Infant birthweight in the US: the role of preconception stressful life events and substance use

Risk of adverse infant outcomes associated with maternal mental health and substance use disorders

PURPOSE

This study aimed to evaluate the association of mental health and substance use disorders on the risk of adverse infant outcomes overall and by race/ethnicity and payer.

METHODS

We used birth certificates (2017-2022; n = 125,071) linked with state-wide insurance claims (2016-2022; n = 7,583,488) to assess the risk of an adverse infant outcome (i.e., prematurity [< 37 weeks gestation] or low birthweight [< 2,500 g]) associated with "any mental health" or "any substance use" disorder overall, by race/ethnicity, and by payer using diagnoses during the 9 months of pregnancy. We additionally evaluated seven specific mental health conditions and four specific substance use disorders.

RESULTS

The rate of having an adverse infant outcome was 13.4%. Approximately 21.5% of birthing individuals had a mental health condition, and 8.7% had a substance use disorder. We found increased adjusted risk of an adverse infant outcome associated with having a mental health condition overall (aRR: 1.28; 95%CI: 1.23-1.32) and for all racial/ethnic groups and payers. We additionally found increased risk associated with substance use disorder overall (aRR: 1.32; 95%CI: 1.25-1.40) and for White, Black, privately-covered, and Medicaid-covered individuals. There was increased risk associated with six of seven mental health and three of four substance use disorders.

CONCLUSIONS

Given the risk of adverse infant outcomes associated with mental health and substance use disorders across racial/ethnic groups and payers, our findings highlight the critical importance of policies and clinical guidelines that support early identification and treatment of a broad spectrum of mental health and substance use disorders throughout the perinatal period.

Parental Preconception Adversity and Offspring Health in African Americans: A Systematic Review of Intergenerational Studies

Background: This systematic review explores the empirical literature addressing the association between parental preconception adversity and offspring physical health in African-American families. Method: We conducted a literature search in PubMed, Web of Science, PsycINFO, CINAHL, and Scopus through June 2021. Articles were included if they: reported data about at least two generations of African-American participants from the same family; measured parental preconception adversity at the individual level; measured at least one offspring physical health outcome; and examined associations between parental adversity and child health. Results: We identified 701 unique articles; thirty-eight articles representing 30 independent studies met inclusion criteria. Twenty-five studies (83%) reported that parental preconception adversity was associated with child health; six studies (20%) reported that parental preconception adversity was not associated with at least one offspring outcome; several studies reported both. Only six studies (20%) reported an association specific to African Americans. Conclusion: Empirical evidence linking parental preconception adversity with offspring physical health in African Americans is limited and mixed. In the current literature, very few studies report evidence addressing intergenerational associations between parental preconception adversity and offspring physical health in the African-American population, specifically, and even fewer investigate forms of parental preconception adversity that have been shown to disproportionately affect African Americans (e.g., racism). To better understand root causes of racial health disparities, more rigorous systematic research is needed to address how intergenerational transmission of historical and ongoing race-based trauma may impact offspring health among African Americans.

Predicting body mass index in early childhood using data from the first 1000 days

Few existing efforts to predict childhood obesity have included risk factors across the prenatal and early infancy periods, despite evidence that the first 1000 days is critical for obesity prevention. In this study, we employed machine learning techniques to understand the influence of factors in the first 1000 days on body mass index (BMI) values during childhood. We used LASSO regression to identify 13 features in addition to historical weight, height, and BMI that were relevant to childhood obesity. We then developed prediction models based on support vector regression with fivefold cross validation, estimating BMI for three time periods: 30-36 (N = 4204), 36-42 (N = 4130), and 42-48 (N = 2880) months. Our models were developed using 80% of the patients from each period. When tested on the remaining 20% of the patients, the models predicted children's BMI with high accuracy (mean average error [standard deviation] = 0.96[0.02] at 30-36 months, 0.98 [0.03] at 36-42 months, and 1.00 [0.02] at 42-48 months) and can be used to support clinical and public health efforts focused on obesity prevention in early life.

