Association between maternal anxiety in pregnancy and increased uterine artery resistance index: cohort based study

A pilot randomised controlled trial of cognitive behavioural therapy for antenatal depression

BACKGROUND

Few trials have evaluated the effectiveness of psychological treatment in improving depression by the end of pregnancy. This is the first pilot randomised controlled trial (RCT) of individual cognitive behavioural therapy (CBT) looking at treating depression by the end of pregnancy. Our aim was to assess the feasibility of delivering a CBT intervention modified for antenatal depression during pregnancy.

METHODS

Women in North Bristol, UK between 8-18 weeks pregnant were recruited through routine contact with midwives and randomised to receive up to 12 sessions of individual CBT in addition to usual care or to continue with usual care only. Women were eligible for randomisation if they screened positive on a 3-question depression screen used routinely by midwives and met ICD-10 criteria for depression assessed using the clinical interview schedule - revised version (CIS-R). Two CBT therapists delivered the intervention. Follow-up was at 15 and 33 weeks post-randomisation when assessments of mental health were made using measures which included the CIS-R.

RESULTS

Of the 50 women assessed for the trial, 36 met ICD-10 depression criteria and were randomised: 18 to the intervention and 18 to usual care. Thirteen of the 18 (72%) women who were allocated to receive the intervention completed 9 or more sessions of CBT before the end of pregnancy. Follow-up rates at 15 and 33 weeks post-randomisation were higher in the group who received the intervention (89% vs. 72% at 15 weeks and 89% vs. 61% at 33 weeks post-randomisation). At 15 weeks post-randomisation (the end of pregnancy), there were more women in the intervention group (11/16; 68.7%) who recovered (i.e. no longer met ICD-10 criteria for depression), than those receiving only usual care (5/13; 38.5%).

CONCLUSIONS

This pilot trial shows the feasibility of conducting a large RCT to assess the effectiveness of CBT for treating antenatal depression before the end of pregnancy. The intervention could be delivered during the antenatal period and there was some evidence to suggest that it could be effective.

TRIAL REGISTRATION

ISRCTN44902048.

Effects of early- and late-gestational maternal stress and synthetic glucocorticoid on development of the fetal hypothalamus-pituitary-adrenal axis in sheep

Prenatal maternal stress (PMS) programs dysregulation of the hypothalamus-pituitary-adrenal axis (HPAA) in postnatal life, though time periods vulnerable to PMS, are still unclear. We evaluated in pregnant sheep the effect of PMS during early gestation [30-100 days of gestation (dGA); term is 150 dGA] or late gestation (100-120 dGA) on development of fetal HPAA function. We compared the effects of endogenous cortisol with synthetic glucocorticoid (GC) exposure, as used clinically to enhance fetal lung maturation. Pregnant sheep were exposed to repeated isolation stress twice per week for 3 h in a separate box with no visual, tactile, or auditory contact with their flock-mates either during early (n = 7) or late (n = 7) gestation. Additional groups received two courses of betamethasone (BM; n = 7; 2 × 110 μg kg(- 1) body weight, 24 h apart) during late gestation (106/107 and 112/113 dGA, n = 7) or acted as controls (n = 7). Fetal cortisol responses to hypotensive challenge, a physiological fetal stressor, were measured at 112 and 129 dGA, i.e. before and during maturation of the HPAA. Hypotension was induced by fetal infusion of sodium nitroprusside, a potent vasodilator. At 112 dGA, neither PMS nor BM altered fetal cortisol responses. PMS, during early or late gestation, and BM treatment increased fetal cortisol responses at 129 dGA with the greatest increase achieved in stressed early pregnant sheep. Thus, development of the HPAA is vulnerable to inappropriate levels of GCs during long periods of fetal life, whereas early gestation is most vulnerable to PMS.

Are exposure-based cognitive behavioral therapies safe during pregnancy?

Anxiety disorders during pregnancy are highly prevalent and associated with serious and enduring consequences for both mother and child. Exposure-based cognitive behavioral (CBT) and behavioral therapies (BT) represent the most empirically supported psychosocial treatments for anxiety disorders in general adult samples. Pregnant women, however, generally have been excluded from this body of research. Evidence that pregnant women inhabit a unique biological context combined with untested assumptions that exposure would unduly stress or harm the fetus have likely prohibited inquiry. This paper seeks to remedy this gap by integrating findings from obstetric, psychiatric, and psychological research to inform central questions regarding exposure-based treatment of anxiety disorders during pregnancy. Based on available evidence, we consider the potential risks and benefits of CBT/BT for anxiety disorders during pregnancy relative to other currently available treatment options. From a multidisciplinary research perspective, we argue that exposure-based therapies are likely to be safe during pregnancy, particularly relative to the alternatives. However, we also highlight critical questions for future research to directly test the biopsychological impact of exposure-based therapies among pregnant women.

Maternal trait personality and childbirth: the role of extraversion and neuroticism

BACKGROUND

anxiety during pregnancy and childbirth can increase risk of complications and interventions for both mother and infant. Although considerable work has explored fear of childbirth and anxiety during labour and subsequent birth outcomes there has been less consideration of the role of more stable maternal personality upon childbirth. Traits of neuroticism and extraversion are however predictive of health outcomes in other fields potentially through biological, psychological and social mechanisms. The aim of the current research was thus to examine the relationship between trait personality and childbirth experience.

METHODS

seven hundred and fifty-five mothers with an infant aged 0-6 months completed a self-report questionnaire including the Ten Item Personality Measure and descriptions of birth experience including mode of birth [vaginal vs. caesarean section] and complications [failure to progress, fetal distress, post-partum haemorrhage, assisted birth and severe tear].

FINDINGS

personality traits were significantly associated with birth experience. Specifically mothers scoring low in extraversion and emotional stability were significantly more likely to have a caesarean section and experience a number of complications during labour and birth including an assisted birth, fetal distress, failure to progress and a severe tear. Findings were independent of maternal age, education and parity.

CONCLUSIONS

the personality traits of extraversion and emotional stability appear to facilitate likelihood of normal birth. Potential explanations for this include biological (physiological reactivity, pain thresholds, oxytocin and dopamine release) and psychological (coping mechanisms, social support, self-efficacy) factors. The findings have important implications for antenatal education and support during labour.

