Prenatal prediction of poor maternal and offspring outcomes: implications for selection into intensive parent support programs

Mental health of adolescents associated with sexual and reproductive outcomes: a systematic review

Objective

To systematically review the literature on the mental health of adolescents associated with sexual and reproductive outcomes, and compare the mental health outcomes with that of other age groups.

Methods

We searched seven databases for relevant peer-reviewed articles published between 1 January 2010 and 25 April 2019. Our inclusion criteria required that the study included age-disaggregated data on adolescents, and focused and assessed mental health outcomes associated with pregnancy or sexually transmitted infections. We extracted data on the specific health event, the mental health outcome and the method of measuring this, and comparisons with other age groups.

Findings

After initially screening 10 818 articles by title and abstract, we included 96 articles in our review. We observed that a wide-ranging prevalence of mental ill-health has been reported for adolescents. However, most studies of mental health during pregnancy did not identify an increased risk of depression or other mental disorders among adolescents compared with other age groups. In contrast, the majority of studies conducted during the postpartum period identified an increased risk of depression in adolescents compared with other age groups. Three studies reported on mental health outcomes following abortion, with varying results. We found no studies of the effect of sexually transmitted infections on mental health among adolescents.

Conclusion

We recommend that sexual and reproductive health services should be accessible to adolescents to address their needs and help to prevent any adverse mental health outcomes.

Low Dose of Abilify (Aripiprazole) in Combination With Effexor XR (Venlafaxine HCl) Resulted in Cessation of Lactation

Postpartum depression (PPD) is a relatively common experience for women, especially those who have a history of preconception and/or prenatal depression. In some cases, pharmaceutical treatment is required to treat the symptoms of PPD. Unfortunately, the use of some of these treatments may have unintended consequences that affect both the newborn and the new mother. Here we report a case where Abilify (aripiprazole) at a low dose (2 mg/day) was prescribed in conjunction with Effexor XR (venlafaxine HCl) at a high dose (225 mg/day), which resulted in the cessation of lactation.

The impact of health on economic and social outcomes in the United Kingdom: A scoping literature review

This is the first review of the evidence, based on longitudinal studies in the United Kingdom, on the association of ill health at any life stage and later social and economic outcomes. The review included a wide range of physical and mental health exposures, both self-reported and objectively measured, as well as social (e.g. life satisfaction) and economic (e.g. employment) outcomes. We searched the Web of Science, key longitudinal datasets based in the UK, major economic journals, Google Scholar and reference lists of relevant publications. The review includes 80 studies. There was strong evidence for the association between early mental health, mainly attention deficit hyperactivity disorder, and lifetime educational, occupational and various social outcomes. Also, both poor physical and mental health in early and middle adulthood, tended to be associated with unemployment and lower socioeconomic status. Among older adults, the evidence quite consistently indicated an association between mental health, chronic conditions, disability/functional limitations, self-rated general health and quality of life, life satisfaction and early retirement. Overall, mental health was consistently found to be associated with a range of social and economic outcomes throughout the lifespan. The evidence for the association between physical health and later outcomes is more inconsistent. A number of methodological challenges need to be addressed, particularly related to causal inference, to produce robust evidence with potential to inform public health policy.

Surveying social adversity in pregnancy: The antenatal risk burden experienced by Australian women

AIM

Many, varied, antenatal risk factors can adversely impact children's health, behaviour and cognition. Understanding the antenatal risk factors experienced by women can help identify which families are most likely to benefit from additional early supports; however, there is a dearth of published Australian antenatal risk data. This study aimed to determine the prevalence and co-occurrence of a broad range of risk factors in a community-based sample of pregnant Australian women.

METHODS

A brief risk factor survey (10 items, including age, social support, health, smoking, stress or anxious mood, education, household income, employment) completed by pregnant women attending the antenatal clinic waiting rooms of 10 public maternity hospitals, which were selected for their provision of care to areas with fewer socio-economic resources in the states of Victoria and Tasmania, between May 2013 and August 2014.

RESULTS

A total of 5586 women participated, with an average age of 29.0 years and gestation of 26.9 weeks. The most prevalent antenatal risk factors were poorer global health (38.9%), not finishing high school (33.5%) and smoking (14.9%), all proportions higher than the general population. Most women reported at least one risk factor (68.6%), with 21.5% reporting ≥3. There was a high degree of co-occurrence between risk factors, especially the three most prevalent.

