Stillbirth: Women´s long-term quality of life, mental health and the subsequent pregnancy. Results from two observational studies on women with a history of stillbirth

Abstract

Background: Experiencing a stillbirth is known to strongly affect women’s mental health in the short term, while the long-term impact on quality of life (QOL) and mental health remains uncertain. Psychological distress is common in the subsequent pregnancy and may be a challenge for healthcare professionals who provide guidance for these women. Interventions during childbirth, such as induced labour and elective caesarean section are more common in this group. Objectives: 1) To measure long-term QOL, well-being, depression and post-traumatic stress symptoms (PTSS) in women with a history of stillbirth, 2) to investigate experiences at the time of stillbirth and identify predictors for long-term PTSS, 3) to estimate the proportions with case-level anxiety, depression and relationship dissatisfaction during and after the subsequent pregnancy and 4) to assess healthcare utilisation, induced labour and caesarean section, and anxiety and dread of childbirth as potential mediators for these outcomes. Methods: This thesis is based on findings from two observational studies. The first study is a retrospective study including 106 women with a history of stillbirth 5-18 years previously, and 262 women with live births. The second study is a prospective cohort including 174 women pregnant after a stillbirth, 362 women pregnant after a live birth and 365 nulliparous women. Bivariate and multivariate linear and logistic regression models were used to quantify the association between previous stillbirth and the various outcomes. Results: A history of stillbirth was not associated with long-term global QOL, subjective well-being or global depression after adjustments for sociodemographic and health-related variables. The majority with a history of stillbirth had seen and held their baby and was satisfied with the support from healthcare professionals. One third showed clinically significant PTSS at follow up, while 13% scored above a (possible) post-traumatic stress disorder (PTSD) level. Risk factors for PTSS were younger age (OR 6.60, p = 0.002), induced abortion prior to stillbirth (OR 5.78, p = 0.009) and higher parity at the time of stillbirth (OR 3.46, p = 0.023). Having held the baby appeared to be protective (OR 0.17, p = 0.004). In the subsequent pregnancy, women with a previous stillbirth were at higher risk of caselevel anxiety (22.5%) and depression (19.7%) compared with women with a previous live birth (4.4% and 10.3% respectively) and previously nulliparous women (5.5% and 9.9% respectively). The differences remained significant in the multivariate analyses. Gestational age at stillbirth (> 30 weeks) and inter-pregnancy interval < 12 months were not significantly associated with case-level depression and/or anxiety. The proportions with case-level anxiety and depression were similar to the reference groups six to 18 months after the birth of a live born baby, but increased slightly 36 months postpartum. Relationship satisfaction did not differ between groups at any time point. Women pregnant after stillbirth had more frequent antenatal visits (mean 10.0 vs. 6.0 and 6.3) and more often induced labour (42.0% vs. 9.4% and 17.8%) and caesarean section (32.2% vs. 11.0% and 16.4%) compared with women with previous live births and previously nulliparous women. Anxiety was a significant, but minor, mediator for the association between previous stillbirth and frequency of antenatal visits. Dread of childbirth was not a significant mediator for the association between previous stillbirth and elective caesarean section. Conclusions: On group level, long-term QOL, well-being, and depression was not affected by a previous stillbirth in our study. However, the stillbirth clearly remains a significant event in many women´s lives as one in three women presented with clinically significant PTSS in the long term. Our findings support common guidelines that encourage women to have contact with their stillborn baby. Case-level anxiety and depression was prevalent in the subsequent pregnancy and antenatal visits, induced labour and caesarean section was more frequent. The psychosocial care provided for this group should be evaluated. Other factors than general anxiety and dread of childbirth could be stronger mediators for the high frequency of elective caesarean sections in the pregnancy after stillbirth, and this should be assessed in future studies.