Maternal socioeconomic and lifestyle factors and life dissatisfaction associated with a small for gestational age infant. The Survey of Neonates in Pomerania (SNiP)

PURPOSE

The aim is to investigate the associations of the mother's socioeconomic and lifestyle factors and life satisfaction with the delivery of a small for gestational age (SGA) infant.

METHODS

Data from 4598 participants of the population-based birth cohort study Survey of Neonates in Pomerania (SniP) including comprehensive information on pregnancies, mothers, and their offspring in Western Pomerania, Germany were used in this study. The associations were analyzed using linear and logistic regression models.

RESULTS

After logistic regression analysis adjusted for height of the mother, women who delivered SGA infants, had lower education (p < 0.01) and smoked more frequently during pregnancy (p < 0.01) compared with mothers of adequate for gestational age (AGA) neonates. A mother with less than 10 years of education and one who continued smoking during pregnancy had an odds ratio (OR) of 2.23 [95% confidence interval (CI) = 1.44 to 3.46] and 2.68 (95% CI = 2.06-3.49) of having an SGA infant, respectively. There was no association between the employment of the mother (p = 0.28), the monthly income (p = 0.09), the family status (p = 0.80), the number of friendships outside the household that the mother would not wish to relinquish (p = 0.47), the number of people that she could rely on in case of an emergency (p = 0.75), or alcohol consumption prior to (p = 0.14) or during the pregnancy (p = 0.99) with SGA. Finally, women who delivered SGA infants were more frequently dissatisfied with their employment (p = 0.03) and financial status (p < 0.01).

CONCLUSIONS

Women who delivered SGA infants had more associated socioeconomic and lifestyle risk factors and were more frequently dissatisfied with their life conditions than mothers of AGA neonates.

Prenatal alcohol exposure and adverse fetal growth restriction: findings from the Japan Environment and Children's Study

BACKGROUNDS

Japanese studies on the association between maternal alcohol consumption and fetal growth are few. This study assessed the effect of maternal alcohol consumption on fetal growth.

METHODS

This prospective birth cohort included 95,761 participants enrolled between January 2011 and March 2014 in the Japan Environment and Children's Study. Adjusted multiple linear and logistic regression models were used to assess the association between prenatal alcohol consumption and infant birth size.

RESULTS

Consumption of a weekly dose of alcohol in the second/third trimester showed a significant negative correlation with standard deviation (SD; Z) scores for body weight, body length, and head circumference at birth, respectively. Consumption of a weekly dose of alcohol during the second/third trimester had a significant positive correlation with incidences of Z-score ≤ -1.5 for birth head circumference. Associations between alcohol consumption in the second/third trimester and Z-score ≤ -1.5 for birth weight or birth length were not significant. Maternal alcohol consumption in the second/third trimester above 5, 20, and 100 g/week affected body weight, body length, and head circumference at birth, respectively.

CONCLUSION

Low-to-moderate alcohol consumption during pregnancy might affect fetal growth. Public health policies for pregnant women are needed to stop alcohol consumption during pregnancy.

IMPACT

This study examined the association between maternal alcohol consumption and fetal growth restriction in 95,761 pregnant Japanese women using the prospective birth cohort. Maternal alcohol consumption in the second/third trimester more than 5, 20, and 100 g/week might affect fetal growth in body weight, body length, and head circumference, respectively. The findings are relevant and important for educating pregnant women on the adverse health effects that prenatal alcohol consumptions have on infants.

A comprehensive assessment of preconception health needs and interventions regarding women of childbearing age: a systematic review

Background

This systematic review summarizes the preconception health needs of women in childbearing age, necessary to be addressed to have an eventual safe and healthy pregnancy.

Methods

Web of Science, PubMed and Scopus were searched. We excluded studies involving women with reproductive system pathologies and referring to interconceptive or pregnancy period and non-empirical or only abstract studies. Two researchers independently performed the blind screening based on titles/abstracts and full-text and the quality assessment.

