CoChat
Sign Up
Cited by 46Maternal Mental Health During Pregnancy and PostpartumGrief, Bereavement, and Mental HealthMaternal and Neonatal Healthcare

Association between stillbirth ≥23 weeks gestation and acute psychiatric illness within 1 year of delivery

Open access
Lewkowitz, Adam K., Rosenbloom, Joshua I., Keller, Matt, López, Julia D., Macones, George A., Olsen, Margaret A., Cahill, Alison G.·2019·American Journal of Obstetrics and Gynecology
DOI 10.1016/j.ajog.2019.06.027PMC PMC6829063
Open this paper in CoChat — free account

Abstract

Background Stillbirth has been associated with emotional and psychologic symptoms. The association between stillbirth and diagnosed postpartum psychiatric illness is less well-known.Objective The purpose of this study was to determine whether women have a higher risk of experiencing clinician-diagnosed psychiatric morbidity in the year after stillbirth vs livebirth.Study design This retrospective cohort study used International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes to identify participants, exposures, and outcomes within the Florida State Inpatient and State Emergency Department databases. The first delivery of female Florida residents aged 13-54 years old from 2005-2014 was included; women with International Classification of Diseases, 9th Revision, Clinical Modification coding for psychiatric illness or substance use during pregnancy were excluded. The exposure was an International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during delivery hospitalization of a stillbirth at ≥23 weeks gestation. The primary outcome was a primary or secondary International Classification of Diseases, 9th Revision, Clinical Modification diagnosis code during an Emergency Department encounter or inpatient admission within 1 year of delivery for a composite of psychiatric morbidity: suicide attempt, depression, anxiety, posttraumatic stress disorder, psychosis, acute stress reaction, or adjustment disorder. The secondary outcome was a substance use composite of drug or alcohol use or dependence. We compared outcomes after delivery of stillbirth vs livebirth using multivariable logistic regression, adjusting for maternal sociodemographic factors, medical comorbidities, and severe intrapartum morbidity. We also used Cox proportional hazard models and tested for violation of the proportional hazard assumption to identify the highest risk time within the year after stillbirth delivery for the primary outcome, adjusting for the same factors and morbidities as in the logistic regression model.Results A total of 8292 women with stillborn singletons and 1,194,758 with liveborn singletons were included. Within 1 year of hospital discharge after stillbirth, 4.0% of the women (n=331) had an Emergency Department encounter or inpatient admission that was coded for psychiatric morbidity; the risk was nearly 2.5 times higher compared with livebirth (1.6%; n=19,746); adjusted odds ratio, 2.47; 95% confidence interval, 2.20- 2.77). Women also had higher risk of having an Emergency Department encounter or inpatient admission coded for drug or alcohol use or dependence in the year after delivery of stillbirth vs livebirth (124 [1.5%] vs 7033 [0.6%]; adjusted odds ratio, 2.41; 95% confidence interval, 1.99-2.90). Cox proportional hazard modeling suggested that the highest risk interval for postpartum psychiatric illness was within 4 months of stillbirth delivery (adjusted hazard ratio, 3.26; 95% confidence interval, 2.63-4.04), although the risk remained high during the 4-12 months after delivery (adjusted hazard ratio, 2.42; 95% confidence interval, 2.13-2.76).Conclusion Coding for psychiatric illness or substance misuse in Emergency Department visits or hospital admissions in the year after delivery of livebirths was not uncommon, corresponding to nearly 2 per 100 women. However, having a stillbirth was associated with increased risk of both psychiatric morbidity (corresponding to 1 per 25 women) and substance misuse (corresponding to 3 in 100 women), with the highest risk of postpartum psychiatric morbidity occurring from delivery until 4 months after delivery.

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Integrity signals

Registry

Crossref · 10.1016/j.ajog.2019.06.027

Cites

38 of 38 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

The claims and statistics of this paper haven’t been checked yet.

Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.

A few free checks a day · papers already verified open instantly · results are public

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Another study found that the odds of depression (as classified by ICD-9) was 2.75 (95% CI 1.93-2.70) among mothers who had been hospitalized or in contact with an emergency department within 1 year of stillbirth, compared to controls.

    “Another study found that the odds of depression (as classified by the International Classification of Diseases, 9th Revision [44];) was 2.75 (95% CI 1.93–2.70) among mothers who had been hospitalized or in contact with an emergency department within 1 year of SB, compared to controls [38].”

    From Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review (2021) · cites this paper as [38]

    The Results report an adjusted odds ratio of 2.75 for depression after stillbirth versus livebirth among women with an ED encounter or hospital admission within one year. The claim gives the wrong 95% confidence interval: 1.93–2.70 is the interval for anxiety; the depression interval is 2.31–3.26. No page number is supplied for this passage. (LLM, conf=0.93)

    Experimental — accuracy not yet measured

  • Mothers with stillbirth had more than four times higher risk of receiving a PTSD diagnosis than women with live birth (RR = 4.36, 95% CI 2.31-8.24), after adjusting for SES, mode of birth, intrapartum maternal morbidity and medical comorbidities.

