Volume 6

Abstract

Objective: To investigate the association of prepregnancy and prenatal depression and/or anxiety on preterm birth (PTB), while also exploring Hispanic/Latina ethnicity as a potential effect modifier.

Methods: Study population included respondents of  UT-PRAMS (2016–2019). Associations between prepregnancy and prenatal depression and/or anxiety and PTB were evaluated using Poisson regression models accounting for stratified survey sampling.

Results: Women with prepregnancy and prenatal depression and anxiety, compared to those without, had a 67 percent (95% CI: 19%, 134%) higher probability of experiencing PTB, after controlling for relevant sociodemographic, lifestyle, and reproductive history factors. Impact of depression on PTB was slightly higher than impact of anxiety. Hispanic/Latina ethnicity was found to protect against PTB for those with prepregnancy and prenatal depression alone (aPR: 0.53, 95% CI: 0.24, 1.21) or both depression and anxiety (aPR: 0.51, 95% CI: 0.18, 1.40) compared to being non-Hispanic/Latina (aPR: 1.79, 95% CI: 1.25, 2.55 for depression alone; aPR: 1.62, 95% CI: 1.18, 2.21 for depression and anxiety).

Conclusions: Overall, Utah women reporting prepregnancy and prenatal depression and anxiety were more likely to have a PTB. Being of Hispanic/Latina ethnicity was found to mitigate the risk of PTB among women with depression and anxiety.

Implications: Prepregnancy and prenatal mental health screenings and treatment are key to lessening the impacts of depression and anxiety on both mother and infant. Hispanic/Latina ethnicity may be  protective against PTB among women experiencing mental distress. Whether this is through increased social support or through a different mechanism should be explored in future research.

Introduction

In 2019, the national preterm birth (PTB) rate rose for the fifth year in a row, affecting approximately 10 percent of infants and causing growing concern among medical and public health officials.² PTB poses several risks to an infant including immature lungs, difficulty regulating body temperature, poor feeding, and slow weight gain.³ Maternal depression and anxiety have been directly linked to PTB, with long-term effects on both mother and baby.^4-7 This is especially relevant since depression is the most common psychiatric disorder in the US and highest among women, with anxiety not far behind.⁹ A recent study reported that women with both mental health disorders were found to have a higher rate of PTB than those with only depression, only anxiety, or without either disorder.¹⁰ An extensive body of prior literature has established that a history of prepregnancy depression and anxiety is a strong risk factor for prenatal depression^11-17 and that prepregnancy and prenatal depression and anxiety are highly comorbid.^18,19 For that reason, this study explores the potential cumulative impact of prepregnancy and prenatal depression and anxiety (PPDA) on the likelihood of PTB in Utah. Ethnicity is also highly associated with the risk of PTB,²⁰ and this study will look at what effect Hispanic/Latina ethnicity, which makes up the second-largest ethnic group in Utah, may have on risk for PTB.

Methods

Study Population: This is a cross-sectional study design using data from the Utah Pregnancy Risk Assessment Monitoring System (UT-PRAMS) survey, Phase 8 (January 1, 2016, through December 31, 2019). The Centers for Disease Control (CDC) developed the standardized data collection methodology used for the national-level PRAMS survey and continues to provide oversight for the survey’s methodology and protocol.^21-23 PRAMS is a mixed-mode surveillance system (mail and telephone) that uses birth certificate information as its population-based sampling frame. One key aspect of PRAMS is the stratified systematic sampling, which oversamples on features related to high-risk women such as mothers of low­-birthweight infants, living in high-risk geographic areas, and belonging to racial/ethnic minority groups.²¹

UT-PRAMS Phase 8 drew stratified (by maternal education and infant birthweight) samples of approximately 200 new mothers (2–6 months after delivery of a live birth) every month.²⁴ New mothers were contacted via mailed questionnaire (available in English and Spanish) multiple times and telephone follow-up. An informed consent document was included with each survey packet explaining the participants’ rights. Consent is implied if the survey is completed. The total sample of Utah mothers completing the PRAMS Phase 8 questionnaire was 5814, reflecting an estimated population of 188,700 women. The sample comprises 16.2 percent Hispanic/Latinas and 10.9 percent non-White, making it representative of Utah’s race/ethnicity makeup consisting of Hispanic/Latinas (14.4%), Blacks or African Americans (1.5%), American Indians or Alaskan Natives (1.6%), Asians (2.7%), Native Hawaiians or Pacific Islanders (1.1%), or those of two or more races (2.2%).²⁵ The expected national PRAMS response rate is 60%, with Utah exceeding this goal at 65% (2016), 66% (2017), 62% (2018), and 69.5% (2019).

Mothers’ responses were linked to extracted birth certificate data items, including pregnancy complications for index birth. The PRAMS weighting process produces an analysis weight considering the stratified sampling along with nonresponse and noncoverage components. The analysis weight of the PRAMS data can be interpreted as the number of women like herself in the population that each respondent represents. This study and the use of PRAMS data (de-identified) have been acknowledged by the University of Utah Institutional Review Board as nonhuman subject research.

Outcome: The primary outcome of interest was whether or not a woman experienced PTB, defined as a live birth before 37 weeks into the pregnancy.² The obstetric estimation of gestation, which uses ultrasonography within the first two trimesters to determine gestational age and the estimated delivery date, is added to the birth certificate within 24–48 hours of the birth.^26,27 However, it is important to note that the obstetric estimation of gestation may vary by up to 10–14 days.²⁸

Exposure: The PRAMS questionnaire asks women whether they had experienced depression or anxiety (each requiring yes/no answers) during the 3 months before the most recent pregnancy (prepregnancy) or during the most recent pregnancy (prenatal). We created a combined impact variable to include women who had both depression and anxiety in the 3 months prior to conception and during pregnancy (PPDA). This combined impact variable was chosen due to the common comorbidity of these 2 disorders in women (both prepregnant and prenatal) as well as the possibility that the combination for a sustained period of time may result in a cumulative impact increasing the risk for PTB.

Covariates: Confounding factors believed to influence both depression and anxiety as well as PTB were determined based on prior literature. Demographic and lifestyle factors included race/ethnicity, maternal age, marital status, maternal education, total household income, and body mass index (BMI). Additionally, smoking, drinking, and prior history of high blood pressure and diabetes as well as reproductive history were also considered as potential confounding factors.^{7,20, 29-32} Given prior theories on the role that maternal race/ethnicity may play in mental health-adverse birth outcome associations,³³ we additionally tested whether Hispanic/Latina ethnicity may modify the association between prepregnancy and prenatal depression and/or anxiety and PTB.

Statistical Analysis: Participant characteristics were reported by the exposure of interest (ie, PPDA) and took into account PRAMS’ weighted analysis formatting.¹⁹ All variables were dichotomous or categorical and reported as weighted percentages.

To explore the associations between prepregnancy and prenatal depression and/or anxiety and PTB, we used Poisson regression models with a robust error variance. The models, accounting for PRAMS’ use of stratified sampling, generated adjusted prevalence ratios (PR) and 95% confidence intervals (CI).^34,35 The referent group was women without PPDA. Mothers who did not have data for key exposure variables were removed from the analysis population. Effect modification by Hispanic/Latina ethnicity was conducted via a stratified analysis and on a multiplicative scale using the Wald test. Stata 15.1 was used for the analysis.

Results

After excluding missing values from key exposure variables (depression before/during pregnancy and anxiety before/during pregnancy), 4166 women (72%) were included in the primary analyses, reflecting an estimated population of 136,090 women (Figure 1).

Among this study population, 13 percent had PPDA while 87 percent did not (Table 1). White non-Hispanic/Latina women were more likely to report PPDA (16%) compared to white Hispanic/Latina women (11%).

The median age was 28 years (mean age 28.8, SE 8.7). The majority of women were White (89.1%), non-Hispanic/Latina (83.8%), married (83.3%), had at least some college (72.9%), and did not smoke (91.5%) or drink alcohol (67.6%) within 2 years before pregnancy. A high percentage did not have the common comorbidities of diabetes (99.6%) or high blood pressure (98.8%) within 2 years prior to pregnancy. Household income ranged from $20,001 to $57,000 for 46.4 percent of the population and was above $57,001 for the remaining participants (Table 1).

Almost a third of mothers in this study gave birth for the first time (34.8%) while the others had experienced 1–3 (56.7%), 4–7 (8.2%), and 8+ (0.3%) previous live births, respectively. Of those with previous live births, 98.1%  delivered a single child, 1.8% delivered twins, and 0.1%  delivered multiples. Of women with a previous live birth 5% of women reported previous PTB. The prepregnancy BMI categories for participants was underweight (10.7%), normal weight (50.8%), overweight (13.5%), and obese (25%). Women with PPDA, compared to those without, were more likely to have a history of smoking and/or drinking alcohol within the past 2 years, to be obese, have high blood pressure, a history of PTB, and/or given birth to multiples.

Association Between Depression and/or Anxiety and Preterm Birth: In the unadjusted analysis we found that women reporting PPDA, compared to those without, were 1.55 (95% CI, 1.22, 1.99) times more likely to experience PTB. Those with depression alone were 1.48 (95% CI, 1.18, 1.85) times more likely to experience PTB, and those with anxiety alone were 1.44 (95% CI, 1.17, 1.78) times more likely (Table 2).