Uterine blood flow in a psychiatric population: impact of maternal depression, anxiety, and psychotropic medication

BACKGROUND

Accumulating evidence suggests that fetal exposure to maternal psychiatric symptoms is associated with future risk for psychopathology. One potential pathway is distress-linked constriction in uterine or umbilical blood flow (UBF). With approximately 6.6% of pregnant women taking an antidepressant, an ecologically valid investigation of this hypothesis must consider the potential concomitant influence of pharmacotherapy on UBF.

METHODS

Pregnant women (n = 101) with lifetime histories of mental illness were evaluated every 4 to 6 weeks during gestation for mood symptoms and medication use; women underwent an ultrasound examination for UBF at approximately 25 weeks gestation.

RESULTS

No associations were observed between UBF and three assessments of maternal prenatal depression and anxiety (acute: coincident with the UBF scan; proximal: within 2 weeks of the scan; chronic: serial symptom ratings). Chronic and acute use of bupropion was associated with reduced UBF, even after controlling for pregnancy complications. Chronic use of atypical antipsychotics also was associated with decreased UBF. There were no associations between serotonergic antidepressant use and UBF.

CONCLUSIONS

Contrary to a popular hypothesis, depression and anxiety-associated reductions in UBF may not be a pathway by which risk is conferred during prenatal development. However, while requiring replication, our findings suggest that prenatal bupropion exposure may be associated with reductions in UBF.

Birth weight, stress, and symptoms of depression in adolescence: evidence of fetal programming in a national Canadian cohort

OBJECTIVE

To investigate evidence of fetal programming in humans by studying whether adolescents born at high or low birth weights (LBW) are more likely to experience symptoms of depression and anxiety after experiencing stress.

METHOD

The sample included 3732 members of a prospective Canadian cohort study assessed for symptoms of depression and anxiety at age 12 to 15 years (2006/2007), and had birth weight and gestational age (GA) data recorded in 1994/1995. Major stressful life events and chronic stressors were also reported throughout childhood.

RESULTS

After adjusting for acute and chronic stress, being born small for GA (SGA) (OR 1.50; 95% CI 1.08 to 2.08) or large (OR 1.31; 95% CI 0.99 to 1.72) for GA was associated with an increased risk of depression and anxiety in adolescence, compared with adolescents who were born at a weight appropriate for their GA. Most interactions between birth weight and stress were not significant; however, the relation between chronic stress and adolescent depression and anxiety was more pronounced in males who were born SGA (interaction P < 0.05).

CONCLUSIONS

The link between birth weight and depression is complex and evidence of fetal programming is inconsistent; however, people born at LBW may be at an increased risk of depression in the face of chronic stress.

Health-related quality of life of infants from ethnic minority groups: the Generation R Study

Purpose

To assess whether the health-related quality of life of infants from ethnic minority groups differs from the health-related quality of life of native Dutch infants and to evaluate whether infant health and family characteristics explain the potential differences.

Methods

We included 4,506 infants participating in the Generation R Study, a longitudinal birth cohort. When the child was 12 months, parents completed the Infant Toddler Quality of Life Questionnaire (ITQOL); ITQOL scale scores in each ethnic subgroup were compared with scores in the Dutch reference population. Influence of infant health and family characteristics on ITQOL scale scores were evaluated using multivariate regression models.

Results

Infants from ethnic minority groups presented significantly lower ITQOL scale scores compared to the Dutch subgroup (e.g., Temperament and Moods scale: median score of Turkish subgroup, 70.8 (IQR, 15.3); median score of Dutch subgroup, 80.6 (IQR, 13.9; P < 0.001)). Infant health and family characteristics mediated an important part of the association between the ethnic minority status and infant health-related quality of life. However, these factors could not fully explain all the differences in the ITQOL scale scores.

Conclusions

Parent-reported health-related quality of life is lower in infants from ethnic minority groups compared to native Dutch infants, which could partly be explained by infant health and by family characteristics.

High pregnancy-related anxiety and prenatal depressive symptoms as predictors of intention to breastfeed and breastfeeding initiation

BACKGROUND

Perinatal mood disorders affect up to 20% of women in the United States. Little is known about how disorders in maternal mood may affect rates of breastfeeding.

OBJECTIVE

To determine the impact of prenatal depressive symptoms and high pregnancy-related anxiety on (1) prenatal intention to breastfeed and (2) breastfeeding initiation.

METHODS

We prospectively followed 1436 pregnant women enrolled in the cohort study Project Viva. The main outcome measures were (1) mother's second trimester self-report of intention to use all or mostly formula in the first week of life and (2) failure to initiate breastfeeding. We defined prenatal depressive symptoms as a second trimester Edinburgh Postpartum Depression Scale (EPDS) score of > or =13 and high pregnancy-related anxiety as a "very much" response to three or more questions on a first trimester pregnancy anxiety scale.

RESULTS

Of the 1436 participants, 9% (n = 125) had prenatal depressive symptoms indicative of depression, and 10% (n = 141) reported high pregnancy-related anxiety; 11% (n = 159) intended to give mostly or only formula in the first week of life, and 86% (n = 1242) initiated breastfeeding. In multivariate analyses, women with prenatal depressive symptoms (OR 1.92, 95% CI 1.11, 3.33) and high pregnancy-related anxiety (OR 1.99, 95% CI 1.12, 3.54) were roughly two times more likely than women without these mood disorders to plan to formula feed. However, neither prenatal depressive symptoms (OR 1.06, 95% CI 0.61, 1.84) nor high pregnancy-related anxiety (OR 1.28, 95% CI 0.74, 2.20) was associated with failure to initiate breastfeeding.

CONCLUSIONS

In a healthcare setting highly supportive of breastfeeding, women with prenatal depressive symptoms and possibly those with high pregnancy-related anxiety were less likely to plan prenatally to breastfeed, although this tendency did not translate into lower breastfeeding initiation rates.

Maternal personality traits and risk of preterm birth and fetal growth restriction

Background/Aims

Maternal personality may increase vulnerability to stress, which could lead to an unfavourable intrauterine environment to the fetus. We sought to investigate the impact of maternal personality traits on adverse birth outcomes such as preterm birth, and fetal growth restriction in the mother-child cohort study (RHEA Study) in Crete, Greece 2007–2009.

