primary/Secondary 225 50.3 80 65.6 284 52.4 21 77.8 University 222 49.7 42 34.4 258 47.6 6 22.2 Employment Status 3.378 11.145 ** 0.14 Working 344 77.0 84 68.9 415 76.6 13 48.1 Not Working 103 23.0 38 31.1 127 23.4 14 51.9 Pregnancy Influenced Employment 4.066 *0.09 0.626 No 290 64.9 67 54.9 342 63.1 15 55.6 Yes 157 35.1 55 45.1 200 36.9 12 44.4 Monthly Income (euros) 1.798 0.996 ≤1000 195 50.4 59 57.8 242 51.5 12 63.2 >1000 192 49.6 43 42.2 228 48.5 7 36.8 *p< 0.05, ** p< 0.01, *** p< 0.001. Table 2. Characteristics of women with probable depression and major depression as a function of pregnancy-related variables. Probable Depression Major Depression First Trimester No (n= 436) Yes (n= 133) No (n= 540) Yes (n= 29) n%n%χ2Vn%n%χ2V Parity 4.928 *0.09 10.197 ** 0.13 Primiparous 270 61.9 68 51.1 329 60.9 9 31.0 Multiparous 166 38.1 65 48.9 211 39.1 20 69.0 Previous Abortions 11.280 ** 0.14 0.024 No 336 77.1 83 62.4 398 73.7 21 72.4 Yes 100 22.9 50 37.6 142 26.3 8 27.6 Pregnancy Planning 2.282 2.569 No 56 12.8 24 18.0 73 13.5 7 24.1 Yes 380 87.2 109 82.0 467 83.5 22 75.9 Pregnancy Reaction 24.026 *** 0.21 13.684 *** 0.16 Positive 418 95.9 111 83.5 507 93.9 22 75.9 Int. J. Environ. Res. Public Health 2021,18, 6789 8 of 17 Table 2. Cont. Negative 18 4.1 22 16.5 33 6.1 7 24.1 Pregnancy Complication 3.637 0.058 No 406 93.1 117 88.0 496 91.9 27 93.1 Yes 30 6.9 16 12.0 44 8.1 2 6.9 Second Trimester No (n= 472) Yes (n= 97) No (n= 546) Yes (n= 23) Parity 6.959 ** 0.11 1.332 Primiparous 292 61.9 46 47.4 327 59.9 11 47.8 Multiparous 180 38.1 51 52.6 219 40.1 12 52.2 Previous Abortions 0.012 0.001 No 348 73.7 71 73.2 402 73.6 17 73.9 Yes 124 26.3 26 26.8 144 26.4 6 26.1 Pregnancy Planning 5.575 *0.10 8.519 ** 0.12 No 59 12.5 21 21.6 72 13.2 8 34.8 Yes 413 87.5 76 78.4 474 86.8 15 65.2 Pregnancy Reaction 7.265 ** 0.11 7.935 ** 0.12 Positive 445 94.3 84 86.6 511 93.6 18 78.3 Negative 27 5.7 13 13.4 35 6.4 5 21.7 Pregnancy Complication 2.407 3.480 No 400 84.7 76 78.4 460 84.2 16 69.6 Yes 72 15.3 21 21.6 86 15.8 7 30.4 Third Trimester No (n = 447) Yes (n= 122) No (n= 542) Yes (n= 27) Parity 1.295 0.001 Primiparous 271 60.6 67 54.9 322 59.4 16 59.3 Multiparous 176 39.4 55 45.1 220 40.6 11 40.7 Previous Abortions 0.251 0.003 No 327 73.2 92 75.4 399 73.6 20 74.1 Yes 120 26.8 30 24.6 146 26.4 7 25.9 Pregnancy Planning 4.048 *0.08 5.687 *0.10 No 56 12.5 24 19.7 72 13.3 8 29.6 Yes 391 87.5 98 80.3 470 86.7 19 70.4 Pregnancy Reaction 11.328 ** 0.14 10.010 ** 0.13 Positive 424 94.9 105 86.1 508 93.7 21 77.8 Negative 23 5.1 17 13.9 34 6.3 6 22.2 Pregnancy Complication 4.380 *0.09 10.698 ** 0.14 No 355 79.4 86 70.5 427 78.8 14 51.9 Yes 92 20.6 36 29.5 115 21.2 13 48.1 Attendance at Maternal Classes 10.357 ** 0.14 6.190 *0.10 No 149 33.3 60 49.2 193 35.6 16 59.3 Yes 298 66.7 62 50.8 349 64.4 11 40.7 *p< 0.05, ** p< 0.01, *** p< 0.001. Table 3. Characteristics of women with probable depression and major depression regarding psychological variables. Probable Depression Major Depression First Trimester No (n= 436) Yes (n= 133) No (n= 540) Yes (n= 29) n%n%χ2Vn%n%χ2V History of Depression 9.610 ** 0.13 