After adjusting for maternal race, age, household income, marital status, and education level, women with PPDA, compared to those without, were 1.67 (95% CI, 1.19, 2.34) more likely to have PTB. Those with depression were 1.54 (95% CI, 1.15, 2.07) times more likely to experience PTB, while those with anxiety were 1.51 (95% CI, 1.16, 1.96) times more likely  (Table 2).

After additional adjustment for previous preterm births, number of previous live born, recurrent diabetes and/or high blood pressure, BMI, and smoking and drinking within the previous 2 years, those with PPDA were 1.59 (95% CI, 1.05, 2.40) more likely to have PTB, while those with depression were 1.56 (95% CI, 1.08, 2.24) more likely to experience PTB and those with anxiety 1.31 (95% CI, 0.95, 1.78) more likely (Table 2). Stratification by Hispanic/Latina ethnicity showed effect modification for prepregnancy and prenatal depression and PTB in both the parsimoniously adjusted model and fully adjusted model (Wald P for both=0.04) (Table 3).

Discussion

After accounting for relevant sociodemographic, lifestyle, and reproductive history factors, women with prepregnancy and prenatal depression and anxiety, compared to those without, had a 67 percent higher probability of experiencing PTB. Women experiencing depression but not anxiety had a 56 percent higher probability of experiencing PTB, and those with anxiety but not depression were 51 percent more likely to have PTB. Our findings indicate that among the entire study population, the cumulative effect of depression and anxiety has a greater potential impact on PTB risk than either alone. Effect modification by Hispanic/Latina ethnicity was found to act as a protective factor against PTB for those with prepregnancy and prenatal depression and anxiety as well as those with depression only.³⁶

Strengths of the Study: The use of PRAMS data allows for a population-based analysis that is representative of all women in Utah, including at-risk women, due to its systematic stratified sampling scheme. Our ability to capture self-reported depression and anxiety data before and during pregnancy and to link these data to birth records for PTB assessment is novel, especially since questions on maternal depression and anxiety were added to the UT-PRAMS survey only in 2016.³⁷ The UT-PRAMS questionnaire and linked birth records also allow us to take into account multiple important confounding factors including sociodemographic, lifestyle, health, and reproductive history.

Limitations of the Data: This study faces the limitation of selection bias by only focusing on mothers who had a live birth.^38,39 The precision and accuracy of obstetric estimation of gestation, which can vary up to 14 days, may potentially lead to misclassification bias. Missing data for the outcome, key exposures, and covariates could lead to selection bias. Recall bias may also be a factor, as the questionnaire asks women at 2–6 months postpartum on experiences they had before and during pregnancy. Social desirability bias may also be a factor as not all mothers may wish to report on their smoking, drinking, or drug use due to the stigma associated with them. Additionally, the PRAMS questionnaire asks women to confirm that they experienced anxiety and/or depression before and during pregnancy without regard to standardized testing and clinical diagnoses.⁴⁰ This may result in the data overestimating the prevalence of diagnosed depression and anxiety or underestimating based on poor screening.⁴¹ The severity of the mental disorder(s) is also not addressed. During PRAMS Phase 8, 43.8% of women were screened for depression during the 12 months before pregnancy, compared with 68.9% during prenatal care visits, and 85.9% during postpartum health care visits. This study did not explore the impact of stress and abuse factors on PTB among UT-PRAMS participants. The intensity of alcohol consumption and tobacco use are not provided in the data, which may directly impact the potential association between health behavior and the risk of PTB; these questions should be included in future questionnaires. The impact of prepregnancy and prenatal depression and/or anxiety on postpartum depression would also benefit from additional study.^{2, 42} Finally, we were not able to explore how race may modify the association between maternal depression and/or anxiety and PTB due to only having access to dichotomous race variable (White vs non-White). Given the high rate of PTB among Black women, more research is needed on potential factors that can explain this disparity.³³

Interpretation: The findings of an association between prepregnancy and prenatal depression and anxiety and PTB is in harmony with a large body of prior research.^{2, 7, 25, 34-45} It is notable that many studies look at depression and anxiety separately instead of as ongoing comorbidities, and this has led to varying results in the literature.^2,17,27 Adhikhari, et al, found that when depression and anxiety coexist, the symptoms are likely to be more severe and pose a higher risk of PTB.⁷ Similar to our findings, both maternal smoking and alcohol consumption can increase the risk of PTB.^46-50 Unlike other studies,^24,29 however, our study did not find that age played a significant role in predicting PTB among women with prepregnancy and prenatal depression and anxiety. This may be because only 13.4% of this sample fell in the high-risk categories of under 18 or over 35 years of age. Liu, et al, reported that prepregnancy obesity is associated with PTB in the general population, which is similar to this study’s findings of a mild association between obesity (BMI >29) and PTB.

The finding of Hispanic/Latina ethnicity as a protective factor against PTB is also in line with existing literature.^{26, 27, 46} Future research should delve further into reasons that Hispanic/Latina ethnicity may be protective, including through increased social support, as has been hypothesized.^{26, 27, 46}

Health Implications

Pregnancy is a particularly vulnerable time for mothers, and the cumulative impact of prepregnancy and prenatal depression and anxiety can affect maternal mood and increase the likelihood of PTB and impaired fetal development. This, in turn, can lead to long-lasting psychological and neurological effects for the child.³² Additional research with a larger, more diverse group is needed to further test the overall associations between a mother’s age, race, ethnicity, and prepregnancy and prenatal depression and anxiety, and PTB.^52,53 Mental health screening during prepregnancy, prenatal, and postpartum visits is imperative to develop appropriate mitigation measures.⁵⁴

Conclusion

By looking at the existence of both depression and anxiety from prepregnancy to birth, the prevalence and cumulative impact of these mental disorders and their association with experiencing PTB can be better understood. This study highlights a positive association, which translates into a higher risk for PTB among women who experience the cumulative impact of prepregnancy and prenatal depression and anxiety, compared to those with only one disorder or none at all. The finding of an effect modification by Hispanic/Latina ethnicity emphasizes the impact of, most likely, social factors associated with maternal ethnicity and the risk of PTB.

Acknowledgements

Data were provided by the Utah Pregnancy Risk Assessment and Monitoring System (PRAMS), a project of the Utah Department of Health (UDOH), the Office of Vital Records and Health Statistics of the UDOH, and the Centers for Disease Control Prevention and Prevention (CDC) of the US Health and Human Services Department. This report does not represent the official views of the CDC or UDOH. We thank Dr. Charles Rogers for his insightful comments and critiques of various versions of the manuscript.

Funding: Research was partially supported by National Institute of Aging (NIA) grants “Hypertensive Disorders of Pregnancy and Subsequent Risk of Vascular Dementia, Alzheimer’s Disease, or Related Dementia: A Retrospective Cohort Study Taking into Account Mid-Life Mediating Factors” (Project K01AG058781; PI: Karen Schliep)

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Citation

Seage M, Petersen M, Carlson M, VanDerslice J, Stanford J, & Schliep K. (2022). What Role Does Hispanic/Latina Ethnicity Play in the Relationship Between Maternal Mental Health and Preterm Birth? Utah Women’s Health Review. doi: 10.26054/0d-dkas-c5qe

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Originally published in Utah Women and Leadership Project, August 2, 2021, No 30. Printed by request in The Utah Women’s Health Review

Setting the Stage

The benefits of physical activity are well documented and improve all aspects of health and overall wellbeing.¹ Globally, on average, 37.1% of women are insufficiently physically active while only 23.4% of men are²; this trend is also found in Utah, where 19.4% of women are insufficiently physically active while only 17.6% of men are.³ While women often live longer than men, they are frequently in worse health.⁴ Physical inactivity con-tributes to the development and severity of chronic diseases including cardiovas-cular disease, diabetes, and hypertension.⁵ In addition to affecting physical health, physical inactivity is also associated with poor mental health. Physical activity can contribute to positive self-image and improved confidence, which is critical for meaningful community participation as well as developing interpersonal relationships.

The Utah Women & Leadership Project (UWLP) seeks to better understand the status, experiences, and challenges of Utah women in order to strengthen the impact of women and girls.⁶ This snapshot summarizes research regarding physical activity levels, access, and barriers for girls (ages 7–11) and young women (ages 12–17) to help decision makers understand that instilling physically active habits early can improve the health and wellbeing of Utah women for the rest of their lives. This research snapshot reviews three key areas: 

   1) Gender physical activity levels and the importance of physical activity;

   2) Gender physical activity factors; and

   3) Recommendations to increase physical activity of Utah girls and young women. 

Guidelines & Comparison

National Recommendations

The majority of Americans do not meet the physical activity guidelines recommended for their age. It is advised that children and adolescents, ages 6 to 17, get 60 minutes or more of moderate-to-vigorous physical activity each day. For adults, at least 150–300 minutes of moderate intensity or 75 minutes of vigorous intensity aerobic physical activity per week, or a combination of both, is recommended.⁷ In terms of steps, the daily recommended average for adolescents and adults is 10,000, and for girls it is 11,500.⁸ However, due to a number of barriers (see “Specific Gender Barriers” section), women and girls are not meeting the guidelines at disproportionately high rates compared to men and boys.