Results

Four major domains resulted from the thematic analysis: knowledge, behaviors and attitudes, health status and access to healthcare services. The most examined topics were knowledge and awareness on preconception health, folic acid assumption, tobacco and alcohol consumption, physical activity and healthy diet.

Conclusions

This review could assist healthcare professionals (physicians, nurses, midwives) in guiding tailored counselling to women to provide the adequate level of preconception care and act as a reference to policymakers.

Maternal smoking status during pregnancy and low birth weight in offspring: systematic review and meta-analysis of 55 cohort studies published from 1986 to 2020

BACKGROUND

Maternal smoking during pregnancy may be associated with low birth weight (LBW) in offspring and global risk estimates have not been summarized previously. We aimed to systematically explore evidence regarding maternal smoking and the LBW risk in offspring globally and examine possible causes of heterogeneity across relevant studies.

METHODS

Comprehensive search of PubMed, Ovid Embase, Ovid Medline (R), and Web of science from inception until October 2021 was carried out. A random-effects meta-analysis was used to estimate the pooled odds ratio (OR) and corresponding 95% confidence interval (CI). Restricted cubic spline analysis with three knots was used to further examine the dose-response relationship.

RESULTS

Literature searches yielded 4940 articles, of which 53 met inclusion criteria (comprising 55 independent studies). Maternal smoking during pregnancy was significantly associated with the risk of LBW in offspring (OR = 1.89, 95% CI = 1.80-1.98). Furthermore, an obvious dose-response relationship between the amount of cigarettes daily smoked in pregnancy and the risk of LBW in offspring was observed. The results of subgroup analyses indicated that the risk of maternal smoking on LBW was larger in more recently conducted studies (P = 0.020) and longer period of active smoking during pregnancy (P = 0.002). No evidence of publication bias was found.

CONCLUSIONS

In summary, maternal smoking in pregnancy was significantly associated with a higher risk of LBW in offspring on a global scale. The risk of maternal smoking on infant LBW seems to be increasing over time, and was higher with longer smoking duration throughout pregnancy and more cigarettes smoked daily.

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.

DNA methylation of GFI1 as a mediator of the association between prenatal smoking exposure and ADHD symptoms at 6 years: the Hokkaido Study on Environment and Children's Health

BACKGROUND

Prenatal smoking exposure has been associated with childhood attention-deficit/hyperactivity disorder (ADHD). However, the mechanism underlying this relationship remains unclear. We assessed whether DNA methylation differences may mediate the association between prenatal smoking exposure and ADHD symptoms at the age of 6 years.

RESULTS

We selected 1150 mother-infant pairs from the Hokkaido Study on the Environment and Children's Health. Mothers were categorized into three groups according to plasma cotinine levels at the third trimester: non-smokers (≤ 0.21 ng/mL), passive smokers (0.21-11.48 ng/mL), and active smokers (≥ 11.49 ng/mL). The children's ADHD symptoms were determined by the ADHD-Rating Scale at the age of 6 years. Maternal active smoking during pregnancy was significantly associated with an increased risk of ADHD symptoms (odds ratio, 1.89; 95% confidence interval, 1.14-3.15) compared to non-smoking after adjusting for covariates. DNA methylation of the growth factor-independent 1 transcriptional repressor (GFI1) region, as determined by bisulfite next-generation sequencing of cord blood samples, mediated 48.4% of the total effect of the association between maternal active smoking during pregnancy and ADHD symptoms. DNA methylation patterns of other genes (aryl-hydrocarbon receptor repressor [AHRR], cytochrome P450 family 1 subfamily A member 1 [CYP1A1], estrogen receptor 1 [ESR1], and myosin IG [MYO1G]) regions did not exert a statistically significant mediation effect.

CONCLUSIONS

Our findings demonstrated that DNA methylation of GFI1 mediated the association between maternal active smoking during pregnancy and ADHD symptoms at the age of 6 years.

