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Physical activity and depressive symptoms during pregnancy among Latina women: a prospective cohort study

Physical activity and depressive symptoms during pregnancy among Latina women: a prospective... Background: Latina women are at increased risk for antenatal depressive disorders, which are common during pregnancy and are associated with elevated risk for poor maternal health and birth outcomes. Physical activity is a potential mechanism to reduce the likelihood of depressive symptoms. The purpose of the study was to assess whether total and domain-specific physical activity in early pregnancy reduced risk for elevated antenatal depressive symptoms in mid-late pregnancy in a population of Latina women at high-risk for depression. Methods: Data from 820 Latina participants in the prospective cohort study Proyecto Buena Salud was examined using multivariable logistic regression. Total, moderate/vigorous, and domain-specific physical activity (household/caregiving, occupational, sports/exercise, transportation) were assessed using the Pregnancy Physical Activity Questionnaire. The Edinburgh Postnatal Depression Scale was used to assess depressive symptoms and identify women with elevated symptoms indicative of at least probable minor depression and probable major depression. Results: A total of 25.9% of participants experienced at least probable minor depression and 19.1% probable major depression in mid-late pregnancy. After adjusting for important risk factors, no significant associations were observed between total physical activity (4th Quartile vs.1st Quartile OR = 1.02, 95% CI = 0.61, 1.71; p-trend = 0.62) or meeting exercise guidelines in pregnancy (OR = 0.96, 95% CI = 0.65, 1.41) and at least probable minor depression; similarly, associations were not observed between these measures and probable major depression. There was a suggestion of increased risk of probable major depression with high levels of household/caregiving activity (4th Quartile vs 1st Quartile OR = 1.51, 95% CI = 0.93, 2.46), but this was attenuated and remained not statistically significant after adjustment. When we repeated the analysis among women who did not have elevated depressive symptoms in early pregnancy (n =596), findings were unchanged, though a nonsignificant protective effect was observed for sport/exercise activity and probable major depression in fully adjusted analysis (OR = 0.63, 95% CI = 0.30, 1.33). Conclusion: Among Latina women at high-risk for antenatal depression, early pregnancy physical activity was not associated with elevated depressive symptoms in mid-to-late pregnancy. Keywords: Physical activity, Antenatal depression, Antenatal depressive symptoms, Latina * Correspondence: kszegda@schoolph.umass.edu Department of Biostatistics & Epidemiology, School of Public Health & Health Sciences, University of Massachusetts, 414 Arnold House, 715 North Pleasant Street, Amherst, MA 01003-9304, USA Baystate Medical Center, Springfield, MA, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 2 of 11 Background inverse association, a number have been limited by Depressive disorders affect up to an estimated 18% of their cross-sectional examination of physical activity women during pregnancy [1]. Depression relapse rates are and depression [18, 21], making it difficult to ascertain particularly high during pregnancy, with some studies whether physical activity affected depression status or finding relapse rates as high as 43% [2]. Latina women in whether depression status lead to decreased physical the United States are at increased risk for antenatal de- activity levels. In addition, the majority of prior studies pression with some studies finding almost double the focused on exercise or leisure time activity and did not prevalence among Latina women compared to non-Latina examine other domains of physical activity (i.e., house- White women [3]. Factors that likely contribute to this hold/caregiving and occupational activity), which may disparity include economic, acculturation, and social chal- be an important consideration in populations that have lenges experienced by Latinas in the U.S. [4], which in- limited ability to participate in leisure time activity. In creases their likelihood of depression overall, and thus the the one study to evaluate other domains of activity, likelihood of reoccurrence or initial onset of a depressive Demissie et al. found that among 1220 well educated, episode during pregnancy. Because depression during predominantly White women in North Carolina, higher pregnancy has been associated with increased risk of poor levels of activity perceived as moderate to vigorous were maternal health outcomes during and following pregnancy associated with a reduction in depressive symptoms. How- (e.g., pre-eclampsia, post-partum depression) [5, 6], as well ever, perceived moderate to vigorous levels of some forms as poor birth outcomes (e.g., admission to neonatal nur- of household/caregiving activity increased risk for de- series, small-for-gestational age) [7, 8], it is important to pressive symptoms [20]. As some household/caregiving identify ways to prevent antenatal depression and reduce activities are included in the list of activities recom- depressive symptoms in this at-risk population. mended by the U.S. Health and Human Services as a Physical activity may prevent the onset of depression means to achieve physical activity guidelines, it is im- [9], which is particularly important in populations that portant to understand the association between different experience a high prevalence of depression and are at types of activities and depression. high-risk for antenatal depression. Exercise and physical In a recent meta-analysis conducted by Daley et al. activity are believed to prevent depression and reduce that examined randomized clinical trials conducted to depressive symptoms by altering neurotransmitter and assess the effect of exercise on the prevention and treat- hormone levels that are associated with depression. It is ment of antenatal depression [14], the meta-analysis found also believed that exercise may reduce depression by dis- a reduction in depressive symptoms among the six studies tracting from depressive symptoms and promoting examined (standardized mean difference = − 0.46, 95% self-efficacy [10, 11]. Among women with antenatal de- CI = − 0.87, − 0.05), but the authors noted the limited pression, physical activity is an alternative option to anti- number and quality of studies available. The authors depressant medications and psychotherapy, which are called for additional research, citing the need for more current common depression treatment options that may studies to better understand subgroup effects, including be underutilized or contraindicated. Studies suggest some the effects of physical activity among nondepressed antidepressants may negatively impact the developing women, as only one study examined the protective ef- fetus [12], which may result in hesitancy among patients fects of physical activity among nondepressed women to take these medications. Psychotherapy can be inaccess- at baseline [14]. ible and unaffordable, particularly among disadvantaged Our study aimed to extend prior work by prospectively populations that experience socioeconomic challenges examining associations between total physical activity [13, 14]. Among Latinos, mental health services such as and domain-specific physical activity on elevated depres- psychotherapy may be particularly underutilized because sive symptoms during pregnancy in a Latina population of cultural beliefs and concerns about stigma and fatalism at high-risk for antenatal depression. In addition, we ex- [15]. Though current U.S. Health and Human Services amined physical activity and elevated depressive symp- guidelines recommend that pregnant women engage in at toms among nondepressed women to better understand least 150 min of moderate intensity aerobic activity per whether physical activity may be associated with the on- week [16], women often do not meet these guidelines. set of depression among women at high-risk. Studies conducted among women in the general popula- tion have generally found that physical activity is inversely Methods associated with depression [17], but research in pregnant Data from Proyecto Buena Salud (PBS) was used to as- populations has been limited. Among studies conducted sess associations between physical activity and depressive with pregnant women, findings have varied with some symptoms. PBS was a prospective cohort study among finding an inverse association [18–21], and others find- Latina prenatal care patients conducted from 2006 to ing no association [22–24]. Amongstudies findingan 2011 at Baystate Medical Center, a large tertiary care Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 3 of 11 center in Western Massachusetts, which has approxi- during pregnancy were assigned a modified intensity value mately 4500 deliveries per year and serves an ethnically di- [28]. Total energy expenditure by domain (household/ verse population. Study design details have been published caregiving, occupational, sports/exercise, transportation) previously [25]. PBS was approved by the Institutional and intensity (moderate, vigorous) were also calculated. Review Boards at the University of Massachusetts, Moderate and vigorous activity were combined into a single Amherst and Baystate Medical Center. category because there were so few women who engaged in Women were recruited at prenatal care visits in early vigorous activity. Total physical activity levels as well as pregnancy (up to 20 weeks gestation). Participants were those for moderate/vigorous, household, and transportation informed of study aims and procedures and asked to activity were categorized into quartiles. Because a large per- provide written informed consent. To reduce language centage of women did not engage in sports/exercise activity and literacy barriers, interviews were conducted in during pregnancy, women were categorized into none, English(73.7%) or Spanishbytrained bilingual interviewers sport/exercise levels “at or below the median,” and “above depending upon participant preference. the median.” For occupational physical activity levels, At the initial interview conducted at recruitment women were categorized as unemployed, “at or below the (mean = 12.4 weeks gestation), information was obtained median” and “above the median.” on socio-demographic, acculturation, behavioral, physical Physical activity was also categorized as to whether activity, and depressive symptoms. Information on depres- participants met current U.S. Health and Human Services sive symptoms was updated in mid-to-late pregnancy physical activity guidelines, which recommend that (mean = 25.7 weeks gestation). Information on medical pregnant women engage in at least 150 min per week history and