***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Associations between salivary cortisol and  maternal psychological distress and well-being  were examined prospect ively on 112 women with normally progressing , singleton pregnancies between 24 and 38 weeks gestation . At each of 5 visits , conducted in 3-week intervals , women provided a saliva sample and completed question naires measuring trait anxiety , depressive symptoms , pregnancy-specific hassles and uplifts , and psychological well-being . Maternal salivary cortisol was unrelated to psychological measures with the exception of minor associations detected with measures of anxiety and depressive symptoms between 30 and 32 weeks only . Findings indicate that self-reported maternal psychological distress and well-being are not associated with significant variation in maternal salivary cortisol levels during the second half of gestation . This suggests that studies that measure psychological factors in pregnancy but do not measure maternal cortisol should exercise caution in assuming activation of the maternal hypothalamic – pituitary – adrenal axis is the mechanism through which maternal psychological factors are transduced to the fetus Study goals were to distinguish between maternal risk factors for fetal versus infant mortality , and to identify which maternal characteristics contributed the greatest risk of mortality overall . This case – control retrospective study abstract ed data on more than forty maternal characteristics from 261 prenatal and delivery records : all 26 fetal deaths , all 40 infant deaths and 195 r and omly selected surviving births in a high-mortality Healthy Start community . Bivariate and multivariate analyses were conducted . The fetal-mortality population was significantly more likely than the infant-mortality population to have no insurance ( P = .047 ) , inadequate prenatal care ( P = .039 ) and previous fetal death ( P = .021 ) . Comparing the combined mortality population with the surviving sample , two tiers of risk emerged : Rare-but-lethal risks , including no prenatal care ( P < .001 ) and Child-Protective-Service involvement ( P = .001 ) , and common- and -dangerous risks , including inadequate maternal weight gain ( OR = 13.55 ) , drug or alcohol abuse ( OR = 8.67 ) , obesity ( OR = 2.77 ) and anemia ( OR = 3.61 ) . Both fetal and infant mortality groups must be considered when identifying maternal risks . Inadequate prenatal weight gain , obesity and anemia contribute as much to feto-infant mortality as substance abuse . Public health efforts to improve maternal nutrition and healthy weight should be redoubled This study investigates the relationship between adverse pregnancy outcomes in high-risk African American women in Washington , DC and sociodemographic risk factors , behavioral risk factors , and the most common and interrelated medical conditions occurring during pregnancy : diabetes , hypertension , preeclampsia , and Body Mass Index ( BMI ) . Data are from a r and omized controlled trial conducted in 6 prenatal clinics . Women in their 1st or 2nd trimester were screened for behavioral risks ( smoking , environmental tobacco smoke exposure , depression , and intimate partner violence ) and demographic eligibility . 1,044 were eligible , interviewed and followed through their pregnancies . Classification and Regression Trees ( CART ) methodology was used to : ( 1 ) explore the relationship between medical and behavioral risks ( reported at enrollment ) , sociodemographic factors and pregnancy outcomes ; ( 2 ) identify the relative importance of various predictors of adverse pregnancy outcomes ; and ( 3 ) characterize women at the highest risk of poor pregnancy outcomes . The strongest predictors of poor outcomes were prepregnancy BMI , preconceptional diabetes , employment status , intimate partner violence , and depression . In CART analysis , preeclampsia was the first splitter for low birthweight ; preconceptional diabetes was the first splitter for preterm birth ( PTB ) and neonatal intensive care admission ; BMI was the first splitter for very PTB , large for gestational age , Cesarean section and perinatal death ; employment was the first splitter for miscarriage . Preconceptional factors strongly influence pregnancy outcomes . For many of these women , the high risks they brought into pregnancy were more likely to impact their pregnancy outcomes than events during pregnancy Background Body image satisfaction in pregnancy may have an important influence on maternal biopsychosocial outcomes . Purpose This study aims to examine the mediating influence of trimesters 2 and 3 body image satisfaction on trimesters 2 and 3 depressive symptoms , exercise behavior , and gestational weight gain . Methods Pregnant women ( N = 151 ; mean age = 30 ) prospect ively completed  study measures via mail during their 1st , 2nd , and 3rd trimesters . Results As predicted , trimesters 2 and 3 body image satisfaction mediated the relationship between trimester 1 body image satisfaction and trimester 2 depressive symptoms and the relationship between trimester 2 body image satisfaction and trimester 3 depressive symptoms . In contrast to the hypothesis , no mediation was observed for the relationship between body image satisfaction and exercise behavior or gestational weight gain . Conclusions These preliminary findings demonstrate that body image satisfaction is an important psychological determinant of depressive symptoms in pregnancy . Promoting healthy body image may be a non-pharmacological strategy that offers protective effects against depressive symptoms during pregnancy OBJECTIVE To identify and describe dietary patterns in a cohort of pregnant women , and investigate whether dietary patterns during pregnancy are related to postpartum depression ( PPD ) . DESIGN The study uses data from the prospect i ve mother-child cohort ' Rhea ' study . Pregnant women completed an FFQ in mid-pregnancy