Methods

Five hundred and eighty pregnant women participating in “Rhea” cohort study completed the Eysenck Personality Questionnaire-Revised (EPQ-R) at 28–32 weeks of gestation. Information on anthropometric measures at birth was obtained from the hospital delivery logs and medical records. Fetal growth restriction was based on a customized model, and multivariate logistic regression models were used adjusting for confounders.

Results

A per unit increase in the EPQ Neuroticism scale increased the risk for fetal weight growth restriction by 9% [Odds Ratio (OR) = 1.09, 95 percent CI: 1.01, 1.19)], and for fetal head circumference growth restriction by 6% [OR = 1.06, 95 percent CI: 1.01, 1.18] after adjusting for maternal age, education, origin, marital status, working status, pre-pregnancy BMI, delivery type, parity, smoking, and alcohol intake during pregnancy.

Conclusions

Maternal neuroticism, which predisposes to negative mood, may be a risk factor for fetal growth restriction.

Genesis of preeclampsia: an epidemiological approach

THERE ARE ANALYZED SOME OF THE MAIN ASPECTS RELATED TO THE CAUSALITY OF PREECLAMPSIA, PRIVILEGING TWO TYPES OF MODELS: the clinic model and the epidemiologic model, first one represented by the hypothesis of the reduced placental perfusion and the second one considering the epidemiologic findings related to the high levels of psychosocial stress and its association with preeclampsia. It is reasoned out the relevance of raising the causality of the disease from an interdisciplinary perspective, integrating the valuable information generated from both types, clinical and epidemiologic, and finally a tentative explanatory model of preeclampsia is proposed, the subclinical and sociocultural aspects that predispose and trigger the disease are emphasized making aspects to stand out: the importance of reduced placental perfusion as an indicator of individual risk, and the high levels of physiological stress, as a result of the unfavorable conditions of the psychosocial surroundings (indicator of population risk) of the pregnant women.

Salivary alpha-amylase during pregnancy: diurnal course and associations with obstetric history, maternal demographics, and mood

Diurnal patterns of salivary alpha amylase (sAA) in pregnant women have not previously been described. The current study employed ecological momentary assessment to examine the association between the diurnal sAA, obstetric history, maternal demographics, and mood during pregnancy. Saliva was self-collected by 83 pregnant women (89% White, age 25.3-43.0 years; mean gestational age 21.9 weeks, range 6-37 weeks; gravida 1-6) at home over three days. Results indicated that current pregnancy (gestational age and fetal sex) and maternal demographics were not related to diurnal sAA. In contrast, a history of previous miscarriage (Parameter = -.17; SE = .05; p < .05) was associated with an atypical diurnal pattern. Even after accounting for obstetric history, trait anxiety (Parameter = .16; SE = .04; p < .001) was associated with increased sAA over the day while chronic levels of fatigue (Parameter = -.06; SE = .03; p < .05) were associated with decreased sAA. In a separate model, we also tested the time varying covariation of sAA and mood. The effects of momentary mood were in contrast to those for trait mood. Both momentary depression (Parameter = .22; SE = .09; p < .01) and vigour/positive mood (Parameter = .12; SE = .04; p < .001) were associated with momentary increases in sAA while momentary anxiety and fatigue were not related to sAA. The findings suggest that basal sAA during pregnancy is sensitive to emotional arousal. Evaluating diurnal patterns of sAA holds promise for advancing understanding of how emotional arousal during pregnancy may affect fetal development.

Maternal Stress during Pregnancy, ADHD Symptomatology in Children and Genotype: Gene-Environment Interaction

OBJECTIVE

Case control studies suggest a relationship between maternal stress during pregnancy and childhood ADHD. However, maternal smoking, parenting style and parental psychiatric disorder are possible confounding factors. Our objective was to control for these factors by using an intra-familial design, and investigate gene-environment interactions.

METHODS

One hundred forty two children, ages 6 to 12, (71 with ADHD, and their 71 non-ADHD siblings) participated in the intra-familial study design. A larger sample of ADHD children (N=305) was genotyped for DAT1 and DRD4 to examine gene-environment interactions. Symptom severity was evaluated using the Child Behavior Checklist (CBCL) and the Conners' Global Index for Parents (CGI-P). The Kinney Medical and Gynecological Questionnaire was used to report stressful events during pregnancies.

RESULTS

LOGISTIC REGRESSION INDICATED THAT MOTHERS WERE MORE LIKELY TO HAVE EXPERIENCED HIGH STRESS DURING PREGNANCY OF THEIR ADHD CHILD COMPARED TO THAT OF THE UNAFFECTED SIBLING (OR: 6.3, p=.01). In the larger sample, DRD4 7/7 genotype was associated with increased symptom severity in the high stress pregnancy (p=.01).

CONCLUSIONS

Maternal stress during pregnancy was associated with the development of ADHD symptomatology after controlling for family history of ADHD and other environmental factors. This association could partly be mediated through the DRD4 genotype.

Cortisol and anxiety response to a relaxing intervention on pregnant women awaiting amniocentesis

BACKGROUND

Stress and anxiety during pregnancy have been associated with premature and low birth weight babies, presumably through fetus over exposion to glucocorticoids. Antenatal stress also seems to have long-term effects upon infant development and adult health. However, medication for stress may carry risks to the expectant mother, therefore the efficacy of non-pharmacological interventions should be investigated.

METHODS

Pregnant women (n=154) awaiting amniocentesis, were randomly assigned in the morning and the afternoon to three groups for 30 min: (1) listening to relaxing music, (2) sitting and reading magazines, and (3) sitting in the waiting-room. Before and after that period, they completed the Spielberger's State and Trait anxiety inventory and provided blood samples for cortisol. The groups were then compared regarding change in cortisol levels and anxiety.

RESULTS

Maternal cortisol and state anxiety were correlated (r=0.25, p=0.04) in the afternoon, but not in the morning. The larger decreases in cortisol occurred in the music group (-61.8 nmol/L, ANOVA: p=0.01), followed by magazine, being differences among groups more pronounced in the morning. Women in the music group also exhibited the greater decreases in state anxiety (p<0.001). Younger mothers with less gestational age were on average the most anxious, and also the ones with greater decreases in cortisol and anxiety levels after relaxation.

