The Association between Immediate Postpartum Depot Medroxyprogesterone Acetate Use and Postpartum Depressive Symptoms.

OBJECTIVE: While postpartum depot medroxyprogesterone acetate (DMPA) is a highly effective form of contraception, some data suggest an association with depressive symptoms. Our objective was to evaluate the relationship between receipt of DMPA in the immediate postpartum period and postpartum depressive symptoms. STUDY DESIGN: This retrospective cohort study included all women who received prenatal and postpartum care at academic obstetric clinics affiliated with a tertiary care institution between January 1, 2008 and December 31, 2014. All women were counseled on contraception prior to hospital discharge. DMPA was available in the hospital pharmacy, and its utilization was documented in the electronic health record. The Patient Health Questionnaire 9 (PHQ-9) was used to screen for postpartum depression for all women at all postpartum visits. A score of 10 or greater was categorized as positive. Bivariable and multivariable analyses were used to identify the association between immediate postpartum DMPA use and a positive postpartum depression screen. RESULTS: Of the 5,073 women who met inclusion criteria, 410 (8.1%) received DMPA prior to hospital discharge. Compared with women who did not receive DMPA, women who received DMPA prior to hospital discharge were younger, more likely to identify as Black race or Latinx ethnicity, and more likely to be publicly insured. Clinical characteristics also differed. Women who received DMPA were more likely to be obese and to have experienced prenatal depressive symptoms, been diagnosed with a hypertensive disorder of pregnancy, delivered preterm, and delivered vaginally. Receipt of immediate postpartum DMPA was not associated with having a positive screen for postpartum depression in bivariable (5.4 vs. 6.0%, p = 0.29) or multivariable (adjusted odds ratio 0.94, confidence interval 0.53-1.68) analyses. CONCLUSION: Receipt of postpartum DMPA is not associated with a positive postpartum PHQ-9 screen. Concerns about precipitating postpartum depression should not preclude the utilization of DMPA as a contraceptive agent. KEY POINTS: · Contraception is an important issue for obstetricians to address with postpartum patients.. · Concerns have been raised over the relationship between DMPA and depression.. · Our study shows that DMPA is not associated with a positive postpartum depression screen..

What Is Long-Acting Reversible Contraception?

This JAMA Patient Page describes types of long-acting reversible contraception, how they are placed and removed, and their potential side effects.

Linguistic features of suicidal thoughts and behaviors: A systematic review.

Language is a potential source of predictors for suicidal thoughts and behaviors (STBs), as changes in speech characteristics, communication habits, and word choice may be indicative of increased suicide risk. We reviewed the current literature on STBs that investigated linguistic features of spoken and written language. Specifically, we performed a search in linguistic, medical, engineering, and general databases for studies that investigated linguistic features as potential predictors of STBs published in peer-reviewed journals until the end of November 2021.We included 75 studies that investigated 279,032 individuals with STBs (age = 29.53 ± 10.29, 35% females). Of those, 34 (45%) focused on lexicon, 20 (27%) on prosody, 15 (20%) on lexicon and first-person singular, four (5%) on (morpho)syntax, and two (3%) were unspecified. Suicidal thoughts were predicted by more intensifiers and superlatives, while suicidal behaviors were predicted by greater usage of pronouns, changes in the amount of verb usage, more prepend and multifunctional words, more nouns and prepositions, and fewer modifiers and numerals. A diverse field of research currently investigates linguistic predictors of STBs, and more focus is needed on their specificity for either suicidal thoughts or behaviors.

Intrapartum nipple stimulation therapy for labor induction: a randomized controlled external pilot study of acceptability and feasibility.

BACKGROUND: Nipple stimulation is purported as a natural and inexpensive method for inducing labor, but its use is understudied. OBJECTIVE: We aimed to assess whether conducting a large randomized controlled trial comparing intrapartum nipple stimulation therapy with oxytocin infusion is feasible and acceptable to patients and obstetrical care providers. STUDY DESIGN: This single-center parallel-group randomized controlled external pilot study (ClinicalTrials.gov Identifier NCT04756089) included women at ≥36 weeks of gestation who were planned to receive exogenous oxytocin for their labor induction. Women who were <18 years old, non-English speaking, or with fetuses at increased risk of neonatal intensive care were excluded. Stratified by parity, women were randomized 3:1 to intrapartum nipple stimulation therapy or immediate receipt of oxytocin. Women assigned to nipple stimulation therapy were asked to stimulate with an electric breast pump or by hand for periods of at least 30 minutes, with breaks as needed for up to 15 minutes at a time, for at least a cumulative 2 hours before considering initiation of oxytocin, and to complete intrapartum diaries. Labor characteristics and outcomes were examined. Validated questionnaires were used to assess the participants' pain level during the intervention, their sense of control during childbirth, and their breastfeeding success. Primary outcome measures were recruitment, adherence to study protocol and follow-up, and crossover rates. RESULTS: A total of 620 women underwent labor induction from March 13, 2021 to June 23, 2021. Of 557 potentially eligible women, 53 were approached by available research staff. Of the 53 women, 24 (45%) consented and enrolled: 18 randomized to nipple stimulation and 6 randomized to oxytocin. Moreover, 1 woman assigned to nipple stimulation withdrew because of delay of clinical care and received oxytocin (crossover rate of 1/24 [4%]), and 1 woman assigned to oxytocin did not receive it because of spontaneous labor progress. All other participants followed their assigned intervention. The 17 women who performed nipple stimulation stimulated for a median duration of 198 (interquartile range, 125-291) minutes and required a median of 69 (interquartile range, 21-80) minutes of stimulation before achieving at least 3 contractions in a 10-minute window, averaged >30 minutes (also known as "adequate" contractions). Among those assigned to nipple stimulation therapy, 15 of 17 women (88%) later received oxytocin infusion before delivery. The median times from intervention start to delivery were 16.4 (interquartile range, 0.6-28.2) hours for women assigned to nipple stimulation and 20.6 (interquartile range, 14.2-23.4) hours for women assigned to oxytocin infusion. Of note, 12 women (50%) completed their postpartum study questionnaires. CONCLUSION: Random assignment to either intrapartum nipple stimulation therapy or oxytocin infusion for labor induction was feasible and acceptable to patients and obstetrical care providers.

