A Cross-sectional Study ofPostpartum Depressive Symptomsand Infant Weight Outcomes: DoWell-Child Visits make aDifference?Rada K Dagher1 and Taryn W Morrissey2

1Department of Health Services Administration, University of Maryland, CollegePark, Maryland, USA2Department of Public Administration and Policy, School of Public Affairs,American University, USA*Corresponding author: Rada K. Dagher, Ph.D., M.P.H., Assistant Professor,School of Public Health, University of Maryland, 3310B School of Public HealthBuilding, College Park, Maryland 20742, USA, Tel: 301-405-1210; Fax:301-405-2542; E-mail: rdagher1@umd.eduRec date: Jul 21, 2014, Acc date: Feb 05, 2015, Pub date: Feb 12, 2015

Abstract

Background: Maternal postpartum depression affects 10% to20% of new mothers, but little research has examined itsrelationship with weight outcomes during infancy and whetherclinical interventions can mitigate this relationship. This studyinvestigated the associations of postpartum depressivesymptoms with infants’ weight-for-length z-scores, obesity, andoverweight at 9 months of age; and whether the number ofwell-child visits moderated these associations.

Methods: We used data from the Early Childhood LongitudinalStudy-Birth Cohort (ECLS-B), a nationally representativesample of approximately 10,700 children born in the U.S. in2001.

Results: At 9 months postpartum, 6% of the mothers wereconsidered severely depressed, and 18.2% either moderatelyor severely depressed, on the Center for Epidemiologic StudiesDepression Scale. Approximately 15% of the infants wereobese and 29% were overweight (at or above the 95th or 85thpercentiles for weight and length, respectively). Highermaternal depression scores were associated with lower odds ofobesity (OR=0.997, 95% CI: 0.970-0.994) and overweight(OR=0.990, 95% CI: 0.981-0.999) among their infants, andhigher numbers of well-child-visits were associated with evenlower odds of child overweight among mothers with higherdepression scores (OR=0.996, 95% CI: 0.993-0.999).Depressive scores had no associations with infants’ continuousweight-for-length z-scores.

Conclusion: While the causal directions and mechanismsremain unclear, findings suggest that well-child visits mayprovide an opportunity to address mothers’ depressivesymptoms and establish healthy habits among their children.

Keywords: Maternal depression; Infant obesity andoverweight; Well-child visits

IntroductionChildhood obesity and overweight are significant public health

problems in the United States (U.S.). Although the obesity rate amongvery young children has decreased in recent years, in 2011-2012, 22.8%of 2 to 5 year old U.S. children were overweight and 8.4% wereconsidered obese [1]. In addition, 15.2% of 9 months old U.S. childrenwere at-risk for obesity and 16.7% were considered obese [2].Childhood obesity is associated with negative health outcomesincluding atherosclerotic plaque [3], development of insulin resistanceand type 2 diabetes [3], and high prevalence of high blood pressure,high plasma triglycerides, low HDL cholesterol levels, asthma,shortness of breath, and obstructive sleep apnea [4,5]. Moreover,childhood obesity has psychological consequences among childrenincluding stigmatization, eating disturbances, and depression [6,7].

Maternal postpartum depression is also an important public healthissue, not only for women themselves but also for their children andfamilies. Postpartum depression is prevalent among 10% to 20% ofnew mothers [8] and has been shown to negatively affect mothers’quality of life [9], their close and intimate relationships [10,11], andmay have negative effects on children’s emotional and cognitivedevelopment [12,13], maternal-infant interactions [14,15], andmaternal self-efficacy in the first few years of a child’s life [16].Postpartum depression typically begins within four weeks afterchildbirth but may start as late as 3, 6, or 9 months postpartum [17].Symptoms can be severe and persistent, usually lasting for months[18].

Maternal postpartum depression may play a role in children’sweight outcomes during early childhood. The postpartum period is animportant time for the infant to develop a secure attachment to themother, which contributes to healthy development [19]. Householdproduction theory maintains that families “produce” child outcomes,such as physical health, through parental resources or a lack thereof[20], including maternal postpartum depression. The literature onfailure to thrive and studies in a number of developing countries haveshown significant associations between maternal depression and infantgrowth delays [21]; however, studies on maternal depression and childobesity-the other end of the growth spectrum- are limited. Depressedmothers may be less likely to breastfeed, contributing to greaterreliance on formula or cow’s milk and bottle-feeding, which isassociated with poorer self-regulation and weight gain in infancy [22].Families with depressed mothers may also have difficulty establishingand maintaining healthy eating habits and mealtime and bedtimeroutines [23,24]. Moreover, the stress from living with a mother facingdepressive symptoms may lead to metabolic abnormalitiescontributing to weight gain [25] or to weight loss [26]. The establishedassociations between maternal depression and impaired mother-infantrelationships [15] may also play a role in infant weight gain or loss.