clinical characteristics of the pregnancy were of moderate intensity aerobic physical activity [16]. abstracted from the medical record after delivery. Women were categorized as meeting the guidelines if they participated in > 7.5 MET-hrs per week of sports/exercise Study population activities that were of moderate-intensity or greater (i.e., Eligibility for PBS was restricted to Latina women of 30 min per day of activity at ≥ 3 METs multiplied by 5 days Puerto Rican or Dominican Republic descent who were per week or 150 min). We focused on sports/exercise ac- either born on one of these islands, or had at least one tivity because studies suggest that household/caregiving or parent or two grandparents born on these islands. Other activities seen as burdensome may increase risk for de- exclusion criteria included: multiple gestation; history of pressive symptoms [29], whereas leisure time activity has diabetes, hypertension, heart or chronic renal disease; less most consistently found to reduce risk of depressive than 16 or greater than 40 years of age; and current use of symptoms [17]. However, we also created a second medications thought to adversely affect glucose tolerance. variable for meeting guidelines that categorized women as A total of 1579 women were enrolled into PBS. Women meeting guidelines based on any domain of moderate or were excluded if they had a miscarriage (n =68). Among greater intensity activity. eligible participants, a total of 1040 women had informa- The PPAQ has demonstrated good reliability and reason- tion on early pregnancy physical activity information. able validity when compared to Actigraph accelerometer Among these women, 820 had information on mid-to-late measures [26]. Intra-class correlations for two administra- pregnancy depressive symptoms and were included in the tions of the PPAQ one week apart were 0.78, 0.82 and 0.81 final dataset for analysis. for total, moderate and vigorous physical activity, and 0.83, 0.86 and 0.93 for sports/exercise, household/caregiving and Assessment of physical activity occupational activity, respectively. Physical activity was assessed in early pregnancy using a modified version of the Pregnancy Physical Activity Assessment of depression Questionnaire (PPAQ) [26]. The tool consists of a series Depressive symptoms were assessed in early and of questions asking respondents to indicate intensity, mid-to-late pregnancy with the Edinburgh Postnatal frequency and time spent engaged in 35 activities from Depression Scale (EPDS) [30], which has been vali- four domains: household/caregiving, occupational, dated as a depression screening tool in pregnant and sports/exercise, and transportation. postpartum women [31]. The EPDS is a 10-item scale Average overall total early pregnancy physical activity that asks respondents to indicate how frequently they weekly energy expenditure (metabolic equivalent have felt various mood states within the past seven days. [MET]-hrs/wk) was calculated by multiplying the amount Examples of items on the EPDS include, “I have been so of time spent on each activity by its intensity and then unhappy that I have been crying,” and “Things have been summing these values. Activity intensities were deter- getting on top of me.” Total scores range from 0 to 30. mined based on the Compendium of Physical Activities Women were categorized as to whether or not they had [27]; activities identified as having a different intensity elevated depressive symptoms indicative of at least Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 4 of 11 probable minor depression (scores13 or higher) or prob- in the case of living with a partner/spouse, as a proxy for a able major depression (scores 15 or higher) [32]. To be strong protective factor (social support) [13, 39, 40]. consistent with the prior literature, EPDS scores were im- Weeks between early and mid-to-late pregnancy inter- puted for participants missing fewer than 10% of EPDS views was also included in multivariable models in scale items by replacing the missing value with the partici- addition to any other potential confounders that changed pant’s average score of the nonmissing items [33]. the odds ratio for the depression measure by more than The EPDS has been shown to have high sensitivity and 10% with their inclusion in the model. Additional covariates specificity for major depression (sensitivity = 100%; identified for inclusion through this method included parity specificity = 96%) and reasonable sensitivity and speci- and generation in the U.S. For domain-specific multivari- ficity for at least probable minor depression (sensiti- able models, we additionally adjusted for MET-hrs/wk. vity = 57%; specificity = 98%) using these cut-points in from all other domains of physical activity. an English-speaking population [34]. The EPDS has We chose not to include stress and anxiety in our mul- also performed well as a depression screening tool in tivariable models because they were both highly correlated Spanish-speaking populations with good sensitivity and with depression (r =0.61–0.78) and we were interested in specificity for at least minor depression (sensitivity = 79%; assessing associations for all cases of depression and their specificity = 96%) and major depression (sensitivity = 83%; inclusion would have obscured associations when anxiety/ specificity = 97%) postnatally [35]. stress and depression co-occurred. In a sensitivity analysis, we repeated analyses using U.S. HHS physical activity Covariates guidelines defined as moderate/vigorous physical activity Information on maternal age, education level, income, from all domains of activity in early pregnancy and whether the participant was living with a partner, gener- mid-to-late pregnancy. ation in the continental U.S., and overall acculturation Because the effects of physical activity on subsequent (Psychological Acculturation Scale) [36] was obtained at depression may vary by baseline depression status [41], the initial pregnancy interview. Smoking status and alco- we then repeated the above analyses among women who hol consumption were assessed at each pregnancy inter- did not have elevated depressive symptoms in early preg- view. Psychosocial stress was assessed by Cohen’s nancy (i.e. did not have at least probable minor depression) Perceived Stress Scale [37] and anxiety was assessed via (n =596) [41]. Finally, we examined differences in charac- the State-Trait Anxiety Survey [38]. Pre-pregnancy teristics between women with and without information on weight, height, parity and presence of morning sickness mid-to-late pregnancy depressive symptom to assess po- during the pregnancy were obtained through the medical tential effects of missing data. All analyses were conducted record. Body mass index (BMI) was calculated as weight using SAS version 9.2 (SAS Institute Inc., Cary, NC). (kg)/height (m ). Results Data analysis Among study participants, 25.9% of women had elevated Univariate statistics were used to describe the study depressive symptoms indicative of at least probable population. Baseline characteristics were compared be- minor depression and 19.1% had depressive symptoms tween women with each of the respective probable indicative of probable major depression in mid-to-late major depression measures and women who did not pregnancy. The mean age was 21.6 years (SD = 4.9). have elevated depressive symptom scores. Unadjusted Women were generally of low socioeconomic status with and multivariable logistic regression analyses were used almost half (48.7%) reporting that they did not complete to assess associations between physical activity in early high school and only 6.1% of women reporting an an- pregnancy and at least probable minor depression and nual household income of $30,000 or greater (Table 1). probable major depression in mid-to-late pregnancy. Almost half of participants (48.4%) were born in Puerto We examined associations between total physical activ- Rico or the Dominican Republic and over two thirds of ity, moderate/vigorous physical activity, domain-specific the study population had low levels of acculturation physical activity (household/caregiving, occupational, (80.7%). Women who smoked during early pregnancy sports/exercise, transportation), and whether women met were more likely to have at least probable minor de- U.S. Health and Human Services (HHS) physical activity pression and probable major depression in mid-to-late guidelines, and each of the elevated depressive symptom pregnancy. In addition, women who were obese outcome measures in separate models. Maternal age, (BMI ≥ 30 kg/m ) or who did not live with a partner/ education, living with a partner/spouse and depression spouse were more likely to have at least probable in early pregnancy (assessed at baseline via the EPDS) minor depression in mid-to-late pregnancy; women were included as a priori confounders in models because who had higher levels of parity were more likely to have they have been identified as risk factors for depression, or probable major depression in mid-to-late pregnancy. Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 5 of 11 Table 1 Participant Characteristics by Elevated Depressive Symptom Scores in Mid-to-Late Pregnancy: Proyecto Buena Salud, 2006–2011 Total Population At Least Probable Minor Depression (EPDS ≥13) Probable Major Depression (EPDS ≥15) a b b n % cases % p-value cases % p-value Maternal Age 16–19 270 32.9 61 28.8 0.40 42 26.9 0.25 20–24 315 38.4 83 39.2 62 39.7 25–29 144 17.6 40 18.9 30 19.2 ≥ 30 91 11.1 28 13.2 22 14.1 Education Less than high school 396 48.8 111 52.9 0.37 87 56.1 0.09 High school graduate or GED 270 33.3 63 30.0 41 26.5 Post high school 146 18.0 36 17.1 27 17.4 Income less than $15,000 242 30.1 75 36.1 0.15 58 37.4 0.13 $15,000–$30,000 121 15.0 27 13.0 18 11.6 $30,000 or greater 49 6.1 10 4.8 8 5.2 Don’t Know/Refused 393 48.8 96 46.2 71 45.8 Acculturation Low 635 80.7 161 79.7 0.68 121 80.7 0.99 High 152 19.3 41 20.3 29 19.3 Generation in U.S. Born in PR/DR 382 48.4 99 49.0 0.72 74 49.7 0.11 Parent born in PR/DR 363 46.0 94 46.5 72 48.3 Grandparent born in PR/DR 44 5.6 9 4.5 3 2.0 Live with partner/spouse no 405 50.3 117 56.0 0.05 82 52.9 0.46 yes 401 49.8 92 44.0 73 47.1 Pre-Pregnancy BMI less than 18.5 43 5.3 11 5.3 < 0.01 7 4.6 0.22 18.5- < 25.0 395 48.8 109 52.4 78 51.3 25.0- < 30.0 180 22.3 29 13.9 25 16.5 30 or greater 191 23.6 59 28.4 42 27.6 Parity 0 live births 336 41.5 75 36.1 0.12 50 32.9 0.03 1 live birth 255 31.5 67 32.2 50 32.9 2 or more live births 219 27.0 66 31.7 52 34.2 Smoking (early pregnancy) no 672 86.6 162 79.0 < 0.01 117 77.0 < 0.01 yes 104 13.4 43 21.0 35 23.0 Alcohol consumption (early pregnancy) no 756 97.4 197 26.1 0.06 147 19.4 0.24 yes 20 2.6 9 45.0 6 30.0 Numbers may not total to 820 due to missing data P-values were calculated using chi-square tests and are for comparisons between cases and noncases Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 