CONCLUSION

A relaxing intervention as short as 30 min, especially listening to music, decreases plasma cortisol and self-reported state anxiety score. Pregnant women might benefit from the routine practice of relaxation in the imminence of clinical stressful events.

Perception of teratogenic risk and the rated likelihood of pregnancy termination: association with maternal depression

OBJECTIVE

Women are often exposed to various medications and medical conditions during pregnancy. Unrealistically high maternal teratogenic risk perception, related to these exposures, may lead to abrupt discontinuation of therapy and (or) termination of a wanted pregnancy. The association between maternal depression and the teratogenic risk perception has not been studied, nor were the actions resulting from this perception. Our objectives were to explore the association between maternal depression, teratogenic risk perception, and the rated likelihood to terminate pregnancy. Additionally, we evaluated possible benefits of counselling.

METHODS

We administered the Edinburgh Postnatal Depression Scale (EPDS) to all women who attended the Motherisk Clinic between October 2007 and April 2010. A visual analogue scale was used to determine maternal risk perception in relation to the specific exposure, and the rated likelihood to terminate the pregnancy, before and after counselling.

RESULTS

We analyzed data from 413 women. Maternal teratogenic risk perception and the rated likelihood to terminate the pregnancy were significantly lower following counselling. An EPDS score of 13 or more was significantly associated with a higher rated likelihood to terminate the pregnancy (P = 0.03). In a multivariable regression analysis, an EPDS score of 13 or more was found to be an independent predictor of a higher personal teratogenic risk perception (P = 0.03).

CONCLUSIONS

Both maternal depression and exposure-directed counselling are associated with maternal risk perception and the rated likelihood to terminate pregnancy. Appropriate counselling may reduce fear of teratogenicity and the likelihood of pregnancy termination.

Newborn neurobehavioral patterns are differentially related to prenatal maternal major depressive disorder and serotonin reuptake inhibitor treatment

BACKGROUND

Prenatal serotonin reuptake inhibitor (SRI) exposure has been related to adverse newborn neurobehavioral outcomes; however, these effects have not been compared to those that may arise from prenatal exposure to maternal major depressive disorder (MDD) without SRI treatment. This study examined potential effects of MDD with and without SRI treatment on newborn neurobehavior.

METHODS

This was a prospective, naturalistic study. Women were seen at an outpatient research center twice during pregnancy (26-28 and 36-38 weeks gestational age (GA)). Psychiatric diagnoses were assessed using the Structured Clinical Interview for the DSM-IV; medication use was measured with the Timeline Follow-Back instrument. Three groups were established based upon MDD diagnosis and SRI use: Control (N = 56), MDD (N = 20), or MDD + SRI (N = 36). Infants were assessed on a single occasion within 3 weeks of birth with the NICU Network Neurobehavioral Assessment Scale. Generalized Linear Modeling was used to examine neurobehavioral outcomes by exposure group and infant age at assessment.

RESULTS

Full-term infants exposed to MDD + SRIs had a lower GA than CON or MDD-exposed infants and, controlling for GA, had lower quality of movement and more central nervous system stress signs. In contrast, MDD-exposed infants had the highest quality of movement scores while having lower attention scores than CON and MDD + SRI-exposed infants.

CONCLUSION

MDD + SRI-exposed infants seem to have a different neurobehavioral profile than MDD-exposed infants in the first 3 weeks after delivery; both groups may have different neurobehavioral profiles with increasing age from birth.

Stress and the social determinants of maternal health among Puerto Rican women: a CBPR approach

This qualitative research project explores how poverty, the built environment, education, working conditions, health care access, food insecurity and perceived discrimination are experienced by Puerto Rican Latinas through the course of their lives. Five focus groups were conducted with the primary objective of documenting community experiences and perspectives regarding: 1) stress, including perceived discrimination based on race/ethnicity (racism); 2) the impact of stress on Puerto Rican women of reproductive age, their families, and/or their community; and 3) stressors that affect maternal health. Focus groups were conducted in English and Spanish in the two cities with the highest rates of premature birth and low infant birthweight in the state of Connecticut. Focus group findings indicate that participants perceived poverty, food insecurity, lack of access to quality education, and unsafe environments as significant life stressors affecting maternal and child health.

Anxiety measures validated in perinatal populations: a systematic review

BACKGROUND

Research and screening of anxiety in the perinatal period is hampered by a lack of psychometric data on self-report anxiety measures used in perinatal populations. This paper aimed to review self-report measures that have been validated with perinatal women.

METHODS

A systematic search was carried out of four electronic databases. Additional papers were obtained through searching identified articles. Thirty studies were identified that reported validation of an anxiety measure with perinatal women.

RESULTS

Most commonly validated self-report measures were the General Health Questionnaire (GHQ), State-Trait Anxiety Inventory (STAI), and Hospital Anxiety and Depression Scales (HADS). Of the 30 studies included, 11 used a clinical interview to provide criterion validity. Remaining studies reported one or more other forms of validity (factorial, discriminant, concurrent and predictive) or reliability. The STAI shows criterion, discriminant and predictive validity and may be most useful for research purposes as a specific measure of anxiety. The Kessler 10 (K-10) may be the best short screening measure due to its ability to differentiate anxiety disorders. The Depression Anxiety Stress Scales 21 (DASS-21) measures multiple types of distress, shows appropriate content, and remains to be validated against clinical interview in perinatal populations.

LIMITATIONS

Nineteen studies did not report sensitivity or specificity data. The early stages of research into perinatal anxiety, the multitude of measures in use, and methodological differences restrict comparison of measures across studies.

CONCLUSION

There is a need for further validation of self-report measures of anxiety in the perinatal period to enable accurate screening and detection of anxiety symptoms and disorders.

Racial residential segregation and low birth weight in Michigan's metropolitan areas

OBJECTIVES

We examined the influence of racial residential segregation, independent of neighborhood economic factors, on the overall and specific etiological risks of low birth weight.

METHODS

We geocoded all singleton births in Michigan metropolitan areas during 2000 to census tracts. We used hierarchical generalized linear models to investigate the association between low birth weight (< 2500 g) and neighborhood-level economic and racial segregation, controlling for individual and neighborhood characteristics. We analyzed competing risks of the 2 etiologies of low birth weight: intrauterine growth restriction and preterm birth.