The findings from the few studies conducted in this area of researchshow conflicting results. Three studies found that exposure tomaternal depression or depressive symptoms during the earlychildhood period was associated with a higher probability of beingoverweight and being obese among infants aged 6-24 months living inlow-income families in Brazil [27], with higher overall adiposityamong 3-year-olds in a prospective sample in Boston [28], and withhigher likelihood of being overweight for children who were 12, 24,and 36 months from 10 states in the U.S. [29]. Conversely, two otherstudies found that maternal depression was associated with slower

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weight gain from 0 to 4 months among infants from NortheastEngland [30], and being exposed to chronic maternal depression wasassociated with lower risk for overweight among Latina infants in SanFrancisco in the first two years of life [26]. A cohort study spanningfive European countries (Belgium, Germany, Italy, Poland, Spain)found no associations between postpartum depression and infants’ z-scores for weight-for-length or other anthropometric indices ininfants’ first two years of life [31]. These contradictory results may beexplained by the diverse samples studied in different countries, studydesign differences and in some instances small sample sizes.

Depressed mothers report less positive parenting practices inrelation to health promotion and disease prevention activities thatcould affect child health and weight. These include lower rates of well-child-care visits and up-to-date vaccinations [32], lower likelihood ofpositive enrichment activity with their children such as reading,singing, and story-telling [33,34], less healthy infant sleep practices[24,34], fewer rules regarding mealtimes [24], and a lower likelihood ofbreastfeeding [34,35]. Despite these established associations and thefact that mothers remain the primary decision-makers for theirchildren’s health behaviors and health services use [31], little is knownon how mothers’ parental practices affect the relationship betweenmaternal depression and children’s weight outcomes, especially thelikelihood of obesity or overweight among children.

If maternal postpartum depression does indeed influence children’sweight outcomes, the clinical and preventive strategies for mitigatingthese effects are important to understand. Well-child visits during thefirst year of a child’s life have been shown in a number of studies topresent a good opportunity for screening mothers for postpartumdepression and ensuring appropriate treatment and follow-up [36].Importantly, most preventive health care for children under two yearsof age is usually administered during these visits, including theadministration of vaccines, anthropomorphic measurements,nutritional guidance, developmental assessments, and screening testsamong others [37]. The American Academy of Pediatrics recommendsa minimum of seven well-child visits during a child’s first year of life[38]. During well-child visits, pediatricians have the opportunity todiscuss nutrition and physical activity with parents and screenchildren for underweight, overweight and obesity as well as addressmothers’ maternal depressive symptoms; thus, well-child visits maymitigate the negative impacts of maternal depression on children’sweight outcomes.

This study addresses these gaps in the literature by investigating therelationship between postpartum maternal depressive symptoms andtheir infants’ weight-for-length z-scores, obesity, and overweightoutcomes at 9 months of age using a nationally representative sampleof U.S. infants. In addition, we test the moderating effect of well-childvisits in the relationship between maternal depressive symptoms andeach of these weight outcomes. We hypothesize that postpartumdepressive symptoms are associated with higher weight-for-length z-scores and an increased likelihood of obesity and overweight amongtheir infants. Further, we hypothesize that associations betweenpostpartum depressive symptoms and poorer infant weight outcomes(higher z-scores, obesity, and overweight) are weaker among infantswho received higher numbers of well-child visits.

Materials and Methods

SampleThis study uses data from the Early Childhood Longitudinal Study-

Birth Cohort (ECLS-B), a comprehensive, longitudinal study of anational sample of approximately 10,700 children born in the U.S. in20011. The ECLS-B over-sampled Asian and American-Indianchildren, twins, and low and very low birth weight children. This studyuses the data collected on these children at 9 months of age (wave 1,collected in 2001-2002). Data were collected using parent surveys,direct child assessments, and observations of the home and childcareenvironments at the 9 months wave. This secondary data analysisreceived exemption by our university Institutional Review Boards.