Utah Comparison

In Utah, 28% of boys meet the recommended physical activity levels set by the state, compared to only 14% of girls (see Figure 1).⁹ These numbers have been consistent over the past ten years, meaning half as many girls and young women are regularly getting recommended physical activity as compared to boys and young men. An analysis of the American College Health Association’s National College Health Assessment III data found that female college students were significantly less likely to meet physical activity guidelines compared to male college students.¹⁰ Research has found that women of various ages report facing more barriers to physical activity than men.¹¹

Specific Gender Barriers

Lack of Options

A major barrier for girls and young women mentioned in the literature in terms of participating in fitness activities is the lack of options for physical activity that they prefer.¹³ Most physical education classes consist primarily of competitive sports, which young women identified as their least favored activity. Women, young and old, show preferences for yoga, walking, biking, and dancing. The scarcity of what they see as viable options, in combination with the lack of discussions with girls and young women on their preferred choice for physical activity, leads to lower rates of participation. When girls and young women are offered different options for physical activity, studies show there are increased levels of autonomy, self-determination, and participation.¹⁴ Studies also suggest that accounting for preferences when developing physical education curricula and after-school physical activity programs can increase participation among young women.¹⁵

Men prefer different types of physical activity than women. Unsurprisingly, men prefer strength training, and women tend to prefer moderate intensity cardiovascular activities.¹⁶ One study found that when given a list of common exercises to perform, male teens and young adults chose strength training exercises and females chose low-impact cardiovascular activities.¹⁷ Interestingly, the benefits of physical activity differ for men and women depending on what types of exercise they participate in. One research team found that women who participate in regular, low-impact activities report higher levels of self-esteem and quality of life compared to women who participate in regular, high-intensity activities.¹⁸ These researchers found that the opposite is true for males, which suggests the need for a gender-tailored approach to engaging young adults in physical activity.

Gender Roles and Perceptions

Societal gender roles are strongly associated with young women’s lack of participation in physical activity. Children, youth, and young adults have differing views on the functionality of their bodies based on their biological sex.¹⁹  Notably, young women experience negative social feedback after participating in a school physical education class if they are not able to shower or change clothes because of how they appear to others, especially to boys.²⁰ Teen women prioritize conforming to socially accepted ideals of beauty, which include being small, slight, and soft. This may come from the perceived lack of social capital for women participating in physical activity beyond maintaining feminine attractiveness.²¹

Positive body image is correlated with increased levels of physical activity,²² yet Utah women have low rates of body acceptance, which may be a factor in correlated low rates of physical activity. A 2017 UWLP report²³ revealed the high rates of cosmetic surgery per capita in Salt Lake City in past years, which trumped that of Los Angeles and was second only to Miami. This report documented the problem that follows from society assessing a woman’s success based on her attractiveness, which reduces a woman’s identity and potential to the shape of her body and increases sexual objectification. 

Another study found that the benefits of physical activity, including reduced levels of stress, were lost if the motivating factor to exercise was weight loss or body toning.²⁴ More specifically, it found that motivating reasons to exercise predicted quality of life outcomes for women over actual exercise. This is concerning as research has found that conforming to societal ideas of attractiveness, including thinness, is, again, young women’s main motivator to participate in physical activity. Encouraging girls and women of all ages to participate for reasons beyond maintaining or achieving attractiveness has been shown to increase their motivation to be physically active. 

Lack of Social Support

Social support from friends was noted as a key factor to girls and young women engaging in physical activity, yet many noted that social support from friends, parents, and teachers to participate was lacking. Girls and young women report less enjoyment in physical activity and less confidence in their abilities as they get older, which may stem from consistent lack of societal encouragement to be physically active, as well as societal pressure to not be competitive or strong.²⁵ The lack of social support also appears in the inadequate facilities and gym attire provided for young women.²⁶ Young women report inadequate changing and showering facilities, a lack of time for showering, and inappropriate gym attire (such as short skirts) as reasons they do not participate in physical education.²⁷ Feeling self-conscious about their physical appearance while wearing exercise or fitness clothing is another barrier to participation in physical activity that teen women face.²⁸

Additional Barriers for Women of Color

Several research studies have reported a variety of additional barriers related to physical activity for girls and women of color.²⁹ For example, one Utah study found that, culturally, Pacific Islanders felt it was unacceptable for women to be in the sun and sweat, which could reduce women’s physical activity. In addition, research by the Women’s Sports Foundation found that the drop-out rate for urban girls of color doubles that of suburban white girls, largely due to increased poverty resulting in a lack of resources.³⁰ Several studies identified hair health among young African American women as a barrier to physical activity.³¹ One team of qualitative researchers found that perspiration on hair and hair style maintenance, image, and social comparisons, along with the lack of solutions to overcome hair-related issues, were all barriers to physical activity for the women of color interviewed.³² Participants of the study also mentioned how the monetary and time burdens of fixing and maintaining hair styles further contributed to the issue.

Moving Forward

Since the passage of Title IX in 1972 mandated that federally funded educational institutions must provide women equal opportunity in sports, the number of women participating in sports went from one in 27 girls to today’s two in five girls participating.³³ While large strides have been made in women’s sports, gaps still exist. According to The National Federation of State High School Associations, in 2018–2019, boys across the nation had 1.13 million more sports opportunities than girls.³⁴ In Utah alone, close to 39,000 boys participate in sports compared to just over 28,000 girls. A nearly 1:1 male-to-female population ratio in Utah leaves almost 11,000 more opportunities for boys to participate in sports than girls.³⁵ About 87% of the National Collegiate Athletic Association (NCAA) schools still provide disproportionately more opportunities to men.³⁶

While there are many programs in Utah and the nation that promote physical activity, few have the specific goal of increasing physical activity levels of girls and young women. Although the problem is recognized, solutions have been slow to be adopted. Research has suggested the following recommendations to address and resolve these problems: 

First, parents and guardians should encourage physical activity for girls and young women. Fewer things have greater impact on a girl’s long-term physical activity levels than her parent’s own physical activity and their enthusiastic encouragement. Findings from the LOOK Longitudinal Study revealed that lower participation in physical activity among girls was associated with weaker influences at the school and family levels.³⁷ These findings suggest that a girl’s lack of involvement in physical activity has roots in sociocultural norms and can be changed with education. Another study reviewed 180 nine-year-old girls and their parents to examine parenting strategies that led to long-term increases in their daughter’s physical activity levels.³⁸ It was found that logistic support (e.g., registering their daughters for sports teams and facilitating transportation to sports events) and explicit modeling (such as the parents themselves participating in physical activity) led to increases in physical activity among the girls studied. The study also reported that having just one physically active parent can have a positive impact on a girl’s long-term participation in physical activity and overall health. 

Second, the most basic way to ensure that girls and women have physical activity options that are favorable to them is by asking what they enjoy doing and then tailoring physical activity options accordingly as preferences may vary by age group, particularly in school physical education classes. Studies³⁹ have reported that girls and women are more likely to be physically active when they enjoy what they are doing and have opportunities to participate with friends and peers as well. 

Third, promote gender inclusivity in all types of sports. Researchers⁴⁰ have found that gendered trends in sports limit teens’ potential by pressuring young men to participate in competitive sports while discouraging girls and young women from doing the same. Encouraging children to explore sports and physical activities that interest them, rather than the ones that girls typically play, can lead to increased interest and engagement.

Finally, improving the visibility of women’s athletics can improve girls’ and young women’s interest in sports, and it can increase societal interest as well. Ensuring that women athletes have access to adequate and equitable facilities, preventative care, media coverage,⁴¹ sponsorship, and funding can increase the credibility of women’s sports. In turn, the fanbase and social support will increase, resulting in expanded opportunities. An important byproduct will be the encouragement young women show for each other as they pursue athletics and, in the long term, a physically active life. 

Conclusion

The benefits of physical activity are clear, yet thousands of Utah girls and women are participating at significantly lower levels than boys and men. With only 28% of boys and 14% of girls meeting the recommended physical activity levels set by the state, change is needed for all.⁴² Exploring the barriers associated with the lower levels of participation, specifically for females, has laid the groundwork for the recommendations for change offered in this snapshot. The way forward requires parental involvement and role-modeling, asking girls and women what they want to do and then providing support for those activities (even if the choices are historically associated with the male gender), and making women’s athletic pursuits and events equally visible for everyone. Finding ways to increase the physical activity of girls and women will improve their overall health and wellbeing, which, in turn, will impact the health and wellbeing of Utah families, communities, and the state as a whole.

Acknowledgements

Special thanks to Angie Kleven for her research support and to our expert reviewers for their feedback: Lori Andersen Spruance (Brigham Young University), Robyn Bretzing (Alpine School District), Tim Brusseau (University of Utah), Ryan Burns (University of Utah), Liz Darger (Brigham Young University), Brett McIff (EPICC), Maya Miyairi (Utah State University), Brenda Ralls (EPICC), and Jason Slack (Utah Valley University). 

References

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Citation

Buesser K, Myrer R, & Madsen SR. (2022). Utah Girls, Young Women, and Physical Activity. Utah Women’s Health Review. doi: 10.26054/0d-4vqm-fg3d

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Research Synopsis

Study question: What is the relationship between pre-pregnancy and pregnancy physical abuse, stressful life events, and post-partum depression (PPD)?

What’s already known: Previous research has shown that physical abuse occurring during pre-pregnancy and prenatal is associated with PPD, but limited research has investigated the interplay between physical abuse, life stress, and PPD.

