Date Published: April 18, 2019
Publisher: Public Library of Science
Author(s): Dorota T. Kopycka-Kedzierawski, Dongmei Li, Jin Xiao, Ronald J. Billings, Timothy D. Dye, Kelli K. Ryckman.
Preterm and low birth weight infants are at greater risk for mortality and a variety of health and developmental problems. Data from the Finger Lakes Perinatal Data System database on 316,956 deliveries occurring between 2004–2014 and pregnancy outcomes were analyzed to assess the association of periodontal (gum) disease with depression, other maternal factors and adverse birth outcomes. Adjusted effects of periodontal disease and depression on adverse birth outcomes were estimated using multiple logistic regression models and path analysis. Having preterm delivery was associated significantly with depression (OR = 1.177; 95% CI: [1.146, 1.208]), having adequate health care (OR = 1.638; 95% CI: [1.589, 1.689]), smoking during pregnancy (OR = 1.259; 95% CI: [1.220, 1.300]), and being less educated (OR = 1.214; 95% CI: [1.174, 1.256]). Having low birth weight was significantly associated with depression (OR = 1.206; 95% CI: [1.170, 1.208]), smoking during pregnancy (OR = 1.855; 95% CI: [1.793, 1.919]), and being less educated (OR = 1.322; 95% CI: [1.275, 1.370]). Periodontal disease was significantly associated with alcohol use during pregnancy (OR = 1.314; 95% CI: [1.227, 1.407]) and white race (OR = 1.192; 95% CI: [1.167, 1.217]). Depression was significantly associated with periodontal disease (OR = 1.762; 95% CI: [1.727, 1.797]) and alcohol use during pregnancy (OR = 1.470; 95% CI: [1.377, 1.570]). We concluded that a positive association existed between depression during pregnancy and adverse birth outcomes, and that depression served as a mediator in the association of periodontal disease with adverse birth outcomes.
Maintaining good oral health during pregnancy is an important aspect of maintaining overall good health during pregnancy and throughout a woman’s lifespan. According to the Advisory Committee for Oral Health Care During Pregnancy, in years 2007–2009, 35% of U.S. women did not attend a dental visit within the past year and 56% of women did not visit a dentist during pregnancy . Numerous studies have shown positive associations of periodontal disease during pregnancy with preterm delivery, low birth weight, low weight for gestational age and increased risk for preeclampsia [2–6]. However, other studies failed to find an association [7, 8]. In a prospective cohort study of pregnant women conducted in North Carolina, periodontal health status and changes in oral health that occurred during pregnancy were assessed. Periodontal disease during pregnancy was reported to be most prevalent among women who were African American, cigarette smokers, and users of public assistance programs. Women with moderate/severe periodontal disease at enrollment were more likely to experience incident disease when compared to those with no disease at enrollment .
The Perinatal Data System (PDS) initiative began in New York State (NYS) in the early 1990s as a perinatal quality improvement initiative funded by the New York State Department of Health. The Upstate New York Regional Perinatal Centers in Albany, Syracuse, Rochester, and Buffalo were among the first demonstration centers for the regionalization of perinatal services in the United States; all evolved into NYS-supported Regional Perinatal Centers with both quality of care and regional perinatal service responsibilities. The PDS effort was envisioned to support a data infrastructure to serve the quality improvement and evaluative needs of the Perinatal Centers, resulting in the PDS demonstration projects starting in 1993. The PDS database includes information on demographics of both infants and parents, access to care, pre-pregnancy risks, antepartum risky behaviors, antepartum infections, antepartum risks, maternal and birth outcomes. The PDS data used for the current analysis was collected between 2004 and 2014. The PDS database contains data on more than 345,000 deliveries that occurred between 2004 and 2014 in thirty counties surrounding Rochester and Syracuse and includes data on pregnancy outcomes; data on 316,956 deliveries formed the basis for the analyses. The University of Rochester Research Subject Review Board (RSRB) approved the study prior to its initiation. The data used in the study were fully anonymized before retrieval.