MeasuresMeasures of infants’ weight-for-length z-scores, obesity, and

overweight serve as dependent variables. Anthropometric measures ofinfants’ weight and length were collected in the lab at 9 months bytrained data collectors. Child length was measured using a measuremat and child weight was measured by subtracting the weight of themother when standing on a SECA weight scale alone from her weightwhen carrying the child. Each physical measurement was obtainedtwice to minimize error. If the two measures were more than 5% apart,a third measurement was taken. The two closest measurements werethen averaged together. Infants’ weight-for-length z-scores and thebinary measures of obesity (at or above the 95th percentile) andoverweight (at or above the 85th percentile) standardized by age andsex, were calculated using Centers for Disease Control (CDC)standards [39].

Our independent variable of maternal depressive symptoms at 9months was measured using a modified version of the Center forEpidemiologic Studies Depression Scale [40]. Consistent with otherresearch using the modified 12-item CES-D, we considered those whoscored 10 or higher on the CES-D scale as experiencing moderate orsevere depressive symptoms and those who scored higher than 15 asexperiencing severe depressive symptoms [34]. However, we usecontinuous depression scores as an independent variable, as we lackclinical diagnoses of depression. Respondents (mostly biologicalmothers) reported the number of well-baby check-ups the child hadreceived since he/she was born, which served as our independent andmoderating variable.

Based on a priori causal assumptions, several covariates that couldconfound the relationship between maternal depressive symptoms andinfant weight outcomes were included as control variables in theregression models. These covariates included child age (in months),child sex (reference=male), child race/ethnicity (Black; Hispanic;multiracial; versus White), household size, birthweight (moderatelylow; very low; versus normal), child health (fair/poor; good; versusexcellent/very good), maternal age (in years), maternal employment(full-time; part-time; looking for work; versus unemployed), mother’smarital status (married versus not), maternal education (high schoolgraduate; college graduate or higher; versus below high schooleducation), household income (four categories of income versus$0-25,000), child’s health insurance status (reference=uninsured),child’s residence (suburban; urban; versus rural), whether the childwas ever breastfed or not, and mothers’ pre-pregnancy weight (in

1 The reported sample sizes are rounded to the nearest 50, per NCES regulations regarding disclosure of restricted-use data.

Citation: Dagher RK, Morrissey TW (2015) A Cross-sectional Study of Postpartum Depressive Symptoms and Infant Weight Outcomes: Do Well-Child Visitsmake a Difference?. J Womens Health, Issues Care 4:2.

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pounds). Frequencies of these variables and their coding in theanalyses can be found in Table 1.

Variable Frequency (%)

or MEAN +/- SD

(unweighted)

Frequency (%)

or MEAN +/- SD

(weighted)**

Range

Child Sex (1= Male) 51.1% 51.1% 0-1

Child Age (months) 10.52 (1.88) 10.48 (1.95) 6.20-22.30

Child Race/Ethnicity 0-1

White (ref.) 41.5% 53.2%

Black 15.9% 13.8%

Hispanic 20.6% 25.6%

Asian1 14.5% 3.5%

Multiracial 7.6% 4.0%

Total Household Size (number of household members) 4.46 (1.52) 4.33 (1.46) 2-19

Child Birthweight 0-1

Normal (ref.) 73.7% 92.5%

Moderately Low 15.5% 6.2%

Very Low 10.8% 1.3%

Child Health 0-1

Excellent/Very Good (ref.) 86.2% 88.3%

Good 10.7% 9.2%

Fair/Poor 3.2% 2.5%

Maternal Age (years) 28.50 (6.55) 28.28 (6.32) 15-68

Maternal Employment 0-1

Not in labor force (ref.) 41.4% 39.6%

>=35 hours/week 32.5% 32.2%

<35 hours/week 17.7% 20.0%

Looking for work 8.3% 8.2%

Mother Married (1=Yes) 65.2% 66.5% 0-1

Maternal Education 0-1

Below high school (ref.) 19.2% 19.6%

Has high school degree 54.5% 56.1%

Has college/higher 26.4% 24.3%

Household Income 0-1

$0-25,000 (ref.) 36.2% 35.3%

$25,001-50,000

$50,001-75,000

29.0%

14.6%

29.2%

15.1%

$75,001-100,000 9.4% 10.1%

Citation: Dagher RK, Morrissey TW (2015) A Cross-sectional Study of Postpartum Depressive Symptoms and Infant Weight Outcomes: Do Well-Child Visitsmake a Difference?. J Womens Health, Issues Care 4:2.

doi:http://dx.doi.org/10.4172/2325-9795.1000179

Volume 4 • Issue 2 • 1000179 • Page 3 of 11 •

>$100,000 10.7% 10.3%

Child has Health Insurance (1=Yes)

