Maternal anxiety during pregnancy and adverse birth outcomes: a systematic review and meta-analysis of prospective cohort studies

Pregnancy-related claustrophobia

A 35-year-old primigravida presented with significant anxiety symptoms at 26 weeks' gestation. Symptoms were preceded by a nightmare about her upcoming labour. She developed repetitive intrusive thoughts of being trapped emotionally and physically in her pregnancy. Her symptoms were suggestive of new-onset claustrophobia associated with pregnancy, which has not been previously reported on. Her symptoms ameliorated with a combination of cognitive-behavioural therapy and pharmacotherapy (sertraline and low dose quetiapine). The later stages of pregnancy were associated with minimal symptoms and the resolution of her subjective 'entrapment'. A subsequent pregnancy resulted in similar although less severe symptomatology. No postpartum anxiety symptoms were demonstrated on both occasions. Anxiety symptoms can adversely impact both the mother and fetus, and thus correct identification and management of pregnancy-related claustrophobia improved symptomatology and functioning and allowed for earlier detection and reduced symptomatology in a subsequent pregnancy.

Cortisol levels versus self-report stress measures during pregnancy as predictors of adverse infant outcomes: a systematic review

Systematically review existing evidence to (1) identify the association between self-report stress and cortisol levels measured during pregnancy; and, (2) assess their association with adverse infant outcomes to determine which is the better predictor. A systematic review was conducted in accordance with PRISMA guidelines. Search terms focused on pregnancy, psychological stress and cortisol. Nine electronic databases were searched, in addition to reference lists of relevant papers. Eligibility criteria consisted of studies that included measurement of self-reported psychological stress, cortisol and assessed their associations with any infant-related outcome. Further limits included studies published in English or Spanish with human female participants. A meta-regression was not feasible due to differences in study samples, measurement tools employed, types of cortisol assessed and outcomes reported. A narrative synthesis was provided. 28 studies were eligible for inclusion. Convergent validity between self-report measures and cortisol was reported by three studies (range r = 0.12-0.41). Higher levels of self-report stress were significantly associated with intrauterine growth restriction (fetal biparietal diameter, low fetal head circumference, abdominal circumference), low gestational age at birth, low anthropometric measures (birth length, head circumference, length of the neonate), poor infant neurodevelopment (cognitive development) and potentially pathogenic gut microbiota (Clostridiaceae Clostridium, Haemophilus) in six studies. Higher cortisol levels were significantly associated with intrauterine growth restriction (fetal biparietal diameter, low fetal head circumference, abdominal circumference), low gestational age at birth, low infant birth weight, poor infant neurodevelopment (attention scores on the Network Neurobehavioral Scale) and low levels of potentially protective gut microbiota (Lactobacillus, Slackia and Actinobaculum) in 13 studies. Of the studies that assessed which type of measure was a better predictor of infant outcomes (n = 6), there was agreement that cortisol levels were statistically better at predicting adverse outcomes than self-reported stress. Self-report stress measures appear to be modest predictors of adverse infant outcomes in comparison to cortisol. A number of methodological limitations need to be addressed in future studies to help understand the relationship between cortisol and self-reported stress and how they are related to adverse infant outcomes.

Faith Practices Reduce Perinatal Anxiety and Depression in Muslim Women: A Mixed-Methods Scoping Review

Higher rates of depression and anxiety are reported among women who belong to racial and ethnic minority groups, contributing to adverse birth outcomes, and remains a taboo topic within the global Muslim community. Non-pharmacological coping mechanisms such as prayer may be employed to reduce perinatal depression and anxiety, however the literature is sparse on the use of this intervention among pregnant Muslim women. Therefore, we aimed to conduct a scoping review examining the use of Muslim faith practices on anxiety and depression in perinatal period. Nine studies were identified that demonstrate that Muslim faith practices reduce perinatal anxiety and depression symptoms. These studies demonstrate that prayers and other faith-based practices, including reciting parts of the Quran, saying a Dua, and listening to audio recordings of prayers are all effective in decreasing anxiety, depression, stress, pain and fear in Muslim women during pregnancy, during childbirth, during an unexpected cesarean section, and when experiencing infant loss. Despite the scoping review's small sample size, findings confirm that incorporation of faith practices effectively reduces perinatal depression and anxiety among Muslim women and should be utilized in clinical settings for non-pharmacological management of perinatal mood disorders.

Mental disorders among pregnant women during the COVID-19 pandemic. A cross-sectional study

BACKGROUND

Pregnancy is the most important event in women's lives and can lead to psychological lability. Several risk factors (such as disasters, events and pandemics) have been correlated with greater prevalence of mental disorders during pregnancy.

OBJECTIVES

To research how pregnant women have been affected by the coronavirus disease-19 (COVID-19) pandemic process, in order to contribute to the limited literature.

DESIGN AND SETTING

Cross-sectional survey study conducted at the Training and Research Hospital of the Faculty of Medicine, University of Ordu, Ordu, Turkey, from February 1 to March 1, 2021.

METHODS

In total, 356 pregnant women were enrolled and completed the survey. Intention of going to hospital and the Beck anxiety, Beck depression, Beck hopelessness and Epworth sleepiness scales were applied to detect mental disorders.

RESULTS

Among the participants, the anxiety, depression, hopelessness and sleepiness scores were 29.2%, 36.2%, 58.1% and 11.8%, respectively. The pregnant women stated that they avoided going to hospital in unnecessary situations by obeying the 'stay at home' calls, but also stated that they were afraid of the potential harmful effects of inadequate physician control. However, most of them stated that they would go to the hospital in emergencies.

CONCLUSIONS

This paper illustrated the effect of the COVID-19 pandemic on the mental health of pregnant women and emphasized their high rates of anxiety, depression, hopelessness and sleepiness. Since presence of mental disorders is indirectly related to poor pregnancy outcomes, preventive strategies should be developed, especially during this pandemic process.

Knowledge, perception, and protective measures of Turkish pregnant women towards COVID-19 pandemic and their effects on anxiety levels

The aim of this study was to assess the knowledge of pregnant women regarding COVID-19 while evaluating the ability of protective measures and their effects on the level of anxiety during this pandemic. Using a prospective cross-sectional survey, 304 pregnant women attending prenatal polyclinics were included in our study between June 10 and July 10, 2020. The mean age of participants was 29.2 ± 6.0 years. The median gestational week was 25, ranging from 25 to 40 weeks of gestation. There was no significant correlation between a gestational week or complicated pregnancy and anxiety. Most participants possessed adequate knowledge and practical skills concerning Covid-19. Women with adequate knowledge were found to be statistically related to a high practice skills score and lower anxiety levels. Good knowledge levels are related to good practice skills and lower anxiety levels. Although pregnancy is not currently considered a risk factor, we believe it is vital to inform pregnant women about COVID-19 since they are naturally prone to mental problems and respiratory infections during pregnancy. Therefore, healthcare professionals should be encouraged to play an active role in this issue, replacing social media, a common source of misinformation for this target demographic.Impact statementWhat is already known on this subject? The prevalence of depression and anxiety symptoms among pregnant women increased significantly after the declaration of human-to-human transmission and the increasingly rapid spread of COVID-19.What do the results of this study add? Pregnant women with good knowledge of COVID-19 were found to have adequate practice skills and lower anxiety levels.What are the implications of these findings for clinical practice and/or further research? The act of informing pregnant women is essential in reducing anxiety levels and taking more accurate measures against COVID-19 because high levels of anxiety and depression can have long-term effects on maternal and foetal health. To minimise the potential for information pollution on social media, health professionals must play a more significant role in informing pregnant women and provide evidence-based information to pregnant women about the effects of COVID-19 on pregnancy.

