Disparities in antidepressant use in pregnancy

Background: The American College of Obstetricians and Gynecologists and the American Psychiatric Association both recommend pharmacotherapy for perinatal depression when the benefits outweigh the risks. While minority adults are less likely to use antidepressant medications compared to Non-Hispanic Whites, whether this pattern occurs among pregnant women is unclear. Objective: We sought to determine the frequency of antidepressant medication use reported during ambulatory care visits for pregnant women and whether these rates varied by race. Methods: We combined the 2006–2010 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS) to obtain nationally representative estimates of outpatient preventive care visits for pregnant women. We then obtained estimates of the prevalence of reported depression and antidepressant use during outpatient visits for pregnant women. To determine whether these estimates varied by race, we used multivariable logistic regression analyses accounting for survey design using SAS 9.2 (PROC SURVEYLOGISTIC) to estimate odds ratios of reported antidepressant use after adjustment for age, insurance status and region of the country. Results: Antidepressant use was reported during 2.2% of all outpatient visits for pregnant women. Providers indicated a depression diagnosis in 4.5% of visits. Among visits for depressed pregnant women, providers reported antidepressant use 25.4% of the time for all visits. Antidepressant use during pregnancy varied significantly by race/ethnicity. Among visits for Non-Hispanic White women, 3.1% included a code for antidepressant use vs. just 1.0% for Non-White women (P<0.0001). After adjustment for age, insurance status, and region of the country, this association persisted with Non-Hispanic White (vs. Non-White) pregnant women having higher odds of antidepressant use (adjusted OR 3.3, 95% CI 2.1, 5.3). Conclusion: Non-Hispanic White women were more likely than Non-White women to be using antidepressants during pregnancy. Whether differences in antidepressant use by race/ethnicity indicates over-treatment of non-Hispanic White women or under-treatment of minorities remains unclear. This disparity warrants investigation with the goal of optimizing maternal mental health while minimizing potential adverse sequelae of antidepressants on developing fetuses

Prenatal Vitamin Use and Vitamin D Status during Pregnancy, Differences by Race and Overweight Status

Objective: We aimed to study whether prenatal vitamin (PNV) use protects against low 25(OH)D levels in all women and particularly in obese and black women who are both at risk of vitamin D deficiency and poor pregnancy outcomes. Study design We studied 1019 women enrolled in a prospective study at Brigham and Women’s Hospital in Boston, 2007–2009. We used multivariable logistic regression to analyze associations of PNV use and odds of vitamin D deficiency defined as 25(OH)D levels < 50 nmol/L. Results: 56% of black and 86% of white women reported pre- and/or post-conceptional PNV use. 75% of black and 19% of white women were vitamin D deficient in the first trimester. PNV use among black women was not associated with vitamin D deficiency (adjusted OR 1.0, 95%CI 0.4, 2.3) but was among white women (3.5, 95%CI 2.1, 5.8)(Interaction P<0.01). Conclusions: Ongoing trials of vitamin D supplementation during pregnancy should consider potential effect modification by race/ethnicity

Prenatal maternal antidepressants, anxiety, and depression and offspring DNA methylation: epigenome-wide associations at birth and persistence into early childhood

Background Maternal mood disorders and their treatment during pregnancy may have effects on the offspring epigenome. We aim to evaluate associations of maternal prenatal antidepressant use, anxiety, and depression with cord blood DNA methylation across the genome at birth and test for persistence of associations in early and mid-childhood blood DNA. Methods A discovery phase was conducted in Project Viva, a prospective pre-birth cohort study with external replication in an independent cohort, the Generation R Study. In Project Viva, pregnant women were recruited between 1999 and 2002 in Eastern Massachusetts, USA. In the Generation R Study, pregnant women were recruited between 2002 and 2006 in Rotterdam, the Netherlands. In Project Viva, 479 infants had data on maternal antidepressant use, anxiety, depression, and cord blood DNA methylation, 120 children had DNA methylation measured in early childhood (~ 3 years), and 460 in mid-childhood (~ 7 years). In the Generation R Study, 999 infants had data on maternal antidepressants and cord blood DNA methylation. The prenatal antidepressant prescription was obtained from medical records. At-mid pregnancy, symptoms of anxiety and depression were assessed with the Pregnancy-Related Anxiety Scale and the Edinburgh Postnatal Depression Scale in Project Viva and with the Brief Symptom Inventory in the Generation R Study. Genome-wide DNA methylation was measured using the Infinium HumanMethylation450 BeadChip in both cohorts. Results In Project Viva, 2.9% (14/479) pregnant women were prescribed antidepressants, 9.0% (40/445) experienced high pregnancy-related anxiety, and 8.2% (33/402) reported symptoms consistent with depression. Newborns exposed to antidepressants in pregnancy had 7.2% lower DNA methylation (95% CI, − 10.4, − 4.1; P = 1.03 × 10−8) at cg22159528 located in the gene body of ZNF575, and this association replicated in the Generation R Study (β = − 2.5%; 95% CI − 4.2, − 0.7; P = 0.006). In Project Viva, the association persisted in early (β = − 6.2%; 95% CI − 10.7, − 1.6) but not mid-childhood. We observed cohort-specific associations for maternal anxiety and depression in Project Viva that did not replicate. Conclusions The ZNF575 gene is involved in transcriptional regulation but specific functions are largely unknown. Given the widespread use of antidepressants in pregnancy, as well as the effects of exposure to anxiety and depression, implications of potential fetal epigenetic programming by these risk factors and their impacts on development merit further investigation