Child Residence 96.5% 95.9% 0-1

Rural area (ref.) 15.0% 14.4%

Suburban area 12.3% 12.0%

Urban Area 72.7% 73.5%

Child was Breastfed (1=Yes) 67.5% 69.5% 0-1

Maternal Pre-pregnancy Weight (Kg) 65.85(16.39) 66.60 (15.87) 34-180

Maternal depression score at 9 months postpartum 5.23(5.58) 4.91(5.45) 0-36

Mothers meeting threshold for severe depression (>15) 6.0% 5.5% 0-1

Mothers meeting threshold for moderate/severe depression (>9) 18.2% 16.1% 0-1

Child weight-for-length z-scores 0.27(1.84) 0.36(1.94) -47.34- -17.07

Child is obese (weight-for-length => 95th percentile) 15.0% 17.0% 0-1

Child overweight (weight-for-length => 85th percentile) 29.0% 32.0% 0-1

Number of well-child visits up to 9 months old 5.64(2.72) 5.40(2.37) 0-20

*Sample size was rounded to the nearest 50, in accordance with NCES regulations. **Frequencies and means using sampling weights. 1Includes Asian/Native Hawaiian/PacificIslander/American Indian/Alaska Native

Table 1: Sample Characteristics (N=10,700)*

Statistical analysesAnalyses were conducted using Stata software (v.11.2; Stata

Corporation, College Station, Texas, USA). Using multiple linearregression, main effects associations between the main independentvariables (maternal depressive symptoms and well-child visits) andinfants’ weight-for-length z-scores were first tested, without thecontrol variables or the interaction effects (Model 1)2. Next, anadjusted model, including the main effects and control variables, wastested (Model 2). Finally, the moderating effect of well-child visits onmaternal depression scores was tested in the adjusted model [41] usingan interaction term (Model 3). These series of analyses were repeatedfor the binary dependent variables of infant obesity and infantoverweight status, using logistic regression analyses.

ResultsTable 1 presents the maternal and infant characteristics of the

sample. The average maternal depression score was 5.23 (SD: 5.58,Range: 0-36); 6% of the mothers met the threshold for being severelydepressed (i.e. >15) and 18.2% met the threshold for being moderatelyor severely depressed (i.e. >9). Approximately 15% of the infants wereobese (had a weight-for-length at or greater than the 95th percentile)and 29% were overweight (had a weight-for-length at or greater thanthe 85th percentile). The average number of well-child visits up to 9months of age in this sample was 5.64 (SD: 2.72; Range: 0-20).

Table 2 presents the results of multiple linear regression analysespredicting infants’ weight-for-length z-scores.

Model 1

Unadjusted main effects

Model 2

Adjusted main effects

Model 3

Adjusted main and interaction effects‡

β 95% CI β 95% CI β 95% CI

Maternal Depression (MD) -0.004 (-0.011, 0.003) -0.002 (-0.009, 0.005) 0.006 (-0.009, 0.021)

Number of well-child visits (WC) -0.033 (-0.048, -0.018)*** -0.016 (-0.032, -0.001)* -0.008 (-0.029, 0.013)

MD* WC (Interaction) -0.001 (-0.004, 0.001)

Child Age (months) -0.021 (-0.043, 0.001)†

2 We also tested maternal depression scores without including well-child visits with each of the infant weight outcomes and the resultswere similar to those where depression scores and well-child visits were tested together.

Citation: Dagher RK, Morrissey TW (2015) A Cross-sectional Study of Postpartum Depressive Symptoms and Infant Weight Outcomes: Do Well-Child Visitsmake a Difference?. J Womens Health, Issues Care 4:2.

doi:http://dx.doi.org/10.4172/2325-9795.1000179

Volume 4 • Issue 2 • 1000179 • Page 4 of 11 •

Child Sex (1= Male) 0.169 (0.091, 0.247)***

Child Race/Ethnicity

White (ref.)

Black -0.085 (-0.216, 0.047)

Hispanic 0.231 (0.113, 0.348)***

Asian1 -0.006 (-0.134, 0.122)

Multiracial 0.074 (-0.074, 0.223)

Household Size -0.013 (-0.041, 0.014)

Birthweight

Normal (ref.)

Moderately Low -0.272 (-0.384, -0.160)***

Very Low -0.413 (-0.549, -0.276)***

Child Health

Excellent/V. good (ref.)