Effects of COVID-19 on maternal anxiety and depressive disease: a literature review

The coronavirus SARS-CoV-2 (COVID-19) infection is a public health emergency of international concern. Pandemics pose a challenge to psychological resilience and can have an adverse impact on mental health. The impact of the ensuing social isolation and loneliness imposed by quarantine along with the worries about the risks of the infection and its economic fallout would appear likely to affect the mental health of the population. It has been reported that women are more likely to experience anxiety and depression symptoms during COVID-19 than men. COVID-19 pandemic had a profound impact on the level of anxiety and depression of pregnant women according to their basal level and pregnancy characteristics. Antenatal mental disorders may be a risk factor for maternal mental health problems such as an increased likelihood of postnatal depression and adverse obstetric and developmental outcomes. Effective coping strategies are associated with better psychological wellbeing during the COVID-19 pandemic, including reduced anxiety and depression. The increased risk of mental disorders due to COVID-19 requires policies to be developed to address prenatal and postpartum care to promote maternal-child wellbeing outcomes.

Maternal Anxiety and Infants Birthweight and Length of Gestation. A sibling design

BACKGROUND

The overall aim of this study is to examine the effect of prenatal maternal anxiety on birthweight and gestational age, controlling for shared family confounding using a sibling comparison design.

METHODS

The data on 77,970 mothers and their 91,165 children from the population-based Mother, Father and Child Cohort Study and data on 12,480 pairs of siblings were used in this study. The mothers filled out questionnaires for each unique pregnancy, at 17^th and 30^th week in pregnancy. Gestational age and birth weight was extracted from the Medical Birth Registry of Norway (MBRN). Associations between prenatal maternal anxiety (measured across the 17^th and 30^th weeks) and birth outcomes (birthweight and gestational age) were examined using linear regression with adjustment for shared-family confounding in a sibling comparison design.

RESULTS

In the population level analysis the maternal anxiety score during pregnancy was inversely associated with new-born's birthweight (Beta = -63.8 95% CI: -92.6, -35.0) and gestational age (Beta = -1.52, 95% CI: -2.15, -0.89) after adjustment for several covariates. The association of the maternal anxiety score with birthweight was no longer significant, but remained for maternal anxiety at 30^th week with gestational age (Beta = -1.11, 95% CI: -1.82, -0.4) after further adjusting for the shared-family confounding in the sibling comparison design.

CONCLUSION

No association was found for maternal prenatal anxiety with birth weight after multiple covariates and family environment were controlled. However, there was an association between prenatal maternal anxiety at 30^th week only with gestational age, suggesting a timing effect for maternal anxiety in third trimester.

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Objective This study examined the independent effect of delivery type and preoperative anxiety on placenta oxidative stress response.

Materials and methods A total of 126 patients who gave birth were divided into two groups according to delivery type: vaginal delivery group (VD) (n=56) and elective cesarean section delivery group (CS) (n=70). The preoperative anxiety levels of pregnant women who came to the delivery room were evaluated with the State Anxiety Inventory (SAI) scale. Malonyldialdehyde (MDA), superoxide dismutase (SOD), total antioxidative status (TAS), total oxidative state (TOS), and oxidative stress index (OSI) levels in umbilical cord blood were compared according to preoperative anxiety level and type of delivery.

Results The CS group had significantly higher MDA (0.88±0.15 versus 0.79±0.09, p=0.001) and TOS (8.37±1.81 versus 7.53±0.77, p=0.019) values compared to the VD group. TAS levels did not differ significantly between the groups. SOD levels were higher in VD group compared to CS group (p=0.049). When the factors affecting oxidative stress biomarkers are analyzed by regression analysis, factors affecting MDA were found to be SAI score (Beta=0.358), CS (Beta=0.212), the factor affecting SOD was found to be VD (Beta=0.318), the factors affecting TOS were found to be SAI score (Beta=0.317) and CS (Beta=0.183).

Conclusıon Oxidative stress biomarker levels in umbilical cord blood and preoperative anxiety levels were higher in patients who underwent elective caesarean section than those who delivered vaginally. Preoperative anxiety was the factor that increased oxidative stress biomarkers of umbilical cord blood the most.

Prenatal maternal posttraumatic stress disorder as a risk factor for adverse birth weight and gestational age outcomes: A systematic review and meta-analysis

BACKGROUND

Although not routinely assessed, prenatal posttraumatic stress disorder (PTSD) is associated with poor maternal mental health and mother-infant bonding. Prenatal PTSD may also be associated with birth weight and gestational age outcomes, but this remains unclear. This systematic review and meta-analysis investigated the association of prenatal PTSD with risk of low birth weight (LBW) or preterm birth (PTB) (dichotomous medically-defined cut-offs) or with birth weight (BW) or gestational age (GA) (continuous variables).

METHODS

A comprehensive literature search was conducted in Web of Science, MedLine, PubMed, and PsychInfo. Data were collected and processed according to Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Study quality was assessed with the Newcastle-Ottowa Quality Assessment Scale. Pooled effect sizes were estimated with random-effects models (correlation for continuous and odds ratios for dichotomous outcomes).

RESULTS

Sixteen studies with 51,470 participants (prenatal PTSD 8%) were included in 4 meta-analyses. Maternal prenatal PTSD was associated with higher risks of LBW (OR = 1.96; 95% CI, 1.26, 3.03; P = .003), PTB (OR = 1.42; 95% CI, 1.16, 1.73; P = .001), and reduced GA (r = -0.04; 95% CI, -0.06, -0.01; P = .002).

LIMITATIONS

Different designs across studies, variety of PTSD assessment practices, and a small pool of studies were noted.

CONCLUSIONS

Findings suggest prenatal PTSD presents increased risks of LBW, PTB, and reduced GA. Evidence of physical harm to neonates from prenatal PTSD provides a powerful rationale to increase prenatal PTSD screening and identify effective prenatal interventions to improve maternal and child outcomes.

Anxiety and depressive symptoms in pregnancy predict low birth weight differentially in male and female infants-findings from an urban pregnancy cohort in India

PURPOSE

This study examined the contributions of antenatal anxiety, depression, and partner violence to low birth weight (LBW) in infants and to sex-specific birth weight outcomes among mothers from a cohort in urban India.

METHODS

Data from 700 mothers from the PRAMMS cohort (Prospective Assessment of Maternal Mental Health Study) were used. Pregnant women were assessed in each trimester-T1, T2 and T3, for symptoms of anxiety, and depression as well as partner violence. Multivariate analyses were performed for the whole sample and then for male and female infants separately. The final multivariable logistic regression models were each built using a backward selection procedure and controlling for confounders. To accommodate longitudinally measured data, change in scores (T2-T1 and T3-T2) of anxiety and depression were included in the model.

RESULTS

Of the 583 women with a singleton live birth, birth weight was available for 514 infants  and LBW was recorded in 80 infants (15.6%). Of these, 23 infants were preterm. Overall, higher T1 Depression scores (OR: 1.11; 95% CI 1.040, 1.187) and an increase in both Depression scores (OR: 1.12; 95% CI 1.047, 1.195) from T1 to T2 and Anxiety scores (OR: 1.32; 95% CI 1.079, 1.603) between T2 and T3 were predictors of LBW. Female infants had a higher chance of LBW with increase in maternal anxiety between T1-T2 (OR: 1.69; 95% CI 1.053, 2.708) and T2-T3 (OR: 1.49; 95% CI 1.058, 2.086); partner violence during pregnancy just failed to reach conventional statistical significance (OR: 2.48; 95% CI 0.810, 7.581) in girls. Male infants had a higher chance of LBW with higher baseline depression scores at T1 (OR: 1.23; 95% CI 1.042, 1.452) and an increase in depression scores (OR: 1.25; 95% CI 1.060, 1.472) from T1 to T2.

CONCLUSION

Increasing prenatal anxiety and depressive symptoms in different trimesters of pregnancy were associated with LBW with sex-specific patterns of association in this sample from a Low and Middle Income Country.

