Postpartum Depression After Mild and Severe Preeclampsia

Abstract

Objective:

To describe the prevalence of postpartum depressive symptoms after preeclampsia, to assess the extent to which the prevalence of postpartum depressive symptoms differs after mild and severe preeclampsia, and to investigate which factors contribute to such differences.

Methods:

Women diagnosed with preeclampsia (n=161) completed the Edinburgh Postnatal Depression Scale (EPDS) at 6, 12, or 26 weeks postpartum. Multiple logistic regression analysis was used to investigate the association between severity of preeclampsia, contributing factors and postpartum depression (PPD) (1) at any time during the first 26 weeks postpartum and (2) accounting for longitudinal observations at three time points.

Results:

After mild preeclampsia, 23% reported postpartum depressive symptoms at any time up to 26 weeks postpartum compared to 44% after severe preeclampsia (unadjusted odds ratio [OR] 2.65, 95% confidence interval [CI] 1.16-6.05) for depression at any time up to 26 weeks postpartum (unadjusted OR 2.57, 95% CI, 1.14-5.76) while accounting for longitudinal observations. Admission to the neonatal intensive care unit (NICU) (adjusted OR 3.19, 95% CI 1.15-8.89) and perinatal death (adjusted OR 2.96, 95% CI 1.09-8.03) contributed to this difference.

Conclusions:

It appears that not the severity of preeclampsia itself but rather the consequences of the severity of the disease (especially admission to the NICU and perinatal death) cause postpartum depressive symptoms. Obstetricians should be aware of the high risk of postpartum depressive symptoms after severe preeclampsia, particularly among women whose infant has been admitted to the NICU or has died.

Introduction

Preeclampsia is a vascular-related pregnancy syndrome of unknown cause that affects approximately 2%–8% of pregnancies.¹ Preeclampsia is associated with both maternal complications (e.g., eclampsia, cerebral hemorrhage, placental abruption, pulmonary edema, acute renal failure, and death) and an increased risk for future maternal vascular and metabolic morbidity (e.g., chronic hypertension, diabetes mellitus, chronic renal failure, coronary artery disease, stroke, and premature death).^1

–4 Moreover, preeclampsia is associated with perinatal complications, such as fetal growth restriction, preterm delivery, and perinatal asphyxia and death.^4,5 Severe preeclampsia is associated with more adverse maternal and child outcomes compared with mild preeclampsia.⁶

Preeclampsia is also considered to have a strong psychologic impact,⁷ particularly severe preeclampsia.^8,9 For example, preeclampsia is associated with posttraumatic stress disorder (PTSD).⁷ Moreover, obstetric complications are possible causal factors in postpartum depression (PPD).¹⁰

According to the DSM-IV criteria, PPD is defined as a nonpsychotic depressive episode that begins or extends into the postpartum period.^11,12 The average prevalence rate of PPD is 13% in unselected populations.¹³ Besides the burden of PPD for the mother, it has adverse effects on the behavioral, intellectual, and emotional development of children.^14

–18 Although studies on PPD after preeclampsia show that women with preeclampsia report more symptoms of depression than patients without preeclampsia, these differences did not reach significance.^7,19,20

To date, it is unknown whether women with mild preeclampsia differ from those with severe preeclampsia in the extent to which they experience symptoms of PPD. It is also not known if PPD is associated with the severity of preeclampsia itself or with the sequelae of the disease, such as admission to the neonatal intensive care unit (NICU) of the infant, admission to high obstetric care or intensive care of the mother, having a cesarean section, or perinatal death.

To provide better postpartum support for women who experience depressive symptoms after preeclampsia, knowledge of the prevalence of depressive symptoms after mild and severe preeclampsia and of the factors that contribute to differences in the prevalence of PPD depression after preeclampsia is needed. Therefore, this prospective cohort study describes the prevalence of postpartum depressive symptoms after preeclampsia and the extent to which the prevalence of postpartum depressive symptoms differs after mild and severe preeclampsia and explores which factors contribute to differences in the prevalence of depressive symptoms.

Materials and Methods

Study population

The present study was embedded in the Pro-Active study, a prospective multicenter cohort study coordinated by the Erasmus MC, University Medical Center Rotterdam. Women who had been diagnosed with preeclampsia were included in the Pro-Active study to appraise their postpartum physical and psychological health and to examine the feasibility of lifestyle interventions after a pregnancy complicated by preeclampsia.