RESULTS

Living in a Black segregated area was associated with increased odds (odds ratio [OR] = 1.15; 95% confidence interval [CI] = 1.03, 1.29; P < .05) of low birth weight after adjusting for individual- and tract-level measures. The analysis suggested that the association between low birth weight and racial segregation was attributable primarily to increased risk of intrauterine growth restriction (OR = 1.19; 95% CI = 1.03, 1.37; P < .05).

CONCLUSIONS

Odds of low birth weight are higher in racially segregated Black neighborhoods in Michigan's metropolitan areas, independent of economic factors. The association appears to operate through intrauterine growth restriction rather than preterm birth.

The contribution of maternal stress to preterm birth: issues and considerations

Preterm birth represents the most significant problem in maternal-child health, with maternal stress identified as a variable of interest. The effects of maternal stress on risk of preterm birth may vary as a function of context. This article focuses on select key issues and questions highlighting the need to develop a better understanding of which particular subgroups of pregnant women may be especially vulnerable to the potentially detrimental effects of maternal stress, and under what circumstances and at which stages of gestation. Issues related to the characterization and assessment of maternal stress and candidate biologic mechanisms are addressed.

Risk and Resilience in Coping With Chronic Life Stress

This review discusses evidence-based perspectives on risk and resilience in coping with chronic life stress. Future directions for inquiry and practice also are addressed.

Discriminatory mass de-housing and low-weight births: scales of geography, time, and level

Struening et al.1 demonstrated a widening disparity of low birthweight (LOB) rates among New York City health areas from 1980-1986, clearly a dynamic process. In contrast, the New York City Department of Health reported static citywide LOB rate in 1988-2008.2 Struening et al.1 is extended here at the health district level with mapping and regression analyses. Additionally, birthweight data are reported for babies born in 1998-2001 to a group of African-American and Dominican women in Upper Manhattan. The data reported in this paper indicate that both fetal programming of the mother herself (life course model) and stress during or shortly before pregnancy may play a role in LOB. Current stress may arise from past events. Intergenerational effects, thus, could arise from stresses on the grandmother and their residual impacts on the mother as well as new stresses on the mother as an adult. The average weight of babies born to the Upper Manhattan mothers who were born in 1970-1974 was 3,466 g, with 1.6% below 2,500 g; that of babies of mothers born in 1975-1979, 3,320 g, with 6% below 2,500 g. The latter group was born during the 1975-1979 housing destruction. Intergenerational impacts of that event may be reflected in this elevated rate of LOB. Health district maps of LOB incidence ranges show improvement from 1990-2000 and then deterioration in 2005 and 2008. Bivariate regressions of socioeconomic (SE) factors and LOB incidence showed many strong associations in 1990; but by 2000, the number and strength of these associations declined. In 1990, 2000, and 2008, black segregation was the SE factor most strongly associated with LOB. Black segregation and murder rate explained about 85% of the pattern of 1990 LOB. Regressing the 1970-1980 percent population change against the SE factors showed effects even in 2000. The 1990 murder rate and 1989 percentage of public assistance explained over half the 2008 LOB incidence pattern. The housing destruction of the 1970s continued to influence LOB incidence indirectly in 2008. The ability of community and individual to cope with current stressors may hinge on resilience status, which is shaped by past events and circumstances. The present interacts with the past in many ways. Serial displacement exemplifies this interaction of immense importance to public health.

Mood disorders and their pharmacological treatment during pregnancy: is the future child affected?

Nearly half the US population will meet criteria for a neuropsychiatric disorder at some point in their lives, and 1 in 17 has a seriously debilitating illness. Although not all affected adults had an identified disorder as a child, increasingly these psychopathologies are conceptualized as the late-stage culmination of aberrant developmental processes shaped by a complex interplay of genes and experience, including experiences in utero. Decades of studies with pregnant animals demonstrate that stress-elicited perturbations in maternal biology affect offspring neurodevelopment. Studies of stress in pregnant women largely mirror these findings. Pregnant women with anxiety and/or depression experience greater life stress, and illness-related alterations in their neurobiology, with a potential to impact fetal neurobehavioral development via associated changes in the intrauterine environment and/or pharmacologic interventions. This article critically reviews findings on child development (including fetal neurobehavior) related to maternal depression, anxiety, and pharmacological treatments, primarily selective serotonin reuptake inhibitors (SSRIs). The hypothesis under review is that, in addition to genetics and characteristics of the postnatal environment, the familial transmission of risk for neuropsychiatric disorders involves a "third path"-prenatal exposure to psychiatric illness and its treatment.

Associations of maternal psychological factors with umbilical and uterine blood flow

OBJECTIVE

Alteration to blood flow in the maternal-foetal compartment has been proposed as a mechanism underlying maternal psychological effects on pregnancy outcomes. This study characterised the progression of umbilical and uterine blood flow resistance in healthy pregnancies and evaluated concurrent and longitudinal associations with maternal anxiety and other psychological factors.

METHODS

The study assessed participants (n=107) at five visits spanning 24-38 weeks gestation. The resistance index (RI) in the uterine and umbilical arteries was measured with Doppler ultrasound. Maternal psychological function was assessed using validated, self-report instruments.

RESULTS

Hierarchical linear modelling revealed that uterine and umbilical RI decreased during the second half of gestation, and that uterine RI was lower in nulliparous women. Few concurrent associations emerged between psychological factors and RI. Longitudinal analyses determined that psychological well-being was associated with decreased left uterine artery RI, and psychological distress was associated with lower right artery RI.

CONCLUSIONS

Although uterine artery resistance was modestly associated with the maternal psychological milieu during gestation, our findings do not indicate an association between increased maternal distress and decreased RI. Thus, this study fails to affirm a key component of the hypothesised relation of maternal stress to foetal outcomes via vasoconstriction.