Association between obsessive-compulsive disorder and obstetrical and neonatal outcomes in the USA: a population-based cohort study

Obsessive-compulsive disorder (OCD) is a mental disorder linked to functional impairments and adverse health outcomes. We sought to examine the association between pregnant women with OCD and obstetrical and neonatal outcomes in the USA. A retrospective population-based cohort study was conducted using data provided by pregnant women from the Nationwide Inpatient Sample, a nationally representative database of hospitalizations in the USA, from 1999 to 2015. Using diagnostic and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), we identified births and classified women by OCD status. Demographic and clinical characteristics were compared for women with and without OCD and multivariate logistic regressions were used to obtain odds ratios (OR) to compare obstetrical and neonatal outcomes between the two groups, adjusting for relevant demographic and clinical variables. Between 1999 and 2015, there were 3365 births to women with OCD, corresponding to an overall prevalence of 24.40 per 100,000 births. Women with OCD were more likely to be older than 25, Caucasian, of higher socioeconomic status, smokers or used drugs and alcohol, and have other comorbid psychiatric conditions. In adjusted models, OCD was associated with a higher risk of gestational hypertension, preeclampsia, premature rupture of membranes, caesarean and instrumental deliveries, venous thromboembolisms and preterm birth. Pregnancies in women with OCD are at high risk of adverse obstetrical and neonatal outcomes. A multidisciplinary approach should be used to identify high risk behaviours and ensure adequate prenatal follow-up and care be available for those with high risk pregnancies.

Birth Stories, Support, and Perinatal Emotional Health among Minority Adolescent Mothers: A Mixed Methods Study

STUDY OBJECTIVE

To explore minority, adolescent birth and perinatal experiences to inform and improve quality of care for this unique group.

DESIGN

Mixed quantitative and qualitative study guided by Bourdieu's Social Fields framework.

SETTING

Clinic dedicated to parenting adolescents, and a local charter school founded to serve pregnant and parenting young adults.

PARTICIPANTS

Sample size for quantitative data: n = 27; qualitative data: n = 14. Average age was 16.39 years (SD = 1.29); most self-identified as Latina/Hispanic or African American/Black/Afro-Caribbean/African.

INTERVENTIONS AND MAIN OUTCOME MEASURES

We used 2 validated surveys: Birth Satisfaction Scale-Revised (BSS-R), and the Postpartum Worry Scale-Revised (PWS-R). The BSS-R has 10 items, and quantifies labor and delivery experiences. The PWS-R has 20 items, and quantifies maternal, infant, and social-emotional worries. The qualitative, semistructured 30-minute interviews with a subset of survey respondents further explored perinatal mental health, labor experiences, and support networks.

RESULTS

BSS-R data resulted in an average score of 25.14 (SD = 5.35), which correlated to moderate satisfaction with birth experience (range, 0-40 with 0 = most negative). The PWS-R average score of 55.79 (SD = 21.06) indicated elevated postpartum worry (range, 20-100 with 20 = most worry). Qualitative interviewees worried about relationships and newborn well-being; support networks fluctuated; distinct events, pain, and fear during labor dominated birth stories. Advice for peers included: tending to social support, stress, and self-care. Nonjudgmental communication, empathy, and emotional connection were desired attributes of their health care team. Participants had anxiety related to social networks and newborn care. Although birth experiences were moderately positive, they were also described as stressful. However, participants were resourceful, insightful, and took advantage of social supports.

CONCLUSION

Birth experiences, patterns of stress, and support networks are uniquely identified and utilized by adolescent mothers. Being heard and feeling connected to providers empowered this group of young, minority adolescents. Participant advice could inform future educational courses, programs, and hospital innovations for perinatal adolescents.

In-Hospital Complications in Pregnant Women With Current or Historical Cancer Diagnoses

OBJECTIVE

To assess the temporal trends, characteristics and comorbidities, and in-hospital cardiovascular and obstetric complications and outcomes of pregnant women with current or historical cancer diagnosis at the time of admission for delivery.

METHODS

We analyzed delivery hospitalizations with or without current or historical cancer between January 1, 2004, and December 31, 2014, from the US National Inpatient Sample database.

RESULTS

We included 43,132,097 delivery hospitalizations with no cancer, 39,118 with current cancer, and 67,336 with historical diagnosis of cancer. The 5 most common types of current cancer were hematologic, thyroid, cervical, skin, and breast cancer. Women with current and historical cancer were older (29 years and 32 years vs 27 years) and incurred higher hospital costs ($4131 and $4078 vs $3521) compared with women without cancer. Most of the cancer types were associated with preterm birth (hematologic: adjusted odds ratio [aOR], 1.48 [95% CI, 1.35 to 1.62]; cervical: aOR, 1.47 [95% CI, 1.32 to 1.63]; breast: aOR, 1.93 [95% CI, 1.72 to 2.16]). Current hematologic cancer was associated with the highest risk of peripartum cardiomyopathy (aOR, 12.19 [95% CI, 7.75 to 19.19]), all-cause mortality (aOR, 6.50 [95% CI, 2.22 to 19.07]), arrhythmia (aOR, 3.82 [95% CI, 2.04 to 7.15]), and postpartum hemorrhage (aOR, 1.31 [95% CI, 1.11 to 1.54]). Having a current or historical cancer diagnosis did not confer additional risk for stillbirth; however, metastases increased the risk of maternal mortality and preterm birth.

CONCLUSION

Women with a current or historical diagnosis of cancer at delivery have more comorbidities compared with women without cancer. Clinicians should communicate the risks of multisystem complications to these complex patients.

Does screening for maternal ACEs in prenatal care predict pregnancy health risk above and beyond demographic and routine mental health screening?

BACKGROUND

Adverse childhood experiences (ACEs), including abuse, neglect, and/or household dysfunction, are associated with physical and mental health difficulties in pregnancy and the postpartum period. These associations have prompted the adoption of screening for ACEs in prenatal care settings; however, little is known about whether asking about ACEs in the prenatal care context is additive to other forms of routine prenatal demographic and mental health screening.

OBJECTIVE

To identify whether ACEs are predictive of cumulative pregnancy health risk and identify whether ACEs predict maternal health risks in pregnancy above and beyond screening for financial stress, depression, and anxiety.

PARTICIPANTS AND SETTING

The electronic medical records of three hundred and thirty-eight patients who accessed prenatal care at a low-risk primary care maternity clinic were included.

METHODS

Women retrospectively self-reported their ACEs during their second prenatal primary care visit (~20 weeks' gestation) and reported financial stress as well as their depressive and anxious symptoms using the PHQ-2 and GAD-2. Health risk factors and complications were documented by healthcare providers in the files at birth. Approximately 32% of patients reported at least one ACE.

RESULTS

Regression analyses revealed that after accounting for financial stress, neither depression nor anxiety predicted cumulative health risk in the antenatal period. ACEs significantly predicted cumulative health risk (B = 0.14, p = .02) and an additional 1.7% of variance in the outcome. However, the model only accounted for 5.0% of the variance in cumulative health risk.

CONCLUSIONS

The total health risk predicted by demographic and ACEs screening is modest in this low-risk sample. Additional research on the implications of broader trauma-informed approaches is needed to evaluate their impact.

Mental disorders during the perinatal period: Results from a nationally representative study

OBJECTIVE

This study examined mental health profiles of pregnant and postpartum females, with and without perinatal complications, compared to non-perinatal females of childbearing age.

METHODS

We analyzed nationally representative data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (N = 36,309; 51.9% female). A validated semi-structured interview assessed past-year DSM-5 mental disorders. Multivariable regressions examined associations between perinatal status and mental disorders, controlling for sociodemographic characteristics.

RESULTS

Using females who were not pregnant in the past year as a reference group, those who were postpartum with complications during pregnancy or delivery had increased odds of any past-year mental disorder (58.7% vs. 46.8%; AOR = 1.56), any depressive/bipolar disorder (26.4% vs. 18.8%; AOR = 1.57), and posttraumatic stress disorder (14.0% vs. 7.3%; AOR = 1.99). In contrast, those who were postpartum without complications did not have increased odds of these disorders. Those who were pregnant without pregnancy complications had reduced odds of any past-year mental disorder (33.7% vs. 46.8%; AOR = 0.55) and any depressive/bipolar disorder (11.7% vs. 18.8%; AOR = 0.60). All perinatal groups had reduced odds of any substance use disorder compared to those who were not pregnant in the past year (18.9-25.7% vs. 29.8% AORs: 0.49-0.78), except those who were postpartum with pregnancy or delivery complications (28.8%).