Patients were eligible for participation in the present study if they had given birth between February 2007 and June 2009, their pregnancy had been complicated by preeclampsia, they were older than 18 years of age, and they understood and spoke the Dutch language. Eligible patients (n=255) were selected by searching the records of four Dutch hospitals (one university hospital and three large general teaching hospitals). The medical ethics committees of all four hospitals approved the study. All selected patients were invited to participate up to 6 weeks postpartum and received an information leaflet and an informed consent form: 174 participants (68%) provided written informed consent. Participants were asked to complete a questionnaire at 6 weeks, 12 weeks, and 26 weeks postpartum.

Data collection and measures

Age and details on the diagnosis of preeclampsia, parity, highest level of obstetric care during admission (standard care, high obstetric care, or intensive care), mode of delivery (vaginal delivery or cesarean section), perinatal death, admission to an NICU, gestational age at delivery, and birth weight were retrieved from hospital records.

Preeclampsia was defined according to the criteria of the American College of Obstetricians and Gynecologists (ACOG): development of blood pressure ≥140/90 mm Hg plus proteinuria (defined as ≥300 mg/day of urinary protein loss) after 20 weeks of gestation in a previously normotensive woman.⁶ Severe preeclampsia was also defined according to ACOG criteria: preeclampsia and at least one of the following: severe blood pressure elevation defined by systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥110 mm Hg, severe proteinuria (≥5 g 24 hours), hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome (defined by thrombocyte count <100*10⁹/L, and/or aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) >30 U/L), convulsion, or fetal growth restriction.⁶ Within the participating hospitals, different treatments are used for mild and severe preeclampsia. Compared with mild preeclampsia, severe preeclampsia is generally treated with intravenous antihypertensive drugs, and eclampsia prophylaxis is treated with magnesium sulfate.

Details on ethnicity and educational level were obtained from a questionnaire administered at 6 weeks postpartum. A participant was categorized as non-Dutch if she, or at least one of her parents, had been born abroad.²¹ Educational level was assessed by the highest level of completed education and placed into three categories: (1) high (university degree), (2) mid (higher vocational training, intermediate vocational training), (3) low (primary school, lower vocational training, intermediate general school).²²

The Edinburgh Postnatal Depression Scale (EPDS),^23,24 a 10-item self-report scale commonly used to screen for PPD, was used to measure postpartum depressive symptoms at 6, 12, and 26 weeks postpartum. A cutoff score of 10 has been suggested to detect possible depression, is likely to detect almost all cases of depression (with very few false negatives), and is particularly useful when the EPDS is the only measure used or when it is used as a first-stage screening scale to identify possible depression.^23,25 Moreover, a cutoff for probable depression has been suggested at 12/13.²³

Statistical analysis

Statistical analysis was performed using SPSS for Windows, version 17.0 (SPSS Inc., Chicago, IL). Frequency tables were used to explore characteristics of the total study population and those classified as having experienced mild or severe preeclampsia. Means and frequencies regarding scores on the EPDS were reported for cutoff scores of both 10 and 13. Mean and frequency differences were examined through independent sample t tests and chi-square statistics, and median differences were analyzed through median tests.

The association between severity of preeclampsia and PPD was investigated in two ways: (1) at any time point during the first 26 weeks postpartum and (2) accounting for longitudinal observations at three time points. To investigate the relationship at any time point, multiple logistic regression analysis was used. Women were considered to report postpartum depressive symptoms at any time point when they scored above the cutoff value of 10 on the EPDS at one or more measured time points. The first logistic regression analysis (model 0) used level of severity of preeclampsia (mild, severe) as an independent variable. A second, multiple logistic regression analysis (model 1) included level of severity of preeclampsia and potential confounders significantly related to postpartum depressive symptoms: age, ethnicity, and educational level. Potential confounders that were not significantly related to postpartum depressive symptoms and to severity of preeclampsia, that is, complication during a previous pregnancy and multiple pregnancies, were excluded from this analysis. Third, a multiple logistic regression model (model 2) was fitted, consisting of the variables in model 1 plus all statistically significantly related potential contributing factors.

