Association Between Urban Green Space and Postpartum Depression, and the Role of Physical Activity: a Retrospective Cohort Study in Southern California

Overview

Journal Lancet Reg Health Am

Date 2023 May 24

PMID 37223828

Authors

Yi Sun

John Molitor

Tarik Benmarhnia

Chantal Avila

Vicki Chiu

Jeff Slezak

David A Sacks

Jiu-Chiuan Chen

Darios Getahun

Jun Wu

Affiliations

Soon will be listed here.

Abstract

Background: Little research exists regarding the relationships between green space and postpartum depression (PPD). We aimed to investigate the relationships between PPD and green space exposure, and the mediating role of physical activity (PA).

Methods: Clinical data were obtained from Kaiser Permanente Southern California electronic health records in 2008-2018. PPD ascertainment was based on both diagnostic codes and prescription medications. Maternal residential green space exposures were assessed using street view-based measures and vegetation types (i.e., street tree, low-lying vegetation, and grass), satellite-based measures [i.e., Normalized Difference Vegetation Index (NDVI), land-cover green space, and tree canopy cover], and proximity to the nearest park. Multilevel logistic regression was applied to estimate the association between green space and PPD. A causal mediation analysis was performed to estimate the proportion mediated by PA during pregnancy in the total effects of green space on PPD.

Findings: In total, we included 415,020 participants (30.2 ± 5.8 years) with 43,399 (10.5%) PPD cases. Hispanic mothers accounted for about half of the total population. A reduced risk for PPD was associated with total green space exposure based on street-view measure [500 m buffer, adjusted odds ratio (OR) per interquartile range: 0.98, 95% CI: 0.97-0.99], but not NDVI, land-cover greenness, or proximity to a park. Compared to other types of green space, tree coverage showed stronger protective effects (500 m buffer, OR = 0.98, 95% CI: 0.97-0.99). The proportions of mediation effects attributable to PA during pregnancy ranged from 2.7% to 7.2% across green space indicators.

Interpretation: Street view-based green space and tree coverage were associated with a decreased risk of PPD. The observed association was primarily due to increased tree coverage, rather than low-lying vegetation or grass. Increased PA was a plausible pathway linking green space to lower risk for PPD.

Funding: National Institute of Environmental Health Sciences (NIEHS; R01ES030353).

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References

Helbich M, Yao Y, Liu Y, Zhang J, Liu P, Wang R . Using deep learning to examine street view green and blue spaces and their associations with geriatric depression in Beijing, China. Environ Int. 2019; 126:107-117. PMC: 6437315. DOI: 10.1016/j.envint.2019.02.013. View

Feng X, Astell-Burt T . Residential green space quantity and quality and symptoms of psychological distress: a 15-year longitudinal study of 3897 women in postpartum. BMC Psychiatry. 2018; 18(1):348. PMC: 6204015. DOI: 10.1186/s12888-018-1926-1. View

Guelfi K, Wang C, Dimmock J, Jackson B, Newnham J, Yang H . A comparison of beliefs about exercise during pregnancy between Chinese and Australian pregnant women. BMC Pregnancy Childbirth. 2015; 15:345. PMC: 4689036. DOI: 10.1186/s12884-015-0734-6. View

Astell-Burt T, Feng X . Association of Urban Green Space With Mental Health and General Health Among Adults in Australia. JAMA Netw Open. 2019; 2(7):e198209. PMC: 6661720. DOI: 10.1001/jamanetworkopen.2019.8209. View

Pun V, Manjourides J, Suh H . Association of neighborhood greenness with self-perceived stress, depression and anxiety symptoms in older U.S adults. Environ Health. 2018; 17(1):39. PMC: 5902952. DOI: 10.1186/s12940-018-0381-2. View

Helbich M, Klein N, Roberts H, Hagedoorn P, Groenewegen P . More green space is related to less antidepressant prescription rates in the Netherlands: A Bayesian geoadditive quantile regression approach. Environ Res. 2018; 166:290-297. DOI: 10.1016/j.envres.2018.06.010. View