Maternal Stress Before Conception Is Associated with Shorter Gestation

BACKGROUND

Stress in pregnancy predicts adverse birth outcomes. Stressors occurring prior to conception may also pose risk for the mother and child. The few published studies on preconception stress test a single stress measure and examine only linear associations with birth outcomes.

PURPOSE

Guided by findings in the prenatal stress literature, the current study aimed to (i) identify latent factors from a set of preconception stress measures and (ii) examine linear and curvilinear associations between these stress factors and length of gestation.

METHODS

Study 1 utilized a sample of 2,637 racially/ethnically diverse women to develop a measurement model of maternal stress from assessments of seven acute and chronic stress measures. Factor analysis revealed three latent factors representing stressors (life events, financial strain, interpersonal violence, discrimination), stress appraisals (perceived stress, parenting stress), and chronic relationship stress (family, partner stress). Study 2 examined the associations of these three latent preconception stress factors with the length of gestation of a subsequent pregnancy in the subset of 360 women who became pregnant within 4.5 years.

RESULTS

Controlling for prenatal medical risks, there was a significant linear effect of stress appraisals on the length of gestation such that more perceived stress was associated with shorter gestation. There was a curvilinear effect of stressors on the length of gestation with moderate levels associated with longer gestation.

CONCLUSIONS

These results have implications for research on intergenerational origins of developmental adversities and may guide preconception prevention efforts. Findings also inform approaches to the study of stress as a multidimensional construct.

Assessing Pregnancy, Gestational Complications, and Co-morbidities in Women With Congenital Heart Defects (Data from ICD-9-CM Codes in 3 US Surveillance Sites)

Improved treatment of congenital heart defects (CHDs) has resulted in women with CHDs living to childbearing age. However, no US population-based systems exist to estimate pregnancy frequency or complications among women with CHDs. Cases were identified in multiple data sources from 3 surveillance sites: Emory University (EU) whose catchment area included 5 metropolitan Atlanta counties; Massachusetts Department of Public Health (MA) whose catchment area was statewide; and New York State Department of Health (NY) whose catchment area included 11 counties. Cases were categorized into one of 5 mutually exclusive CHD severity groups collapsed to severe versus not severe; specific ICD-9-CM codes were used to capture pregnancy, gestational complications, and nongestational co-morbidities in women, age 11 to 50 years, with a CHD-related ICD-9-CM code. Pregnancy, CHD severity, demographics, gestational complications, co-morbidities, and insurance status were evaluated. ICD-9-CM codes identified 26,655 women with CHDs, of whom 5,672 (21.3%, range: 12.8% in NY to 22.5% in MA) had codes indicating a pregnancy. Over 3 years, age-adjusted proportion pregnancy rates among women with severe CHDs ranged from 10.0% to 24.6%, and 14.2% to 21.7% for women with nonsevere CHDs. Pregnant women with CHDs of any severity, compared with nonpregnant women with CHDs, reported more noncardiovascular co-morbidities. Insurance type varied by site and pregnancy status. These US population-based, multisite estimates of pregnancy among women with CHD indicate a substantial number of women with CHDs may be experiencing pregnancy and complications. In conclusion, given the growing adult population with CHDs, reproductive health of women with CHD is an important public health issue.

Preconception Exposure to Fine Particulate Matter Leads to Cardiac Dysfunction in Adult Male Offspring