Previous research among women without preeclampsia has shown that obstetric factors contribute to the occurrence of PPD.²⁶ Perinatal complications, such as hospitalization during pregnancy, emergency cesarean section, suspicion of fetal distress, low birth weight, low gestational age at delivery, a medically indicated delivery provided by an obstetrician, admission to the NICU, and perinatal death, have been found to increase the risk of PPD.^27

–30 These perinatal complications are also associated with preeclampsia, particularly severe preeclampsia.^4
–6 Therefore, the factors highest level of obstetric care of the mother, mode of delivery, gestational age at delivery, birth weight, admission to the NICU, days of NICU admission, and perinatal death were considered relevant consequences of preeclampsia and, therefore, potential contributing factors to differences in depressive symptoms after mild and severe preeclampsia. Before evaluating the contribution of these factors, zero-order correlations and chi-squares were calculated for severity of preeclampsia and potential contributing factors in order to explore associations between potential contributing factors and severity of preeclampsia and to assess multicollinearity between potential contributing factors. This showed that multicollinearity could be a problem for the variables, gestational age at delivery, birth weight, NICU admission, and days of NICU admission, because these variables had correlations of >0.70.³¹ (Appendix). Therefore, of these variables we included only NICU admission in the regression analyses because it is expected that an NICU admission of a child has a large impact on postpartum depressive symptoms of a mother. Thus, the factors, highest level of obstetric care, mode of delivery, NICU admission, and perinatal death, were considered as potential contributing factors, and the factors, gestational age at delivery, birth weight, and days of NICU admission, were excluded from this analysis.

To evaluate the association between severity of preeclampsia and PPD while accounting for longitudinal observations at three time points, the analyses using the three models were repeated by performing similar logistic regression analysis with the generalized estimating equations (GEE) method.³² GEE is an extension of the quasi-likelihood approach used in generalized linear models (GLM). GEE is a generalization of GLM that takes into account within-group correlation encountered in longitudinal data.³³

Results

Study population

Of the 174 participants, 137 completed the EPDS at 6 weeks postpartum, 142 completed the EPDS at 12 weeks, and 142 participants completed the EPDS at 26 weeks postpartum. The population for analysis was composed of 161 women who obtained scores on the EPDS at at least one time point. Most participants were Dutch (94%), had experienced severe preeclampsia (76%), and were primiparous (77%). Mean age was 31 (standard deviation [SD] 5) years. Compared with women who experienced mild preeclampsia, women with severe preeclampsia were younger (p<0.05), were more often admitted to the high obstetric care or intensive care unit (p<0.001), more often had a cesarean section (p<0.001), had a lower gestational age at delivery (p<0.001), delivered an infant with a lower birth weight (p<0.001), and their infant was more often admitted to the NICU (p<0.001). Women with severe preeclampsia experienced perinatal death (5%), whereas no woman with mild preeclampsia experienced perinatal death (Table 1). Women included in the study population (n=161) were less often of non-Dutch origin (6%) compared with women (n=13, 31%) who were left out of the study population (p<0.01). The groups did not differ on all other characteristics.

Table 1.

Characteristics of Study Population (n=161) and Their Offspring (n=178)