Good -0.183 (-0.313, -0.052)**

Fair/Poor -0.062 (-0.299, 0.176)

Maternal Age 0.006 (-0.002, 0.013)

Maternal Employment

Not in labor force (ref.)

>=35 hours/week 0.024 (-0.072, 0.120)

<35 hours/week -0.056 (-0.166, 0.055)

Looking for work -0.078 (-0.231, 0.076)

Marital Status (1= Mother Married) -0.147 (-0.251, -0.042)**

Maternal Education

Below high school (ref.)

Has high school degree -0.126 (-0.245, -0.008)*

Has college/higher -0.072 (-0.232, 0.088)

Household Income

$0-25,000 (ref.)

$25,001-50,000 0.029 (-0.078, 0.136)

$50,001-75,000 0.051 (-0.088, 0.191)

$75,001-100,000 -0.010 (-0.175, 0.156)

>$100,000 0.083 (-0.086, 0.252)

Child is Insured (1=Yes) -0.002 (-0.223, 0.219)

Child Residence

Rural area (ref.)

Citation: Dagher RK, Morrissey TW (2015) A Cross-sectional Study of Postpartum Depressive Symptoms and Infant Weight Outcomes: Do Well-Child Visitsmake a Difference?. J Womens Health, Issues Care 4:2.

doi:http://dx.doi.org/10.4172/2325-9795.1000179

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Suburban area 0.161 (0.015, 0.308)*

Urban Area 0.148 (0.034, 0.262)*

Child was Breastfed (1=Yes) 0.007 (-0.082, 0.097)

Mother’s Pre-pregnancy Weight 0.007 (0.005, 0.009)***

1 Includes Asian/Native Hawaiian/Pacific Islander/American Indian/Alaska Native

‡The Coefficients and Confidence Intervals for control variables are not shown here for brevity but the same control variables adjusted for in Model 2 were adjusted for in Model 3.

Table 2: Multiple linear regression analyses modeling the relationship between maternal depressive symptoms and infant weight-for-length z-scores

Unadjusted and adjusted analyses show a significant associationbetween the total number of well-child visits and weight-for-length z-scores (β=-0.033; β=-0.016, respectively); each additional well-childvisit was associated with a 0.016 decrease in z-scores in the adjustedanalyses. No significant associations were found between maternaldepressive symptoms and weight-for-length z-scores. Model 3, whichis inclusive of the interaction effect, found no moderating effect forwell-child visits. The control variables showed notable results. Maleinfants averaged higher weight-for-length z-scores than females(β=0.169) and Hispanic infants averaged higher z-scores than whiteinfants (β=0.231). Infants who had moderately or very low birthweights had lower weight-for-length z-scores than infants who were

born with normal birth weight (β=-0.272; β=-0.413, respectively).Infants reported by their mothers to be in good health had lower z-scores than those with excellent or very good health (β=-0.183).Infants whose mothers were married had lower weight-for-length z-scores than those whose mothers were not married (β=-0.147) andthose whose mothers had a high school degree had lower z-scores thanthose whose mothers did not have a high school degree (β=-0.126).Infants who lived in urban or suburban areas had higher z-scores thanthose who lived in rural areas (β=0.148; β=0.161, respectively). Finally,higher maternal pre-pregnancy weight was associated with increasedweight-for-length z-scores among their children (β=0.007).

Model 1

Unadjusted main effects

Model 2

Adjusted main effects

Model 3

Adjusted main and interaction effects ‡

OR 95% CI OR 95% CI OR 95% CI

Maternal Depression (MD) 0.988 (0.977, 0.999)* 0.982 (0.970, 0.994)** 0.997 (0.971, 1.023)

Number of well-child visits (WC) 0.994 (0.972, 1.017) 1.010 (0.985, 1.035) 1.024 (0.990, 1.060)

MD * WC (Interaction) 0.997 (0.993, 1.002)

Child Age (months) 1.004 (0.970, 1.039)

Child Sex (1= Male) 1.227 (1.084, 1.390)***

Child Race/Ethnicity

White (ref.)

Black 1.033 (0.840, 1.272)

Hispanic 1.284 (1.071, 1.539)**

Asian1 0.930 (0.754, 1.147)

Multiracial 1.080 (0.855, 1.364)

Household Size 1.012 (0.970, 1.056)

Birthweight

Normal (ref.)