What this study adds: Among a representative Utah population of 142,963 women, 16% reported PPD between 2016 and 2018. Reproductive history and life stress (partner-related, traumatic, financial, and emotional), women with a history of physical abuse had a 1.56 higher adjusted prevalence ratio (95% CI: 1.19, 2.07) of experiencing PPD compared to their counterparts after adjusting for sociodemographic factors. In addition, partner-related stress was also independently associated with PPD, with a 1.32 higher prevalence ratio (95% CI: 1.07, 1.65) of PPD among women reporting partner-related stress compared to those who did not, adjusting for the same factors.

Abstract

Objective: To assess whether a history of physical abuse and stressful life events were associated with postpartum depression (PPD) among at-risk women.

Methods: Included were Utah women who gave birth between 2016 and 2018 who agreed to participate in the Utah Pregnancy Risk Monitoring System (UT-PRAMS). UT-PRAMs follows a stratified systematic sampling scheme, oversampling on lower levels of education and lower infant birth weight. Considering important confounding factors and a stratified sampling scheme, relationships between maternal history of physical abuse, life stressors (partner, traumatic, financial, or emotional stressors), and PPD were assessed via Poisson regression models with robust error variance.

Results: From January 1, 2016, to December 31, 2018, 4,101 participants, representative of an estimated population of 142,963 women, completed the UT-PRAMS survey. After adjusting for maternal age, race/ethnicity, education, income, marital status, prior preterm births, parity, depression before and during pregnancy, tobacco or alcohol use and life stressors, women who experienced pre-pregnancy or prenatal physical abuse had a 1.56 (9% CI, 1.19, 2.07) higher adjusted prevalence ratio compared to women who did not. In the same fully adjusted model, partner-related stress was also independently associated with PPD (aPR 1.32; 95% CI, 1.07, 1.65).

Conclusion: Physical abuse and partner-related stress (including divorce/separation, frequent arguments, partner who is not supportive of the pregnancy) were significant predictors of PPD after accounting for numerous other sociodemographic, lifestyle, and health history indicators.

Introduction

Negative consequences of post-partum depression (PPD) are significant, for both birthing parents and their offspring.^1-6 Morbidity and mortality associated with PPD are deserving of increased scrutiny overall and especially in Utah, the nation’s youngest state (median age 30.5 years)⁷ and fourth-most fertile state, with a fertility rate of 68.4 births per 1,000 women aged 15 through 44 years.⁸ National prevalence of PPD among postpartum women is 12.5 percent⁹; in Utah, the PPD prevalence is 15.3 percent among mothers.

Several factors known to contribute to risk for PPD are pronounced in Utah.¹⁰ The state ranks last in the nation for pay parity between men and women.¹¹ A growing body of research demonstrates that socioeconomic factors, including lack of pay parity, may collectively have multiplicative synergistic impact on adverse health outcomes, including depression and addiction.^12-15 Significantly, an estimated 36.9 percent of Utah women have been victims of domestic violence, compared to the national average of approximately 25 percent, and Utah is rated the 17^th-worst state in the nation for domestic violence.⁷

The 2-fold purpose of this study was to examine (1) the association between physical abuse (pre-pregnancy and prenatal) and PPD and (2) the impact of stressful life events on the risk of PPD.^{16, 17} A better understanding of the predictors of PPD may be instrumental in designing and implementing interventions that have the potential to decrease the incidence of PPD and its adverse impacts.

Methods

Study Population: This cross-sectional study¹⁸ was conducted among women who participated in the Utah Pregnancy Risk Assessment Monitory System (UT-PRAMS) survey between January 1, 2016, and December 31, 2018, recalling pre-pregnancy, prenatal, and early postpartum events and exposures. PRAMS is a surveillance program of the US Centers for Disease Control and Prevention (CDC) that gathers data across the nation (most states and territories as well as tribal and local health departments) and provides geographic-specific data critical in accomplishing its primary goal of reducing infant mortality, which is a common world-wide measure of overall national health.¹⁹ Since its inception in 1987, PRAMS has been utilized as a useful data source in ascertaining the changing risks and health outcomes associated with pregnancy for women and children. In addition to measuring pregnancy health, data is collected on socioeconomic status, life experiences, and quality of life, with the additional goals of mitigating risks and adverse health outcomes for women and children.

To address health risks and outcomes that are most pertinent to their unique populations, states and territories maintain a measure of control over stratifying data collection. UT-PRAMS oversamples women of lower education levels and infant birth weight to purposely capture data on a known high-risk population.²⁰ Approximately 200 women are contacted each month and asked to complete the survey. Those contacted are randomly selected within each stratum.

Primary Exposure, Physical Abuse: The primary exposure of interest was physical abuse experienced before and during pregnancy. Participants were asked the following questions: (1) “In the 12 months before you got pregnant with your new baby, did any of the following people push, hit, slap, kick, choke, or physically hurt you in any other way?”, with options being“husband or partner,” “ex-husband or ex-partner,” and “someone else.” Participants were instructed “for each person to check ‘No’ if they did not hurt you during this time or ‘Yes’ if they did.” (2) A similar question was asked for the period of pregnancy, switching the first part of the question to “During your most recent pregnancy.”

Secondary Exposure, Life Stress: The secondary exposure of interest for this study was life stress. The Phase 8 PRAMS questionnaire includes 13 questions regarding specific stressful events in the 12-month period prior to the birth of the child. The stressful events listed are (in order asked):

(1) A close family member was very sick and had to go into the hospital;
(2) I got separated or divorced from my husband or partner;
(3) I moved to a new address;
(4) I was homeless or had to sleep outside, in a car, or in a shelter;
(5) My husband or partner lost his job;
(6) I lost my job even though I wanted to go on working;
(7) My husband, partner, or I had a cut in work hours or pay;
(8) I was apart from my husband or partner due to military deployment or extended work related travel;
(9) I argued with my husband or partner more than usual;
(10) My husband or partner said he didn’t want me to be pregnant;
(11) I had problems paying the rent, mortgage, or other bills;
(12) My husband, partner, or I went to jail;
(13) Someone very close to me had a problem with drinking or drugs;
(14) Someone very close to me died.

A dichotomous variable (yes/no) was used for each event, and the events were categorized into 1 of 4 groups: partner-related stress (questions 2, 7, 8, 9), traumatic stress (questions 4, 11, 12), financial stress (questions 5, 6, 7, 10) and emotional stress (question 1). Question 3 (move to new address) was not included in our analysis given that the outcome could be either a positive or negative experience.²¹

Primary Outcome: Postpartum Depression: The primary outcome measure of interest for this study was PPD, which was determined by having answered “always” or “often” to either of the following 2 UT-PRAMS questions that captured postpartum depressed mood and anhedonia: (1) “Since your new baby was born, how often have you felt down, depressed, or hopeless?”, and (2) “Since your new baby was born, how often have you had little interest or little pleasure in doing things you usually enjoyed?”

Covariates: Covariates considered as potential confounding factors known to impact risk of abuse, life stress, and PPD included maternal age (continuous), race (White/non-White), ethnicity (Hispanic/non-Hispanic), marital status (married/not married), income level (≤$30,000, $30,000-$55,000, ≥$55,000), parity (continuous), history of preterm birth (yes/no), tobacco or alcohol consumption in past 2 years (yes/no), and depression before or during index pregnancy (yes/no). Lower educational attainment has also been shown to be more common among women who experience PPD,^22-24 and the differences between the overall population of Utah women and the study participants are shown in Figure 1. Accounting for some missing data, 58 individuals surveyed in this data sample were under the age of 18 years and too young to have achieved education levels measured here.

Statistical Analysis: Sociodemographic and health history characteristics among women with and without PPD were compared using the chi-square test for categorical and t test for continuous variables, considering the complex sampling design. To test the association between physical abuse, life stressors, and PPD, unadjusted and adjusted robust Poisson distribution models were used to estimate unadjusted and adjusted prevalence ratios (PR) and 95% confidence intervals (CI). Adjusted models considered maternal age, race/ethnicity, education, income, marital status, prior preterm births, parity, depression before and during pregnancy, and tobacco or alcohol use in last 2 years. An additional adjustment for pre-pregnancy and prenatal partner-related, traumatic, financial, and emotional stress was done for the final model looking at physical abuse and PPD. Similarly, an additional adjustment for pre-pregnancy and prenatal physical abuse was done for the final model looking at stressful life events and PPD. Data analysis was generated using SAS software version 9.4 (SAS Institute, Inc., Cary, NC) and Stata Software 14.2 (StataCorp, LLC, College Station, TX).

Results

Sample Characteristics: A total of 4,101 women, representing 142,963 Utah women who delivered during that time frame, completed the UT-PRAMS survey between 2016 and 2018. Among the respondents, 72.7 percent were White, 15.0 percent White-Hispanic, 5.3 percent non-White–Hispanic, and 7.0 percent non-White, non-Hispanic. Over 77 percent of study subjects were married, 20.2 percent never married, and 2.3 percent divorced or widowed. The mean age was 28.4 years (range, 15-44 years), with approximately 22 percent living at very low income levels of $20,000 or less per year, and the highest education level of almost half of the participants (46.8%) was a high school diploma. While the World Population Review reports that nearly 37 percent of Utah women experience abuse in their lifetimes,⁷ only 5 percent of respondents in this study reported pre-pregnancy and/or prenatal abuse. Women with PPD compared to women without PPD were inclined to be younger, unmarried, and more likely to consume alcohol, smoke, and have a history of depression and life stress (Table 1). They also leaned toward lower education and income levels (Figures 2 and 3).