6 of 11 On average, household/caregiving physical activity analyses. For example, for total activity the adjusted odds accounted for the largest average proportion of energy ratio for probable major depression when comparing Q to expenditure (56.0%) and sports/exercise activity the least Q was 1.21 (95% CI = 0.56, 2.64; p-trend = 0.70) and for (6.4%). Almost half of women did not engage in sports/ meeting exercise guidelines was 0.82 (95% CI = 0.43, 1.55) exercise activity in early pregnancy (46.5%) and 51.7% of when compared to women who did not meet guidelines. women were not employed in early pregnancy. Women with the highest levels of sports/exercise activity We examined associations between total physical ac- who did not have elevated depressive symptoms in early tivity in early pregnancy and elevated depressive symp- pregnancy appeared to have a lower odds of probable major toms in mid-to-late pregnancy (Table 2). In unadjusted depression (OR 0.63, 95% CI = 0.30, 1.33) after adjusting for analyses, the odds ratio for at least probable minor depres- important risk factors and other domains of activity, but sion for women with the highest level of total physical ac- this was not statistically significant. tivity as compared to the lowest level was elevated, but Lastly, women who were missing mid-to-late preg- not statistically significant (4th Quartile [Q ]vs. 1stQuar- nancy depressive symptom information did not differ tile [Q ] odds ratio [OR] = 1.28, 95% confidence interval from women with this information by early pregnancy 1 : [CI] = 0.83, 1.98; p-trend = 0.21). After adjustment for age, probable depression status (at least probable minor de- education, living situation, parity, generation in the U.S., pression or probable major depression) and also did not at least probable minor depression in early pregnancy, and differ according to age, BMI, parity, generation in the weeks between interviews, this odds ratio was attenuated U.S., whether they lived with a partner or spouse, or to 1.02, (95% CI = 0.61, 1.71; p-trend = 0.62). Results early pregnancy smoking status; however they had were similar for probable major depression (unadjusted higher levels of education (p < 0.01), income (p = 0.01), Q vs. Q OR = 1.28, 95% CI = 0.79, 2.05; p-trend = 0.27 and acculturation (p = 0.02) and were more likely to have 4 1: vs. adjusted Q vs. Q OR = 0.96, 95% CI = 0.55, 1.70; had a preterm birth (p < 0.001). 4 1: p-trend = 0.83). Similarly, we did not observe significant associations between moderate/vigorous activity or meet- Discussion ing physical activity guidelines and mid-to-late pregnancy In our prospective cohort study of 820 Latina women, elevated depressive symptom outcomes. We also did not we did not observe statistically significant associations be- observe significant associations in a sensitivity analysis tween total and domain-specific physical activity in early using U.S. HHS physical activity guidelines defined as mod- pregnancy and mid-to-late pregnancy elevated depressive erate/vigorous physical activity from all domains of activity. symptoms. We similarly did not observe significant associa- We then examined associations between domains of tions when restricting our analyses to women who did not early pregnancy physical activity and mid-to-late preg- have elevated depressive symptoms in early pregnancy. nancy elevated depressive symptom outcomes (Table 2). Few studies have examined the association between Women with the highest level of household/caregiving total and domain specific physical activity and depres- activity had 1.51 times the odds of probable major de- sion during pregnancy. Our findings that physical activ- pression compared to women with the lowest level (95% ity and sports/exercise activity were not associated with CI = 0.93, 2.46), but again this was not statistically sig- elevated depressive symptom outcomes are consistent nificant and was further attenuated after adjustment for with the findings of several other studies examining important risk factors (OR = 1.18, 95% CI = 0.63, 2.21). these associations [22–24]. Similar to our findings, Point estimates for the other domains of physical activity Symons-Downs et al. did not find an independent asso- (i.e., occupational, sports/exercise, and transportation) ciation between exercise behavior and depressive symp- and odds ratios of at least probable minor depression or toms in prospective analysis during pregnancy in their probable major depression were closer to 1.0 and also study of 230 predominantly White, highly educated not statistically significant in both unadjusted and ad- women [22]. In the one study to evaluate other domains justed analyses (Table 2). In domain-specific analyses of activity, Demissie et al. similarly did not find significant that included additional adjustment for MET-hrs/wk. associations between absolute levels (MET-hrs per week) of from other domains of physical activity, we similarly ob- total (OR = 0.71, 95% CI = 0.42, 1.18) or domain-specific served no significant associations. moderate to vigorous physical activity and elevated depres- We then repeated the above analyses restricted to sive symptoms among 1220 predominantly White women women who did not have elevated depressive symptoms in North Carolina [20]. However, when the authors used (i.e. did not have at least probable minor depression) in participant perception of intensity to classify activities, they early pregnancy (n = 596) (Table 3). Similar to our pri- found that moderate levels of total moderate to vigorous mary analysis, we did not observe significant associations activity was inversely associated with elevated depressive between any of the physical activity measures and de- symptoms (OR = 0.56, 95% CI = 0.38, 0.83) and that mod- pressive symptom outcomes in unadjusted or adjusted erate levels of moderate to vigorous household activity Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 7 of 11 Table 2 Odds ratios of mid-to-late pregnancy probable depression by various early pregnancy physical activity levels: Proyecto Buena Salud, 2006–2011 At least Probable Minor Depression (EPDS≥13) Probable Major Depression (EPDS≥15) b c b c Cases Unadjusted Adjusted Adjusted Cases Unadjusted Adjusted Adjusted n % OR 95% CI OR 95% CI OR 95% CI n % OR 95% CI OR 95% CI OR 95% CI Total physical activity 1st Quartile 53 27.9 referent referent 40 21.1 referent referent 2nd Quartile 36 19.8 0.64 0.39, 1.03 0.52 0.30, 0.90 n/a 27 14.8 0.65 0.38, 1.12 0.55 0.30, 1.02 n/a 3rd Quartile 44 22.1 0.73 0.46, 1.16 0.72 0.42, 1.23 32 16.1 0.72 0.43, 1.20 0.72 0.39, 1.31 4th Quartile 64 32.5 1.28 0.83, 1.98 1.02 0.61, 1.71 49 25.4 1.28 0.79, 2.05 0.96 0.55, 1.70 p-trend 0.21 0.62 0.27 0.83 Met exercise guidelines no 142 25.7 referent referent 101 18.3 referent referent yes 68 26.6 1.05 0.75, 1.46 0.96 0.65, 1.41 n/a 53 20.7 1.17 0.80, 1.69 1.12 0.73, 1.71 n/a Moderate/vigorous intensity 1st Quartile 51 25.6 referent referent 34 17.1 referent referent 2nd Quartile 44 21.8 0.81 0.51, 1.28 0.60 0.35, 1.03 n/a 36 17.8 1.05 0.63, 1.76 0.78 0.43, 1.43 n/a 3rd Quartile 57 27.4 1.10 0.71, 1.70 0.73 0.44, 1.22 42 20.2 1.23 0.74, 2.03 0.86 0.48, 1.53 4th Quartile 58 28.7 1.17 0.75, 1.82 0.89 0.53, 1.50 42 20.8 1.27 0.77, 2.10 0.94 0.52, 1.69 p-trend 0.28 0.92 0.28 0.95 Domain of Activity Household/ caregiving 1st Quartile 49 26.6 referent referent referent 34 18.5 referent referent referent 2nd Quartile 48 24.5 0.89 0.56, 1.42 1.11 0.64, 1.93 1.03 0.59, 1.81 39 19.9 1.10 0.66, 1.83 1.37 0.73, 2.55 1.26 0.67, 2.37 3rd Quartile 44 21.8 0.77 0.48, 1.22 0.67 0.38, 1.18 0.64 0.36, 1.13 27 13.4 0.68 0.39, 1.18 0.59 0.30, 1.14 0.56 0.29, 1.10 4th Quartile 60 30.0 1.18 0.76, 1.84 0.93 0.53, 1.64 0.85 0.48, 1.52 51 25.5 1.51 0.93, 2.46 1.18 0.63, 2.21 1.09 0.57, 2.08 p-trend 0.58 0.45 0.31 0.24 0.80 0.68 Occupational unemployed 115 29.3 referent referent 86 21.9 referent referent referent at or below 42 19.9 0.60 0.40, 0.90 0.74 0.47, 1.17 0.78 0.48, 1.26 31 14.7 0.62 0.39, 0.96 0.84 0.50, 1.42 0.96 0.56, 1.63 median above median 52 25.7 0.84 0.57, 1.23 0.88 0.55, 1.39 0.85 0.53, 1.37 37 18.3 0.80 0.52, 1.23 0.85 0.51, 1.41 0.85 0.50, 1.44 Sports/Exercise none 94 25.0 referent referent referent 67 17.8 referent referent referent at or below 59 27.8 1.16 0.79, 1.69 1.27 0.82, 1.97 1.1 0.70, 1.75 43 20.3 1.17 0.77, 1.80 1.33 0.81, 2.18 1.16 0.69, 1.94 median above median 57 25.9 1.05 0.72, 1.54 0.98 0.63, 1.52 0.9 0.57, 1.44 44 20.0 1.15 0.76, 1.76 1.13 0.70, 1.83 0.98 0.59, 1.64 Transportation 1st Quartile 61 26.2 referent referent referent 47 20.2 referent referent referent 2nd Quartile 41 24.3 0.90 0.57, 1.43 0.82 0.48, 1.41 0.74 0.42, 1.30 26 15.4 0.72 0.43, 1.22 0.64 0.35, 1.19 0.55 0.29, 1.06 3rd Quartile 46 22.9 0.84 0.54, 1.30 0.99 0.60, 1.65 0.95 0.56, 1.62 34 16.9 0.81 0.49, 1.31 0.94 0.53, 1.65 0.82 0.45, 1.48 4th Quartile 62 30.1 1.21 0.80, 1.84 1.21 0.75, 1.97 1.22 0.72, 2.06 48 23.3 1.20 0.76, 1.90 1.10 0.65, 1.88 1.06 0.60, 1.90 p-trend 0.47 0.36 0.39 0.43 0.52 0.68 Met American College of Obstetricians and Gynecologists guidelines of > 7.5 MET-hrs/week in sports/exercise activities of moderate-intensity or greater Adjusted for age, education, live with partner or spouse, parity, generation in U.S., at least probable minor depression in early pregnancy and weeks between interviews Additionally adjusted for energy expenditure from other domains of physical activity increased risk for elevated depressive symptoms, suggest- different types of physical activity. For example, women ing that perception of physical activity may impact the in our study were predominantly of low socioeconomic association. status and had high levels of baseline depressive symp- Differences in findings may be due to differences in toms, which may impact associations as physical activity study populations, as well as, differential effects of has been suggested to have different effects depending Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 8 of 11 on levels of depression [41]. Importantly, the largest some other potential forms of bias because unlike source of physical activity energy expenditure in our other depression screening tools that have been used population was household/caregiving with almost half of in many of the studies that have examined associa- women not participating in any sports/exercise activity. tions between physical activity and elevated depressive Studies suggest that type of physical activity has differen- symptoms during pregnancy, the EPDS takes into account tial effects on depression in the general population, with common somatic depressive symptoms that are also exercise/leisure time activity generally having a positive symptoms of pregnancy. effect on depression and household/caregiving physical We had information on a number of important risk activity either having no effect or increasing risk for de- factors that may