CONCLUSION

Results highlight the importance of mental health screening among perinatal females, particularly those who are postpartum and experience perinatal complications. Findings may inform the development of targeted interventions for this subpopulation.

Investigating prenatal perceived support as protective factor against adverse birth outcomes: a community cohort study

BACKGROUND

Studies show that prenatal maternal anxiety may act as a risk factor for adverse birth outcomes, whilst prenatal social support may rather act as a protective factor. However, studies examining prenatal anxiety symptoms, prenatal perceived support, and neonatal and/or obstetric outcomes are lacking.

OBJECTIVE

This study investigated whether, in a community sample, prenatal perceived support: (1) had a protective influence on birth outcomes (gestational age (GA), birthweight (BW), 5-minute Apgar score, and mode of delivery); (2) acted as a protective factor, moderating the relationship between anxiety symptoms and the aforementioned birth outcomes.

METHOD

During their third trimester of pregnancy, 182 nulliparous child-bearers completed standardized questionnaires of anxiety (HADS-A) and perceived support (MOS-SSS). Birth outcomes data was extracted from medical records.

RESULTS

(1) Perceived support did not significantly predict any birth outcomes. However, perceived tangible support - MOS-SSS subscale assessing perceived material/financial aid - significantly positively predicted the 5-minute Apgar score. (2) Perceived support did not significantly moderate the relationship between anxiety symptoms and birth outcomes. However, perceived tangible support significantly moderated the relationship between anxiety symptoms and the 5-minute Apgar score.

CONCLUSION

When experienced within non-clinical thresholds, prenatal anxiety symptoms do not increase the risk of adverse neonatal and obstetric outcomes when perceived support is present.

Cumulative life stressors and stress response to threatened preterm labour as birth date predictors

PURPOSE

Preterm birth represents one of the main causes of neonatal morbimortality and a risk factor for neurodevelopmental disorders. Appropriate predictive methods for preterm birth outcome, which consequently would facilitate prevention programs, are needed. We aim to predict birth date in women with a threatened preterm labour (TPL) based on stress response to TPL diagnosis, cumulative life stressors, and relevant obstetric variables.

METHODS

A prospective cohort of 157 pregnant women with TPL diagnosis between 24 and 31 weeks gestation formed the study sample. To estimate the stress response to TPL, maternal salivary cortisol, α-amylase levels, along with anxiety and depression symptoms were measured. To determine cumulative life stressors, previous traumas, social support, and family functioning were registered. Then, linear regression models were used to examine the effect of potential predictors of birth date.

RESULTS

Lower family adaptation, higher Body Mass Index (BMI), higher cortisol levels and TPL diagnosis week were the main predictors of birth date. Gestational week at TPL diagnosis showed a non-linear interaction with cortisol levels: TPL women with middle- and high-cortisol levels before 29 weeks of gestation went into imminent labour.

CONCLUSION

A combination of stress response to TPL diagnosis (salivary cortisol) and cumulative life stressors (family adaptation) together with obstetric factors (TPL gestational week and BMI) was the best birth date predictor. Therefore, a psychosocial therapeutic intervention program aimed to increase family adaptation and decrease cortisol levels at TPL diagnosis as well as losing weight, may prevent preterm birth in symptomatic women.

Maternal psycho-social risk factors associated with maternal alcohol consumption and Fetal Alcohol Spectrum Disorder: a systematic review

PURPOSE

Fetal Alcohol Spectrum Disorder (FASD) is a preventable range of neurocognitive disorders associated with the biological mother's consumption of alcohol during pregnancy. However, on average, 45% of Australian women continue to consume alcohol during pregnancy resulting in a high rate of alcohol-exposed pregnancies and risk of FASD. This level of exposure is higher than the estimated global average of alcohol-exposed pregnancies (9.8%). This systematic literature review aims to identify demographic, health and psycho-social variables associated with alcohol consumption during pregnancy which may lead to FASD.

METHODS

Using PRISMA principles, this systematic literature review reports on psycho-social factors which increase the risk of alcohol consumption during pregnancy thereby increasing the risk of FASD.

RESULTS

Fourteen studies were accepted into this review. Studies were conducted across several countries and included a total of 386,067 cases. Seven studies were case-controlled and seven were cross-sectional design. Multiple studies identified the significance of prior mental illness, anxiety, depression, exposure to abuse and/or domestic violence and alcohol consumption behaviours of partners and family members as strong predictors of risky alcohol consumption during pregnancy and therefore associated risk of FASD.

CONCLUSION

Clinical services may be able to use the evidence-based findings from this review to improve assessment and treatment services for vulnerable women to reduce alcohol-exposed pregnancies.

Perinatal Behavioral Health, the COVID-19 Pandemic, and a Social Determinants of Health Framework

The United States has greater prevalence of mental illness and substance use disorders than other developed countries, and pregnant women are disproportionately affected. The current global COVID-19 pandemic, through the exacerbation of psychological distress, unevenly affects the vulnerable population of pregnant women. Social distancing measures and widespread closures of businesses secondary to COVID-19 are likely to continue for the foreseeable future and to further magnify psychosocial risk factors. We propose the use of a social determinants of health framework to integrate behavioral health considerations into prenatal care and to guide the implementation of universal and comprehensive psychosocial assessment in pregnancy. As the most numerous and well-trusted health care professionals, nurses are ideally positioned to influence program and policy decisions at the community and regional levels and to advocate for the full integration of psychosocial screening and behavioral health into prenatal and postpartum care as core components.

Interactive relations between maternal prenatal stress, fetal brain connectivity, and gestational age at delivery

Studies reporting significant associations between maternal prenatal stress and child outcomes are frequently confounded by correlates of prenatal stress that influence the postnatal rearing environment. The major objective of this study is to identify whether maternal prenatal stress is associated with variation in human brain functional connectivity prior to birth. We utilized fetal fMRI in 118 fetuses [48 female; mean age 32.9 weeks (SD = 3.87)] to evaluate this association and further addressed whether fetal neural differences were related to maternal health behaviors, social support, or birth outcomes. Community detection was used to empirically define networks and enrichment was used to isolate differential within- or between-network connectivity effects. Significance for χ2 enrichment was determined by randomly permuting the subject pairing of fetal brain connectivity and maternal stress values 10,000 times. Mixtures modelling was used to test whether fetal neural differences were related to maternal health behaviors, social support, or birth outcomes. Increased maternal prenatal negative affect/stress was associated with alterations in fetal frontoparietal, striatal, and temporoparietal connectivity (β = 0.82, p < 0.001). Follow-up analysis demonstrated that these associations were stronger in women with better health behaviors, more positive interpersonal support, and lower overall stress (β = 0.16, p = 0.02). Additionally, magnitude of stress-related differences in neural connectivity was marginally correlated with younger gestational age at delivery (β = -0.18, p = 0.05). This is the first evidence that negative affect/stress during pregnancy is reflected in functional network differences in the human brain in utero, and also provides information about how positive interpersonal and health behaviors could mitigate prenatal brain programming.

Neighborhoods, Racism, Stress, and Preterm Birth Among African American Women: A Review

African American women are more likely to experience preterm birth (<37 completed weeks gestation) compared with White women. African American women are also more likely to live in neighborhoods characterized as disadvantaged (i.e., exhibiting higher rates of vacant housing, poorer property conditions, and more litter and crime) and to experience racial discrimination compared with White women. These chronic stressors have been related to preterm birth (PTB) among African American women. This review focuses on potential stress-related pathways by which neighborhood disadvantage and racial discrimination increase the risk for PTB among African American women. Specifically, we propose cortisol, systemic inflammation, proteome and lipidome profiles, and telomere shortening as potential mediators linking these social determinants of health with PTB among African American women. Examination of these factors and the signaling pathways they contribute to will increase our knowledge of the effects of social determinants of health on PTB for African American women.

Risk of adverse perinatal outcomes in infants born to mothers with mental health conditions

INTRODUCTION

Maternal mental health conditions have been shown to affect perinatal outcomes negatively. However, knowledge on the impact of different types and severities of maternal mental health conditions is needed. The objective of this study was to determine the association between maternal mental health status and perinatal health outcomes in the infant.