CONCLUSIONS

This study reveals the considerable and varied risk burden experienced by Australian women during pregnancy. By understanding where need is greatest and tailoring support accordingly, risk factor assessment provides an opportunity to address equity through health care, ultimately optimising the future developmental outcomes of all children.

Maternal fish consumption during pregnancy and smoking behavioural patterns

n-3 Highly unsaturated fatty acids (HUFA), are essential components of neuronal membranes and mediate a range of complex bioactive properties including gene expression, myelination, cell-signalling and dopaminergic function. Deficits in n-3 HUFA have been linked to increased risks for addictive disorders, thus we posited that lower fish consumption would be associated with greater risks for perinatal smoking among 9640 mothers enroled in the Avon Longitudinal Study of Parents and Children. We used univariable and multivariable regression models to examine relationships between self-reported prenatal dietary intakes of n-3 HUFA-rich foods (fish and shellfish) and maternal smoking; outcomes included cessation and the number of cigarettes smoked per d. Both before and during pregnancy, there was consistent evidence (P<0·001) of protective fish intake-smoking associations; relative to mothers reporting no fish consumption, those who reported some fish consumption (<340 g/week) and high fish consumption (340 g+/week) at 32 weeks of gestation showed lower likelihoods of smoking (adjusted P values <0·001). Respective OR for these relationships were 0·87 (95% CI 0·77, 0·97) and 0·73 (95% CI 0·61, 0·86). Although the prevalence of smoking diminished, from a high of 31·6% (pre-pregnancy) to a low of 18·7% (second trimester), the magnitude of fish intake-smoking associations remained stable following adjustment for confounders. These observations suggest that greater fish or n-3 HUFA consumption should be evaluated as an intervention to reduce or prevent smoking in randomised clinical trials.

Maternal Immune Activation During the Third Trimester Is Associated with Neonatal Functional Connectivity of the Salience Network and Fetal to Toddler Behavior

Prenatal maternal immune activation (MIA) is associated with altered brain development and risk of psychiatric disorders in offspring. Translational human studies of MIA are few in number. Alterations of the salience network have been implicated in the pathogenesis of the same psychiatric disorders associated with MIA. If MIA is pathogenic, then associated abnormalities in the salience network should be detectable in neonates immediately after birth. We tested the hypothesis that third trimester MIA of adolescent women who are at risk for high stress and inflammation is associated with the strength of functional connectivity in the salience network of their neonate. Thirty-six women underwent blood draws to measure interleukin-6 (IL-6) and C-reactive protein (CRP) and electrocardiograms to measure fetal heart rate variability (FHRV) at 34-37 weeks gestation. Resting-state imaging data were acquired in the infants at 40-44 weeks postmenstrual age (PMA). Functional connectivity was measured from seeds placed in the anterior cingulate cortex and insula. Measures of cognitive development were obtained at 14 months PMA using the Bayley Scales of Infant and Toddler Development-Third Edition (BSID-III). Both sexes were studied. Regions in which the strength of the salience network correlated with maternal IL-6 or CRP levels included the medial prefrontal cortex, temporoparietal junction, and basal ganglia. Maternal CRP level correlated inversely with FHRV acquired at the same gestational age. Maternal CRP and IL-6 levels correlated positively with measures of cognitive development on the BSID-III. These results suggest that MIA is associated with short- and long-term influences on offspring brain and behavior.SIGNIFICANCE STATEMENT Preclinical studies in rodents and nonhuman primates and epidemiological studies in humans suggest that maternal immune activation (MIA) alters the development of brain circuitry and associated behaviors, placing offspring at risk for psychiatric illness. Consistent with preclinical findings, we show that maternal third trimester interleukin-6 and C-reactive protein levels are associated with neonatal functional connectivity and with both fetal and toddler behavior. MIA-related functional connectivity was localized to the salience, default mode, and frontoparietal networks, which have been implicated in the pathogenesis of psychiatric disorders. Our results suggest that MIA alters functional connectivity in the neonatal brain, that those alterations have consequences for cognition, and that these findings may provide pathogenetic links between preclinical and epidemiological studies associating MIA with psychiatric risk in offspring.