Moderately Low 0.552 (0.451, 0.676)***

Very Low 0.481 (0.373, 0.621)***

Child Health

Citation: Dagher RK, Morrissey TW (2015) A Cross-sectional Study of Postpartum Depressive Symptoms and Infant Weight Outcomes: Do Well-Child Visitsmake a Difference?. J Womens Health, Issues Care 4:2.

doi:http://dx.doi.org/10.4172/2325-9795.1000179

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Excellent/V. good (ref.)

Good 0.925 (0.746, 1.146)

Fair/Poor 1.052 (0.720, 1.537)

Maternal Age (years) 1.007 (0.995, 1.019)

Maternal Employment

Not in labor force (ref.)

>=35 hours/week 1.064 (0.914, 1.239)

<35 hours/week 0.915 (0.764, 1.095)

Looking for work 1.023 (0.806, 1.299)

Marital Status (1= Mother Married) 0.788 (0.671, 0.927)**

Maternal Education

Below high school (ref.)

Has high school 1.052 (0.874, 1.265)

Has college/higher 1.197 (0.929, 1.543)

Household Income

<$25,000 (ref.)

$25,001-50,000 0.986 (0.835, 1.164)

$50,001-75,000 0.866 (0.692, 1.083)

$75,001-100,000 0.685 (0.518, 0.905)**

>$100,000 0.809 (0.615, 1.064)

Child is Insured (1=Yes) 1.109 (0.777, 1.583)

Child Residence

Rural (ref.)

Suburban area 1.212 (0.962, 1.525)

Urban Area 1.105 (0.917, 1.331)

Child was Breastfed (1=Yes) 0.904 (0.785, 1.041)

Mother’s Pre-pregnancy Weight 1.009 (1.006, 1.013)***

1Includes Asian/Native Hawaiian/Pacific Islander/American Indian/Alaska Native. †p< 0.10 *p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001. ‡The Coefficients and Confidence Intervals forcontrol variables are not shown here for brevity but the same control variables adjusted for in Model 2 were adjusted for in Model 3.

Table 3: Logistic regression analyses modeling the relationship between maternal depressive symptoms and infant obesity

Model 1

Unadjusted main effects

Model 2

Adjusted main effects

Model 3

Adjusted main andinteraction effects‡

OR 95% CI OR 95% CI OR 95% CI

Maternal Depression (MD) 0.993 (0.984, 1.001) 0.990 (0.981, 0.999)* 1.010 (0.989, 1.031)

Number of well-child visits (WC) 0.970 (0.952, 0.988)*** 0.988 (0.969, 1.008) 1.008 (0.981, 1.036)

Citation: Dagher RK, Morrissey TW (2015) A Cross-sectional Study of Postpartum Depressive Symptoms and Infant Weight Outcomes: Do Well-Child Visitsmake a Difference?. J Womens Health, Issues Care 4:2.

doi:http://dx.doi.org/10.4172/2325-9795.1000179

Volume 4 • Issue 2 • 1000179 • Page 7 of 11 •

MD* WC (Interaction) 0.996 (0.993,0.999)*

Child Age (months) 0.985 (0.958, 1.012)

Child Sex (1= Male) 1.236 (1.122, 1.362)***

Child Race/Ethnicity

White (ref.)

Black 0.977 (0.829, 1.150)

Hispanic 1.196 (1.036, 1.382)*

Asian1 0.921 (0.785, 1.081)

Multiracial 1.014 (0.844, 1.219)

Household Size 1.008 (0.975, 1.043)

Birthweight

Normal (ref.)

Moderately Low 0.626 (0.540, 0.725)***

Very Low 0.525 (0.435, 0.634)***

Child Health

Excellent/V. good (ref.)

Good 0.826 (0.697, 0.978)*

Fair/Poor 1.061 (0.789, 1.427)

Maternal Age (years) 1.002 (0.993, 1.012)

Maternal Employment

Not in labor force (ref.)

>=35 hours/week 1.090 (0.967, 1.227)

<35 hours/week 0.997 (0.868, 1.144)

Looking for work 0.906 (0.747, 1.099)

Marital Status (1= Mother Married) 0.782 (0.687, 0.889)***

Maternal Education

Below high school (ref.)

Has high school 0.944 (0.816, 1.093)

Has college/higher 1.089 (0.894, 1.328)

Household Income

<$25,000 (ref.)