The database includes a dichotomous survey question asked of all postpartum mothers that states: “Did you have any problems with your gums at any time during pregnancy, for example, swollen or bleeding gums?” The depression information was collected using the following question in the PDS survey questionnaire: “During your pregnancy, would you say that you were (select one): Not depressed at all, A little depressed, Moderately depressed, Very depressed, Very depressed and had to get help”. The depression question was adopted from the CDC’s PRAMS (Pregnancy Risk Assessment and Monitoring System) [16–19]. The CDC initiated PRASMS in 1987 to provide state-specific, population-based surveillance of selected maternal behaviors that occur before, during and after pregnancy. The variables related to gestational age were defined as follows: SGA-small for gestational age (a binary variable), was defined as less than 10 percentile of the birth weight among infants with same gender and gestational age. LGA- large for gestational age (a binary variable), was defined as greater than 90 percentile of the birth weight among infants with same gender and gestational age. Birth outcomes data were extracted from medical records. Birth registrars who collect the data for the Perinatal Data System are instructed to first abstract medical records to obtain outcomes data, complemented with maternal interviews where necessary. Birth certificate data were used to derive the Adequacy of Prenatal Care Utilization (APNCU) Index that categorized women as follows: Adequate Plus (A+), Adequate, Intermediate, and Inadequate. The Index is based on the ratio of observed to expected (O/E) number of prenatal visits. The expected number of visits is based on the American College of Obstetricians and Gynecologists (ACOG) recommendations. In our analysis, we grouped Adequate Plus and Adequate as Adequate category and grouped intermediate and inadequate as the others category to create a binary variable for prenatal care. The grouping was completed to increase the power of the path analysis. Race and ethnic categories included in the PDS were as follows: White, Black, Asian, American Indian/Native Hawaiian, Other, Multiple races and Hispanic, Non-Hispanic ethnic categories. In our analyses, we used White vs. Non-White category, as a majority of the women in the PDS database were White, and to increase the power of the path analysis we made race a binary variable. Hispanic/Non-Hispanic category was not included in the final analyses, as it was not significantly associated with any of the outcome variables in the preliminary analyses.
Our findings obtained from a large perinatal database in the Finger Lakes region of NY State suggest that depression during pregnancy is associated with all adverse birth outcomes under study, including being small for gestational age, being large for gestational age, being preterm and having low birth weight. Depression often remains untreated during pregnancy despite the fact that the prevalence of psychosocial stress is substantial . Contrary to earlier views, pregnancy is not protective against a major depressive episode that may be dangerous to the pregnant woman and the baby. The vast burden of depression on women, their children and their families has been well-acknowledged over the past twenty years , however there is a need for serious, rigorously conducted research into effective and safe treatment for depression in women, particularly at times over the course of the of reproductive years. A systematic review reported that prevalence rates for depression assessed by the validated screening instruments were 7.4%, 12.8% and 12.0% for the first, second, and third trimesters, respectively . The authors of the review concluded that rates of depression, especially during the second and third trimesters of pregnancy were substantial and that clinical and economic studies to estimate maternal and fetal consequences were essential. In the current study, 32.7% of women reported depression during pregnancy (Table 2). Women, who reported depressive symptoms during pregnancy more likely delivered babies that were small for gestational age, had preterm delivery and delivered babies that had low birth weight when compared to women who did not report depressive symptoms during pregnancy. Our findings are in agreement with a systematic review and meta-analysis on depression and adverse birth outcomes  and also with the results of a large community based birth cohort study and a prospective cohort study conducted in Holland and the US [11, 12]. A recent literature review that assessed the risk of adverse pregnancy outcomes and perinatal and neonatal complications of the offspring related to in utero exposure to antidepressants suggested antidepressant exposure was associated with fetal growth changes and shorter gestations, although effects were small .