Nguyen P, Astell-Burt T, Rahimi-Ardabili H, Feng X . Green Space Quality and Health: A Systematic Review. Int J Environ Res Public Health. 2021; 18(21). PMC: 8582763. DOI: 10.3390/ijerph182111028. View

Reid C, Clougherty J, Shmool J, Kubzansky L . Is All Urban Green Space the Same? A Comparison of the Health Benefits of Trees and Grass in New York City. Int J Environ Res Public Health. 2017; 14(11). PMC: 5708050. DOI: 10.3390/ijerph14111411. View

Song H, Lane K, Kim H, Kim H, Byun G, Le M . Association between Urban Greenness and Depressive Symptoms: Evaluation of Greenness Using Various Indicators. Int J Environ Res Public Health. 2019; 16(2). PMC: 6352234. DOI: 10.3390/ijerph16020173. View

10.

Runkle J, Matthews J, Sparks L, McNicholas L, Sugg M . Racial and ethnic disparities in pregnancy complications and the protective role of greenspace: A retrospective birth cohort study. Sci Total Environ. 2021; 808:152145. DOI: 10.1016/j.scitotenv.2021.152145. View

11.

Fong K, Hart J, James P . A Review of Epidemiologic Studies on Greenness and Health: Updated Literature Through 2017. Curr Environ Health Rep. 2018; 5(1):77-87. PMC: 5878143. DOI: 10.1007/s40572-018-0179-y. View

12.

McEachan R, Prady S, Smith G, Fairley L, Cabieses B, Gidlow C . The association between green space and depressive symptoms in pregnant women: moderating roles of socioeconomic status and physical activity. J Epidemiol Community Health. 2015; 70(3):253-9. PMC: 4789818. DOI: 10.1136/jech-2015-205954. View

13.

Markevych I, Schoierer J, Hartig T, Chudnovsky A, Hystad P, Dzhambov A . Exploring pathways linking greenspace to health: Theoretical and methodological guidance. Environ Res. 2017; 158:301-317. DOI: 10.1016/j.envres.2017.06.028. View

14.

Larkin A, Hystad P . Evaluating street view exposure measures of visible green space for health research. J Expo Sci Environ Epidemiol. 2018; 29(4):447-456. DOI: 10.1038/s41370-018-0017-1. View

15.

Yonkers K, Vigod S, Ross L . Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women. Obstet Gynecol. 2011; 117(4):961-977. DOI: 10.1097/AOG.0b013e31821187a7. View

16.

Garrett J, White M, Huang J, Ng S, Hui Z, Leung C . Urban blue space and health and wellbeing in Hong Kong: Results from a survey of older adults. Health Place. 2018; 55:100-110. DOI: 10.1016/j.healthplace.2018.11.003. View

17.

Zock J, Verheij R, Helbich M, Volker B, Spreeuwenberg P, Strak M . The impact of social capital, land use, air pollution and noise on individual morbidity in Dutch neighbourhoods. Environ Int. 2018; 121(Pt 1):453-460. DOI: 10.1016/j.envint.2018.09.008. View

18.

Slezak J, Sacks D, Chiu V, Avila C, Khadka N, Chen J . Identification of Postpartum Depression in Electronic Health Records: Validation in a Large Integrated Health Care System. JMIR Med Inform. 2023; 11:e43005. PMC: 10018380. DOI: 10.2196/43005. View

19.

Sun Y, Sheridan P, Laurent O, Li J, Sacks D, Fischer H . Associations between green space and preterm birth: Windows of susceptibility and interaction with air pollution. Environ Int. 2020; 142:105804. PMC: 7340571. DOI: 10.1016/j.envint.2020.105804. View

20.

van den Bosch M, Ode Sang A . Urban natural environments as nature-based solutions for improved public health - A systematic review of reviews. Environ Res. 2017; 158:373-384. DOI: 10.1016/j.envres.2017.05.040. View