$25,001-50,000 1.019 (0.893, 1.164)

$50,001-75,000 0.899 (0.754, 1.072)

$75,001-100,000 0.950 (0.772, 1.169)

>$100,000 1.051 (0.853, 1.296)

Child is Insured (1= Yes) 0.959 (0.731, 1.258)

Citation: Dagher RK, Morrissey TW (2015) A Cross-sectional Study of Postpartum Depressive Symptoms and Infant Weight Outcomes: Do Well-Child Visitsmake a Difference?. J Womens Health, Issues Care 4:2.

doi:http://dx.doi.org/10.4172/2325-9795.1000179

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Child Residence

Rural (ref.)

Suburban area 1.172 (0.978, 1.404)†

Urban Area 1.082 (0.938, 1.250)

Child was Breastfed (1= Yes) 0.888 (0.795, 0.992)*

Mother’s Pre-pregnancy Weight 1.008 (1.005, 1.011)***

1Includes Asian/Native Hawaiian/Pacific Islander/American Indian/Alaska Native. †p< 0.10; *p ≤ 0.05; **p ≤ 0.01; ***p ≤ 0.001. ‡ The Coefficients and Confidence Intervals forcontrol variables are not shown here for brevity but the same control variables adjusted for in Model 2 were adjusted for in Model 3

Table 4: Logistic regression analyses modeling the relationship between maternal depressive symptoms and infant overweight

DiscussionThis study investigated associations between mothers’ postpartum

depressive symptoms and their infants’ weight outcomes using a large,national dataset. Importantly, this study examined whether receipt ofthe recommended number of well-child visits mitigates the expectedrelationship between maternal depressive symptoms and infants’weight outcomes. In general, findings indicate that maternaldepressive symptoms, as measured at 9 months, are associated with avery small decrease in the likelihood of obesity and overweight amongtheir infants. Further, there is some evidence that more well-childvisits are associated with lower weight-for-length z-scores and lowerodds of overweight among infants of mothers with higher depressionscores. There are two primary explanations for these results.

First, mothers’ postpartum depression interferes with parentingbehaviors related to their infants’ weight outcomes, such as feedingpractices, for which there is evidence [34,35], and this in turn affectstheir weight and growth. Contrary to our hypotheses, however, wefound that higher maternal depressive scores were associated with avery small decrease in the odds of obesity and overweight among theirinfants. It may be that, similar to research in international contexts[30] or in subpopulations in the U.S. [26], maternal depressioninterferes with a mothers’ ability to breastfeed, provide adequate foodor regular feeding practices and meal times for their young children.This in turn may lead to lower odds of being overweight or obese, butcould potentially lead to child underweight. Indeed, previous researchhas linked maternal depressive symptoms and children’s underweightin certain contexts [42,43] and to food insecurity in the U.S [44]. Inaddition, given the established association between maternaldepression and impaired mother-infant relationships [15] and theinfluence of maternal responsiveness on the infant’s capacity todevelop self-regulation [45], it may be that infants may lose weight inresponse to maternal depression. While an important public healthissue internationally, child underweight is much less common in theU.S. than overweight, with an estimated 3% of 2 to 5 year old childrenconsidered underweight (a BMI below the 5th percentile) in 2007-2010[46]. That is, although lower odds of overweight and lower obesity areoften viewed as positive, the children of depressed mothers may be atrisk for under nutrition. However, the receipt of well-child visitsstrengthened this relationship, such that more well-child visits wereassociated with lower odds of overweight. It may be that thismitigating effect occurs among the high end of the distribution, interms of children’s weight; that is, well-child visits provide anopportunity for assistance on feeding practices or other weight-related

issues, which decreases overweight among infants at risk. Theassociation between more well-child visits and lower weight-for-lengthz-scores and the moderating effects of well-child visits on therelationship between maternal depression scores and infants’overweight outcomes suggest that well-child visits may be a potentialtool for addressing child overweight. However, an alternativeexplanation is that well child visits could be a marker of more capableparents who can not only get their child to a well child visit more oftenbut may also make better choices around food, sleep, and otherhealthy practices. These potential explanations should be investigatedin future research.

A second explanation for the identified associations betweenmaternal depression, well-child visits, and infant weight is one ofselection. Indeed, some research finds no associations of maternaldepression with infant growth [47], weight outcomes of children atschool age [48], or with children’s BMI [49]. Our analyses control for arange of maternal, child, and household characteristics, but results aresubject to omitted variable bias in that several factors related tomaternal postpartum depressive symptoms, infants’ weight outcomes,and receipt of well-child visits are likely unmeasured and thusuncontrolled. For example, an infant with special needs or in need ofhealth care may see the doctor more often and potentially also be atrisk for experiencing maternal depression. Further, it may be thatfamilies with depressed mothers have different health care usepatterns. Previous research suggests that depressed mothers usepreventive care less often and visit emergency rooms more often thannon-depressed mothers [32].