confound associations between physical pressive symptoms [17, 29]. Household/caregiving activ- activity and depression during pregnancy, however, we ity may be stressful for women, which could negate any did not have information on history of pre-pregnancy positive effects of physical activity or increase risk for depression, which is a risk factor for antenatal depres- depressive symptoms. Indeed, a study by Molarius et al. sion. Nonetheless, as depression relapse rates are high found that the more burdensome study participants during pregnancy [2], we anticipate that many of these perceived domestic activities, the greater the risk for women would have a recurrence during pregnancy. By depressive symptoms [29]. adjusting for early pregnancy depression, we were able A number of studies have examined associations be- to adjust for this confounding to some degree, though tween physical activity and antenatal depression among there are some women who may have had a recurrence patients who were not diagnosed as clinically depressed later in pregnancy, which could lead to confounding if at baseline [14, 42], however, antenatal depression is history of depression was associated with physical activity. often undiagnosed [43] and no studies that we are aware of In addition, we did not have information on diet, another excluded women who had elevated depressive symptoms potential confounder. Exercise behavior is positively asso- indicative of probable depression at baseline. In the recent ciated with healthy eating [46] and studies suggest that meta-analysis by Daley et al., the authors identified one ran- nutrient deficiency (e.g. n-3 fatty acids, B vitamins, folate) domized controlled trial of an aerobic exercise program and high energy intake (particularly that of unhealthy conducted among clinically nondepressed patients by food) may be associated with depression [47, 48]. In Robledo-Colonia et al. which found an average four-point addition, diet may be on the causal pathway between reductionindepressive symptom score among intervention physical activity and depression because physical activity group participants [14, 44]. However, some participants had may suppress appetite and studies suggest caloric restric- baseline depressive symptom scores, as measured by the tion may have an anti-depressant effect [49]. Center for Epidemiologic Studies - Depression Scale, which It is possible that women who were depressed in early were higher than the widely used screening cut-point for pregnancy were less likely to complete the mid-to-late significant depressive symptoms or depression [44, 45], sug- pregnancy interview on depression. We found that gesting that some women may have had undiagnosed de- women missing mid-to-late pregnancy depressive symptom pression at baseline. In our analysis, after excluding women information did not differ by early pregnancy probable de- with baseline depressive symptoms, sports/exercise may pression status or on the majority of sociodemographic, have had a protective impact on incident probable major medical history, and behavioral factors than women not depression, but this was not statistically significant. missing this information, although they had higher levels of Our study had several potential limitations. First, the education, income, and acculturation, and were more likely EPDS is a tool that assesses depressive symptoms and is not to have had a preterm birth. Socioeconomic status, which a clinical measure of depression. However, the EPDS is includes factors such as income and education, is positively widely used to indicate probable depressive disorder and has associated with exercise activity [50, 51], and inversely asso- been demonstrated to have strong sensitivity and specificity ciated with depression [52] with individuals of lower socio- for depression during pregnancy when validated compared economic status experiencing higher rates of depression. to a structured clinical interview [34]. Though the validation Loss of women with higher incomes and levels of education studies for antenatal depression were conducted using the during follow-up would have potentially biased a protective English version of the tool and the Spanish version has not finding of sports/exercise activity towards the null. In been validated, we expect the Spanish version to have rela- addition, as a result of this loss to follow-up, we had lower tively comparable sensitivity and specificity because both the power to detect effects than originally planned and the Spanish and English versions had good sensitivity and speci- study needs replication in a larger sample. Finally, we used ficity for postnatal depression using the same cut-offs to odds ratios as our estimates of effect. Though they are valid define depression [34, 35]. If bias did occur as a result of estimates of effect, caution should be taken in inferring risk misclassification of depression, results would have been as they may overestimate effects because the outcomes biased towards the null. However, the EPDS minimizes were not rare [53]. Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 9 of 11 Table 3 Odds ratios of mid-to-late pregnancy probable depression by early pregnancy physical activity levels among nondepressed women in early pregnancy: Proyecto Buena Salud, 2006–2011 At least Probable Minor Depression (EPDS ≥13) Probable Major Depression (EPDS ≥15) b c b c Cases Unadjusted Adjusted Adjusted Cases Unadjusted Adjusted Adjusted n % OR 95% CI OR 95% CI OR 95% CI n % OR 95% CI OR 95% CI OR 95% CI Total physical activity 1st Quartile 24 17.1 referent referent 16 11.4 referent referent 2nd Quartile 17 12.8 0.71 0.36, 1.39 0.66 0.33, 1.32 n/a 10 7.5 0.63 0.28, 1.44 0.57 0.24, 1.37 n/a 3rd Quartile 19 12.6 0.70 0.36, 1.34 0.71 0.36, 1.43 12 8.0 0.67 0.31, 1.47 0.70 0.30, 1.62 4th Quartile 22 17.3 1.01 0.54, 1.91 1.04 0.53, 2.03 16 12.6 1.12 0.53, 2.34 1.21 0.56, 2.64 p-trend 0.96 0.94 0.79 0.70 Met exercise guidelines no 69 16.7 referent referent n/a 43 10.4 referent referent n/a yes 20 11.6 0.65 0.38, 1.11 0.69 0.40, 1.18 14 8.1 0.76 0.40, 1.42 0.82 0.43, 1.55 Moderate/vigorous intensity 1st Quartile 25 16.0 referent referent n/a 15 9.6 referent referent n/a 2nd Quartile 23 15.2 0.94 0.51, 1.74 0.93 0.49, 1.77 16 10.6 1.11 0.53, 2.34 1.11 0.51, 2.41 3rd Quartile 20 14.4 0.88 0.47, 1.67 0.92 0.47, 1.79 11 7.9 0.81 0.36, 1.82 0.90 0.39, 2.08 4th Quartile 21 14.7 0.90 0.48, 1.70 0.90 0.46, 1.76 15 10.5 1.10 0.52, 2.34 1.14 0.51, 2.55 p-trend 0.71 0.76 0.99 0.88 Domain of Activity Household/ caregiving 1st Quartile 25 18.3 referent referent referent 15 11.0 referent referent referent 2nd Quartile 22 14.4 0.75 0.40, 1.41 0.94 0.48, 1.86 0.95 0.48, 1.91 16 10.5 0.95 0.45, 2.00 1.25 0.55, 2.85 1.20 0.52, 2.77 3rd Quartile 17 11.6 0.59 0.30, 1.15 0.67 0.32, 1.40 0.71 0.33, 1.50 8 5.5 0.47 0.19, 1.15 0.58 0.22, 1.56 0.57 0.21, 1.55 4th Quartile 21 15.9 0.85 0.45, 1.60 0.99 0.47, 2.06 0.98 0.46, 2.11 17 12.9 1.20 0.57, 2.52 1.60 0.67, 3.84 1.53 0.62, 3.78 p-trend 0.46 0.75 0.78 0.99 0.55 0.61 Occupational unemployed 44 16.5 referent referent referent 28 10.5 referent referent referent at or below median 20 11.8 0.68 0.38, 1.20 0.58 0.32, 1.07 0.58 0.31, 1.09 13 7.7 0.71 0.36, 1.41 0.65 0.31, 1.37 0.68 0.32, 1.45 above median 23 15.5 0.93 0.54, 1.61 0.80 0.42, 1.53 0.72 0.37, 1.43 15 10.1 0.96 0.49, 1.86 0.77 0.35, 1.73 0.67 0.29, 1.56 Sports/Exercise none 45 16.0 referent referent referent 31 11.0 referent referent referent at or below median 26 16.7 1.05 0.62, 1.78 1.08 0.63, 1.87 0.93 0.52, 1.67 13 8.3 0.73 0.37, 1.45 0.80 0.40, 1.61 0.58 0.27, 1.24 above median 18 12.1 0.72 0.40, 1.30 0.76 0.41, 1.38 0.65 0.34, 1.42 13 8.7 0.77 0.39, 1.52 0.85 0.42, 1.71 0.63 0.30, 1.33 Transportation 1st Quartile 27 15.7 referent referent referent 16 9.3 referent referent referent 2nd Quartile 18 14.8 0.93 0.49, 1.78 0.87 0.44, 1.73 0.76 0.36, 1.57 12 9.8 1.06 0.48, 2.34 0.98 0.42, 2.26 0.88 0.37, 2.09 3rd Quartile 26 16.8 1.08 0.60, 1.95 1.11 0.59, 2.08 1.01 0.53, 1.95 18 11.6 1.28 0.63, 2.61 1.34 0.62, 2.86 1.05 0.47, 2.32 4th Quartile 18 13.0 0.80 0.42, 1.52 0.90 0.46, 1.75 0.76 0.36, 1.58 11 7.9 0.84 0.38, 1.87 0.94 0.41, 2.17 0.72 0.29, 1.80 p-trend 0.65 0.95 0.63 0.89 0.91 0.61 Met American College of Obstetricians and Gynecologists guidelines of > 7.5 MET-hrs/week in sports/exercise activities of moderate-intensity or greater Adjusted for age, education, live with partner or spouse, parity, generation in U.S., and weeks between interviews Additionally adjusted for energy expenditure from other domains of physical activity Szegda et al. 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Psychosom Med. 2001;63(5):830–4. The authors acknowledge the staff of Proyecto Buena Salud for their support 9. Mammen G, Faulkner G. Physical activity and the prevention of depression: a on this study. We also express gratitude to the Proyecto Buena Salud study systematic review of prospective studies. Am J Prev Med. 2013;45(5):649–57. participants for their willingness to participate in this study. 10. Paluska SA, Schwenk TL. Physical activity and mental health: current concepts. Sports Med. 2000;29(3):167–80. Funding 11. Craft LL. Exercise and clinical depression: examining two psychological This study was supported by NIH grant DK064902 from the National Institute mechanisms. Psychol Sport Exerc. 2005;6(2):151–71. of Diabetes and Digestive and Kidney Diseases. 12. Udechuku A, Nguyen T, Hill R, Szego K. Antidepressants in pregnancy: a systematic review. Aust N Z J Psychiatry. 2010;44(11):978–96. Availability of data and materials 13. O'Keane V, Marsh M. Depression during pregnancy. BMJ. 2007;334(7601):1003–5. The datasets analyzed for this study are available from author LCT on 14. Daley AJ, Foster L, Long G, Palmer C, Robinson O, Walmsley H, Ward R. The reasonable request. effectiveness of exercise for the prevention and treatment of antenatal depression: systematic review with meta-analysis. BJOG. 2015;122(1):57–62. Authors’ contributions 15. Kouyoumdjian H, Zamboanga BL, Hansen DJ. Barriers to community mental KS, LCT, EBJ, SP, PP and GM provided substantial input into the study design, health Services for Latinos: treatment considerations. Clin Psychol Sci Pract. data analysis and interpretation. ND provided substantial input into study 2003;10(4):394–422. design and methods. KS conducted the literature review, analysis, and 16. U.S. Health and Human Services Physical Activity Guidelines Advisory drafted the manuscript. All the authors reviewed and approved the final Committee. Chapter 7: additional considerations for some adults. 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Physical activity and depressive symptoms during pregnancy among Latina women: a prospective cohort study

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Springer Journals
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Copyright © 2018 by The Author(s).