The Association between Maternal Race and Ethnicity and Risk Factors for Primary Cesarean Delivery in Nulliparous Women.

OBJECTIVE: To understand whether maternal, perinatal, and systems-level factors can be identified to explain racial/ethnic disparities in cesarean delivery rates. STUDY DESIGN: This retrospective cohort study included nulliparous women with singleton gestations who delivered at a tertiary care center from 2015 to 2017. Maternal, perinatal, and systems-level factors were compared by race/ethnicity. Multilevel multivariable logistic regression was used to identify whether race/ethnicity was independently associated with cesarean. Effect modification was evaluated using interaction terms. Bivariable analyses and multinomial logistic regression were used to determine differences in indication for cesarean. RESULTS: Of 9,865 eligible women, 2,126 (21.5%) delivered via cesarean. The frequency of cesarean was lowest in non-Hispanic white women (19.2%) and highest in non-Hispanic black women (28.2%; p < 0.001). Accounting for factors associated with cesarean delivery did not lessen the odds of cesarean associated with non-Hispanic black race (aOR: 1.58, 95% CI: 1.31-1.91). Compared with non-Hispanic white women, non-Hispanic black women were more likely to undergo cesarean for nonreassuring fetal status (aOR: 2.73, 95% CI: 2.06-3.61). CONCLUSION: Examined maternal, perinatal, and systems-level risk factors for cesarean delivery did not explain the racial/ethnic disparities observed in cesarean delivery rates. Increased cesarean delivery for nonreassuring fetal status contributed substantially to this disparity.

The Association between Positive Antenatal Depression Screening and Breastfeeding Initiation and Continuation.

OBJECTIVE: This study was aimed to determine the association between antenatal depression and breastfeeding initiation and continuation at 6 weeks postpartum. STUDY DESIGN: This retrospective cohort study included all live-born deliveries after 24weeks' gestation at a single tertiary care institution between 2009 and 2014 with a documented antenatal depression screen using the Patient Health Questionnaire-9 (PHQ-9). During the study period, it was recommended that routine screening occur during both the first and third trimesters. A positive screen was defined as a PHQ-9 score ≥ 10. Breastfeeding initiation and continuation until 6 weeks' postpartum were compared between women with and without a positive screen using bivariable analyses. Stepwise backward elimination regressions were used to identify whether a positive screen was independently associated with breastfeeding rates after controlling for confounders. RESULTS: Among the 2,871 women meeting inclusion criteria, 302 (10.5%) were screened positive for antenatal depression. After adjusting for confounders, there were no differences in breastfeeding initiation (adjusted odds ratio [aOR] = 0.78, 95% confidence interval [CI]: 0.52-1.16), but women with a positive antenatal depression screen were significantly less likely to continue breastfeeding at 6 weeks' postpartum (aOR= 0.67, 95% CI: 0.48-0.96). CONCLUSION: A positive antenatal depression, screened in the first or third trimester, is a significant risk factor for early breastfeeding cessation.

Diabesity and Perinatal Mental Health: Evidence-based Recommendations for Screening and Intervention.

Perinatal mental illness, obesity, and diabetes mellitus are common complications of the perinatal period that are becoming ever more prevalent and frequently co-occur. This review seeks to examine the prevalence of comorbid obesity/diabetes (termed "diabesity") and mental illness in the perinatal period and current understandings of the psychosocial and pathophysiological relationships between these diseases. We will present current guidelines for screening and make recommendations for adaptations of mental health treatment in patients with this comorbidity. Finally, we present future directions for research and clinical intervention.

Multivariable Analysis of the Association between Antenatal Depressive Symptomatology and Postpartum Visit Attendance.

OBJECTIVE: We sought to evaluate whether antenatal depression was associated with postpartum visit nonattendance. STUDY DESIGN: This retrospective cohort study included women who received prenatal care at the academic outpatient offices of a single tertiary care center between March 1, 2009, and December 31, 2014. Women were screened for antenatal depression using the Patient Health Questionnaire-9. Attendance at the postpartum visit was compared between women with and without antenatal depressive symptomatology using bivariate and multivariable analyses. RESULTS: Of the 2,870 women who met the inclusion criteria, 566 (19.7%) did not attend the postpartum visit. Women who did not attend a postpartum visit were younger and more likely to be a racial/ethnic minority, publicly insured, or multiparous; they were more likely to have a higher body mass index, as well as a vaginal delivery. Compared with those without antenatal depressive symptomatology, women with antenatal depressive symptomatology were significantly less likely to attend their postpartum visit (18.6 vs. 29.2%, p < 0.001). This association persisted even after controlling for potential confounders (adjusted odds ratio: 0.69, 95% confidence interval: 0.48-0.99). CONCLUSION: Antenatal depressive symptomatology is significantly associated with nonattendance at the postpartum visit.