Our numerous covariates involving demographic and maternalcharacteristics produced findings that add to the growing body ofliterature on health disparities relating to infant weight outcomes.Consistent with this literature [50], Hispanic infants were more likelyto be overweight and obese at 9 months than White infants and hadhigher weight-for-length z-scores. Infants living in lower-incomehouseholds and whose mothers were not married had higher z-scoresand higher odds of being obese than their counterparts in line withother studies [51]. Higher maternal pre-pregnancy weight wasassociated with increased length-for-weight z-scores and increasedodds of obesity and overweight among their infants [52]. Infants whowere breastfed had lower odds of overweight than those who were notas reported in the literature [53]. Additionally, the persisting effects oflow birth weight on infants’ weight outcomes at 9 months areapparent, such that these infants continue to be at the lower end of theweight distribution as evidenced by lower length-for-weight z-scoresand lower odds of obesity and overweight.

Citation: Dagher RK, Morrissey TW (2015) A Cross-sectional Study of Postpartum Depressive Symptoms and Infant Weight Outcomes: Do Well-Child Visitsmake a Difference?. J Womens Health, Issues Care 4:2.

doi:http://dx.doi.org/10.4172/2325-9795.1000179

Volume 4 • Issue 2 • 1000179 • Page 9 of 11 •

LimitationsAs with all research, this study has several limitations. First,

findings identified in this analysis are associations rather than causaleffects. For example, while maternal depression may change herfeeding behaviors and thus children’s weight, it is also possible thatchildren’s feeding problems could contribute to mothers’ depression.Second, our independent variable of maternal depressive symptomshas been found to be valid and reliable, but is not a clinical diagnosisof depression and is reported by mothers themselves. Third, we usemeasures of children’s weight-for-length at 9 months, which may bean imperfect measure of weight risk at this age, and approximatesBMI, which is a limited measure of adiposity at any age because it doesnot distinguish fat from muscle [54]. Further, we use the weight andheight standards recommended by the CDC; other studies may use theWorld Health Organization (WHO) standards, which are based on abroader sample of children [55]. Fourth, with the exception of infants’weight and length, our moderating and control variables are largelyreported by mothers; to the extent that depressive symptoms affect theresponses, these variables may be biased. Finally, mothers’ depressivesymptoms and their children’s weight outcomes were measured at thesame time (9 months); there may be a lagged effect of depression onchildren’s weight, such that positive associations between maternaldepression and child obesity and overweight emerge as children age.

ConclusionThis is one of the first studies to examine the moderating effects of

well-child visits on the association between mothers’ postpartumdepression and the concurrent weight outcomes of their infants usinga national U.S. sample. We find some evidence that mothers’depressive symptoms are associated with decreased odds of beingobese or overweight among their infants at 9 months of age, and thatreceipt of more well-child visits strengthens the latter negativerelationship. While the causal directions and mechanisms remainunclear, findings suggest that well-child visits may provide anopportunity to educate parents about healthy eating habits andaddressing mothers’ depressive symptoms, potentially benefiting theweight outcomes of children at risk for overweight. More research isneeded to clarify the causal relationship between maternal depressionand infants’ weight outcomes and to determine whether clinicalinterventions during well-child visits can help promote healthy weight.

Funding SupportThis project was supported by Grant Number R40MC23630 from

the Maternal and Child Health Bureau of the Health Services andResources Administration, U.S. Department of Health and HumanServices. Its contents are solely the responsibility of the authors and donot necessarily represent the official views of the Department ofHealth and Human Services.

AcknowledgmentsAuthors’ contributions: Rada K. Dagher contributed to the project’s

conception, secured the project funding as the Co-PrincipalInvestigator, conducted the statistical analyses, drafted the majority ofthe initial manuscript, and approved the final manuscript assubmitted. Taryn W. Morrissey led the conceptual design of the study,secured the project funding as the Principal Investigator, wrote thediscussion and conclusion sections, edited the manuscript, andapproved the final manuscript as submitted.

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Citation: Dagher RK, Morrissey TW (2015) A Cross-sectional Study of Postpartum Depressive Symptoms and Infant Weight Outcomes: Do Well-Child Visitsmake a Difference?. J Womens Health, Issues Care 4:2.

doi:http://dx.doi.org/10.4172/2325-9795.1000179

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