18.247 *** 0.19 No 412 94.5 115 86.5 506 93.7 21 72.4 Yes 24 5.5 18 13.5 34 6.3 8 27.6 Worsening Mood in Previous Pregnancies (n= 234) 4.908 *0.15 6.049 *0.16 No 147 87.5 50 75.8 184 86.0 13 65.0 Yes 21 12.5 16 24.4 30 14.0 7 35.0 Int. J. Environ. Res. Public Health 2021,18, 6789 9 of 17 Table 3. Cont. Trait Anxiety 50.455 *** 0.30 10.463 *** 0.14 No 428 98.2 109 82.0 491 90.9 21 72.4 Yes 8 1.8 24 18.0 49 9.1 8 27.6 State Anxiety 77.467 *** 0.37 7.770 ** 0.12 No 419 96.1 93 69.9 513 95.0 24 82.8 Yes 17 3.9 40 30.1 27 5.0 5 17.2 Second Trimester No (n= 472) Yes (n= 97) No (n= 546) Yes (n= 23) History of Depression 14.206 *** 0.16 12.267 *** 0.15 No 446 94.5 81 83.5 510 93.4 17 73.9 Yes 26 5.5 16 16.5 36 6.6 6 26.1 Worsening Mood in Previous Pregnancies (n= 234) 15.040 *** 0.25 11.106 ** 0.22 No 163 89.1 34 66.7 191 86.0 6 50.0 Yes 20 10.9 17 33.3 31 14.0 6 50.0 Trait Anxiety 42.958 *** 0.28 38.396 *** 0.26 No 459 97.2 78 80.4 522 95.6 15 65.2 Yes 13 2.8 19 19.6 24 4.4 8 34.8 State Anxiety 70.950 *** 0.35 30.385 *** 0.23 No 464 98.3 75 77.3 523 95.8 16 69.6 Yes 8 1.7 22 22.7 23 4.2 7 30.4 Third Trimester No (n= 447) Yes (n= 122) No (n= 542) Yes (n= 27) History of Depression 12.348 *** 0.15 14.259 *** 0.16 No 423 94.6 104 85.2 507 93.5 20 74.1 Yes 24 5.4 18 14.8 35 6.5 7 25.9 Worsening Mood in Previous Pregnancies (n= 234) 5.246 *0.16 7.619 *0.18 No 155 87.6 42 73.7 191 85.7 6 54.5 Yes 22 12.4 15 26.3 32 14.3 5 45.5 Trait Anxiety 39.298 *** 0.26 41.005 *** 0.27 No 436 97.5 101 82.8 519 95.8 18 66.7 Yes 11 2.5 21 17.2 23 4.2 9 33.3 State Anxiety 84.056 *** 0.38 28.939 *** 0.23 No 438 98.0 90 73.8 510 94.1 18 66.7 Yes 9 2.0 32 26.2 32 5.9 9 33.3 *p< 0.05, ** p< 0.01, *** p< 0.001. 3.4. Predictors of Depression in Each Trimester Predictors of the presence of probable depression and major depression in each of the trimesters are shown in Tables 4and 5. Age, previous miscarriages, state anxiety, and perceived stress were predictors of probable depression in the first trimester. Specifically, being aged 30 years old or younger (OR = 2.55), having had previous miscarriages (OR = 3.28), having a high state of anxiety (OR = 3.97) as well as higher perceived stress (OR = 1.24) increased the likelihood of probable depression in the first trimester. In the second trimester, having had probable depression in the first trimester (OR = 13.61) as well as higher perceived stress in the first (OR = 1.14) and second trimesters (OR = 1.35) increased the likelihood of having probable depression. In the third trimester, the predictors of probable depression were having had major depression in the first trimester (OR = 5.43), probable depression in the second trimester (OR = 6.19), and an elevated state of anxiety (OR = 4.88) and higher perceived stress (OR = 1.16) in the third trimester. In the first trimester, the predictors of major depression were having perceived that pregnancy had a negative influence on employment (OR = 3.20) and having higher per- Int. J. Environ. Res. Public Health 2021,18, 6789 16 of 17 13. Vázquez, M.B.; Míguez, M.C. Validation of the Edinburgh postnatal depression scale as a screening tool for depression in Spanish pregnant women. J. Affect. Disord. 