MATERIAL AND METHODS

This register-based cohort study included all live-born infants in Denmark born between 2000 and 2016. Exposed infants were grouped based on whether the mothers received mental health care in primary care settings only (minor conditions) or required specialized psychiatric intervention (moderate-severe conditions) within 12 months before childbirth. Modified Poisson regression analyses were applied to produce adjusted risk ratios (aRRs) for each perinatal outcome of interest. The primary outcomes were neonatal mortality, 5-minute Apgar scores <7 and <4 and newborn hospital admission during the neonatal period. Secondary outcomes included several neonatal morbidities such as respiratory distress syndrome and abstinence syndrome.

RESULTS

A total of 952 071 infants were included in the analysis; 4.0% had mothers with minor mental health conditions and 2.9% had mothers with moderate-severe conditions. The risk of neonatal death in exposed infants was aRR 1.08 (95% CI 0.93-1.27) for minor mental health conditions and aRR 0.93 (95% CI 0.78-1.11) for moderate-severe conditions. Both exposure groups had increased risks of 5-minute Apgar scores <7 (minor: aRR 1.28, 95% CI 1.16-1.41; moderate-severe: aRR 1.49, 95% CI 1.34-1.66); 5-minute Apgar scores <4 (minor: aRR 1.10, 95% CI 0.93-1.30; moderate-severe: aRR 1.18, 95% CI 0.98-1.43), and hospital admission during the neonatal period (minor: aRR 1.20, 95% CI 1.17-1.23; moderate-severe: aRR 1.22, 95% CI 1.19-1.26) along with several neonatal morbidities. An explicit high risk was seen for abstinence syndrome (minor: aRR 10.30, 95% CI 8.40-12.63; moderate-severe: aRR 12.13, 95% CI 10.17-15.67).

CONCLUSIONS

Infants of mothers with moderate-severe and minor mental health conditions were at increased risks of multiple adverse perinatal outcomes. Effective supportive interventions to improve outcomes in both groups are needed.

Maternal-focused interventions to improve infant growth and nutritional status in low-middle income countries: A systematic review of reviews

BACKGROUND

Small and nutritionally at-risk infants under 6 months (<6m) are a vulnerable group at increased risk of mortality, morbidity, poor growth and sub-optimal development. Current national and international (World Health Organization) management guidelines focus mainly on infants' needs, yet growing evidence suggests that maternal factors also influence infant outcomes. We aimed to inform future guidelines by exploring the impacts of maternal-focused interventions on infant feeding and growth.

METHODS

We conducted a systematic review of reviews published since 2008 (PROSPERO, register number CRD 42019141724). We explored five databases and a wide variety of maternal-focused interventions based in low- and middle-income countries. Infant outcomes of interest included anthropometric status, birthweight, infant mortality, breastfeeding and complementary feeding practices. Given heterogenous interventions, we present a narrative synthesis of the extracted data.

RESULTS

We included a total of 55 systematic reviews. Numerous maternal interventions were effective in improving infant growth or feeding outcomes. These included breastfeeding promotion, education, support and counselling interventions. Maternal mental health, while under-researched, showed potential to positively impact infant growth. There was also some evidence for a positive impact of: women's empowerment, m-health technologies, conditional cash transfers, water, sanitation and hygiene and agricultural interventions. Effectiveness was increased when implemented as part of a multi-sectoral program. Antenatal supplementation with macronutrient, multiple micronutrients, Vitamin D, zinc, iron folic acid and possibly calcium, iodine and B12 in deficient women, improved birth outcomes. In contrast, evidence for postnatal supplementation was limited as was evidence directly focusing on small and nutritionally at-risk infants; most reviews focused on the prevention of growth faltering.

CONCLUSION

Our findings suggest sufficient evidence to justify greater inclusion of mothers in more holistic packages of care for small and nutritionally at-risk infants aged <6m. Context specific approaches are likely needed to support mother-infant dyads and ensure infants survive and thrive.

The impact of maternal prenatal mental health disorders on stillbirth and infant mortality: a systematic review and meta-analysis

Evidence about the association between maternal mental health disorders and stillbirth and infant mortality is limited and conflicting. We aimed to examine whether maternal prenatal mental health disorders are associated with stillbirth and/or infant mortality. MEDLINE, Embase, PsycINFO, and Scopus were searched for studies examining the association of any maternal prenatal (occurring before or during pregnancy) mental health disorder(s) and stillbirth or infant mortality. A random-effects meta-analysis was used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). The between-study heterogeneity was quantified using the I² statistic. Subgroup analyses were performed to identify the source of heterogeneity. Of 4487 records identified, 28 met our inclusion criteria with 27 contributing to the meta-analyses. Over 60% of studies examined stillbirth and 54% of them evaluated neonatal or infant mortality. Thirteen studies investigated the association between maternal depression and anxiety and stillbirth/infant mortality, pooled OR, 1.42 (95% CI, 1.16-1.73; I², 76.7%). Another 13 studies evaluated the association between severe maternal mental illness and stillbirth/infant mortality, pooled OR, 1.47 (95% CI, 1.28-1.68; I², 62.3%). We found similar results for the association of any maternal mental health disorders and stillbirth/infant mortality (OR, 1.59; 95% CI, 1.43-1.77) and in subgroup analyses according to types of fetal/infant mortality. We found no significant evidence of publication bias. Maternal prenatal mental health disorders appear to be associated with a moderate increase in the risk of stillbirth and infant mortality, although the mechanisms are unclear. Efforts to prevent and treat these disorders may reduce the scale of stillbirth/infant deaths.

Mental health among pregnant women under public health interventions during COVID-19 outbreak in Wuhan, China

Coronavirus disease 2019 (COVID-19) has become a pandemic. As the first city struck by the COVID-19 outbreak, Wuhan had implemented unprecedented public health interventions. The mental health of pregnant women during these anti-epidemic controls remains unknown. A total of 274 pregnant women living in Wuhan during the COVID-19 outbreak took part in our investigation online. The data on mental health conditions were evaluated using Edinburgh Postnatal Depression Scale (EPDS), Self-Rating Anxiety Scale (SAS), Chinese Perceived Stress Scale (CPSS), and Pittsburgh Sleep Quality Index (PSQI). We also collected the information on physical health status and precautionary measures against COVID-19. The prevalence of depression, anxiety, stress, and poor sleep quality was 16.1%, 13.9%, 42.7%, 37.6%, respectively. Comparing to SAS, PSQI score in pregnant women who participated in the survey after April 8 (date of Wuhan reopening), those data collected before April 8 were significantly higher. High levels of stress, severe health concerns over the fetus, and poor hygienic practices were negatively associated with mental health conditions. In conclusion, a large proportion of pregnant women reported psychological symptoms during the epidemic, which negatively related to the severe health concerns over fetus and poor hygienic practices. More psychological support during the epidemic would promote maternal mental well-being.

Psychometric Properties of the Perinatal Anxiety Screening Scale Administered to Italian Women in the Perinatal Period

Literature stressed the importance of using valid, reliable measures to assess anxiety in the perinatal period, like the self-rated Perinatal Anxiety Screening Scale (PASS). We aimed to examine the psychometric properties of the Italian PASS version in a sample of Italian women undergoing mental health screening during their third trimester of pregnancy and its diagnostic accuracy in a control perinatal sample of psychiatric outpatients. Sample comprised 289 women aged 33.17 ± 5.08, range 19-46 years, undergoing fetal monitoring during their third trimester of pregnancy, with 49 of them retested 6 months postpartum. Controls were 60 antenatal or postnatal psychiatric outpatients aged 35.71 ± 5.02, range 22-50 years. Groups were assessed through identical self- and clinician-rating scales. Confirmatory Factor Analysis (CFA), Principal Component Analysis (PCA), Pearson's correlations and receiver operating characteristic were conducted for PASS. PCA and CPA confirmed four-factor structure with slight differences from the original version. Construct validity and test-retest reliability were supported. Cut-off was 26. The PASS correlated with principal anxiety scales. Despite small sample size, findings confirm reliability and validity of the Italian PASS version in assessing anxiety symptoms in the perinatal period. Its incorporation in perinatal care will improve future mother and child psychological health.