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Medicine & Public Health; Reproductive Medicine; Maternal and Child Health; Gynecology
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1471-2393
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Abstract

Background: Latina women are at increased risk for antenatal depressive disorders, which are common during pregnancy and are associated with elevated risk for poor maternal health and birth outcomes. Physical activity is a potential mechanism to reduce the likelihood of depressive symptoms. The purpose of the study was to assess whether total and domain-specific physical activity in early pregnancy reduced risk for elevated antenatal depressive symptoms in mid-late pregnancy in a population of Latina women at high-risk for depression. Methods: Data from 820 Latina participants in the prospective cohort study Proyecto Buena Salud was examined using multivariable logistic regression. Total, moderate/vigorous, and domain-specific physical activity (household/caregiving, occupational, sports/exercise, transportation) were assessed using the Pregnancy Physical Activity Questionnaire. The Edinburgh Postnatal Depression Scale was used to assess depressive symptoms and identify women with elevated symptoms indicative of at least probable minor depression and probable major depression. Results: A total of 25.9% of participants experienced at least probable minor depression and 19.1% probable major depression in mid-late pregnancy. After adjusting for important risk factors, no significant associations were observed between total physical activity (4th Quartile vs.1st Quartile OR = 1.02, 95% CI = 0.61, 1.71; p-trend = 0.62) or meeting exercise guidelines in pregnancy (OR = 0.96, 95% CI = 0.65, 1.41) and at least probable minor depression; similarly, associations were not observed between these measures and probable major depression. There was a suggestion of increased risk of probable major depression with high levels of household/caregiving activity (4th Quartile vs 1st Quartile OR = 1.51, 95% CI = 0.93, 2.46), but this was attenuated and remained not statistically significant after adjustment. When we repeated the analysis among women who did not have elevated depressive symptoms in early pregnancy (n =596), findings were unchanged, though a nonsignificant protective effect was observed for sport/exercise activity and probable major depression in fully adjusted analysis (OR = 0.63, 95% CI = 0.30, 1.33). Conclusion: Among Latina women at high-risk for antenatal depression, early pregnancy physical activity was not associated with elevated depressive symptoms in mid-to-late pregnancy. Keywords: Physical activity, Antenatal depression, Antenatal depressive symptoms, Latina * Correspondence: kszegda@schoolph.umass.edu Department of Biostatistics & Epidemiology, School of Public Health & Health Sciences, University of Massachusetts, 414 Arnold House, 715 North Pleasant Street, Amherst, MA 01003-9304, USA Baystate Medical Center, Springfield, MA, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 2 of 11 Background inverse association, a number have been limited by Depressive disorders affect up to an estimated 18% of their cross-sectional examination of physical activity women during pregnancy [1]. Depression relapse rates are and depression [18, 21], making it difficult to ascertain particularly high during pregnancy, with some studies whether physical activity affected depression status or finding relapse rates as high as 43% [2]. Latina women in whether depression status lead to decreased physical the United States are at increased risk for antenatal de- activity levels. In addition, the majority of prior studies pression with some studies finding almost double the focused on exercise or leisure time activity and did not prevalence among Latina women compared to non-Latina examine other domains of physical activity (i.e., house- White women [3]. Factors that likely contribute to this hold/caregiving and occupational activity), which may disparity include economic, acculturation, and social chal- be an important consideration in populations that have lenges experienced by Latinas in the U.S. [4], which in- limited ability to participate in leisure time activity. In creases their likelihood of depression overall, and thus the the one study to evaluate other domains of activity, likelihood of reoccurrence or initial onset of a depressive Demissie et al. found that among 1220 well educated, episode during pregnancy. Because depression during predominantly White women in North Carolina, higher pregnancy has been associated with increased risk of poor levels of activity perceived as moderate to vigorous were maternal health outcomes during and following pregnancy associated with a reduction in depressive symptoms. How- (e.g., pre-eclampsia, post-partum depression) [5, 6], as well ever, perceived moderate to vigorous levels of some forms as poor birth outcomes (e.g., admission to neonatal nur- of household/caregiving activity increased risk for de- series, small-for-gestational age) [7, 8], it is important to pressive symptoms [20]. As some household/caregiving identify ways to prevent antenatal depression and reduce activities are included in the list of activities recom- depressive symptoms in this at-risk population. mended by the U.S. Health and Human Services as a Physical activity may prevent the onset of depression means to achieve physical activity guidelines, it is im- [9], which is particularly important in populations that portant to understand the association between different experience a high prevalence of depression and are at types of activities and depression. high-risk for antenatal depression. Exercise and physical In a recent meta-analysis conducted by Daley et al. activity are believed to prevent depression and reduce that examined randomized clinical trials conducted to depressive symptoms by altering neurotransmitter and assess the effect of exercise on the prevention and treat- hormone levels that are associated with depression. It is ment of antenatal depression [14], the meta-analysis found also believed that exercise may reduce depression by dis- a reduction in depressive symptoms among the six studies tracting from depressive symptoms and promoting examined (standardized mean difference = − 0.46, 95% self-efficacy [10, 11]. Among women with antenatal de- CI = − 0.87, − 0.05), but the authors noted the limited pression, physical activity is an alternative option to anti- number and quality of studies available. The authors depressant medications and psychotherapy, which are called for additional research, citing the need for more current common depression treatment options that may studies to better understand subgroup effects, including be underutilized or contraindicated. Studies suggest some the effects of physical activity among nondepressed antidepressants may negatively impact the developing women, as only one study examined the protective ef- fetus [12], which may result in hesitancy among patients fects of physical activity among nondepressed women to take these medications. Psychotherapy can be inaccess- at baseline [14]. ible and unaffordable, particularly among disadvantaged Our study aimed to extend prior work by prospectively populations that experience socioeconomic challenges examining associations between total physical activity [13, 14]. Among Latinos, mental health services such as and domain-specific physical activity on elevated depres- psychotherapy may be particularly underutilized because sive symptoms during pregnancy in a Latina population of cultural beliefs and concerns about stigma and fatalism at high-risk for antenatal depression. In addition, we ex- [15]. Though current U.S. Health and Human Services amined physical activity and elevated depressive symp- guidelines recommend that pregnant women engage in at toms among nondepressed women to better understand least 150 min of moderate intensity aerobic activity per whether physical activity may be associated with the on- week [16], women often do not meet these guidelines. set of depression among women at high-risk. Studies conducted among women in the general popula- tion have generally found that physical activity is inversely Methods associated with depression [17], but research in pregnant Data from Proyecto Buena Salud (PBS) was used to as- populations has been limited. Among studies conducted sess associations between physical activity and depressive with pregnant women, findings have varied with some symptoms. PBS was a prospective cohort study among finding an inverse association [18–21], and others find- Latina prenatal care patients conducted from 2006 to ing no association [22–24]. Amongstudies findingan 2011 at Baystate Medical Center, a large tertiary care Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 3 of 11 center in Western Massachusetts, which has approxi- during pregnancy were assigned a modified intensity value mately 4500 deliveries per year and serves an ethnically di- [28]. Total energy expenditure by domain (household/ verse population. Study design details have been published caregiving, occupational, sports/exercise, transportation) previously [25]. PBS was approved by the Institutional and intensity (moderate, vigorous) were also calculated. Review Boards at the University of Massachusetts, Moderate and vigorous activity were combined into a single Amherst and Baystate Medical Center. category because there were so few women who engaged in Women were recruited at prenatal care visits in early vigorous activity. Total physical activity levels as well as pregnancy (up to 20 weeks gestation). Participants were those for moderate/vigorous, household, and transportation informed of study aims and procedures and asked to activity were categorized into quartiles. Because a large per- provide written informed consent. To reduce language centage of women did not engage in sports/exercise activity and literacy barriers, interviews were conducted in during pregnancy, women were categorized into none, English(73.7%) or Spanishbytrained bilingual interviewers sport/exercise levels “at or below the median,” and “above depending upon participant preference. the median.” For occupational physical activity levels, At the initial interview conducted at recruitment women were