2019,246, 515–521. [CrossRef] 14. Rallis, S.; Skouteris, H.; McCabe, M.; Milgrom, J. A prospective examination of depression, anxiety and stress throughout pregnancy. Women Birth 2014,27, e36–e42. [CrossRef] 15. Yanikkerem, E.; Ay, S.; Mutlu, S.; Goker, A. Antenatal depression: Prevalence and risk factors in a hospital based Turkish sample. J. Pak. Med. Assoc. 2013,63, 472–477. [PubMed] 16. Yu, Y.; Li, M.; Pu, L.; Wang, S.; Wu, J.; Ruan, L.; Jiang, S.; Wang, Z.; Jiang, W. Sleep was associated with depression and anxiety status during pregnancy: A prospective longitudinal study. Arch. Womens Ment. Health 2017,20, 695–701. [CrossRef] [PubMed] 17. Weng, S.C.; Huang, J.P.; Huang, Y.L.; Lee, T.S.; Chen, Y.H. Effects of tobacco exposure on perinatal suicidal ideation, depression, and anxiety. BMC Public Health 2016,16, 623. [CrossRef] [PubMed] 18. Marchesi, C.; Bertoni, S.; Maggini, C. Major and minor depression in pregnancy. Obstet. Gynecol. 2009 ,113, 1292–1298. [CrossRef] 19. Ajinkya, S.; Jadhav, P.R.; Srivastava, N.N. Depression during pregnancy: Prevalence and obstetric risk factors among pregnant women attending a tertiary care hospital in Navi Mumbai. Ind. Psychiatry J. 2013,22, 37–40. [CrossRef] 20. Park, J.H.; Karmaus, W.; Zhang, H. Prevalence of and risk factors for depressive symptoms in Korean women throughout pregnancy and in postpartum period. Asian Nurs. Res. 2015,9, 219–225. [CrossRef] 21. Míguez, M.C.; Vázquez, M.B. Risk factors for antenatal depression: A review. World J. Psychiatr. 2021, in press. 22. Bödecs, T.; Szilagyi, E.; Cholnoky, P.; Sándor, J.; Gonda, X.; Rihmer, Z.; Horváth, B. Prevalence and psychosocial background of anxiety and depression emerging during the first trimester of pregnancy: Data from a Hungarian population-based sample. Psychiatr. Danub. 2013,25, 352–358. 23. De Vargas, C.; Coll, N.; Da Silveira, M.; Garcia-Bassani, D.; Netsi, E.; César Wehrmeister, F.; . . . Stein, A. Antenatal depressive symptoms among pregnant women: Evidence from a Southern Brazilian population-based cohort study. J. Affect. Disord. 2017 , 209, 140–146. [CrossRef] 24. Husain, N.; Parveen, A.; Husain, M.; Saeed, Q.; Jafri, F.; Rahman, R.; Tomenson, B.; Chaudhry, I.B. Prevalence and psychosocial correlates of perinatal depression: A cohort study from urban Pakistan. Arch. Womens Ment. Health 2011 ,14, 395–403. [CrossRef] 25. Thompson, O.; Ajayi, I. Prevalence of antenatal depression and associated risk factors among pregnant women attending antenatal clinics in Abeokuta north local government area, Nigeria. Depress. Res. Treat. 