Physical Abuse and Postpartum Depression: Four percent of women reported abuse, with 3 percent reporting abuse during pregnancy (1% by husband or partner, 1% by ex-husband or ex-partner, and 1% by someone else) and 4 percent reporting abuse before pregnancy (1% by husband or partner, 2% by ex-husband or ex-partner, and 1% by someone else). Twelve percent of women with any abuse prior to or during pregnancy experienced PPD compared to 3% of women who did not report abuse (Table 1). In the unadjusted analyses, women who experienced any physical abuse had a 3.06 higher PR (95% CI, 2.43, 3.85) of having PPD compared to women who did not (Table 2). After adjusting for maternal age, race/ethnicity, education, income, marital status, prior preterm births, parity, depression before and during pregnancy, and smoking or alcohol consumption in the last two years, the aPR was 1.74 (95% CI, 1.32, 2.29). Further adjustment for partner-related, traumatic, financial, and emotional stress did not appreciably alter findings (aPR 1.56; 95% CI, 1.19, 2.07) (Table 2).

Life Stressors and Postpartum Depression: Among the total sample, 25 percent of women reported partner-related stress (42% with PPD and 22% without PPD), 12 percent traumatic stress (24% with PPD and 10% without PPD), 47 percent financial stress (57% with PPD and 45% without PPD), and 28 percent emotional stress (34% with PPD and 27% without PPD) (Table 1). In the unadjusted analyses, women who experienced any partner-related, traumatic, financial, or emotional stress had a 2.12 higher PR (95% CI, 1.77, 2.53), 2.35 higher PR (95% CI, 1.93, 2.84), 1.53 higher PR (95% CI, 1.28, 1.84), and 1.29 higher PR (95% CI: 1.07, 1.56) of having PPD, respectively, than women who did not (Table 2). Adjustment for potential confounders including other stressors and physical abuse attenuated the results. However, women who reported partner-related stress, compared to those who did not, still showed a 32 percent higher prevalence of PPD (95% CI, 7%-65%) (Table 2).

Discussion

Findings from this study revealed that women who were exposed to pre-pregnancy and prenatal abuse were at a 1.6 higher probability for PPD after considering numerous confounding factors such as life stressors in the year before birth. The results also suggested that exposure to life stressors, notably partner-related stress, is associated with a 1.3 higher probability of PPD after similar adjustment. Age, educational attainment, income, and marital status, among other elements, are known demographic factors that may reliably predict PPD risk. Screening of these demographic indicators in conjunction with careful exploration of exposure to partner-related abuse and experienced stress may provide opportunities for PPD prevention and mitigation interventions.

The findings from the UT-PRAMS data are validated by other studies in both low-income and high-income countries.^25-29 For example, a study by Desmaraids et al. conducted in Western Canada looking at intimate partner abuse before and during pregnancy showed that 84 percent with postpartum mental health problems reported abuse before pregnancy, and 70 percent experienced abuse during pregnancy.³⁰Similarly, Tsai et al. employed secondary data analysis among women during pregnancy and postpartum in South Africa; the study reported a significant association between intimate partner violence and depression during pregnancy and postpartum.³¹ Additionally, this study found both independent and adjusted significant associations between physical abuse and PPD. In a study conducted in France, Gaillard and colleagues corroborated these findings with physical abuse and depression during pregnancy having significant associations with PPD.³² Although the present study utilized a cross-sectional study design, other studies using different methods arrived at similar findings and conclusions. Rogathi et al., in a prospective cohort study of postpartum depression among women who experienced intimate partner violence, showed that the odds of having postpartum depression increased by more than 3 times compared to women who did not.³³ Similar to the present study, younger women were inclined to develop more PPD than older women.³³

The effects of physical abuse, coupled with other social health factors, can be long-lasting. A study of physical, sexual, and social health factors with associated trajectories of maternal depressive symptoms in pregnant women showed that 32.7 percent of women manifested subclinical depressive symptoms with 9 percent showing persistent symptoms of depression up to 4 years postpartum.³⁴

The present study also found that partner-related stress, such as arguments, was a significant predictor of PPD. This is consistent with findings from other studies.³⁵ A Japanese study by Miura et al. revealed that verbal and physical abuse during pregnancy was significantly associated with PPD even after adjusting for potential confounders (OR=7.05, 95% CI, 2.23-10.55).³⁵ The findings from Muira and colleagues are important for this present study because similar questions and responses were used in determining the occurrence of physical abuse. These similar results established the co-existence of physical and verbal abuse from intimate partners. Thus, establishing the history of exposure to physical violence and verbal abuse serves as an important measure in determining association. In a study conducted in Ohio, Das et al. concluded that a documented history of exposure to depression during pregnancy is significant in identifying mothers who are at higher risk of anxiety and stress. Furthermore, stressful life events determined by using the Life Events Questionnaire (LEQ) to measure the degree of life stress have been found to be significantly associated with the prevalence of PPD.²⁷  Thus, these factors should be screened in combination with depression.³⁶

Limitations

Our study has limitations. First, the outcome of interest, PPD, lacks an official medical diagnosis and is dependent on participant responses to survey data. While screening questions mimic validated clinical screening tools,³⁷ they may not always correctly classify the actual condition of PPD. Second, an important demographic factor for which this data set differs from the overall Utah population is race and ethnicity. The dataset contains the following racial breakdown: 72.7 percent White, 6.9 percent non-White, non-Hispanic, and 20.3 percent Hispanic (higher than the national average). Thus, findings from this study will be generalizable for White and, to some extent, Hispanic women but no other minority groups prevalent in Utah.

Conclusion

It may be of value to explore the relative impact of specific factors associated with adverse outcomes, as this data may help inform decisions about use of finite resources in mitigating and preventing harm. Our study found that exposure to abuse before and during pregnancy, in addition to partner-related stress, were significant predictors of PPD. Further examination may be warranted to explore the interplay between partner-related physical abuse, life stressors, and perceived stress on risk of PPD, as women may suffer similar negative life events but appraise the impact or severity differently.

Acknowledgements

Data were provided by the Utah Pregnancy Risk Assessment Monitoring System, a project of the Utah Department of Health (UDOH), the Office of Vital Records and Health Statistics of the UDOH, and the Centers for Disease Control and Prevention (CDC) of the United States Department of Health and Human Services. The authors extend appreciation to the participants who made the study possible. This report does not represent the official views of the UDOH or CDC.

Funding: Dr. Karen Schliep was supported by a NIH National Institute of Aging (NIA) grant, “Hypertensive Disorders of Pregnancy and Subsequent Risk of Vascular Dementia, Alzheimer’s Disease, or Related Dementia: A Retrospective Cohort Study Taking into Account Mid-Life Mediating Factors” (K01AG058781). Dr. Charles R. Rogers was financially supported by 5 For the Fight, the University of Utah Huntsman Cancer Institute, the V Foundation for Cancer Research, and a NIH National Cancer Institute (NCI) grant (K01CA234319). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, 5 For the Fight, V Foundation for Cancer Research, Huntsman Cancer Institute, or the University of Utah.

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Citation

K Kah, J Dailey-Provost, JB Stanford, CR Rogers, & K Schliep. (2022). Association Between Pre-pregnancy and Pregnancy Physical Abuse, Partner-related Stress, and Post-partum Depression: Findings from the Utah Pregnancy Risk Assessment and Monitoring System (UT-PRAMS), 2016-2018. Utah Women’s Health Review. https://doi.org/10.26054/0d-0tbc-7vhj

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Background

Infertility is a common chronic condition affecting 8% to 12% of couples in the United States and worldwide.^1-3 Infertility is unique because it is usually experienced by a couple and not an individual. Since the underlying causes of infertility are most commonly (in approximately 50% of cases) due to a combination of male and female factors, it is often necessary to treat both people.^1,4

Infertility is defined as the inability of a couple to conceive after having regular sexual relations without using contraception for 12 months or more in a woman younger than 35 years and for at least 6 months in a woman aged 35 or older.⁵ Primary infertility is defined as the “inability to achieve a spontaneous clinical pregnancy,” whereas secondary infertility is defined as “the inability to achieve a spontaneous clinical pregnancy following a previous spontaneous pregnancy.”⁶ Infertility rates may be rising due to trends in delaying pregnancy, since advanced reproductive age increases the risk for infertility.⁷ Women typically experience peak fecundability in their mid-20s, with a gradual but significant decline in fecundability beginning at age 32, followed by a more rapid decrease beginning at age 37.⁸ Men begin to experience an increased probability of sterility beginning in their late 30s, with rates accelerating after age 40.⁷  

Infertility treatment in Utah is of particular interest, because the state has a strong pronatalist culture and one of the highest birth rates in the US.^9-12 The main objectives of this data snapshot are (1) to provide updated estimates of the prevalence of fertility treatments among women in Utah experiencing a live birth and (2) to assess how treatments for infertility are associated with women’s age and prior live births.¹²

Methods

To investigate fertility treatment in Utah, we used 2009-2015 data for women aged 20 to 40+ years from the Utah Pregnancy Risk Assessment Monitoring System (PRAMS) via the IBIS-PH interactive query system. PRAMS is an ongoing population-based surveillance system funded and conducted by the Centers for Disease Control and Prevention (CDC) in collaboration with state health departments, which samples mothers who have given birth to a live infant.¹³ In Utah, PRAMS is maintained by the Utah Department of Health’s Reproductive Health Program. Approximately 200 Utah mothers randomly selected from birth certificate data are sampled every month to participate in UT-PRAMS. UT-PRAMS uses a stratified sampling system based on maternal education and infant weight to capture smaller but higher at-risk populations.¹⁴ Weighted response rates for 2009-2015 were between 67% and 81%, above CDC-required minimum response rates.