National origin and behavioural problems of toddlers: the role of family risk factors and maternal immigration characteristics

In many societies the prevalence of behavioural problems in school-aged children varies by national origin. We examined the association between national origin and behavioural problems in 1½-year-old children. Data on maternal national origin and the Child Behavior Checklist for toddlers (n = 4943) from a population-based cohort in the Netherlands were used. Children from various non-Dutch backgrounds all had a significantly higher mean behavioural problem score. After adjustment for family risk factors, like family income and maternal psychopathology, the differences attenuated, but remained statistically significant. Non-Dutch mothers with immigration risk factors, such as older age at immigration or no good Dutch language skills, reported significantly more behavioural problems in their offspring. In conclusion, the present study indicated more behavioural problems in immigrant toddlers from various backgrounds. Researchers and policymakers aiming to tackle disparities in behavioural problems should take into account that risks associated with national origin are intertwined with unfavourable family and immigration characteristics.

Evolutionary functions of early social modulation of hypothalamic-pituitary-adrenal axis development in humans

The hypothalamic-pituitary-adrenal axis (HPAA) is highly responsive to social challenges. Because stress hormones can have negative developmental and health consequences, this presents an evolutionary paradox: Why would natural selection have favored mechanisms that elevate stress hormone levels in response to psychosocial stimuli? Here we review the hypothesis that large brains, an extended childhood and intensive family care in humans are adaptations resulting from selective forces exerted by the increasingly complex and dynamic social and cultural environment that co-evolved with these traits. Variations in the modulation of stress responses mediated by specific HPAA characteristics (e.g., baseline cortisol levels, and changes in cortisol levels in response to challenges) are viewed as phenotypically plastic, ontogenetic responses to specific environmental signals. From this perspective, we discuss relations between physiological stress responses and life history trajectories, particularly the development of social competencies. We present brief summaries of data on hormones, indicators of morbidity and social environments from our long-term, naturalistic studies in both Guatemala and Dominica. Results indicate that difficult family environments and traumatic social events are associated with temporal elevations of cortisol, suppressed reproductive functioning and elevated morbidity. The long-term effects of traumatic early experiences on cortisol profiles are complex and indicate domain-specific effects, with normal recovery from physical stressors, but some heightened response to negative-affect social challenges. We consider these results to be consistent with the hypothesis that developmental programming of the HPAA and other neuroendocrine systems associated with stress responses may facilitate cognitive targeting of salient social challenges in specific environments.

OCD in the Perinatal Period: Is Postpartum OCD (ppOCD) a Distinct Subtype? A Review of the Literature

Background: It has been suggested that the perinatal period is a period of increased risk for the development and/or exacerbation of OCD and that postpartum OCD (ppOCD) presents a distinct clinical picture. This raises the possibility that ppOCD might be a distinct subtype of OCD. This review examines this contention. Method: A search using Ovid (Medline, PsycINFO and Embase), EBSCO, Cochrane Library, Web of Science (ISI), Pubmed databases and Google Scholar was carried out using the key words: “obsessive compulsive disorder” (and derivatives), “perinatal”, “pregnancy”, “postnatal”, “postpartum”, “mothers” (and derivatives), “anxiety disorders” and “subtypes.” These articles and their references were reviewed. Results: The majority of studies reviewed were retrospective, which makes it impossible to infer causality. Two prospective studies found a higher incidence of OCD in the postpartum period. These were carried out in Turkey and Brazil and, as such, may be limited in their applicability to other cultural groups. Conclusion: The concept of ppOCD as a specific subtype has not been robustly demonstrated. The evidence that OCD is more prevalent in the postpartum period is mixed. The evidence that OCD in the postpartum period presents a distinctive clinical picture with specific symptomatology and course is more compelling. In view of the impact of culture and religion on the expression of OCD, collaborative, international, prospective studies that take into account the methodological and definitional issues raised in this review are necessary to provide clarification.

Prenatal depression effects and interventions: a review

This review covers research on the negative effects of prenatal depression and cortisol on fetal growth, prematurity and low birthweight. Although prenatal depression and cortisol were typically measured at around 20 weeks gestation, other research suggests the stability of depression and cortisol levels across pregnancy. Women with Dysthymia as compared to Major Depression Disorder had higher cortisol levels, and their newborns had lower gestational age and birthweight. The cortisol effects in these studies were unfortunately confounded by low serotonin and low dopamine levels which in themselves could contribute to non-optimal pregnancy outcomes. The negative effects of depression and cortisol were also potentially confounded by comorbid anxiety, by demographic factors including younger age, less education and lower SES of the mothers and by the absence of a partner or a partner who was unhappy about the pregnancy or a partner who was depressed. Substance use (especially caffeine use) was still another risk factor. All of these problems including prenatal depression, elevated cortisol, prematurity and low birthweight and even postpartum depression have been reduced by prenatal massage therapy provided by the women's partners. Massage therapy combined with group interpersonal psychotherapy was also effective for reducing depression and cortisol levels. Several limitations of these studies were noted and suggestions for future research included exploring other predictor variables like progesterone/estriol ratios, immune factors and genetic determinants. Further research is needed both on the potential use of cortisol as a screening measure and the use of other therapies that might reduce prenatal depression and cortisol in the women and prematurity and low birthweight in their infants.

First-borns carry a higher metabolic risk in early adulthood: evidence from a prospective cohort study

BACKGROUND

Birth order has been associated with early growth variability and subsequent increased adiposity, but the consequent effects of increased fat mass on metabolic risk during adulthood have not been assessed. We aimed to quantify the metabolic risk in young adulthood of being first-born relative to those born second or subsequently.

METHODOLOGY AND PRINCIPAL FINDINGS

Body composition and metabolic risk were assessed in 2,249 men, aged 17-19 years, from a birth cohort in southern Brazil. Metabolic risk was assessed using a composite z-score integrating standardized measurements of blood pressure, total cholesterol, high density lipoprotein, triglycerides and fat mass. First-borns had lower birth weight z-score (Δ = -0.25, 95%CI -0.35, -0.15,p<0.001) but showed greater weight gain during infancy (change in weight z-score from birth to 20 months: Δ = 0.39, 95%CI 0.28-0.50, p<0.0001) and had greater mean height (Δ = 1.2 cm, 95%CI: 0.7-1.6, p<0.0001) and weight (Δ = 0.34 kg, 95%CI: 0.13-0.55, p<0.002) at 43 months. This greater weight and height tracked into early adulthood, with first-borns being significantly taller, heavier and with significantly higher fat mass than later-borns. The metabolic risk z-score was significantly higher in first-borns.