and the Edinburg Postpartum Depression Scale ( EPDS ) at 8 - 10 weeks postpartum . Dietary patterns during pregnancy ( ' health conscious ' , ' Western ' ) were identified using principal component analysis . Associations between dietary patterns categorized in tertiles and PPD symptoms were investigated by multivariable regression models after adjusting for confounders . SETTING Heraklion , Crete , Greece , 2007 - 2010 . SUBJECTS A total of 529 women , participating in the ' Rhea ' cohort . RESULTS High adherence to a ' health conscious ' diet , characterized by vegetables , fruit , pulses , nuts , dairy products , fish and olive oil , was associated with lower EPDS scores ( highest v. lowest tertile : β-coefficient = -1·75 , P = 0·02 ) . Women in the second ( relative risk ( RR ) = 0·52 , 95 % CI 0·30 , 0·92 ) or third tertile ( RR = 0·51 , 95 % CI 0·25 , 1·05 ) of the ' health conscious ' dietary pattern were about 50 % less likely to have high levels of PPD symptoms ( EPDS ≥ 13 ) compared with those in the lowest tertile . CONCLUSIONS This is the first prospect i ve study showing that a healthy diet during pregnancy is associated with reduced risk for PPD . Additional longitudinal studies and trials are needed to confirm these findings BACKGROUND The impact of prenatal depression on pregnancy outcomes is largely unknown . METHODS We conducted a population -based prospect i ve cohort study among pregnant women of the Kaiser Permanente Medical Care Program to examine the impact of prenatal depression on the risk of preterm delivery . We interviewed pregnant women in their early pregnancy . Women 's depressive symptoms were ascertained using the st and ard Center for Epidemiological Studies Depression Scale ( CESD ) . The presence of significant prenatal depressive symptoms and severe depressive symptoms was determined by CESD scores > or = 16 and > or = 22 , respectively . RESULTS Among the 791 participants who answered CESD questions and delivered a live birth , after controlling for potential confounders using the Cox proportional hazard regression , women with CESD scores > or = 16 had almost twice the risk of preterm delivery compared with women without depressive symptoms : adjusted hazard ratio ( aHR ) = 1.9 , 95 % confidence interval ( CI ) 1.0 - 3.7 . The risk of preterm delivery increased with increasing severity of depression : aHR = 1.6 ( CI 0.7 - 3.6 ) for CESD 16 - 21 and aHR = 2.2 ( CI 1.1 - 4.7 ) for CESD > or = 22 . The risk of preterm delivery associated with prenatal depression appears to be exacerbated by low educational level , a history of fertility problems and the presence of obesity and stressful events . The observed associations were not confounded by the use of antidepressants , although some of the associations did not reach statistical significance . CONCLUSIONS Our findings show that pregnant women with depressive symptoms are at increased risk of preterm delivery and , in addition , provide preliminary evidence that social and reproductive risk factors as well as obesity and stressful events may exacerbate the effect OBJECTIVE We assessed the relation between prepregnancy body mass index ( BMI ) and the likelihood of  major depressive disorder ( MDD ) during pregnancy and tested whether this association was modified by gestational weight gain . METHOD Women ( N = 242 ) were enrolled at < 20 weeks gestation into a prospect i ve cohort study . Diagnosis of MDD was made with the Structured Clinical Interview for DSM-IV at 20 , 30 , and 36 weeks gestation .  Gestational weight gain was compared with the 1990 Institute of Medicine weight gain recommendations . To assess the independent association between prepregnancy BMI and the odds of MDD , MDD at each time point was used as the dependent measure in a multivariable longitudinal logistic regression model employing generalized estimating equations . The data were collected from 2003 - 2007 . RESULTS There was a strong , positive dose-response association between prepregnancy BMI and the likelihood of MDD ( P = .002 ) . Compared with a BMI of 18 , the adjusted odds ratios ( 95 % confidence interval ) for BMI s of 23 , 28 , and 33 were 1.4 ( 1.1 to 1.7 ) , 1.9 ( 1.3 to 2.9 ) , and 2.6 ( 1.4 to 4.3 ) , respectively . Gestational weight gain significantly modified this effect . Among women with weight gains within and above the 1990 Institute of Medicine recommendations , pregravid overweight was associated with a greater likelihood of MDD . In contrast , all women with weight gains below recommended levels had an elevated odds of depression regardless of their pregravid BMI ( P < .05 ) . CONCLUSIONS Because pregravid overweight , poor gestational weight gain , and MDD all pose substantial risks for fetal development and birth outcomes , health care providers should monitor depression levels in these women to facilitate appropriate depression intervention OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity BACKGROUND An ecological analysis found that the docosahexaenoic acid content in mother 's milk and seafood intake were inversely correlated with postpartum depression . This prospect i ve study investigated the relationship of consumption of selected high-fat foods and specific types of fatty acids with the risk of postpartum depression . METHOD The subjects were 865 Japanese women .  Dietary data were obtained from a self-administered diet history question naire during pregnancy . The Edinburgh Postnatal Depression Scale ( EPDS ) was used for the evaluation of postpartum depression . Adjustment was made for age , gestation , parity , cigarette smoking , family structure , family income , education , changes in diet in the previous month , 
    Output:
    
: Health care providers should be aware that women who are obese when they become pregnant are more likely to experience elevated antenatal and postpartum depression symptoms than normal-weight women , with intermediate risks for overweight women