The outcome of interest was birth to couples that had received fertility treatment, defined as the index birth. Couples without a prior pregnancy who received fertility treatments were classified as experiencing primary infertility; women with 1-4 previous live births who received fertitily treatments were classified as experiencing secondary infertility.⁶ This was assessed via the question, “Did you take any fertility drugs or receive any medical procedures from a doctor, nurse, or other health care worker to help you get pregnant with your new baby?” The response to this question was binary (yes/no). Age was categorized into 5 groups: 20-24, 25-29, 30-34, 35-39, and 40+ years. Parity was dichotomized into those without a prior live birth (indicator of primary infertility) and those with 1-4 prior live births (indicator of secondary infertility). Mothers with 5 or more live births were excluded from the current study due to very small numbers and relatively larger standard errors. Weighted prevalence and 95% confidence intervals (CI) are reported. IBIS-PH interactive query system for UT-PRAMS data takes into account the weighted stratified sampling per CDC protocol.¹³

Results

A total of 10,396 women, with a yearly range from 1,367 to 1,666, participated in UT-PRAMS from 2009 to 2015. Most women (83.0%) were younger than 35 years, with 14.0% aged 35-39 and only 3.0% aged 40 and older. The overall proportion of infertility treatment among study participants was 10.6% (95% CI: 9.3, 11.1).

The prevalence of infertility treatment among women with live births is higher among older women (Figure 1). It ranges from less than 5.0% at 20-24 years to over 25.0% at age 40 years or older.

Table 1 illustrates the prevalence of infertility treatment among women in different age groups based on whether they had experienced a previous live birth or not, which may serve as an indicator for secondary or primary infertility, respectively. Rates of infertility treatment increase with age, especially among women who have never experienced a live birth previously and therefore may suffer from primary infertility. For women aged 20-24 years, there is minimal difference between women with a previous live birth compared to women without a previous live birth: 3.7% (95% CI 2.3, 6.1) and 5.2% (95% CI 3.7, 7.2), respectively.

In the 25-29 and the 30-34 year age groups, the percentage of participants without any previous live birth who received infertility treatments was 2.5 times higher than participants with previous live births. In women aged 35-39 years, the percentage of women without a prior live birth who received infertility treatment was about the same as for women aged 30-34 years, but there was a higher percentage of women with probable secondary infertility who received infertility treatment. Finally, for women aged 40 years and older, the prevalence of fertility treatment is 18.9% (95% CI 9.0, 35.3) for women with prior live birth, and 65.6% (95% CI 33.7, 87.7) for women without prior live birth, albeit with wide confidence intervals.

Discussion

This data snapshot of Utah during 2009-2015 revealed that about 10% of women who ultimately had a live birth sought treatment for infertility. Given that the PRAMS database samples only women who successfully experience a live birth, the actual percentage of women who sought treatment for infertility is likely much higher. Although not directly comparable, data from the National Survey for Family Growth (NSFG), conducted during 2002-2015, shows that the percentage of all married women aged 15-44 years who received infertility services was consistently around 12.0%. Additionally, in the NSFG studies, the percentage of women aged 15-44 years with primary infertility who have ever received any infertility service ranged from 6.5% to 7.1%, which was approximately the same proportion of women with secondary infertility.¹⁴ In contrast, among Utah women aged 25 years or older, those who had not previously had a live birth were more than twice as likely to receive infertility treatments as compared to those with presumably secondary infertility: 16.4% to 65.6% versus 5.9% to18.9%, respectively.

Although we do not know the proportion of infertility treatment that did not result in live birth, it is well established that with other factors being equal, infertility treatment is more likely to be successful among couples with secondary infertility.¹⁵ Further, in the prior UT-PRAMS study mentioned above, seeking early infertility treatment was more common among women with at least one prior live birth.⁹ Therefore, if there is a bias in our ascertainment of fertility treatment, it would tend to inflate the prevalence of fertility treatment among those with secondary infertility. This strengthens our finding that women with primary infertility were much more likely to seek infertility treatment than women with secondary infertility (9%-15% absolute difference between ages 25–39, and over 45% in women aged 40-44 years). This may reflect the predominant religious culture in Utah that stresses the importance of having children.⁹ The cultural emphasis might be a relatively stronger motivation for having the first versus subsequent children. This may be similar to some societies where children are highly valued for social, cultural, and economic reasons.¹⁶ In such social settings, women experiencing infertility may experience emotional distress.^17,18

At the intersection of the 7 domains of health, infertility has a considerable bearing on almost all of them, and especially in the areas of physical, social, and emotional health. There is evidence that the psychological effects of infertility are similar to that of cancer and heart diseases.¹⁸ Infertility or subfertility indicate the presence of other underlying physical illnesses in either women (e.g.,ovulatory dysfunction, hormonal abnormalities) or men (e.g., oligospermia, infection).¹⁹ Furthermore, infertility itself may be a risk factor for early mortality in both women and men.^20-21

Since infertility is a relatively common chronic condition that can significantly impact a person’s health and well-being, efforts for prevention and early identification are important. It may be beneficial for individuals to develop a greater awareness of their reproductive capacity, including how to determine whether they may be fertile or not. Women can learn to chart external signs or biomarkers that reflect internal hormonal changes that result in ovulation, which is essential for female fertility.²² By using fertility awareness-based methods (FABMs), women can also monitor their health and work with physicians trained in restorative reproductive medical (RRM) approaches to identify and treat potential underlying causes of infertility.^23-25 Men may also benefit by learning about the factors that affect their fertility and the steps they can take to improve their reproductive health. Finally, clinicians should counsel patients about their reproductive life plans by discussing patients’ goals. The reproductive life plan encourages women and men to reflect on their reproductive intentions in the context of their personal values and life goals.²⁶

Limitations of our study of infertility treatment in Utah come from the use of the PRAMS database. First, the dataset only includes women who experienced a live birth. Because women without a live birth are not included in the PRAMS database, the actual percentage of Utah women seeking infertility treatment is higher, as fertility treatment does not guarantee live birth. Second, receiving fertility treatment does not necessarily always indicate that infertility was present. Studies with earlier UT-PRAMS datasets (2004-2008) found that 5.0% of women received infertility treatment even though they did not meet the formal definition for infertility, i.e., had been trying to conceive for less than 6-12 months.¹⁰ For these 2 reasons, our findings of the prevalence of fertility treatment by age and parity cannot be directly translated into an estimate of the prevalence of primary or secondary infertility. Nevertheless, they do provide important insight into the patterns of the use of infertility treatment in Utah.

Acknowledgements

Pregnancy Risk Assessment Monitoring System (PRAMS) retrieved on March 11, 2021, from Utah Department of Health, Center for Health Data and Informatics, Indicator-Based System for Public Health. Website: http://ibis.health.utah.gov/

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22. Senapati S. (2018). Infertility: a marker of future health risk in women?. Fertility and sterility, 110(5), 783–789. https://doi.org/10.1016/j.fertnstert.2018.08.058
23. Manhart MD, Duane M, Lind A, Sinai I, Golden-Tevald J. Fertility awareness-based methods of family planning: a review of effectiveness for avoiding pregnancy using SORT. Osteopathic Fam Physician. 2013;5(1):2-8.
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Citation

M Duane, DO Agyemang, S Najmabadi, and JB Stanford. (2022). Fertility treatment in Utah: a pooled analysis of 2009–2015 Utah Pregnancy Risk Assessment Monitoring System (PRAMS) data. Utah Women’s Health Review. doi: 10.26054/0d-krxq-yh6z.

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Abstract

Objective: To assess the SRH needs of adolescents with CF and create a SRH education guideline for CF providers.

Methods: Adolescents and young adults (AYA) were asked to complete a questionnaire about SRH educational needs. If the AYA was under the age of 18 years, their parent was also asked to participate. Survey data were analyzed using descriptive statistics, the Mann Whitney U test, and content analysis of the qualitative data. An evidence-based SRH education guideline was developed and presented to key stakeholders. CF clinic staff were asked to complete a pre- and a post-intervention survey to assess their perspectives of the guideline and report perceived barriers to SRH education. Surveys were created using recommendations from previous SRH education research and CF content experts.

Results: 29 AYA and 17 parents completed the survey. 13 CF staff completed the pre-intervention survey and 8 completed the post-intervention survey. Of the AYA surveyed, 18 (62.1%) were female and 11 (37.9%) were male. 31% (9/29) of AYA reported they had talked with a CF provider about SRH. 47.2% (8/17) of parents reported their child had talked about SRH with a CF provider. Almost all participants reported they want CF-related reproduction included in SRH education. Although not statistically significant, CF clinic staff who reported that they currently include or would include SRH education in their practice increased from 50% to 87.5%.

Conclusions: The findings confirm the significant need for improved SRH education for adolescents with CF and the need for standardization in care. Adolescents in this CF center want SRH education from their CF care team. The lack of statistically significant differences in the results of CF staff could be related to sample size or resistance to practice change.

Implications: Future action is needed to address barriers to SRH education and implement an SRH education guideline.