CONCLUSIONS/SIGNIFICANCE

First-born status is associated with significantly elevated adiposity and metabolic risk in young adult men in Brazil. Our results, linking cardiovascular risk with life history variables, suggest that metabolic risk may be associated with the worldwide trend to smaller family size and it may interact with changes in behavioural or environmental risk factors.

Effects of relaxation on psychobiological wellbeing during pregnancy: a randomized controlled trial

Prenatal maternal stress is associated with adverse birth outcomes and may be reduced by relaxation exercises. The aim of the present study was to compare the immediate effects of two active and one passive 10-min relaxation technique on perceived and physiological indicators of relaxation. 39 healthy pregnant women recruited at the outpatient department of the University Women's Hospital Basel participated in a randomized controlled trial with an experimental repeated measure design. Participants were assigned to one of two active relaxation techniques, progressive muscle relaxation (PMR) or guided imagery (GI), or a passive relaxation control condition. Self-reported relaxation on a visual analogue scale (VAS) and state anxiety (STAI-S), endocrine parameters indicating hypothalamic-pituitary-adrenal (HPA) axis (cortisol and ACTH) and sympathetic-adrenal-medullary (SAM) system activity (norepinephrine and epinephrine), as well as cardiovascular responses (heart rate, systolic and diastolic blood pressure) were measured at four time points before and after the relaxation exercise. Between group differences showed, that compared to the PMR and control conditions, GI was significantly more effective in enhancing levels of relaxation and together with PMR, GI was associated with a significant decrease in heart rate. Within the groups, passive as well as active relaxation procedures were associated with a decline in endocrine measures except epinephrine. Taken together, these data indicate that different types of relaxation had differential effects on various psychological and biological stress systems. GI was especially effective in inducing self-reported relaxation in pregnant women while at the same time reducing cardiovascular activity.

Life course perspectives on the epidemiology of depression

Life course epidemiology seeks to understand how determinants of health and disease interact across the span of a human life, and has made significant contributions to understanding etiological mechanisms in many chronic diseases, including schizophrenia. The life course approach is ideal for understanding depression: causation in depression appears to be multifactorial, including interactions between genes and stressful events, or between early life trauma and later stress in life; timing of onset and remission of depression varies widely, indicating differing trajectories of symptoms over long periods of time, with possible differing causes and differing outcomes; and early life events and development appear to be important risk factors for depression, including exposure to acute and chronic stress in the first years of life. To better understand etiology and outcome of depression, future research must move beyond basic epidemiologic techniques that link specific exposures to specific outcomes and embrace life course principles and methods. Time-sensitive modelling techniques that are able to incorporate multiple interacting factors across long periods of time, such as structural equation models, will be critical in understanding the complexity of causal and influencing factors from early development to the end stages of life. Using these models to identify key pathways that influence trajectories of depression across the life course will help guide prevention and intervention.

Maternal hurricane exposure and fetal distress risk

Logistic regression and spatial analytic techniques are used to model fetal distress risk as a function of maternal exposure to Hurricane Andrew. First, monthly time series compare the proportion of infants born distressed in hurricane affected and unaffected areas. Second, resident births are analyzed in Miami-Dade and Broward counties, before, during, and after Hurricane Andrew. Third, resident births are analyzed in all Florida locales with 100,000 or more persons, comparing exposed and unexposed gravid females. Fourth, resident births are analyzed along Hurricane Andrew's path from southern Florida to northeast Mississippi. Results show that fetal distress risk increases significantly with maternal exposure to Hurricane Andrew in second and third trimesters, adjusting for known risk factors. Distress risk also correlates with the destructive path of Hurricane Andrew, with higher incidences of fetal distress found in areas of highest exposure intensity. Hurricane exposed African-American mothers were more likely to birth distressed infants. The policy implications of in utero costs of natural disaster exposure are discussed.

A psychosomatic intervention in pregnant in-patient women with prenatal somatic risks

PURPOSE

This study examined whether a short-term psychosomatic intervention during pregnancy had effects on characteristics of labour and delivery as well as on the long-term course of anxiety, depression and physical complaints in pregnant in-patient women.

METHODS

All gynaecological and obstetric inpatients of a university hospital, who had either exhibited complications during their pregnancy or were considered high-risk pregnancies, were examined. Symptoms of anxiety and depression (HADS) and physical symptoms (GBB) were assessed by standardised questionnaires. Women with elevated scores on either the HADS or the GBB were randomly assigned to either a treatment group, which had received a psychosomatic intervention or an untreated control group. Of the n = 238 women who were assessed during their stay in our hospital, n = 135 were included in the follow-up 1-year later.

RESULTS

More than one-third of the participants (38.7%) had elevated scores of anxiety, depression and/or physical symptoms. The psychosomatic intervention had a significant effect on anxiety scores (p = 0.006), but not on depression scores, physical complaints and characteristics of labour and delivery.

CONCLUSIONS

Findings suggest that a short-term psychosomatic intervention can have a positive long-term effect on anxiety symptoms. Future studies are needed to show whether the reduction of anxiety symptoms in turn can lead to a reduction of postnatal complications and lower rates of disturbed mother-child interactions.

Maternal life events during pregnancy and offspring language ability in middle childhood: The Western Australian Pregnancy Cohort Study

BACKGROUND

There is accumulating evidence for a link between maternal stress during pregnancy and later behavioural and emotional problems in children. Little research has examined other developmental outcomes.

AIM

To determine the effect of maternal stress during pregnancy on offspring language ability in middle childhood.

STUDY DESIGN

Longitudinal pregnancy cohort-study.

SUBJECTS

A total of 2900 mothers were recruited prior to the 18th week of pregnancy, delivering 2868 live births. The language ability of just under half of the offspring cohort (n=1309; 45.6% of original sample) was assessed in middle childhood (Mean age=10;7, Standard deviation=0;2, range: 9;5-11;11).

OUTCOME MEASURES

Language ability was measured using the Peabody Picture Vocabulary Test-Revised (PPVT-R). The main predictor variable was the frequency of 10 typically 'stressful' life events experienced by mothers during early and/or late pregnancy. Children were allocated to four groups according to whether they were exposed to high maternal stress (>or=2 life events) during early pregnancy only, late pregnancy only, both, or neither.