categorized as unemployed, “at or below the (mean = 12.4 weeks gestation), information was obtained median” and “above the median.” on socio-demographic, acculturation, behavioral, physical Physical activity was also categorized as to whether activity, and depressive symptoms. Information on depres- participants met current U.S. Health and Human Services sive symptoms was updated in mid-to-late pregnancy physical activity guidelines, which recommend that (mean = 25.7 weeks gestation). Information on medical pregnant women engage in at least 150 min per week history and clinical characteristics of the pregnancy were of moderate intensity aerobic physical activity [16]. abstracted from the medical record after delivery. Women were categorized as meeting the guidelines if they participated in > 7.5 MET-hrs per week of sports/exercise Study population activities that were of moderate-intensity or greater (i.e., Eligibility for PBS was restricted to Latina women of 30 min per day of activity at ≥ 3 METs multiplied by 5 days Puerto Rican or Dominican Republic descent who were per week or 150 min). We focused on sports/exercise ac- either born on one of these islands, or had at least one tivity because studies suggest that household/caregiving or parent or two grandparents born on these islands. Other activities seen as burdensome may increase risk for de- exclusion criteria included: multiple gestation; history of pressive symptoms [29], whereas leisure time activity has diabetes, hypertension, heart or chronic renal disease; less most consistently found to reduce risk of depressive than 16 or greater than 40 years of age; and current use of symptoms [17]. However, we also created a second medications thought to adversely affect glucose tolerance. variable for meeting guidelines that categorized women as A total of 1579 women were enrolled into PBS. Women meeting guidelines based on any domain of moderate or were excluded if they had a miscarriage (n =68). Among greater intensity activity. eligible participants, a total of 1040 women had informa- The PPAQ has demonstrated good reliability and reason- tion on early pregnancy physical activity information. able validity when compared to Actigraph accelerometer Among these women, 820 had information on mid-to-late measures [26]. Intra-class correlations for two administra- pregnancy depressive symptoms and were included in the tions of the PPAQ one week apart were 0.78, 0.82 and 0.81 final dataset for analysis. for total, moderate and vigorous physical activity, and 0.83, 0.86 and 0.93 for sports/exercise, household/caregiving and Assessment of physical activity occupational activity, respectively. Physical activity was assessed in early pregnancy using a modified version of the Pregnancy Physical Activity Assessment of depression Questionnaire (PPAQ) [26]. The tool consists of a series Depressive symptoms were assessed in early and of questions asking respondents to indicate intensity, mid-to-late pregnancy with the Edinburgh Postnatal frequency and time spent engaged in 35 activities from Depression Scale (EPDS) [30], which has been vali- four domains: household/caregiving, occupational, dated as a depression screening tool in pregnant and sports/exercise, and transportation. postpartum women [31]. The EPDS is a 10-item scale Average overall total early pregnancy physical activity that asks respondents to indicate how frequently they weekly energy expenditure (metabolic equivalent have felt various mood states within the past seven days. [MET]-hrs/wk) was calculated by multiplying the amount Examples of items on the EPDS include, “I have been so of time spent on each activity by its intensity and then unhappy that I have been crying,” and “Things have been summing these values. Activity intensities were deter- getting on top of me.” Total scores range from 0 to 30. mined based on the Compendium of Physical Activities Women were categorized as to whether or not they had [27]; activities identified as having a different intensity elevated depressive symptoms indicative of at least Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 4 of 11 probable minor depression (scores13 or higher) or prob- in the case of living with a partner/spouse, as a proxy for a able major depression (scores 15 or higher) [32]. To be strong protective factor (social support) [13, 39, 40]. consistent with the prior literature, EPDS scores were im- Weeks between early and mid-to-late pregnancy inter- puted for participants missing fewer than 10% of EPDS views was also included in multivariable models in scale items by replacing the missing value with the partici- addition to any other potential confounders that changed pant’s average score of the nonmissing items [33]. the odds ratio for the depression measure by more than The EPDS has been shown to have high sensitivity and 10% with their inclusion in the model. Additional covariates specificity for major depression (sensitivity = 100%; identified for inclusion through this method included parity specificity = 96%) and reasonable sensitivity and speci- and generation in the U.S. For domain-specific multivari- ficity for at least probable minor depression (sensiti- able models, we additionally adjusted for MET-hrs/wk. vity = 57%; specificity = 98%) using these cut-points in from all other domains of physical activity. an English-speaking population [34]. The EPDS has We chose not to include stress and anxiety in our mul- also performed well as a depression screening tool in tivariable models because they were both highly correlated Spanish-speaking populations with good sensitivity and with depression (r =0.61–0.78) and we were interested in specificity for at least minor depression (sensitivity = 79%; assessing associations for all cases of depression and their specificity = 96%) and major depression (sensitivity = 83%; inclusion would have obscured associations when anxiety/ specificity = 97%) postnatally [35]. stress and depression co-occurred. In a sensitivity analysis, we repeated analyses using U.S. HHS physical activity Covariates guidelines defined as moderate/vigorous physical activity Information on maternal age, education level, income, from all domains of activity in early pregnancy and whether the participant was living with a partner, gener- mid-to-late pregnancy. ation in the continental U.S., and overall acculturation Because the effects of physical activity on subsequent (Psychological Acculturation Scale) [36] was obtained at depression may vary by baseline depression status [41], the initial pregnancy interview. Smoking status and alco- we then repeated the above analyses among women who hol consumption were assessed at each pregnancy inter- did not have elevated depressive symptoms in early preg- view. Psychosocial stress was assessed by Cohen’s nancy (i.e. did not have at least probable minor depression) Perceived Stress Scale [37] and anxiety was assessed via (n =596) [41]. Finally, we examined differences in charac- the State-Trait Anxiety Survey [38]. Pre-pregnancy teristics between women with and without information on weight, height, parity and presence of morning sickness mid-to-late pregnancy depressive symptom to assess po- during the pregnancy were obtained through the medical tential effects of missing data. All analyses were conducted record. Body mass index (BMI) was calculated as weight using SAS version 9.2 (SAS Institute Inc., Cary, NC). (kg)/height (m ). Results Data analysis Among study participants, 25.9% of women had elevated Univariate statistics were used to describe the study depressive symptoms indicative of at least probable population. Baseline characteristics were compared be- minor depression and 19.1% had depressive symptoms tween women with each of the respective probable indicative of probable major depression in mid-to-late major depression measures and women who did not pregnancy. The mean age was 21.6 years (SD = 4.9). have elevated depressive symptom scores. Unadjusted Women were generally of low socioeconomic status with and multivariable logistic regression analyses were used almost half (48.7%) reporting that they did not complete to assess associations between physical activity in early high school and only 6.1% of women reporting an an- pregnancy and at least probable minor depression and nual household income of $30,000 or greater (Table 1). probable major depression in mid-to-late pregnancy. Almost half of participants (48.4%) were born in Puerto We examined associations between total physical activ- Rico or the Dominican Republic and over two thirds of ity, moderate/vigorous physical activity, domain-specific the study population had low levels of acculturation physical activity (household/caregiving, occupational, (80.7%). Women who smoked during early pregnancy sports/exercise, transportation), and whether women met were more likely to have at least probable minor de- U.S. Health and Human Services (HHS) physical activity pression and probable major depression in mid-to-late guidelines, and each of the elevated depressive symptom pregnancy. In addition, women who were obese outcome measures in separate models. Maternal age, (BMI ≥ 30 kg/m ) or who did not live with a partner/ education, living with a partner/spouse and depression spouse were more likely to have at least probable in early pregnancy (assessed at baseline via the EPDS) minor depression in mid-to-late pregnancy; women were included as a priori confounders in models because who had higher levels of parity were more likely to have they have been identified as risk factors for depression, or probable major depression in mid-to-late pregnancy. Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 5 of 11 Table 1 Participant Characteristics by Elevated Depressive Symptom Scores in Mid-to-Late Pregnancy: Proyecto Buena Salud, 2006–2011 Total Population At Least Probable Minor Depression (EPDS ≥13) Probable Major Depression (EPDS ≥15) a b b n % cases % p-value cases % p-value Maternal Age 16–19 270 32.9 61 28.8 0.40 42 26.9 0.25 20–24 315 38.4 83 39.2 62 39.7 25–29 144 17.6 40 18.9 30 19.2 ≥ 30 91 11.1 28 13.2 22 14.1 Education Less than high school 396 48.8 111 52.9 0.37 87 56.1 0.09 High school graduate or GED 270 33.3 63 30.0 41 26.5 Post high school 146 18.0 36 17.1 27 17.4 Income less than $15,000 242 30.1 75 36.1 0.15 58 37.4 0.13 $15,000–$30,000 121 15.0 27 13.0 18 11.6 $30,000 or greater 49 6.1 10 4.8 8 5.2 Don’t Know/Refused 393 48.8 96 46.2 71 45.8 Acculturation Low 635 80.7 161 79.7 0.68 121 80.7 0.99 High 152 19.3 41 20.3 29 19.3 Generation in U.S. Born in PR/DR 382 48.4 99 49.0 0.72 74 49.7 0.11 Parent born in PR/DR 363 46.0 94 46.5 72 48.3 Grandparent born in PR/DR 44 5.6 9 4.5 3 2.0 Live with partner/spouse no 405 50.3 117 56.0 0.05 82 52.9 0.46 yes 401 49.8 92 44.0 73 47.1 Pre-Pregnancy BMI less than 18.5 43 5.3 11 5.3 < 0.01 7 4.6 0.22 18.5- < 25.0 395 48.8 109 52.4 78 51.3 25.0- < 30.0 180 22.3 29 13.9 25 16.5 30 or greater 191 23.6 59 28.4 42 27.6 Parity 0 live births 336 41.5 75 36.1 0.12 50 32.9 0.03 1 live birth 255 31.5 67 32.2 50 32.9 2 or more live births 219 27.0 66 31.7 52 34.2 Smoking (early pregnancy) no 672 86.6 162 79.0 < 0.01 117 77.0 < 0.01 yes 104 13.4 43 21.0 35 23.0 Alcohol consumption (early pregnancy) no 756 97.4 197 26.1 0.06 147 19.4 0.24 yes 20 2.6 9 45.0 6 30.0 Numbers may not total to 820 due to missing data P-values were calculated using chi-square tests and are for comparisons between cases and noncases Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 6 of 11 On average, household/caregiving physical activity analyses. For example, for total activity the adjusted odds accounted for the largest average proportion of energy ratio for probable major depression when comparing Q to expenditure (56.0%) and sports/exercise activity the least Q was 1.21 (95% CI = 0.56, 2.64; p-trend = 0.70) and for (6.4%). Almost half of women did not engage in sports/ meeting exercise guidelines was 0.82 (95% CI = 0.43, 1.55) exercise activity in early pregnancy (46.5%) and 51.7% of when compared to women who did not meet guidelines. women were not employed in early pregnancy. Women with the highest levels of sports/exercise activity We examined associations between total physical ac- who did not have elevated depressive symptoms in early tivity in early pregnancy and elevated depressive symp- pregnancy appeared to have a lower odds of probable major toms in mid-to-late pregnancy (Table 2). In unadjusted depression (OR 0.63, 95% CI = 0.30, 1.33) after adjusting for analyses, the odds ratio for at least probable minor depres- important risk factors and other domains of activity, but sion for women with the highest level of total physical ac- this was not statistically significant. tivity as compared to the lowest level was elevated, but Lastly, women who were missing mid-to-late preg- not statistically significant (4th Quartile [Q ]vs. 1stQuar- nancy depressive symptom information did not differ tile [Q ] odds ratio [OR] = 1.28, 95% confidence interval from women with this information by early pregnancy 1 : [CI] = 0.83, 1.98; p-trend = 0.21). After adjustment for age, probable depression status (at least probable minor de- education, living situation, parity, generation in the U.S., pression or probable major depression) and also did not at least probable minor depression in early pregnancy, and differ according to age, BMI, parity, generation in the weeks between interviews, this odds ratio was attenuated U.S., whether they lived with a partner or spouse, or to 1.02, (95% CI = 0.61, 1.71; p-trend = 0.62). Results early pregnancy smoking status; however they had were similar for probable major depression (unadjusted higher levels of education (p < 0.01), income (p = 0.01), Q vs. Q OR = 1.28, 95% CI = 0.79, 2.05; p-trend = 0.27 and acculturation (p = 0.02) and were more likely to have 4 1: vs. adjusted Q vs. Q OR = 0.96, 95% CI = 0.55, 1.70; had a preterm birth (p < 0.001). 4 1: p-trend = 0.83). Similarly, we did not observe significant associations between moderate/vigorous activity or meet- Discussion ing physical activity guidelines and mid-to-late pregnancy In our prospective cohort study of 820 Latina women, elevated depressive symptom outcomes. We also did not we did not observe statistically significant associations be- observe significant associations in a sensitivity analysis tween total and domain-specific physical activity in early using U.S. HHS physical activity guidelines defined as mod- pregnancy and mid-to-late pregnancy elevated depressive erate/vigorous physical activity from all domains of activity. symptoms. We similarly did not observe significant associa- We then examined associations between domains of tions when restricting our analyses to women who did not early pregnancy physical activity and mid-to-late preg- have elevated depressive symptoms in early pregnancy. nancy elevated depressive symptom outcomes (Table 2). Few studies have examined the association between Women with the highest level of household/caregiving total and domain specific physical activity and depres- activity had 1.51 times the odds of probable major de- sion during pregnancy. Our findings that physical activ- pression compared to women with the lowest level (95% ity and sports/exercise activity were not associated with CI = 0.93, 2.46), but again this was not statistically sig- elevated depressive symptom outcomes are consistent nificant and was further attenuated after adjustment for with the findings of several other studies examining important risk factors (OR = 1.18, 95% CI = 0.63, 2.21). these associations [22–24]. Similar to our findings, Point estimates for the other domains of physical activity Symons-Downs et al. did not find an independent asso- (i.e., occupational, sports/exercise, and transportation) ciation between exercise behavior and depressive symp- and odds ratios of at least probable minor depression or toms in prospective analysis during pregnancy in their probable major depression were closer to 1.0 and also study of 230 predominantly White, highly educated not statistically significant in both unadjusted and ad- women [22]. In the one study to evaluate other domains justed analyses (Table 2). In domain-specific analyses of activity, Demissie et al. similarly did not find significant that included additional adjustment for MET-hrs/wk. associations between absolute levels (MET-hrs per week) of from other domains of physical activity, we similarly ob- total (OR = 0.71, 95% CI = 0.42, 1.18) or domain-specific served no significant associations. moderate to vigorous physical activity and elevated depres- We then repeated the above analyses restricted to sive symptoms among 1220 predominantly White women women who did not have elevated depressive symptoms in North Carolina [20]. However, when the authors used (i.e. did not have at least probable minor depression) in participant perception of intensity to classify activities, they early pregnancy (n = 596) (Table 3). Similar to our pri- found that moderate levels of total moderate to vigorous mary analysis, we did not observe significant associations activity was inversely associated with elevated depressive between any of the physical activity measures and de- symptoms (OR = 0.56, 95% CI = 0.38, 0.83) and that mod- pressive symptom outcomes in unadjusted or adjusted erate levels of moderate to vigorous household activity Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 7 of 11 Table 2 Odds ratios of mid-to-late pregnancy probable depression by various early pregnancy physical activity levels: Proyecto Buena Salud, 2006–2011 At least Probable Minor Depression (EPDS≥13) Probable Major Depression (EPDS≥15) b c b c Cases Unadjusted Adjusted Adjusted Cases Unadjusted Adjusted Adjusted n % OR 95% CI OR 95% CI OR 95% CI n % OR 95% CI OR 95% CI OR 95% CI Total physical activity 1st Quartile 53 27.9 referent referent 40 21.1 referent referent 2nd Quartile 36 19.8 0.64 0.39, 1.03 0.52 0.30, 0.90 n/a 27 14.8 0.65 0.38, 1.12 0.55 0.30, 1.02 n/a 3rd Quartile 44 22.1 0.73 0.46, 1.16 0.72 0.42, 1.23 32 16.1 0.72 0.43, 1.20 0.72 0.39, 1.31 4th Quartile 64 32.5 1.28 0.83, 1.98 1.02 0.61, 1.71 49 25.4 1.28 0.79, 2.05 0.96 0.55, 1.70 p-trend 0.21 0.62 0.27 0.83 Met exercise guidelines no 142 25.7 referent referent 101 18.3 referent referent yes 68 26.6 1.05 0.75, 1.46 0.96 0.65, 1.41 n/a 53 20.7 1.17 0.80, 1.69 1.12 0.73, 1.71 n/a Moderate/vigorous intensity 1st Quartile 51 25.6 referent referent 34 17.1 referent referent 2nd Quartile 44 21.8 0.81 0.51, 1.28 0.60 0.35, 1.03 n/a 36 17.8 1.05 0.63, 1.76 0.78 0.43, 1.43 n/a 3rd Quartile 57 27.4 1.10 0.71, 1.70 0.73 0.44, 1.22 42 20.2 1.23 0.74, 2.03 0.86 0.48, 1.53 4th Quartile 58 28.7 1.17 0.75, 1.82 0.89 0.53, 1.50 42 20.8 1.27 0.77, 2.10 0.94 0.52, 1.69 p-trend 0.28 0.92 0.28 0.95 Domain of Activity Household/ caregiving 1st Quartile 49 26.6 referent referent referent 34 18.5 referent referent referent 2nd Quartile 48 24.5 0.89 0.56, 1.42 1.11 0.64, 1.93 1.03 0.59, 1.81 39 19.9 1.10 0.66, 1.83 1.37 0.73, 2.55 1.26 0.67, 2.37 3rd Quartile 44 21.8 0.77 0.48, 1.22 0.67 0.38, 1.18 0.64 0.36, 1.13 27 13.4 0.68 0.39, 1.18 0.59 0.30, 1.14 0.56 0.29, 1.10 4th Quartile 60 30.0 1.18 0.76, 1.84 0.93 0.53, 1.64 0.85 0.48, 1.52 51 25.5 1.51 0.93, 2.46 1.18 0.63, 2.21 1.09 0.57, 2.08 p-trend 0.58 0.45 0.31 0.24 0.80 0.68 Occupational unemployed 115 29.3 referent referent 86 21.9 referent referent referent at or below 42 19.9 0.60 0.40, 0.90 0.74 0.47, 1.17 0.78 0.48, 1.26 31 14.7 0.62 0.39, 0.96 0.84 0.50, 1.42 0.96 0.56, 1.63 median above median 52 25.7 0.84 0.57, 1.23 0.88 0.55, 1.39 0.85 0.53, 1.37 37 18.3 0.80 0.52, 1.23 0.85 0.51, 1.41 0.85 0.50, 1.44 Sports/Exercise none 94 25.0 referent referent referent 67 17.8 referent referent referent at or below 59 27.8 1.16 0.79, 1.69 1.27 0.82, 1.97 1.1 0.70, 1.75 43 20.3 1.17 0.77, 1.80 1.33 0.81, 2.18 1.16 0.69, 1.94 median above median 57 25.9 1.05 0.72, 1.54 0.98 0.63, 1.52 0.9 0.57, 1.44 44 20.0 1.15 0.76, 1.76 1.13 0.70, 1.83 0.98 0.59, 1.64 Transportation 1st Quartile 61 26.2 referent referent referent 47 20.2 referent referent referent 2nd Quartile 41 24.3 0.90 0.57, 1.43 0.82 0.48, 1.41 0.74 0.42, 1.30 26 15.4 0.72 0.43, 1.22 0.64 0.35, 1.19 0.55 0.29, 1.06 3rd Quartile 46 22.9 0.84 0.54, 1.30 0.99 0.60, 1.65 0.95 0.56, 1.62 34 16.9 0.81 0.49, 1.31 0.94 0.53, 1.65 0.82 0.45, 1.48 4th Quartile 62 30.1 1.21 0.80, 1.84 1.21 0.75, 1.97 1.22 0.72, 2.06 48 23.3 1.20 0.76, 1.90 1.10 0.65, 1.88 1.06 0.60, 1.90 p-trend 0.47 0.36 0.39 0.43 0.52 0.68 Met American College of Obstetricians and Gynecologists guidelines of > 7.5 MET-hrs/week in sports/exercise activities of moderate-intensity or greater Adjusted for age, education, live