Introduction

Problem Description

Adolescents and young adults (AYA) with cystic fibrosis (CF) encounter similar sexual and reproductive challenges as their healthy counterparts. They also have disease-specific sexual and reproductive health (SRH) concerns.¹ 42% of adolescent girls with CF report being sexually active.¹ Survival rates and overall health are improving for CF, with more individuals living into adulthood.^1-4 This creates a greater need for SRH information for AYA with CF.

Available Knowledge

There are no guidelines for SRH education for AYA with CF.⁵ The Cystic Fibrosis Foundation has information regarding SRH for individuals with CF, but there are no guidelines for providers.⁶ Studies have looked at patient preferences for SRH education.^{5, 7, 8}

Rationale

The ACE Star Model of Knowledge Transformation was used to conceptualize the implementation. This is a model for knowledge transfer and application in healthcare quality improvement.⁹ It includes discovery research, evidence summary, translation to guideline, practice integration, and evaluation (Figure 1).¹⁰

Specific Aims

The purpose of this project was to assess the SRH educational needs of AYA with CF by surveying these individuals, their parents, and the CF care team, and to create an evidence-based SRH education guideline, present it to key stakeholders, and evaluate the CF care team’s assessment of the guideline.

Methods

Context

This project was completed at a Cystic Fibrosis Foundation-accredited CF center associated with an academic medical center in the Intermountain West serving five states. The center has an adult and a pediatric clinic; both clinics were involved with this project. The pediatric and adult teams consist of physicians, nurse practitioners, physician assistants, pharmacists, social workers, dietitians, respiratory therapists, registered nurses, and other health team members. Most patients seen in the CF center are White. For this project, only patients aged 14 to 24 years were included. For patients under the age of 18 years, their parents were also asked to participate. 

Intervention

Surveys were created to assess AYA and parent needs related to SRH education. A survey for CF clinic staff was also created to assess SRH education needs, barriers, and attitudes. For four months, AYA and parents seen in the CF center were asked to participate by completing a paper questionnaire. Additionally, the parent survey was made available online via a link posted on a regional CF social media page. The CF staff survey was emailed to clinic staff to complete.

Based on the results from the needs assessment, a SRH education guideline for CF providers was developed using evidence-based recommendations related to SRH in pediatric chronic disease. The purpose of the guideline was to help clinicians in educating adolescents with CF. While developing the guideline, stakeholders were asked for their input and recommendations.

A report of the results from the needs assessment and the SRH education guideline were prepared and presented to key stakeholders in the CF center. A survey was created to assess the CF care team’s perspective on the satisfaction, feasibility, and usability of the SRH education guideline as well as their confidence, attitudes, and perceived barriers to using it. Following the presentation, this survey was sent to the CF clinic staff via email.

Study of the Intervention

13 CF clinic staff participated in the pre-intervention survey (pre-survey), and 8 CF staff in the post-intervention survey (post-survey). CF staff were surveyed before and after they were presented with the clinic needs assessment findings and SRH education guideline to compare findings and evaluate the guideline. Pre- and post-surveys were sent via email. This project did not have a comparison group. There were no other quality improvement projects related to SRH education being implemented at the same time in the CF center at this institution.

Measures

The surveys used to measure processes and outcomes were created using recommendations from previous research done in SRH education. The surveys were reviewed and piloted by content experts and CF providers for content appropriateness, face validity, and ease of completion. Surveys included closed, open-ended, and Likert scale questions. The AYA and parent survey included a Likert scale of very satisfied to very dissatisfied to measure participant satisfaction with SRH education they had received and current SRH knowledge. CF staff’s perceived importance of SRH education and topics were measured in the pre-survey using a Likert scale of 1 to 5, with 5 representing very important. Additionally, the CF staff survey included measurements of confidence, comfort, resources, and skills needed to provide SRH education using a Likert scale of strongly agree to strongly disagree. The CF staff post-survey included the same measures and were compared to pre-survey results using the Mann Whitney U test. Pilot data demonstrated that each survey took less than 10 minutes to complete.

The data from paper surveys for AYA and parents were entered electronically into a secure data base for statistical analysis. After entry, the paper survey data was compared carefully to the electronic data to ensure no errors were made. Additionally, the surveys from CF clinic staff that were completed electronically were reviewed for completeness and accuracy.

Analysis

Quantitative survey results were analyzed using descriptive statistics, including frequency distributions and summary statistics for central tendency and variability. The Mann Whitney U test was used to evaluate pre- and post-survey data, as data was non-parametric and unpaired. A content analysis was completed for qualitative survey results by carefully reading and coding responses. The coded data were then categorized, organized, and summarized to identify common themes.

Ethical Considerations

This study was approved by the University of Utah Institutional Review Board. Participation in the study was completely voluntary, and participants could withdraw at any time. Parental permission, consent, and assent were explained on the survey cover letter, and completion of the survey implied consent. No signatures were obtained. Participants were assured that their survey responses were confidential; furthermore, surveys remained anonymous to protect confidentiality. There were no conflicts of interest to disclose.

Results

29 AYA 14 to 24 years of age participated in the survey (Table 1). Most participants reported they had received SRH education regarding CF (89.7%), however, only 19.2% reported receiving this education from a healthcare provider. It was reported as being most frequently received at school, from a parent, or the internet. School and a parent were most frequently reported as the most important source of information on SRH. The majority (57.7%) of AYA reported they were satisfied with the SRH education they had received, but only 31% reported they had talked with a CF provider about SRH. Of those who said they had talked with a CF provider regarding SRH, the majority (66.6%) was either very satisfied or satisfied with the education. Puberty and fertility/pregnancy were the most common topics to have been discussed with a CF provider (Figure 2). 55.2% of participants reported that age 13 to 15 would be their preferred age to start discussing SRH. When asked about preferences regarding from whom they would want to receive SRH education, 38% had no preference, 24% preferred a CF provider, 24% preferred a parent; 48.3% had no gender preference. The majority (65%) of AYA reported that their ideal educational resource would be an online resource. Almost all respondents (96%) reported they would want CF-related reproduction included in SRH education (Figure 3).

In reviewing open-ended survey questions, the AYA who participated repeatedly stated that they want more information regarding SRH or would have wanted more information as an adolescent (N=16). These responses included statements such as “make it more of a topic during the teenage years,” “talk about it more,” “giving more information,” and “have the discussion early.” Another common theme identified was patient comfort during SRH discussions (N=5). Responses included “make it not sound gross” and “ask them if they feel comfortable talking about it.” Two respondents spoke about privacy, such as “no parents in the room” and “speak about it without parents present.” Family (N=10), health (N=8), and SRH (N=5) were common themes in responses when participants were asked what they value for their future life. Responses included “a healthy one,” “being sexually healthy,” “being healthy enough to have kids,” “family,” and “I want to have safe sex practices, effective contraception and a family eventually.”

17 parents of CF adolescents participated in the parent survey (Table 2). The majority (58.8%) of parents reported that their child had received SRH education regarding CF. Of those who had received SRH education regarding CF, 90% of parents reported it was from a CF provider, and 70% reported it was from a parent. 41.2% of parents reported their child had not talked about SRH with a CF provider, while 47.1% reported their child had. If their child had talked to a CF provider about SRH, 50% of parents were either very satisfied or satisfied with the education. The most discussed topic was puberty, followed by fertility/pregnancy (Figure 4). 41.2% of parents reported they would prefer their child receive SRH education from both the parent and a CF care team member, and 35.3% had no preference. Over 40% of parents felt that before age 13 was the most appropriate age for SRH education, and 35% felt age 13 to 15 was the most appropriate. Most parents reported the ideal educational resource would be a written resource (52.9%). The top three topics that parents want to be included in their child’s SRH education were CF-related reproduction, healthy relationships, and puberty.

According to open-ended responses in the parent survey, parents consistently reported the desire for the CF care team to understand the needs of the parent and patient (N=8) such as “don’t be nervous about discussing sex and make it a natural discussion when the patient is ready,” “listening and allowing time for them to open up, ask questions…” and “find out how much the parents want this discussed with their child.” One parent felt that standardization would be helpful. They said, “just making it a routine part of the exam and discussing [it] openly from childhood to adulthood.” Other common themes for how to support adolescents with SRH education included resources (N=3) and CF-specific information (N=2). Family (N=6) and knowledge (N=3) were common themes of what parents value for their children’s future. Responses included “that she be comfortable and knowledgeable in her own body…have all information and education to be able to make choices that are right for her” and “that she understands what she needs to happen in order to get pregnant and have a safe and healthy pregnancy.”

The CF staff pre-survey was sent via email to 24 participants and left open for a 7-week time frame. A reminder email was sent after 5 weeks. The response rate was 54% (N=13). The largest number of respondents were pediatric CF providers (38.5%). No adult CF providers responded. Half of the respondents reported that they currently include SRH education in their practice. 84.6% of participants felt that the CF provider or team has a role in the discussion or provision of SRH care for adolescents with CF. The large majority (83.3%) felt that the CF provider should be the one to initiate SRH discussions. Of note, 23% reported that multiple team members should be involved in the discussion of SRH issues. The pre-survey results showed that the CF staff’s perceived importance of SRH care averaged 4.3 (± 0.75) on a scale of 1 to 5, with 5 representing very important. Additionally, results showed that CF staff’s perceived importance of including urinary incontinence, contraception, and fertility in SRH education averaged 4 or greater using the same scale (4 ± 0.8, 4.2 ± 0.9, 4.3 ± 0.8 respectively). There was a wide range of the perceived importance of including puberty, menstruation, and vulvovaginal candidiasis in SRH education with averages of 3.8 (± 1.5), 3.8 (± 1.4), and 4 (± 1.4), respectively, using the same scale. Table 3 shows the results for all SRH topics.