RESULTS

Mixed-effects regression analyses revealed no association between the maternal experience of two or more stressful life events at any time-point during pregnancy and PPVT-R scores. Repeating the regression analyses with more lenient (>or=1 life events) or strict (>or=3 life events) thresholds for defining high-levels of maternal stress did not alter the pattern of findings.

CONCLUSIONS

Maternal experience of typically stressful life events during pregnancy has a negligible effect on vocabulary development to middle childhood.

Association between antenatal distress and uterine artery pulsatility index

Although studies have found associations between maternal distress/anxiety and alterations in blood flow, data across different trimesters are inconsistent. We, therefore, sought to determine the association between measures of distress and uterine blood flow in all three trimesters. Healthy women with low-risk singleton pregnancies were recruited from antenatal clinics. Women were assessed at 13-14 weeks (T1), 21-22 weeks (T2), and 32-33 weeks (T3) of gestation with measures of distress and anxiety (the K10, Perceived Stress Scale, and the State Subscale of the Spielberger State-Trait Anxiety Inventory [STAI]) and with uterine Doppler flow velocity studies. The Trait Subscale of the STAI was done either at T1 or T2. Thirty women were seen at T1, 79 women were seen at T2, and 59 women were seen at T3. No significant correlations were found between measures of distress and anxiety and umbilical artery pulsatility index (PI) or middle cerebral artery PI at any time-point. Small positive correlations between trait anxiety and uterine artery PI were found, but these were not significant after adjustment for alcohol and nicotine use (any use as well as problem drinking/nicotine dependence). At T3 but not T1 or T2, women scoring above 20 on the K10 (a standardized cutoff for the presence of axis I psychiatric disorders) had higher uterine artery PI than those scoring below 20.This was significant after adjusting for alcohol and nicotine use, as well as when nicotine dependence was considered. This work highlights the complexities of the relationship between increased measures of distress and anxiety and changes in the placental circulation. Further work in this area is needed to explore the underlying mechanisms which account for this relationship and to delineate fully the extent to which the relationship is determined by the presence of psychiatric and substance use disorders.

Developing the Birth Unit Design Spatial Evaluation Tool (BUDSET) in Australia: A Qualitative Study

Objective:

To develop a tool known as the Birth Unit Design Spatial Evaluation Tool (BUDSET), to assess the optimality of birth unit design.

Background:

The space provided for childbirth influences the physiology of women in labor. Optimal birth spaces are likely to enable women to have physiologically normal labor and birth. The measurement of an optimal birth space is currently impossible, because limited tools are available. Research into optimal birth unit design is also limited.

Methods:

The BUDSET was developed using a qualitative study. Data collection included an extensive literature review, interviews with key informants (architects, midwife clinicians, and researchers) and an expert panel. A Pattern Language format was used to synthesize the literature and data obtained from the key informants.

Results:

The BUDSET is based on 18 design principles and is divided into four domains (Fear Cascade; Facility; Aesthetics; Support) with three to eight assessable items in each.

Conclusion:

Birth units must be designed so that they facilitate and support the physiology of normal childbirth. The BUDSET may provide a way to assess the optimality of birth units and determine which domain areas may need to be improved.

Parents' experiences of an abnormal ultrasound examination - vacillating between emotional confusion and sense of reality

Background

An ultrasound examination is an important confirmation of the pregnancy and is accepted without reflection to any prenatal diagnostic aspects. An abnormal finding often comes unexpectedly and is a shock for the parents. The aim was to generate a theoretical understanding of parents' experiences of the situation when their fetus is found to have an abnormality at a routine ultrasound examination.

Methods

Sixteen parents, mothers and fathers, whose fetus had been diagnosed with an abnormality during an ultrasound scan in the second or third trimester, were interviewed. The study employed a grounded theory approach.

Results

The core category vacillating between the emotional confusion and sense of reality is related to the main concern assessment of the diagnosis impact on the well-being of the fetus. Two other categories Entering uncertainty and Involved in an ongoing change and adaptation have each five sub-categories.

Conclusions

Parents are aware of that ultrasound examination is a tool for identifying abnormalities prenatally. The information about the abnormality initially results in broken expectations and anxiety. Parents become involved in ongoing change and adaptation. They need information about the ultrasound findings and the treatment without prolonged delay and in a suitable environment. The examiner who performs the ultrasound examination must be aware of how anxiety can be intensified by environmental factors. All parents should to be offered a professional person to give them support as a part of the routine management of this situation.

Anxiety disorders before birth and self-perceived distress during pregnancy: associations with maternal depression and obstetric, neonatal and early childhood outcomes

BACKGROUND

Maternal perinatal mental health has been shown to be associated with adverse consequences for the mother and the child. However, studies considering the effect of DSM-IV anxiety disorders beyond maternal self-perceived distress during pregnancy and its timing are lacking.

AIMS

To examine the role of maternal anxiety disorders with an onset before birth and self-perceived distress during pregnancy for unfavourable maternal, obstetric, neonatal and childhood outcomes.

STUDY DESIGN

DSM-IV mental disorders and self-perceived distress of 992 mothers as well as obstetric, neonatal and childhood outcomes of their offspring were assessed in a cohort sampled from the community using the Munich-Composite International Diagnostic Interview. Logistic regression analyses revealed associations (odds ratios) between maternal anxiety disorders and self-perceived distress during pregnancy with maternal depression after birth and a range of obstetric, neonatal and childhood psychopathological outcomes.

RESULTS

Lifetime maternal anxiety disorders were related to offspring anxiety disorders, but not to offspring externalizing disorders. Analyses focussing on maternal DSM-IV anxiety disorders before birth yielded associations with incident depression after birth. In addition, self-perceived distress during pregnancy was associated with maternal depression after birth, preterm delivery, caesarean section, separation anxiety disorder, ADHD, and conduct disorder in offspring.

CONCLUSION

Findings confirm the transmission of anxiety disorders from mother to offspring. Apart from maternal anxiety, self-perceived distress during pregnancy also emerged as a putative risk factor for adverse outcomes. The finding that maternal anxiety disorders before birth yielded less consistent associations, suggests that self-perceived distress during pregnancy might be seen as a putative moderator/mediator in the familial transmission of anxiety.