2016,16, 1–15. [CrossRef] 26. Banti, S.; Mauri, M.; Oppo, A.; Borri, C.; Rambelli, C.; Ramacciotti, D.; Montagnani, M.S.; Camilleri, V.; Cortopassi, S.; Rucci, P.; et al. From the third month of pregnancy to 1 year postpartum. Prevalence, incidence, recurrence, and new onset of depression. Results from the perinatal depression-research & screening unit study. Compr. Psychiatry 2011 ,52, 343–351. [CrossRef] [PubMed] 27. Benute, G.R.G.; Nomura, R.M.Y.; Reis, J.S.; Fraguas-Junior, R.; Lucia, M.C.S.; Zugaib, M. Depression during pregnancy in women with a medical disorder: Risk factors and perinatal outcomes. Clinics 2011,65, 1127–1131. [CrossRef] [PubMed] 28. Ogbo, F.A.; Eastwood, J.; Hendry, A.; Jalaludin, B.; Agho, K.E.; Barnett, B.; Page, A. Determinants of antenatal depression and postnatal depression in Australia. BMC Psychiatry 2018,18, 49. [CrossRef] [PubMed] 29. Weobong, B.; Asbroek, A.H.A.; Soremekun, S.; Manu, A.A.; Owusu-Agyei, S.; Prince, M.; Kirkwood, B.R. Association of antenatal depression with adverse consequences for the mother and newborn in rural Ghana: Findings from the DON population-based cohort study. PLoS ONE 2014,9, e116333. [CrossRef] 30. Giardinelli, L.; Innocenti, A.; Benni, L.; Stefanini, M.C.; Lino, G.; Lunardi, C.; Svelto, V.; Afshar, S.; Bovani, R.; Castellini, G.; et al. Depression and anxiety in perinatal period: Prevalence and risk factors in an Italian sample. Arch. Womens Ment. Health 2012 ,15, 21–30. [CrossRef] 31. Kheirabadi, G.R.; Maracy, M.R. Perinatal depression in a cohort study on Iranian women. J. Res. Med. Sci. 2010,15, 41–49. 32. González-Mesa, E.; Kabukcuoglu, K.; Körükcü, O.; Blasco, M.; Ibrahim, N.; Kavas, T. Cultural factors influencing antenatal depression: A cross-sectional study in a cohort of Turkish and Spanish women at the beginning of the pregnancy. J. Affect. Disord. 2018,238, 256–260. [CrossRef] 33. Mohammad, K.I.; Gamble, J.; Creedy, D.K. Prevalence and factors associated with the development of antenatal and postnatal depression among Jordanian women. Midwifery 2011,27, 238–245. [CrossRef] 34. Waldie, K.E.; Peterson, E.R.; D’Souza, S.; Underwood, L.; Pryor, J.E.; Carr, P.A.; Grant, C.; Morton, S.M.B. Depression symptoms during pregnancy: Evidence from Growing Up in New Zealand. J. Affect. Disord. 2015,186, 66–73. [CrossRef] [PubMed] 35. Fadzil, A.; Balakrishnan, K.; Razali, R.; Sidi, H.; Malapan, T.; Japaraj, R.P.; Midin, M.; Jaafar, N.R.N.; Das, S.; Manaf, M.R.A. Risk factors for depression and anxiety among pregnant women in Hospital Tuanku Bainun, Ipoh, Malaysia. Asia Pac. Psychiatry 2013 , 5, 7–13. [CrossRef] [PubMed] 36. Redinger, S.; Norris, S.A.; Pearson, R.M.; Richter, L.; Rochat, T. First trimester antenatal depression and anxiety: Prevalence and associated factors in an urban population in Soweto, South Africa. J. Dev. Orig. Health Dis. 2018,9, 30–40. [CrossRef] 37. Rich-Edwards, J.; Kleinman, K.; Abrams, A.; Harlow, B.L.; McLaughlin, T.J.; Joffe, H.; Gillman, M.W. Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. J. Epidemiol. Community Health 2006,60, 221–227. [CrossRef] 38. Cox, J.; Holden, J.M.; Sagovsky, R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br. J. Psychiatry 1987,150, 782–786. [CrossRef] [PubMed] Int. J. Environ. Res. Public Health 2021,18, 6789 17 of 17 39. First, M.B.; Spitzer, R.L.; Gibbon, M.; Williams, J.B.W. Entrevista clínica estructurada para los trastornos del eje I del DSM-IV- versión clínica (SCID-CV) [Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV)]. 