Changes in Prenatal Testing During the COVID-19 Pandemic

Objective: The coronavirus disease 2019 (COVID-19) pandemic disrupted healthcare delivery, including prenatal care. The study objective was to assess if timing of routine prenatal testing changed during the COVID-19 pandemic. Methods: Retrospective observational cohort study using claims data from a regional insurer (Highmark) and electronic health record data from two academic health systems (Penn Medicine and Yale New Haven) to compare prenatal testing timing in the pre-pandemic (03/10/2018-12/31/2018 and 03/10/2019-12/31/2019) and early COVID-19 pandemic (03/10/2020-12/31/2020) periods. Primary outcomes were second trimester fetal anatomy ultrasounds and gestational diabetes (GDM) testing. A secondary analysis examined first trimester ultrasounds. Results: The three datasets included 31,474 pregnant patients. Mean gestational age for second trimester anatomy ultrasounds increased from the pre-pandemic to COVID-19 period (Highmark 19.4 vs. 19.6 weeks; Penn: 20.1 vs. 20.4 weeks; Yale: 18.8 vs. 19.2 weeks, all p \u3c 0.001). There was a detectable decrease in the proportion of patients who completed the anatomy survey \u3c20 weeks\u27 gestation across datasets, which did not persist at \u3c23 weeks\u27 gestation. There were no consistent changes in timing of GDM screening. There were significant reductions in the proportion of patients with first trimester ultrasounds in the academic institutions (Penn: 57.7% vs. 40.6% and Yale: 78.7% vs. 65.5%, both p \u3c 0.001) but not Highmark. Findings were similar with multivariable adjustment. Conclusion: While some prenatal testing happened later in pregnancy during the pandemic, pregnant patients continued to receive appropriately timed testing. Despite disruptions in care delivery, prenatal screening remained a priority for patients and providers during the COVID-19 pandemic

Race and preterm birth--the case for epigenetic inquiry.

Preterm birth and infant mortality disproportionately affect African American families compared to White families. More than 18% of African American infants are born preterm (< 37 weeks' gestation) compared to just less than 12% of White infants. Consequently, African American infants are twice as likely to die in their first year of life as White infants. Differences in socioeconomic status, prenatal care usage, and behavioral characteristics fail to explain the disparity in preterm birth between African Americans and Whites. Epidemiologic data support a life-course conceptual model for African American women's pregnancy disadvantage. Life-course factors influence pregnancy outcomes through two proposed mechanisms: early-life (fetal) programming of reproductive potential and cumulative wear and tear (weathering). The biologic mechanisms behind this theory are poorly understood. In this commentary, we argue that epigenetic inquiry represents the next frontier in investigating the mechanisms underlying racial disparities in birth outcome. We propose this with the hope that these discoveries will lead to opportunities for interventions and ultimate improvements in birth outcomes

Epigenetics—a potential mediator between air pollution and preterm birth

Preterm birth is a major cause of infant morbidity and mortality and a potential risk factor for adult chronic disease. With over 15 million infants born preterm worldwide each year, preterm birth poses a global health concern. There is a possible association between air pollution and preterm birth, though studies have been inconsistent, likely due to variation in study design. How air pollution induces health effects is uncertain; however, studies have repeatedly demonstrated the effects of air pollution on epigenetic modifications. More recent evidence suggests that epigenetics may, in turn, be linked to preterm birth. Discovery of environmentally modifiable epigenetic processes connected to preterm birth may help to identify women at risk of preterm birth, and ultimately lead to development of new preterm birth prevention measures