Assessment of anxiety during pregnancy: are existing multiple anxiety scales suitable and comparable in measuring anxiety during pregnancy?

BACKGROUND

This study examined the performance of multiple anxiety scales in measuring anxiety during pregnancy, an important issue due to the possible effect of pregnancy-related symptoms on the measurement of anxiety.

METHODS

Secondary data on anxiety, measured by the State-Trait Anxiety Inventory-State (STAI-S) 20-item and six-item scales, the Edinburgh Postnatal Depression Scale-Anxiety Subscale (EPDS-3A) and the Symptoms Checklist-90-Anxiety Subscale (SCL-90), were obtained from two pregnancy cohort studies. Both cohorts completed the EPDS-3A, while 3341 women completed the STAI-S and 2187 women completed the SCL-90, with 231 women participating in both cohorts. Data were analyzed using confirmatory factor analysis and Spearman correlation.

RESULTS

The STAI-6 had adequate model fit, while the STAI-20 and the SCL-90 had inadequate model fit. Model fitness for the EPDS-3A could not be assessed due to its low number of items. The correlation between the STAI-20 and STAI-6 was excellent (r = 0.93). The correlation of EPDS-3A with other anxiety scales was low to moderate (r (STAI-20) = 0.57, r (STAI-6) = 0.53 and r (SCL-90) = 0.44). The correlation of SCL-90 with both STAI-20 and STAI-6 was low (r < 0.50).

CONCLUSION

Findings indicate that these scales do not measure anxiety as a single dimension and that these scales are incomparable and may conceptualize anxiety differently.

Maternal fecal microbiome predicts gestational age, birth weight and neonatal growth in rural Zimbabwe

BACKGROUND

Preterm birth and low birth weight (LBW) affect one in ten and one in seven livebirths, respectively, primarily in low-income and middle-income countries (LMIC) and are major predictors of poor child health outcomes. However, both have been recalcitrant to public health intervention. The maternal intestinal microbiome may undergo substantial changes during pregnancy and may influence fetal and neonatal health in LMIC populations.

METHODS

Within a subgroup of 207 mothers and infants enrolled in the SHINE trial in rural Zimbabwe, we performed shotgun metagenomics on 351 fecal specimens provided during pregnancy and at 1-month post-partum to investigate the relationship between the pregnancy gut microbiome and infant gestational age, birth weight, 1-month length-, and weight-for-age z-scores using extreme gradient boosting machines.

FINDINGS

Pregnancy gut microbiome taxa and metabolic functions predicted birth weight and WAZ at 1 month more accurately than gestational age and LAZ. Blastoscystis sp, Brachyspira sp and Treponeme carriage were high compared to Western populations. Resistant starch-degraders were important predictors of birth outcomes. Microbiome capacity for environmental sensing, vitamin B metabolism, and signalling predicted increased infant birth weight and neonatal growth; while functions involved in biofilm formation in response to nutrient starvation predicted reduced birth weight and growth.

INTERPRETATION

The pregnancy gut microbiome in rural Zimbabwe is characterized by resistant starch-degraders and may be an important metabolic target to improve birth weight.

FUNDING

Bill and Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Agency for Development and Cooperation, US National Institutes of Health, and UNICEF.

The impact of prenatal stressful life events on adverse birth outcomes: A systematic review and meta-analysis

BACKGROUND

Stressful life events as important stressors have gradually been recognized as the potential etiology that may lead to adverse birth outcomes such as preterm birth (PTB), low birth weight (LBW), and small for gestational age (SGA). However, researches on this topic have shown relatively inconsistent results. This systematic review and meta-analysis was performed to synthesize available data on the association between prenatal stressful life events and increased risks of PTB, LBW, and SGA.

METHODS

Electronic databases were searched from their inception until September 2020. Pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated to assess the association between prenatal stressful life events and PTB, LBW, and SGA using random effects models. In addition, subgroup analyses, cumulative meta-analyses, sensitivity analyses, and publication bias diagnosis were conducted. STATA 14.0 was applied for statistical analyses.

RESULTS

Totally 31 cohort studies involving 5,665,998 pregnant women were included. Prenatal stressful life events were associated with a 20% higher risk of PTB (RR = 1.20, 95%CI = 1.10-1.32), a 23% increased risk for LBW (RR = 1.23, 95%CI = 1.10-1.39), and a 14% higher risk of SGA (RR = 1.14, 95%CI = 1.08-1.20). Sensitivity analysis indicated the results were stable.

CONCLUSIONS

Findings indicated that pregnant women experiencing prenatal stressful life events were at increased risk of PTB, LBW, and SGA. This information provided additional supports that pregnant women experiencing prenatal stressful life events would benefit from receiving assessment and management in prenatal care services.

Integrating anthropometric and cardiometabolic health methods in stress, early experiences, and development (SEED) science

Within Stress, Early Experiences, and Development (SEED) science, there is a growing body of research demonstrating complex associations not only between stress, development, and psychopathology, but also with chronic disease risk factors. We argue that it is important for SEED researchers to consider including child anthropometric and physical health measures to more comprehensively capture processes of risk and resilience. Broader adoption of harmonized anthropometry and health measures in SEED research will facilitate collaborations, yielding larger datasets for research in high-risk populations, and greater opportunity to replicate existing findings. In this review, we identify optimal anthropometric and cardiometabolic health measurement methods used from infancy through adolescence, including those that are low-burden and inexpensive. Methods covered include: waist, hip, and head circumference, height, length, weight, pubertal development, body composition, blood pressure, arterial stiffness, carotid intima media thickness, and serum measures of cardiometabolic risk and inflammation. We provide resources for SEED researchers to integrate these methods into projects or to better understand these methods when reading the literature as well as where to find collaborators for more in-depth studies incorporating these measures. With broader integration of psychological and physical health measures in SEED research, we can better inform theory and interventions to promote health and resilience in individuals who have experienced early stress.

Pregnancy and obstetric complications in women with a history of childhood maltreatment: Results from a nationally representative sample

INTRODUCTION

A history of childhood maltreatment is associated with increased risk of perinatal complications, with research primarily focused on childhood sexual abuse. Limited research has examined the relationship between different types of childhood maltreatment on perinatal complications, particularly in population-based samples.

METHODS

This study examined the association between childhood maltreatment and self-reported perinatal complications in a sample of pregnant and postpartum women (n = 1279) drawn from the 2012-2013 NESARC-III, a nationally representative survey of United States adults.

RESULTS

Nearly half (45%) of pregnant or postpartum women reported at least one form of childhood maltreatment and a quarter (24.6%) of these women experienced a perinatal complication compared to 13.5% of women without a history of childhood maltreatment. Exposure to any childhood maltreatment, childhood sexual abuse and intimate partner violence (IPV) during childhood were significantly associated with increased odds of perinatal complications after adjusting for sociodemographic characteristics and lifetime psychiatric disorders (AOR ranged from 1.87 to 2.09). Experiencing two or more types of childhood maltreatment (compared to none) was also associated with increased odds of perinatal complications (AOR 2.18 [99% CI = 1.22, 3.90]).

CONCLUSIONS

This association may be explained by vulnerability to physical diseases/complications due to persistent changes in biological stress systems, physical injuries from abuse, or as a result of traumatic memories triggered by pregnancy and childbirth. Findings highlight one of many negative sequelae of childhood maltreatment and the importance of promoting healthcare provider awareness of this association so they can provide appropriate interventions when needed.

Risk of Preterm Birth and Newborn Low Birthweight in Military Women with Increased Pregnancy-Specific Anxiety

INTRODUCTION

Prenatal maternal anxiety and depression have been implicated as possible risk factors for preterm birth (PTB) and other poor birth outcomes. Within the military, maternal conditions account for 15.3% of all hospital bed days, and it is the most common diagnostic code for active duty females after mental disorders. The majority of women (97.6%) serving on active duty are women of childbearing potential. Understanding the impact that prenatal maternal anxiety and depression can have on PTB and low birthweight (LBW) in a military population is critical to providing insight into biological pathways that alter fetal development and growth. The purpose of the study was to determine the impact of pregnancy-specific anxiety and depression on PTB and LBW within a military population.