According to the open-ended responses from CF staff, standardization of SRH education (N=8) and more information (N=11) were consistently reported as ways to improve confidence and comfort with SRH care. Responses included statements such as “a culture that it is an expected part of adolescent care,” “having aligned goals or standards that all providers and team members in clinic discuss,” “protocols and ownership from all of the CF providers,” and “information, talking points, a standardized way to dismiss family from room.” Identified barriers to providing SRH education included the following common themes: culture (N=4), family concerns (N=7), time (N=2), and provider comfort/confidence (N=7).

The CF staff post-survey was sent via email to 10 participants and left open for 3 weeks. A reminder email was sent after 2 weeks. The response rate was 80% (N=8). The largest number of respondents were pediatric CF providers and pediatric CF nurses. The large majority of respondents reported they plan to include SRH education in their practice (87.5%).

CF staff’s perceived confidence and comfort in providing SRH education averaged 3.75 (± 0.6) and 4 (± 0.6) in the pre-survey and 3.6 (±0.9) and 3.5 (± 1.0) in the post-survey, respectively, on a scale of strongly agree to strongly disagree. The CF care team’s perception of having the resources and skills to provide SRH education averaged 3.25 (± 0.8) and 4 (± 0.6) in the pre-survey and 2.9 (±0.8) and 3.75 (±0.7) in the post-survey, respectively, using the same scale. There was no statistically significant difference in the CF care team’s self-assessment of their confidence and comfort in providing SRH education and their perception of having the needed resources and skills. Additionally, there was no statistical difference found in the perceived importance of SRH education (Table 4). Although not statistically significant, there was an increase in participants who reported they would include SRH education in their practice to 87.5%, compared to the 50% who reported they currently include SRH education in their practice in the pre-survey.

Half of the participants in the CF staff post-survey either strongly agreed or agreed with the statements “the proposed SRH guideline is sustainable” and “the proposed SRH guideline is easy to use.” Most participants, 75%, reported they neither agreed nor disagreed with the statement, “I will use the proposed SRH guideline.” Only 37.5% agreed that “the proposed CF SRH guideline can be implemented in the CF clinic.”

In the open-ended responses from CF staff in the post-survey, time (N=5) and resistance from parents (N=3) were consistently reported as barriers and concerns to providing SRH education and using the proposed SRH guideline. Additionally, the importance of SRH education was described by participants (N=4).

The missing data included one incomplete CF staff pre-survey. The survey was completed online, and 1 participant failed to answer all the questions. Since the survey was anonymous, it was not possible to recover the missing data.

Discussion

Summary

The results demonstrate that adolescents with CF and their parents want information about SRH from their CF care team. Adolescents reported that more information about SRH from their CF care team would help them feel better supported in their SRH decisions and concerns. Although members of the CF care team reported the importance of SRH education, only 50% reported that they currently include it in their practice. Prior to this project, the CF center identified a gap in care with no standard SRH education guidelines for CF providers to follow and no data specific to their patients’ SRH needs. Following the presentation of the SRH education guideline, there was no statistically significant difference found in the CF clinic staff’s self-assessment of confidence and comfort in providing SRH education and their access to needed resources and skills. Although not statistically significant, there was an improvement in the percentage of staff that stated they would include SRH education in their practice.

The study was strengthened by the overall number of surveys completed and the fact that multiple groups were surveyed, including AYA, parents, and CF staff. Additionally, there was a wide range of ages surveyed among AYA with CF, from 14 to 24 years.

Interpretation

The results support current literature on SRH education for adolescents with CF. In addition, our study found that more than half of AYAs surveyed reported they had not discussed SRH with a CF provider. Frayman and Sawyer reported that young adults receive the majority of their SRH knowledge from their parents²; we found that 70% of AYAs surveyed received SRH education from their parents. Our study found that the CF care team feels SRH education is important and that they play a role in discussions around SRH, but only 50% of care team members are currently including it as part of the care they provide. Qualitative results from this study found that CF clinic staff lack confidence and comfort to provide SRH education; Kazmerski et al reported comparable findings.¹¹

The impact of the project on people and systems was evident when presenting the proposed SRH education guideline to the CF care team. The guideline was met with resistance: there was general resistance to practice change as well as concerns regarding the difficulties of implementing new activities in a busy specialty clinic, such as lack of time, need for training, and individual comfort level. The proposed SRH education guideline is inexpensive but may be time-intensive to execute. However, based on the results of this study that indicate that adolescents with CF want SRH education, the effort would be worthwhile. 

The lack of statistically significant differences in the CF staff results could be related to several factors. Although there was a robust overall survey response, there was a small CF staff sample size with 13 pre-survey and 8 post-survey participants. Additionally, barriers within the clinic, including resistance to practice change, could have contributed to the lack of statistically significant findings.  

Limitations

There are several limitations to the generalizability of the study. Only 1 parent survey was completed online via social media. Efforts were made to adjust for this limitation by allowing more time to complete the survey and a reminder post. The sample was homogenous, with almost all respondents identifying as White and English speaking, but this is consistent with the ethnic demographics of CF.

The risk of selection bias on results is another identified limitation. More females completed the AYA survey than males (62.1% and 37.9%, respectively). Additionally, there were more parents of daughters with CF than sons with CF (82.4% and 41.2%, respectively). It is possible that females and parents of females were more willing and comfortable to complete the survey and return it. Although CF is not a sex-linked genetic disease, it is also possible that more females were seen in the clinic during the timeframe of the project.

Health Implications

The findings in this project confirm the significant need for improved SRH education for adolescents with cystic fibrosis and the need for standardization in care. This project provided valuable data to the CF center regarding their own patients’ needs and a proposed SRH education guideline based on those needs as well as evidence-based recommendations. The proposed guideline has the potential to improve SRH education for adolescents with CF. The next steps for this project include addressing identified barriers and implementation of the proposed SRH education guideline in this CF center. Given the significant response from adolescent girls and their parents, this may be the first group to target.

Acknowledgements

Thank you to Fadi Asfour, MD, for his input and feedback regarding project development and implementation. Thank you to Sue Meihls, RN, and Jennifer Kinsfather, RN, for their support and assistance in the project implementation.

Funding

No outside funding was utilized in the design or implementation of this project.

References

1. Kazmerski TM, Sawicki GS, Miller E, et al. Sexual and reproductive health behaviors and experiences reported by young women with cystic fibrosis. J Cyst Fibros. Jan 2018;17(1):57-63. doi:10.1016/j.jcf.2017.07.017

2.  Frayman KB, Sawyer SM. Sexual and reproductive health in cystic fibrosis: a life-course perspective. Lancet Respir Med. Jan 2015;3(1):70-86. doi:10.1016/s2213-2600(14)70231-0

3. Scotet V, L’Hostis C, Férec C. The Changing Epidemiology of Cystic Fibrosis: Incidence, Survival and Impact of the CFTR Gene Discovery. Genes (Basel). May 26 2020;11(6)doi:10.3390/genes11060589

4. Kazmerski TM, Borrero S, Sawicki GS, et al. Provider Attitudes and Practices toward Sexual and Reproductive Health Care for Young Women with Cystic Fibrosis. J Pediatr Adolesc Gynecol. Oct 2017;30(5):546-552. doi:10.1016/j.jpag.2017.01.009

5.  Kazmerski TM, Hill K, Prushinskaya O, et al. Perspectives of adolescent girls with cystic fibrosis and parents on disease-specific sexual and reproductive health education. Pediatr Pulmonol. Aug 2018;53(8):1027-1034. doi:10.1002/ppul.24015

6. Reproductive Health and Fertility. Cystic Fibrosis Foundation. Accessed September 3, 2021. https://www.cff.org/Life-With-CF/Transitions/Reproductive-Health-and-Fertility/

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8. Kazmerski TM, Miller E, Sawicki GS, et al. Developing Sexual and Reproductive Health Educational Resources for Young Women with Cystic Fibrosis: A Structured Approach to Stakeholder Engagement. Patient. Apr 2019;12(2):267-276. doi:10.1007/s40271-018-0342-4

9. Schaffer MA, Sandau KE, Diedrick L. Evidence-based practice models for organizational change: overview and practical applications. J Adv Nurs. May 2013;69(5):1197-209. doi:10.1111/j.1365-2648.2012.06122.x

10.  Stevens K. Stevens Star Model of Knowledge Transformation. Academic Center for Evidence-Based Practice: The University of Texas Health Science Center at San Antonio. Accessed September 3, 2021. https://nursing.uthscsa.edu/onrs/starmodel/star-model.asp

11. Kazmerski TM, Prushinskaya OV, Hill K, et al. Sexual and Reproductive Health of Young Women With Cystic Fibrosis: A Concept Mapping Study. Acad Pediatr. Apr 2019;19(3):307-314. doi:10.1016/j.acap.2018.08.011

Citation

Taylor CS and Hamilton JL. (2021). Sexual and Reproductive Health Education for Adolescents with Cystic Fibrosis. Utah Women’s Health Review. doi: 10.26054/0d-2vdj-c5d8.

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