1997. Versión Clínica Ed. Masson. Barcelona. Available online: https://libreriaolejnik.cl/fichas/90090.pdf (accessed on 17 November 2015). 40. Remor, E. Psychometric properties of a European Spanish version of the Perceived Stress Scale (PSS). Span. J. Psychol. 2006 ,9, 86–93. [CrossRef] [PubMed] 41. Cohen, S.; Kamarck, T.; Mermelstein, R. A global measure of perceived stress. J. Health Soc. Behav. 1983,24, 385–396. [CrossRef] 42. Spielberg, C.D.; Gorsuch, R.L.; Lushene, R.E. Manual of State-Trait Anxiety Inventory; Consulting Psichologists Press: Palo Alto, CA, USA, 1970. 43. Ahmed, A.; Bowen, A.; Feng, C.X.; Muhajarine, N. Trajectories of maternal depressive and anxiety symptoms from pregnancy to five years postpartum and their prenatal predictors. BMC Pregnancy Childbirth 2019,19, 26. [CrossRef] 44. Lee, H.; Kim, K.E.; Kim, M.Y.; Park, C.G.; Han, J.Y.; Choi, E.J. Trajectories of depressive symptoms and anxiety during pregnancy and associations with pregnancy stress. Int. J. Environ. Res. Public Health 2021,18, 2733. [CrossRef] [PubMed] 45. Segre, L.S.; O’Hara, M.W.; Arndt, S.; Stuart, S. The prevalence of postpartum depression: The relative significance of three social status indices. Soc. Psychiatry Psychiatr. Epidemiol. 2007,42, 316–321. [CrossRef] [PubMed] 46. Marcos-Nájera, R.; Rodríguez-Muñoz, M.F.; Lara, M.A.; Navarrete, L.; Le, H.N. A cross-cultural analysis of the prevalence and risk factors for prenatal depression in Spain and Mexico. Cult. Med. Psychiatry 2020, 1–14. [CrossRef] 47. Koutra, K.; Vassilaki, M.; Georgiou, V.; Koutis, A.; Bitsios, P.; Chatzi, L.; Kogevinas, M. Antenatal maternal mental health as determinant of postpartum depression in a population based mother-child cohort (Rhea Study) in Crete, Greece. Soc. Psychiatry Psychiatr. Epidemiol. 2014,49, 711–721. [CrossRef] [PubMed] 48. Sedgh, G.; Bankole, A.; Oye-Adeniran, B.; Adewole, I.F.; Singh, S.; Hussain, R. Unwanted pregnancy and associated factors among Nigerian women. Int. Fam. Plan Perspect. 2006,32, 175–184. [CrossRef] 49. Bouchard, G. Adult couples facing a planned or an unplanned pregnancy. J. Fam. Issues 2005,26, 619–637. [CrossRef] 50. Bouchard, G.; Boudreau, J.; Hébert, R. Transition to parenthood and conjugal life: Comparisons between planned and unplanned pregnancies. J. Fam. Issues 2006,27, 1512–1531. [CrossRef] 51. Vesga-López, O.; Blanco, C.; Keyes, K.; Olfson, M.; Grant, B.F.; Hasin, D.S. Psychiatric disorders in pregnant and postpartum women in the United States. Arch. Gen. Psychiatry 2008,65, 805. [CrossRef] 52. Falah-Hassani, K.; Shiri, R.; Dennis, C.L. Prevalence and risk factors for comorbid postpartum depressive symptomatology and anxiety. J. Affect. Disord. 2016,198, 142–147. [CrossRef] 53. Ross, L.E.; Gilbert Evans, S.E.; Sellers, E.M.; Romach, M.K. Measurement issues in postpartum depression part 1: Anxiety as a feature of postpartum depression. Arch. Womens Ment. Health 2003,6, 51–57. [CrossRef] 54. Van den Bergh, B.R.H.; Mulder, E.J.H.; Mennes, M.; Glover, V. Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: Links and possible mechanisms. A review. Neurosci. Biobehav. Rev. 2005 ,29, 237–258. [CrossRef] [PubMed]