Miscarriage and Postpartum Depression

New research questions whether pregnancy loss increases risk

Many women experience intense grief following a miscarriage, and some research has found that a previous pregnancy loss can put women at greater risk for postpartum depression. But a new study published in the Maternal and Child Health Journal found that women who experienced miscarriages were not more vulnerable to depression during subsequent pregnancies or for six to twelve months after delivery.

Researchers at Pennsylvania State University conducted telephone surveys of 2,800 women who were having their first child and asked them about depressive symptoms when they were in their last trimester and again at one, six, and 12 months after delivery. About one in six of the women had had at least one previous miscarriage.

Miscarriage – the loss of a pregnancy before 20 weeks of gestation – is one of the most common types of pregnancy loss. An estimated 15 to 20 percent of confirmed pregnancies end in a miscarriage.

The researchers found that about 5 percent of women who had a miscarriage experienced depressive symptoms in the third trimester of a subsequent pregnancy, which was similar to the rate among women who had not lost a pregnancy. However, more women who miscarried experienced depressive symptoms one month after giving birth (5 percent compared with 3 percent of the women who had not had a miscarriage). But by 6 and 12 months postpartum, the rates of depression were similar between the two groups, 4 percent.

"I think this shows the resilience of women," says Cara Bicking Kinsey, PhD, MPH, lead author of the study, and a neonatal intensive care nurse at Penn State Hershey Children's Hospital. "Women don't need to feel like it's inevitable that they won't adjust to pregnancy or parenting after a previous miscarriage, even though they were probably attached to their [earlier] pregnancy."

Even in the first month after childbirth when women in the study with a previous miscarriage seemed more vulnerable to depression, the depressive symptoms were only slightly worse than among women who had not had a miscarriage.

The researchers found that the increased risk of depression at one month postpartum could be attributed to factors such as stress, including worries about the new baby, finances, and a difficult delivery. The researchers could not pinpoint the specific factors that were affecting women with a history of miscarriage, or why. "It's possible that the stress [of being a new mother] may remind them of their previous baby that they lost," says Bicking Kinsey.

Other research suggests a connection between miscarriage and PPD
Emma Robertson Blackmore, PhD, a psychologist at the University of Florida, says the new study, which she was not involved in, is potentially reassuring because depressive symptoms did not persist for women who had miscarriages. However, she cautions that the way this type of research is carried out could lead to an underestimation of the impact of previous miscarriages.

For example, women who agree to participate in long-term studies tend to be the ones who are struggling less. In addition, it's easier to downplay how you are feeling during telephone interviews than it is face to face.

In her own research, Robertson Blackmore found that women who had had a miscarriage or stillbirth were at higher risk of depression and anxiety during a subsequent pregnancy and for up to three years after the birth of a healthy child. "I think in our study we identified this subgroup of women who were susceptible to ongoing episodes of depression and anxiety [that were] precipitated by miscarriage," she says.

Because of her research and other studies, Robertson Blackmore thinks that pregnancy loss should be considered a risk factor for depression during pregnancy and in the postpartum period, just like a family history of depression and other stressful life events.

One study, which Seleni reported on last November, found that women who had lost a pregnancy were more likely to experience depression and anxiety within the first year of having a child.

"Healthcare providers should ask [pregnant women] whether they had a miscarriage, and if their grief persisted for more than a couple of months," says Robertson Blackmore. They can then be more vigilant for signs of perinatal depression, which is very treatable through counseling and medication, she adds.

In the current study, researchers looked at depression risk in the third trimester. However, as Robertson Blackmore points out, this is after the point that women lost earlier pregnancies, and negative feelings would probably have subsided. Other studies have found that women with previous miscarriages do experience more depression and anxiety in the first and second trimesters than women who have not had miscarriages.

Even though her study did not find that women with a history of miscarriage were at higher risk of depression overall, Bicking Kinsey says she hopes it will raise awareness among doctors and nurses to ask pregnant women about previous pregnancy loss and how they are dealing with it. "We know there are some women who have trouble grieving and coping with previous miscarriage even during a current pregnancy," she says.

The first few weeks postpartum could also be difficult for a woman who has had a miscarriage. "Women may have some conflicting feelings about the congratulations and the support that they're getting now that they've given birth to a healthy infant compared to the pregnancy they lost before," Bicking Kinsey says, "and they want recognition of the child they lost."