MATERIAL AND METHODS

Pregnancy-specific anxiety and depression were measured for 246 pregnant women in each trimester. Individual slopes for seven different measures of pregnancy anxiety and one depression scale were calculated using linear mixed models. Logistic regression, adjusted and unadjusted models, were applied to determine the impact on PTB and LBW.

RESULTS

For each 1/10 unit increase in the anxiety slope as it related to well-being, the risk of LBW increased by 83% after controlling for parity, PTB, and active duty status. Similarly, a 1/10 unit rise in the anxiety slope related to accepting pregnancy, labor fears, and helplessness increased the risk of PTB by 37%, 60%, and 54%, respectively.

CONCLUSIONS

Pregnancy-specific anxiety was found to significantly increase the risk of PTB and LBW in a military population. Understanding this relationship is essential in developing effective assessments and interventions. Results emphasize the importance of prenatal maternal mental health to fetal health and birth outcomes. Further research is needed to determine the specific physiological pathways that link prenatal anxiety and depression with poor birth outcomes.

The impact of mental health parity laws on birth outcomes

Prior studies have found that poor mental health during pregnancy is associated with poor birth outcomes, but little is known about the ability of mental health care access and treatment to counteract these effects. I use a difference-in-differences strategy exploiting the staggered enactment of state mental health parity laws in 25 states from 1995 to 2002 to identify the impact of mental health care access on the probability of an adverse birth outcome. These state mental health parity laws are insurance mandates requiring coverage of mental health care be equivalent to physical health care. Using birth records, I find that, among the group of mothers most likely to have private insurance, introduction of a mental health parity law in a state decreased the probability of an adverse birth outcome. Furthermore, I find that the parity laws decreased the likelihood that a pregnant woman hospitalized for delivery would receive a mental illness diagnosis.

Psychological state during pregnancy is associated with sleep quality: preliminary findings from MY-CARE cohort study

Psychological distress during pregnancy may increase the risk of adverse maternal and infant outcomes. Past studies have demonstrated the association between circadian disturbances with psychological health. However, the roles of chronotype and social jetlag on psychological state during pregnancy are yet to be identified. We aimed to examine the psychological state in pregnant women and its relations to chronotype, social jetlag (SJL), sleep quality and cortisol rhythm. The current study included a subsample of participants from an ongoing cohort study. A total of 179 primigravidas (mean age 28.4 ± 4.0 years) were recruited. Chronotype and sleep quality during the second trimester were assessed using the Morning-Eveningness Questionnaire (MEQ) and Pittsburgh Sleep Quality Index (PSQI), respectively. SJL was calculated based on the difference between mid-sleep on workdays and free days. Psychological state of participants was evaluated using the Depression, Anxiety, and Stress Scale-21 (DASS-21). Subsamples (n = 70) provided salivary samples at 5 time points over a 24 h period during the second trimester for cortisol assay. A higher proportion of pregnant women experienced moderate to severe anxiety symptoms (n = 77, 43.0%), followed by depressive (n = 17, 9.5%) and stress (n = 14, 7.8%) symptoms. No association was observed between chronotype and psychological distress during pregnancy. There was no significant difference in cortisol rhythms in relation to psychological distress. SJL and sleep quality were significantly associated with stress symptoms among pregnant women in the second trimester. Poor sleep quality, particularly daytime dysfunction (β = 0.37, p = .006) and sleep disturbances (β = 0.23, p = .047), were significantly associated with psychological distress (depressive, anxiety and stress symptoms) during the second trimester. The findings suggest that sleep is a potential modifiable lifestyle factor that can be targeted to improve psychological health among pregnant women.

Pregnancy-related anxiety and its associated factors during COVID-19 pandemic in Iranian pregnant women: a web-based cross-sectional study

BACKGROUND

Pregnancy is a risk factor for coronavirus disease 2019 (COVID-19). Pregnant women suffer from varying levels of pregnancy-related anxiety (PRA) which can negatively affect pregnancy outcomes. The aim of this study was to assess PRA and its associated factors during the COVID-19 pandemic.

METHODS

This web-based cross-sectional study was conducted in 2020 on 318 pregnant women purposively recruited from primary healthcare centers in Sari and Amol, Iran. Data were collected using questionnaires (PRAQ, Edinburg, KAP of COVID-19, CDA-Q and Demographic questionnaire), which were provided to participants through the social media or were completed for them over telephone. Data were analyzed with the linear regression and the logistic regression analysis, at the significance level of 0.05 using the SPSS software (v. 21).

RESULTS

Around 21% of participants had PRA, 42.1% had depression, and 4.4% had COVID-19 anxiety. The significant predictors of PRA were number of pregnancies (P = 0.008), practice regarding COVID-19 (P < 0.001), COVID-19 anxiety (P < 0.001), depression (P < 0.001), and social support (P = 0.025) which explained 19% of the total variance. Depression and COVID-19 anxiety increased the odds of PRA by respectively four times and 13%, while good practice regarding COVID-19 decreased the odds by 62%.

CONCLUSION

Around 21% of pregnant women suffer from PRA during the COVID-19 pandemic and the significant predictors of PRA during the pandemic include number of pregnancies, practice regarding COVID-19, COVID-19 anxiety, depression, and social support. These findings can be used to develop appropriate strategies for the management of mental health problems during pregnancy in the COVID-19 pandemic.

Stress During Pregnancy and the Development of Diseases in the offspring: A Systematic-Review and Meta-Analysis

OBJECTIVE

The goal of this systematic-review and meta-analysis was to assess whether high maternal stress during pregnancy is associated with the development of pediatric pathology.

DESIGN

Epidemiological peer-reviewed studies published in English or Spanish assessing associations between maternal stress during pregnancy and psychiatric and medical diseases were selected.

PARTICIPANTS

We retrieved 73,024 citations; 42 studies meeting inclusion criteria were assessed. Overall sample included 65,814,076 women.

FINDINGS

Overall odds ratio for the development of a medical disease was OR=1.24 (CI₉₅=1.11, 1.39), Z=3.85, p<.01. Overall odds ratio for psychiatric disorders was OR=1.28 (CI₉₅=1.06, 1.56), Z=2.54, p<.02. Multivariate meta-analysis showed a significant coefficient for autism spectrum disorder studies, B=0.42, SE=0.16, Z=2.67, p<.01. We found a significant overall effect size for autism spectrum disorder (OR=1.45 [CI₉₅=1.24, 1.70], Z=4.69, p<.01). In terms of medical diseases, studies including obesity and infantile colic presented a significant overall effect size, as OR=1.20 (CI₉₅=1.03, 1.39), Z=2.41, p<.02. The highest effect size was found regarding the first trimester (B=1.62, SE=0.16, Z=9.90, p<.01).

KEY CONCLUSIONS

We concluded that exposure to high levels of stress during pregnancy are associated with autism spectrum disorder, obesity, and infantile colic in offspring.

IMPLICATIONS FOR PRACTICE

Maternal stress during pregnancy should be addressed to tackle its potential impact in health across the life span.

Prenatal and postnatal maternal anxiety and amygdala structure and function in young children

Anxiety symptoms are relatively common during pregnancy and are associated with behavioural problems in children. The amygdala is involved in emotion regulation, and its volume and function are associated with exposure to prenatal maternal depression. The associations between perinatal maternal anxiety and children's amygdala structure and function remain unclear. The objective of this study was to determine associations between prenatal and postnatal maternal anxiety and amygdala structure and function in children. Maternal anxiety was measured during the second trimester of pregnancy and 12 weeks postpartum. T1-weighted anatomical data and functional magnetic resonance imaging data were collected from 54 children (25 females), between the ages of 3-7 years. Amygdala volume was calculated and functional connectivity maps were created between the amygdalae and the rest of the brain. Spearman correlations were used to test associations between amygdala volume/functional connectivity and maternal anxiety symptoms, controlling for maternal depression symptoms. Second trimester maternal anxiety symptoms were negatively associated with functional connectivity between the left amygdala and clusters in bilateral parietal regions; higher maternal anxiety was associated with increased negative connectivity. Postnatal maternal anxiety symptoms were positively associated with child amygdala volume, but this finding did not remain significant while controlling for total brain volume. These functional connectivity differences may underlie behavioral outcomes in children exposed to maternal anxiety during pregnancy.