	% of study population (unless otherwise specified)
	Total n=161	Mild preeclampsia n=39	Severe preeclampsia n=122	p value ^a
Women (n=161)
Age in years: mean (SD)	31.2 (4.5)	32.7 (4.7)	30.7 (4.3)	0.014
18–30	49.1	38.5	52.5	0.181
31–42	50.9	61.5	47.5
Ethnicity
Dutch	94.4	89.7	95.9	0.222
Other	5.6	10.3	4.1
Educational level				0.784
Low	16.3	12.8	17.4
Midlevel	67.5	69.2	66.9
High	16.3	17.9	15.7
Preeclampsia or perinatal death in previous pregnancy				0.862
NA, primiparous	76.6	73.7	77.5
No	10.1	10.5	10.0
Yes	13.3	15.8	12.5
Multiple pregnancies
Singleton pregnancy	90.7	97.4	88.5	0.120
Multiple pregnancy	9.3	2.6	11.5
Highest level of obstetric care
Standard care	61.6	97.4	50.4	<0.001
High obstetric care	36.5	2.6	47.1
Intensive care	1.9	0	2.5
Delivery
Normal vaginal	26.1	51.3	18.0	<0.001
Instrumental vaginal	7.5	23.1	2.5
Cesarean section	66.5	25.6	79.5
Gestational age at delivery
<34 weeks	51.6	5.1	66.4	<0.001
34–37 weeks	14.3	10.3	15.6
>37 weeks	34.2	84.6	18.0
Gestational age at delivery (days): median (IQR)	236 (50.5)	268 (16.0)	219.5 (46.7)	<0.001
Depressive symptoms: mean (SD)
6 weeks postpartum	6.9 (5.7)	4.5 (5.0)	7.8 (5.8)	0.003
12 weeks postpartum	5.3 (5.1)	3.2 (3.5)	5.9 (5.4)	0.001
26 weeks postpartum	5.4 (5.0)	5.6 (5.1)	5.3 (5.0)	0.754
Any time postpartum	5.8 (5.3)	4.4 (4.6)	6.3 (5.5)	0.001
Depressive symptoms (cutoff ≥10 on EPDS)
6 weeks postpartum	29.2	11.1	35.6	0.005
12 weeks postpartum	21.1	8.8	25.0	0.044
26 weeks postpartum	19.0	21.2	18.3	0.713
Any time postpartum	39.1	23.1	44.3	0.018
Score of ≥10 at one time point	23.0	12.8	26.2	0.130
Score of ≥10 at two time points	11.2	7.7	12.3
Score of ≥10 across all three time points	5.0	2.6	5.7
Depressive symptoms (cut off ≥13 on EPDS)
6 weeks postpartum	17.5	5.6	21.8	0.028
12 weeks postpartum	10.6	2.9	13.0	0.097
26 weeks postpartum	8.5	12.1	7.3	0.387
Any time postpartum	23.6	15.4	26.2	0.165
Score of ≥13 at one time point	17.4	12.8	18.9	0.492
Score of ≥13 at two time points	4.3	2.6	4.9
Score of ≥13 across all three time points	1.9	0	2.5
Offspring (n=178)
Birth weight (g): median (IQR)	1700 (1870)	3075 (989)	1340 (1438)	<0.001
Admission to NICU	57.9	14.3	71.3	<0.001
Days of NICU admission: median (IQR)	39 (55)	65 (17)	38 (53)	0.198
Perinatal death	3.9	0	5.1	0.201

Women with mild preeclampsia compared to women with severe preeclampsia. p values <0.05 are bold.

EPDS, Edinburgh Postnatal Depression Scale; IQR, interquartile range; NA, not applicable; NICU, neonatal intensive care unit; SD, standard deviation.

Prevalence of depressive symptoms after mild and severe preeclampsia

Women who had severe preeclampsia more frequently reported postpartum depressive symptoms at 6 and 12 weeks postpartum compared with women who experienced mild preeclampsia. After mild preeclampsia, 23% reported postpartum depressive symptoms at any time up to 26 weeks postpartum compared with 44% after severe preeclampsia (OR 2.65, 95% CI 1.16-6.05) for depression at any time up to 26 weeks postpartum (OR 2.57, 95% CI 1.14-5.76) while accounting for longitudinal observations (Table 1).

After severe preeclampsia, the percentage of women who reported postpartum depressive symptoms decreased over time from 36% at 6 weeks postpartum to 25% at 12 weeks and to 18% at 26 weeks postpartum, whereas this percentage in women who experienced mild preeclampsia decreased over time from 11% at 6 weeks to 9% at 12 weeks but increased to 21% at 26 weeks postpartum. Although the course of the prevalence of depressive symptoms differed over time after mild and severe preeclampsia, the difference was not significant. Both with and without adjustment for time and with and without adjustment for the confounders age, ethnicity, and educational level, the women who had severe preeclampsia had an increased risk for developing postpartum depressive symptoms compared with women who had mild preeclampsia (Table 2).

Table 2.

Odds Ratios and 95% Confidence Intervals for Postpartum Depressive Symptoms Among Women After Preeclampsia (n=161), According to Severity of Preeclampsia and Potential Contributing Factors

	Model 0 ^a	Model 1 ^b	Model 2 ^c
At any time postpartum
Severity of preeclampsia
Mild preeclampsia	1	1	1
Severe preeclampsia	2.65 (1.16-6.05)	2.80 (1.14-6.91)	1.39 (0.44-4.43)
NICU admission
No			1
Yes			3.19 (1.15-8.89)
Highest level of obstetric care
Standard care			1
High obstetric or intensive care			0.98 (0.43-2.19)
Delivery
Vaginal			1
Cesarean section			0.71 (0.26-1.98)
Perinatal death
No			1
Yes			4.59 (0.62-34.1)
Accounting for longitudinal observations at 6, 12, and 26 weeks postpartum
Severity of preeclampsia
Mild preeclampsia	1	1	1
Severe preeclampsia	2.57 (1.14-5.76)	2.54 (1.08-6.01)	1.43 (0.51-3.99)
NICU admission
No			1
Yes			2.09 (0.93-4.72)
Perinatal death
No			1
Yes			2.96 (1.09-8.03)

Symptoms of postpartum depression are defined as a score ≥10 on the Edinburgh Postnatal Depression Scale at either 6, 12, or 26 weeks postpartum.