with partner or spouse, parity, generation in U.S., at least probable minor depression in early pregnancy and weeks between interviews Additionally adjusted for energy expenditure from other domains of physical activity increased risk for elevated depressive symptoms, suggest- different types of physical activity. For example, women ing that perception of physical activity may impact the in our study were predominantly of low socioeconomic association. status and had high levels of baseline depressive symp- Differences in findings may be due to differences in toms, which may impact associations as physical activity study populations, as well as, differential effects of has been suggested to have different effects depending Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 8 of 11 on levels of depression [41]. Importantly, the largest some other potential forms of bias because unlike source of physical activity energy expenditure in our other depression screening tools that have been used population was household/caregiving with almost half of in many of the studies that have examined associa- women not participating in any sports/exercise activity. tions between physical activity and elevated depressive Studies suggest that type of physical activity has differen- symptoms during pregnancy, the EPDS takes into account tial effects on depression in the general population, with common somatic depressive symptoms that are also exercise/leisure time activity generally having a positive symptoms of pregnancy. effect on depression and household/caregiving physical We had information on a number of important risk activity either having no effect or increasing risk for de- factors that may confound associations between physical pressive symptoms [17, 29]. Household/caregiving activ- activity and depression during pregnancy, however, we ity may be stressful for women, which could negate any did not have information on history of pre-pregnancy positive effects of physical activity or increase risk for depression, which is a risk factor for antenatal depres- depressive symptoms. Indeed, a study by Molarius et al. sion. Nonetheless, as depression relapse rates are high found that the more burdensome study participants during pregnancy [2], we anticipate that many of these perceived domestic activities, the greater the risk for women would have a recurrence during pregnancy. By depressive symptoms [29]. adjusting for early pregnancy depression, we were able A number of studies have examined associations be- to adjust for this confounding to some degree, though tween physical activity and antenatal depression among there are some women who may have had a recurrence patients who were not diagnosed as clinically depressed later in pregnancy, which could lead to confounding if at baseline [14, 42], however, antenatal depression is history of depression was associated with physical activity. often undiagnosed [43] and no studies that we are aware of In addition, we did not have information on diet, another excluded women who had elevated depressive symptoms potential confounder. Exercise behavior is positively asso- indicative of probable depression at baseline. In the recent ciated with healthy eating [46] and studies suggest that meta-analysis by Daley et al., the authors identified one ran- nutrient deficiency (e.g. n-3 fatty acids, B vitamins, folate) domized controlled trial of an aerobic exercise program and high energy intake (particularly that of unhealthy conducted among clinically nondepressed patients by food) may be associated with depression [47, 48]. In Robledo-Colonia et al. which found an average four-point addition, diet may be on the causal pathway between reductionindepressive symptom score among intervention physical activity and depression because physical activity group participants [14, 44]. However, some participants had may suppress appetite and studies suggest caloric restric- baseline depressive symptom scores, as measured by the tion may have an anti-depressant effect [49]. Center for Epidemiologic Studies - Depression Scale, which It is possible that women who were depressed in early were higher than the widely used screening cut-point for pregnancy were less likely to complete the mid-to-late significant depressive symptoms or depression [44, 45], sug- pregnancy interview on depression. We found that gesting that some women may have had undiagnosed de- women missing mid-to-late pregnancy depressive symptom pression at baseline. In our analysis, after excluding women information did not differ by early pregnancy probable de- with baseline depressive symptoms, sports/exercise may pression status or on the majority of sociodemographic, have had a protective impact on incident probable major medical history, and behavioral factors than women not depression, but this was not statistically significant. missing this information, although they had higher levels of Our study had several potential limitations. First, the education, income, and acculturation, and were more likely EPDS is a tool that assesses depressive symptoms and is not to have had a preterm birth. Socioeconomic status, which a clinical measure of depression. However, the EPDS is includes factors such as income and education, is positively widely used to indicate probable depressive disorder and has associated with exercise activity [50, 51], and inversely asso- been demonstrated to have strong sensitivity and specificity ciated with depression [52] with individuals of lower socio- for depression during pregnancy when validated compared economic status experiencing higher rates of depression. to a structured clinical interview [34]. Though the validation Loss of women with higher incomes and levels of education studies for antenatal depression were conducted using the during follow-up would have potentially biased a protective English version of the tool and the Spanish version has not finding of sports/exercise activity towards the null. In been validated, we expect the Spanish version to have rela- addition, as a result of this loss to follow-up, we had lower tively comparable sensitivity and specificity because both the power to detect effects than originally planned and the Spanish and English versions had good sensitivity and speci- study needs replication in a larger sample. Finally, we used ficity for postnatal depression using the same cut-offs to odds ratios as our estimates of effect. Though they are valid define depression [34, 35]. If bias did occur as a result of estimates of effect, caution should be taken in inferring risk misclassification of depression, results would have been as they may overestimate effects because the outcomes biased towards the null. However, the EPDS minimizes were not rare [53]. Szegda et al. BMC Pregnancy and Childbirth (2018) 18:252 Page 9 of 11 Table 3 Odds ratios of mid-to-late pregnancy probable depression by early pregnancy physical activity levels among nondepressed women in early pregnancy: Proyecto Buena Salud, 2006–2011 At least Probable Minor Depression (EPDS ≥13) Probable Major Depression (EPDS ≥15) b c b c Cases Unadjusted Adjusted Adjusted Cases Unadjusted Adjusted Adjusted n % OR 95% CI OR 95% CI OR 95% CI n % OR 95% CI OR 95% CI OR 95% CI Total physical activity 1st Quartile 24 17.1 referent referent 16 11.4 referent referent 2nd Quartile 17 12.8 0.71 0.36, 1.39 0.66 0.33, 1.32 n/a 10 7.5 0.63 0.28, 1.44 0.57 0.24, 1.37 n/a 3rd Quartile 19 12.6 0.70 0.36, 1.34 0.71 0.36, 1.43 12 8.0 0.67 0.31, 1.47 0.70 0.30, 1.62 4th Quartile 22 17.3 1.01 0.54, 1.91 1.04 0.53, 2.03 16 12.6 1.12 0.53, 2.34 1.21 0.56, 2.64 p-trend 0.96 0.94 0.79 0.70 Met exercise guidelines no 69 16.7 referent referent n/a 43 10.4 referent referent n/a yes 20 11.6 0.65 0.38, 1.11 0.69 0.40, 1.18 14 8.1 0.76 0.40, 1.42 0.82 0.43, 1.55 Moderate/vigorous intensity 1st Quartile 25 16.0 referent referent n/a 15 9.6 referent referent n/a 2nd Quartile 23 15.2 0.94 0.51, 1.74 0.93 0.49, 1.77 16 10.6 1.11 0.53, 2.34 1.11 0.51, 2.41 3rd Quartile 20 14.4 0.88 0.47, 1.67 0.92 0.47, 1.79 11 7.9 0.81 0.36, 1.82 0.90 0.39, 2.08 4th Quartile 21 14.7 0.90 0.48, 1.70 0.90 0.46, 1.76 15 10.5 1.10 0.52, 2.34 1.14 0.51, 2.55 p-trend 0.71 0.76 0.99 0.88 Domain of Activity Household/ caregiving 1st Quartile 25 18.3 referent referent referent 15 11.0 referent referent referent 2nd Quartile 22 14.4 0.75 0.40, 1.41 0.94 0.48, 1.86 0.95 0.48, 1.91 16 10.5 0.95 0.45, 2.00 1.25 0.55, 2.85 1.20 0.52, 2.77 3rd Quartile 17 11.6 0.59 0.30, 1.15 0.67 0.32, 1.40 0.71 0.33, 1.50 8 5.5 0.47 0.19, 1.15 0.58 0.22, 1.56 0.57 0.21, 1.55 4th Quartile 21 15.9 0.85 0.45, 1.60 0.99 0.47, 2.06 0.98 0.46, 2.11 17 12.9 1.20 0.57, 2.52 1.60 0.67, 3.84 1.53 0.62, 3.78 p-trend 0.46 0.75 0.78 0.99 0.55 0.61 Occupational unemployed 44 16.5 referent referent referent 28 10.5 referent referent referent at or below median 20 11.8 0.68 0.38, 1.20 0.58 0.32, 1.07 0.58 0.31, 1.09 13 7.7 0.71 0.36, 1.41 0.65 0.31, 1.37 0.68 0.32, 1.45 above median 23 15.5 0.93 0.54, 1.61 0.80 0.42, 1.53 0.72 0.37, 1.43 15 10.1 0.96 0.49, 1.86 0.77 0.35, 1.73 0.67 0.29, 1.56 Sports/Exercise none 45 16.0 referent referent referent 31 11.0 referent referent referent at or below median 26 16.7 1.05 0.62, 1.78 1.08 0.63, 1.87 0.93 0.52, 1.67 13 8.3 0.73 0.37, 1.45 0.80 0.40, 1.61 0.58 0.27, 1.24 above median 18 12.1 0.72 0.40, 1.30 0.76 0.41, 1.38 0.65 0.34, 1.42 13 8.7 0.77 0.39, 1.52 0.85 0.42, 1.71 0.63 0.30, 1.33 Transportation 1st Quartile 27 15.7 referent referent referent 16 9.3 referent referent referent 2nd Quartile 18 14.8 0.93 0.49, 1.78 0.87 0.44, 1.73 0.76 0.36, 1.57 12 9.8 1.06 0.48, 2.34 0.98 0.42, 2.26 0.88 0.37, 2.09 3rd Quartile 26 16.8 1.08 0.60, 1.95 1.11 0.59, 2.08 1.01 0.53, 1.95 18 11.6 1.28 0.63, 2.61 1.34 0.62, 2.86 1.05 0.47, 2.32 4th Quartile 18 13.0 0.80 0.42, 1.52 0.90 0.46, 1.75 0.76 0.36, 1.58 11 7.9 0.84 0.38, 1.87 0.94 0.41, 2.17 0.72 0.29, 1.80 p-trend 0.65 0.95 0.63 0.89 0.91 0.61 Met American College of Obstetricians and Gynecologists guidelines of > 7.5 MET-hrs/week in sports/exercise activities of moderate-intensity or greater Adjusted for age, education, live with partner or spouse, parity, generation in U.S., and weeks between interviews Additionally adjusted for energy expenditure from other domains of physical activity Szegda et al. 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