Background Particulate matter (particles < 2.5 μm [ PM _2.5]) exposure during the in utero and postnatal developmental periods causes cardiac dysfunction during adulthood. Here, we investigated the potential priming effects of preconception exposure of PM _2.5 on cardiac function in adult offspring. Methods and Results Male and female friend leukemia virus b (FVB) mice were exposed to either filtered air ( FA ) or PM _2.5 at an average concentration of 38.58 μg/m³ for 6 hours/day, 5 days/week for 3 months. Mice were then crossbred into 2 groups: (1)  FA _male× FA _female (both parents were exposed to FA preconception) and, (2) PM _2.5male× PM _2.5female (both parents were exposed to PM _2.5 preconception). Male offspring were divided: (1) preconception FA (offspring born to FA exposed parents) and, (2) preconception PM _2.5 (offspring born to PM _2.5 exposed parents) and analyzed at 3 months of age. Echocardiography identified increased left ventricular end systolic volume and reduced posterior wall thickness, reduced %fractional shortening and %ejection fraction in preconception PM _2.5 offspring. Cardiomyocytes isolated from preconception PM _2.5 offspring showed reduced %peak shortening, -dL/dT, TPS 90 and slower calcium reuptake (tau). Gene and protein expression revealed modifications in markers of inflammation ( IL -6, IL -15, TNF α, NF қB, CRP , CD 26E, CD 26P, intercellular adhesion molecule 1, and monocyte chemoattractant protein-1) profibrosis (collagen type III alpha 1 chain), oxidative stress ( NOS 2), antioxidants (Nrf2, SOD , catalase), Ca²⁺ regulatory proteins ( SERCA 2a, p- PLN , NCX ), and epigenetic regulators (Dnmt1, Dnmt3a, Dnmt3b, Sirt1, and Sirt2) in preconception PM _2.5 offspring. Conclusions Preconception exposure to PM _2.5 results in global cardiac dysfunction in adult offspring, suggesting that abnormalities during development are not limited to the prenatal or postnatal periods but can also be determined before conception.

Ontogeny and programming of the fetal temporal cortical endocannabinoid system by moderate maternal nutrient reduction in baboons (Papio spp.)

Poor nutrition during pregnancy is a worldwide public health problem. Maternal nutrient reduction (MNR) is associated with maternal and fetal stress and a sex-dependent decrease in nonhuman primate (NHP) cognitive performance. Early life stress potentiates epileptogenesis in a sex-specific manner, and temporal lobe (TL) epilepsy is associated with neurocognitive disorders. The endogenous cannabinoid system (ECS) demonstrates remarkable developmental changes and plays a key role in aging-related diseases (e.g., dementia). Baboons have been studied as a natural model of epilepsy and express all ECS system components. We therefore evaluated baboon fetal temporal cortex ECS ontogenic and MNR-dependent changes. At 120 days gestational age (dGA) (term 185 days), maternal, fetal, and placental morphometry were similar between control and MNR pregnancies. MNR maternal weight gain was decreased compared with controls at 165 dGA independent of fetal sex. In male fetuses, expression of ECS synthesizing and degrading enzymes was gestational age-dependent, with the exception of fatty acid amide hydrolase (FAAH). MNR had a sex-specific effect on the protein expression of CB1R during development: CB1R protein expression was decreased in fetal temporal cortex of male fetuses at 120 and 140 dGA. Our data reveal that the MNR has sex-specific effects on temporal cortical expression of the ECS in baboon offspring and shows vulnerability of ECS in male fetuses during gestation.

Lifetime substance use as a predictor of postpartum mental health

Postpartum mood disorders (PPMD) affect approximately 10-20% of women and have adverse consequences for both mom and baby. Lifetime substance use has received limited attention in relation to PPMD. The present study examined associations of lifetime alcohol and drug use with postpartum mental health problems. Women (n = 100) within approximately 3 months postpartum (M = 2.01, SD = 1.32) participated in semi-structured interviews querying lifetime substance use, mental health history, and postpartum symptoms of anxiety, stress, posttraumatic stress disorder (PTSD), depression, and obsessive compulsive disorder. The study was conducted in an urban Canadian city from 2009 to 2010. Analyses revealed that lifetime substance use increased the variability explained in postpartum PTSD (p = .011), above and beyond sociodemographic characteristics and mental health history. The same trend, though not significant, was observed for stress (p = .059) and anxiety (p = .070). Lifetime drug use, specifically, was associated with postpartum stress (p = .021) and anxiety (p = .041), whereas lifetime alcohol use was not (ps ≥ .128). Findings suggest that lifetime drug use is associated with PPMD. Future research should examine whether screening for lifetime drug use during antenatal and postpartum care improves identification of women experiencing PPMD.