Model 0, unadjusted model with severity of preeclampsia as independent variable.

Model 1, model with severity of preeclampsia adjusted for age, ethnicity, and educational level.

Model 2, model with severity of preeclampsia and statistically significant related potential contributing factors, adjusted for age, ethnicity, and educational level.

Contributing factors

Both NICU admission and perinatal death were found to be contributing factors (Table 2).

NICU admission was found to be a contributing factor to differences in the prevalence of postpartum depressive symptoms after mild and severe preeclampsia at any time point (OR 3.19, 95% CI 1.15-8.89). With the variables, NICU admission, highest level of obstetric care, mode of delivery, and perinatal death added to the variables included in model 1, severity of preeclampsia was no longer a significantly related predictor of postpartum depressive symptoms (Table 2).

While accounting for longitudinal observations, perinatal death was found to be a contributing factor to the differences in the prevalence of postpartum depressive symptoms (OR 2.96, 95% CI 1.09-8.03). With the variables, NICU admission and perinatal death, added to the variables included in model 1, severity of preeclampsia was no longer a significantly related predictor of postpartum depressive symptoms (Table 2).

Discussion

This first study to examine the impact of the severity of preeclampsia on the prevalence of postpartum depressive symptoms shows that women with severe preeclampsia more often report postpartum depressive symptoms than do women with mild preeclampsia. However, it seems that not the severity of preeclampsia itself but rather the consequences of the severity of the disease (especially admission to the NICU and perinatal death) cause postpartum depressive symptoms.

Methodologic considerations

The present study did not include a control group of postpartum women with an uncomplicated pregnancy. Moreover, the small sample size of formerly mild preeclamptic women limits the power to detect differences in postpartum depressive symptoms. To confirm our findings, future longitudinal prospective cohort studies should contain larger subgroups of women with complicated pregnancies and should also include a group of women with uncomplicated pregnancies. Preferably, future studies should incorporate a baseline measurement before pregnancy to rule out any potential preexisting differences (such as differences in the prevalence of overweight and history of depression). Previous research has shown that a history of past psychiatric illness,^28,34,35 life events (death of a loved one, divorce, or losing a job),³⁵ and anxiety or depression during pregnancy^28,34,35 are risk factors for the development of PPD. Receiving social support has been found to be a protective factor against developing PPD.^30,35 We were not able to include these known predictors for PPD in our analyses. The lack of such known predictors in our multivariate analyses might have led to an overestimation of the association between postpartum depressive symptoms and contributing obstetric factors.

We do not have complete details of the 81 (255 eligible women −174 participants) women who declined participation, so we cannot make any definite conclusions about biases. We did find that the 13 women who were left out of the study population were more often of non-Dutch origin. As the data from our study population have shown that being non-Dutch is associated with reported depressive symptoms at 6 months postpartum (data not shown), our results about the number of women who reported depressive symptoms might have been underestimated.

Selection bias might have occurred, as the majority of eligible patients gave birth in the Erasmus University Medical Center (a tertiary referral hospital). Patients who gave birth in this university hospital generally experience more severe complications compared to women in other hospitals in the surrounding area. This explains the relatively high number of women with severe preeclampsia in the Pro-Active cohort and may have contributed to a higher prevalence of depressive symptoms. If the population had consisted of relatively more women who had experienced mild preeclampsia, the prevalence of depressive symptoms in our study population might have been somewhat lower.

It is not known if the different nature of the different medical treatments for mild and severe preeclampsia influenced the development of depressive symptoms after delivery.

In the present study, the high rate of depressive symptoms after preeclampsia (particularly after severe preeclampsia) confirms other studies reporting a frequent need for psychological support after severe preeclampsia.³⁶ Our finding that the postpartum psychological condition improves over time confirms previous research on postpartum psychosocial condition after early-onset hypertensive disorders.⁸ Our women with severe preeclampsia more frequently reported postpartum depressive symptoms at 6 and 12 weeks postpartum, but women who had mild preeclampsia more frequently reported depressive symptoms at 26 weeks postpartum. This might be a chance result, however, in the small group of women in the present study who had mild preeclampsia.