Human Placenta Buffers the Fetus from Adverse Effects of Perceived Maternal Stress

Maternal stress during pregnancy is linked to several negative birth outcomes. The placenta, a unique pregnancy-specific organ, not only nourishes and protects the fetus but is also the major source of progesterone and estrogens. As the placenta becomes the primary source of maternal progesterone (P4) and estradiol between 6-9 weeks of gestation, and these hormones are critical for maintaining pregnancy, maternal stress may modulate levels of these steroids to impact birth outcomes. The objective was to test whether maternal perceived stress crosses the placental barrier to modulate fetal steroids, including cortisol, which is a downstream indicator of maternal hypothalamic-pituitary-adrenal (HPA) axis regulation and is associated with negative fetal outcomes. Nulliparous women, 18 years or older, with no known history of adrenal or endocrine illness were recruited during their third trimester of pregnancy at the University of California San Francisco (UCSF) Mission Bay hospital obstetrics clinics. Simultaneous measurement of 10 steroid metabolites in maternal (plasma and hair) and fetal (cord blood and placenta) samples was performed using tandem mass spectrometry along with assessment of the perceived stress score and sociodemographic status. While the maternal perceived stress score (PSS) and sociodemographic status were positively associated with each other and each with the body mass index (BMI) (r = 0.73, p = 0.0008; r = 0.48, p = 0.05; r = 0.59, p = 0.014, respectively), PSS did not correlate with maternal or fetal cortisol, cortisone levels, or fetal birth weight. Regardless of maternal PSS or BMI, fetal steroid levels remained stable and unaffected. Progesterone was the only steroid analyte quantifiable in maternal hair and correlated positively with PSS (r = 0.964, p = 0.003), whereas cord estradiol was negatively associated with PSS (r = -0.94, p = 0.017). In conclusion, hair progesterone might serve as a better marker of maternal stress than cortisol or cortisone and maternal PSS negatively impacts fetal estradiol levels. Findings have implications for improved biomarkers of stress and targets for future research to identify factors that buffer the fetus from adverse effects of maternal stress.

Cognitive-behavioral therapy in pregnant women with generalized anxiety disorder: a retrospective cohort study on therapeutic efficacy, gestational age and birth weight

OBJECTIVE

To evaluate the efficacy of cognitive behavioral therapy in the treatment of generalized anxiety disorder during pregnancy and its effects on gestational age and birth weight.

METHODS

The sample included 28 untreated patients and 23 patients treated with CBT. Psychiatric diagnoses were determined through the Structured Clinical Interview for the DSM-IV. Symptom severity was assessed with standardized rating scales.

RESULTS

Post-treatment levels of anxiety symptoms were significantly lower than baseline. There was no significant difference in gestational age or newborn birth weight between the cognitive behavioral therapy group and the untreated group.

CONCLUSIONS

Cognitive behavioral therapy appears to be a safe and effective treatment for generalized anxiety disorder during pregnancy.

Status and related factors of depression, perceived stress, and distress of women at home rest with threatened preterm labor and women with healthy pregnancy in Taiwan

BACKGROUND

Women with threatened preterm labor (TPTL) resting at home face several life challenges, but their psychological well-being has been ignored. This study aimed to explore the status and related factors of the psychological status of women with TPTL resting at home, and to compare the psychological status differences between TPTL and healthy pregnant women.

METHODS

A cross-sectional, multiple time-point study was conducted to repeatedly assess depression, perceived stress, and distress in 49 TPTL women and 62 healthy pregnant women during pregnancy in Taiwan. Mann-Whitney U tests were used to compare the psychological status differences between these women and the generalized estimating equation was used to identify the factors related to their psychological status.

RESULTS

The TPTL women's perceived stress at 24-27 weeks (p=0.047) and 32-35 weeks (p=0.04) and distress at each time point was significantly greater than that of healthy pregnant women (p<0.001). The common distress experienced by TPTL women was the inability to provide self-care and family care, the baby's health and safety, and to request leave from work for bed rest. Positive personalities, gestational age, preterm birth history, follow-up status and employment have been shown to be related to the psychological status of TPTL women.

LIMITATIONS

The major limitation of this study is the small sample size.

CONCLUSION

This study contributed to a better understanding of the emotional burdens of women with TPTL resting at home. Such findings highlight the need for constructing effective interventions to alleviate the psychological burden of these women.

Effect of maternal mental health during pregnancy on infant growth at six months of age in Suburban communities in South of Iran

Background: Due to the controversial effects of mental health disorders during pregnancy on infant health, the present study aimed to evaluate the effect of gestational depression, stress, and anxiety on the growth of offspring at six months of age in disadvantaged communities in South of Iran.

Methods: The sample comprised of 470 pregnant women (response rate=98%) who are participated in the Bandar Abbas Pregnancy Cohort study. Maternal mental health was measured by the DASS-21 questionnaire during pregnancy. Data on infant growth was collected based on infant`s growth chart at six months of age. The relative risk of suboptimal infant growth was calculated by Modified Poisson regression models at 5% significant level.

Results: The prevalence of depression, anxiety, and stress was 19.0%, 26.1% and 6.5%, respectively. At six months of age, the mean (SD) of infant`s weight (gram), height (cm) and head circumference (cm) were 7287.30 (1019.85), 63.23 (5.62) and 41.39 (2.70), respectively. Compared to normal mothers, the risk of suboptimal weight at six months of age significantly increased by 71% in mothers who were classified as having depression (Adjusted RR: 1.71, 95% CI: 1.07, 2.09). The presence of anxiety significantly increased the risk of suboptimal height at six months of age by 43% (ARR: 1.43, 95% CI: 1.07, 1.92). There were no statistically significant effects of either depression anxiety or stress on the suboptimal head circumference at six months of age.

Conclusion: Our results showed that mental health disorders of pregnant women might adversely influence the weight and height growth of offspring within the first six months of age. Screening protocols to early diagnose of mental health disorders during pregnancy, and to strict follow up of diagnosed cases postpartum are proposed.

Impact of Perinatal Depression and Anxiety on Birth Outcomes: A Retrospective Data Analysis

OBJECTIVES

During the perinatal period, 10-20% of women experience anxiety and/or depression. Untreated perinatal depression has the potential for adverse effects on the family and infant resulting in long-term deleterious consequences. This study measured the association between self-reported depression using the Edinburgh Postnatal Depression Scale scores, self-reported anxiety and neonatal birth outcomes.

METHODS

A retrospective design was used with ObstetriX™ data retrieved from 16 metropolitan and rural hospitals in NSW, Australia during 2009-2014. Data were available for 53,646 singleton births. The Edinburgh Postnatal Depression Scale was used to identify self-reported depression while women self-reported pregnancy related anxiety. Regression modelling measured the effects of self-reported depression and self-reported pregnancy related anxiety on neonatal birth outcomes. Linear regression and logistic regression were used to model the effect on birth weight, gestational age, admission to NICU or the SCN, outcome (stillborn vs livebirth), and Apgar scores. Cox proportional hazards regression was used to estimate the effect on neonatal length of stay.

RESULTS

Babies born to women self-reporting anxiety were more likely to have birth complications, be admitted to the nursery, had lower Apgar scores and longer hospital stays. Babies born to women self-identifying as experiencing a level of depression were more likely to have a lower birth weight, shorter gestational age, and, lower Apgar score. These babies were more likely to be admitted to the nursery with an increased length of stay.

CONCLUSIONS

Perinatal anxiety and depression contribute to poor birth outcomes. Early detection of maternal perinatal anxiety and depression is an important step towards treatment interventions. More research is needed to identify models of care that are effective in identifying and managing perinatal depression and anxiety to improve birth outcomes for women and their babies.