    “Mothers with SB had above four times higher risk (RR = 4.36 [95% CI 2.31–8.24]) than women with live birth to receive a PTSD diagnosis, after adjusting for SES, mode of birth, intrapartum maternal morbidity and medical comorbidities.”

    From Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review (2021) · cites this paper as [38]

    The Results report more than fourfold higher odds of a PTSD code after stillbirth for inpatient hospitalizations, and Materials and Methods list the stated adjustment factors. But the reported inpatient estimate is an adjusted odds ratio of 5.36 (95% CI 2.73–10.51); our copy does not substantiate the claimed RR of 4.36 (95% CI 2.31–8.24). The inpatient estimate may concern a narrower outcome, so it does not by itself contradict that number. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • One year after stillbirth, the risk of PTSD diagnosis was two times higher than the risk of depression and anxiety diagnosis.

    “In the study by Lewkowitz et al. [38], the risk of being diagnosed with PTSD 1 year after SB was two times higher than the risk of being diagnosed with depression and anxiety.”

    From Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review (2021) · cites this paper as [38]

    The Results (page unavailable) report that, within one year, the adjusted odds of an inpatient PTSD code after stillbirth versus livebirth were 5.36; the reported adjusted odds ratios for depression and anxiety were 2.75 and 2.29. The PTSD association is roughly twice as large, but these are comparisons with livebirth—not evidence that women after stillbirth were twice as likely to receive a PTSD diagnosis as a depression or anxiety diagnosis. The PTSD figure also comes from an inpatient-only analysis, unlike the reported depression and anxiety figures. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Seven of the depression studies included a control group of parents with live births; three were retrospective cohort studies, one was cross-sectional, one was a prospective case-control study, and two were longitudinal case-control studies.

    “Seven of these studies included a control group of parents with live births; three were retrospective cohort studies [38–40], one study utilized a cross-sectional design [35], and one investigation applied a prospective case-control design [4]. The remaining two studies were longitudinal case-control studies [2, 5].”

    From Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review (2021) · cites this paper as [38]

  • Lewkowitz et al. found that the odds of being coded for anxiety according to ICD-9 during an emergency department encounter or inpatient admission within 1 year of delivery was ORadj = 2.29 (95% CI 1.93-2.70), adjusted for several control variables.

    “In the study by Lewkowitz et al. [38], the odds of being coded for anxiety according to the International Classification of Diseases, 9th Revision, during an Emergency Department encounter or inpatient admission within 1 year of delivery, was ORadj = 2.29 (95% CI 1.93–2.70), when adjusted for several control variables (Table 1).”

    From Depression, anxiety, PTSD, and OCD after stillbirth: a systematic review (2021) · cites this paper as [38]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

The self-check needs the paper’s full text.

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. [17]The American College of Obstetricians and Gynecologists. Management of stillbirth. ACOG Practice Bulletin No. 102. Obstet Gynecol. 2009; 102: 201– 207.
  2. [18]Agency for Healthcare Research and Quality. Agency for Healthcare Research AndHCUP Database Healthcare Cost and Utilization Project (HCUP). Rockville, MD http://www.hcupus.ahrq.gov/databases.jsp. 21413206

Cited by

Sorted by citations

Related

Authors
Lewkowitz, A. K., Rosenbloom, J. I., Keller, M., López, J. D., Macones, G. A., Olsen, M. A., & Cahill, A. G.
Affiliations
Washington University in St. Louis (US)
Corresponding author
Lewkowitz, Adam K.
ORCID
Venue
American Journal of Obstetrics and Gynecology
Publisher
Elsevier BV
Published
2019-11
Volume
221
Issue
5
Pages
491.e1-491.e22
ISSN
0002-9378 (ISSN-L)
DOI
10.1016/j.ajog.2019.06.027
PMC
PMC6829063
OpenAlex
W2949925596
Cited by
46
References
38
Citations by year
2026: 9 · 2025: 12 · 2024: 5 · 2023: 8 · 2022: 3 · 2021: 5 · 2020: 2 · 2019: 2
FWCI
2.76
Type
journal article
Language
en
Open access
Licence
Locations
  • American Journal of Obstetrics and Gynecology (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institutes of Health
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
  • Social Sciences › Psychology › Clinical Psychology › Grief, Bereavement, and Mental Health
  • Health Sciences › Health Professions › General Health Professions › Maternal and Neonatal Healthcare
Keywords
stillbirth, maternal mental health, suicide attempts, depression, anxiety, post-traumatic stress disorder, substance use, alcohol consumption, drug use, emergency department visits, hospitalization, postpartum period, stillbirth risk factors, maternal sociodemographic factors
MeSH terms
Adolescent, Adult, Mental Disorders, Emergency Service, Hospital, Female, Florida, Gestational Age, Hospitalization, Humans, Pregnancy, Retrospective Studies, Cohort Studies, Proportional Hazards Models, Substance-Related Disorders, Stillbirth, Young Adult

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review