Compared with the analysis at any point where admission to the NICU was identified as a the most important contributing factor, the analysis accounting for longitudinal observations identified perinatal death as the most important contributing factor to differences in depressive symptoms between formerly mild and severe preeclamptic women. When looking at NICU admission and perinatal death separately, however, both were identified as contributing factors in both analyses. Probably because of limited power and the fact that there was a significant interaction between NICU admission and time, and not between perinatal death and time (data not shown), only one of them remained significant when looking at the combination of these contributing factors in the final models. Therefore, these findings suggest that both NICU admission and perinatal death contribute to differences in the prevalence of postpartum depressive symptoms after mild and severe preeclampsia. This is in line with previous findings. It has been suggested that admission to the intensive care unit in itself affects psychological distress.^37,38 In addition, perinatal death was found to be a contributing factor to PPD among postpartum women after an uncomplicated delivery.²⁸ In line with previous findings, the factors, highest level of obstetric care and mode of delivery, were associated with postpartum depressive symptoms at any time in the univariate analyses (data not shown).²⁷ In the multivariate analyses and in the analyses that accounted for longitudinal observations, however, these factors were not significantly associated with depressive symptoms.

This first study examining whether women with mild preeclampsia differ from those with severe preeclampsia with regard to postpartum depressive symptoms found that women with severe preeclampsia more often experienced postpartum depressive symptoms than did women with mild preeclampsia. Our findings suggest that not severe preeclampsia itself but rather the obstetric complications frequently experienced by women with severe preeclampsia cause this higher prevalence of postpartum depressive symptoms among women with severe preeclampsia. Obstetric complications previously have been found to contribute to postpartum depressive symptoms.^26

–30

This study has some important implications for clinical practice. Because of the high prevalence of depressive symptoms after preeclampsia, particularly after severe preeclampsia, obstetricians should be aware of depressive symptoms among these women, particularly among women whose child had been admitted to the NICU or whose child has died. The results of this study seem to suggest that obstetricians should be aware of depressive symptoms among postpartum women who experienced NICU admission or perinatal death regardless of whether or not they experienced preeclampsia. Psychological treatment (e.g., psychoeducation or supportive and autonomy-increasing techniques) can increase coping abilities and is effective in managing postnatal depression.^39,40 Furthermore, rapid recognition and referral seem to be associated with shorter treatment duration.⁴¹ Therefore, it is important that postpartum depressive symptoms be diagnosed as early as possible and that women receive adequate professional psychological support as soon as possible. Obstetricians and other physicians can play a major role in determining such postpartum depressive symptoms at an early stage. The EPDS can be used on a regular basis to screen women; when screened positive for depressive symptoms, these women can be referred for appropriate psychologic support.

Footnotes

Acknowledgments

We thank all Pro-Active participants and the employees of the participating obstetric departments of the St. Elisabeth Hospital in Tilburg, the St. Franciscus Gasthuis in Rotterdam, and the Maasstad Hospital in Rotterdam, The Netherlands. We are grateful to research nurses Joke van Rhee and Wilma Keller-van der Es for their contribution to data collection and Gerard Borsboom for his assistance with statistical analysis. This study was funded by the Netherlands Organization for Health Research and Development (ZonMw Grant # 6120.0024).

Disclosure Statement

No competing financial interests exist.

Appendix

Intercorrelations Between Predictor Variables

	Age	Ethnicity	Educational level	Severity of preeclampsia	Highest level of obstetric care	Mode of delivery	Gestational age at delivery	Birth weight	NICU admission
Age
Ethnicity	−0.060
Educational level	0.066	−0.190
Severity of preeclampsia	−0.193	−0.115	−0.051
Highest level of obstetric care	−0.151	0.031	−0.090	0.412
Mode of delivery	−0.214	−0.056	−0.139	0.489	0.320
Gestational age at delivery	0.287	−0.030	0.112	−0.518	−0.483	−0.436
Birth weight	0.319	0.028	0.094	−0.560	−0.404	−0.504	0.926
NICU admission	−0.278	−0.056	−0.133	0.549	0.352	0.561	−0.708	−0.757
Perinatal death	−0.092	0.081	−0.054	0.121	0.209	−0.042	−0.355	−0.280	0.005

p values of <0.05 are bold.

NICU, neonatal intensive care unit.

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