The feasibility and acceptability of a population-level antenatal risk factor survey: Cross-sectional pilot study

AIM

Australian data on the prevalence and distribution of antenatal risk factors are scarce. This study aimed to investigate (i) the feasibility and acceptability of an antenatal risk factor survey collected in public settings and (ii) whether the survey risk factors co-occur with more sensitive risk factors that are privately asked by clinicians.

METHODS

Design and setting: study-designed survey linked with clinician-collected risk factors.

PARTICIPANTS

pregnant women attending antenatal clinics at two Victorian hospitals.

MEASURES

(i) study-designed survey: young pregnancy, no support, poor/fair/good general health, anxious mood, not finishing high school, no income, long-term illness, living without another adult, not employed, never had a job and proxy poverty measures; (ii) Clinician-collected data: smoking, alcohol/marijuana/drug use, domestic violence, social issues, history of mental health problems and depression symptoms.

ANALYSES

(i) feasibility and acceptability were assessed through survey completion. Each item was assessed for whether they discriminated risk; dichotomised into risk versus no risk; with a total count calculated. (ii) Co-occurrence was assessed by examining how the risk factor count agreed with clinician-collected items.

RESULTS

One hundred and sixty-six of 186 (89%) eligible women completed the survey; 139 of 166 (84%) consented to linking clinician-collected data. The high response and zero missing data demonstrated feasibility and acceptability. Of women with linked data, 92 of 139 (66%) had ≥1 survey risk factor and 30 of 139 (22%) had ≥3; 36 of 139 (26%) had at least one co-occurring clinician-collected risk factor.

CONCLUSIONS

This survey provides a simple, rapid approach to gathering antenatal risk data publicly. It may be a helpful addition to clinicians' standard history collection.

Gestational hormone profiles predict human maternal behavior at 1-year postpartum

In many non-human species, including primates, gestational reproductive hormones play an essential role in the onset of maternal motivation and behaviors. We investigated the associations between prepartum estradiol and progesterone and maternal behavior at 1-year postpartum in 177 women. Blood was obtained at five gestational time points and an index of quality of maternal care was determined using a well-validated mother-child interaction protocol. Women who exhibited higher quality maternal care at 1-year postpartum were characterized by unique gestational profiles of estradiol, progesterone and the estrogen to progesterone ratio; specifically by slower accelerations and levels of these hormone trajectories beginning in midgestation. Further, it appeared that both fetal sex and parity moderated these findings, with first time mothers and mothers of females showing stronger associations. In sum, these data document persisting associations between prepartum hormone profiles and human maternal behavior. More broadly, these findings add to the growing literature highlighting the perinatal period as one of critical neurodevelopment in the lifespan of the human female.

Maternal tobacco smoking in pregnancy and children's socio-emotional development at age 5: The EDEN mother-child birth cohort study

BACKGROUND

There is debate as to whether maternal tobacco use in pregnancy is related to offspring behaviour later on. We tested this association examining multiple aspects of children's behaviour at age 5 and accounting for parental smoking outside of pregnancy, as well as child and family characteristics.

METHODS

Data come from a prospective community based birth cohort study (EDEN; n=1113 families in France followed since pregnancy in 2003-2005 until the child's 5th birthday). Maternal tobacco use in pregnancy was self-reported. Children's socio-emotional development (emotional symptoms, conduct problems, symptoms of hyperactivity/inattention, peer relationship problems, prosocial behaviour) was assessed by mothers using the Strengths and Difficulties Questionnaire (SDQ) at age 5 years. Logistic regression analyses controlled for Inverse Probability Weights (IPW) of maternal tobacco use calculated based on study center, children's characteristics (sex, premature birth, low birth weight, breastfeeding), maternal characteristics (age at the child's birth, psychological difficulties and alcohol use in pregnancy, post-pregnancy depression, and smoking), paternal smoking in and post-pregnancy, parental educational attainment, family income, parental separation, and maternal negative life events.

RESULTS

Maternal smoking in pregnancy only predicted children's high symptoms of hyperactivity/inattention (sex and study center-adjusted ORs: maternal smoking in the 1st trimester: 1.95, 95%CI: 1.13-3.38; maternal smoking throughout pregnancy: OR=2.11, 95%CI: 1.36-3.27). In IPW-controlled regression models, only children of mothers who smoked throughout pregnancy had significantly elevated levels of hyperactivity/inattention (OR=2.20, 95%CI: 1.21-4.00).

CONCLUSIONS

Maternal tobacco smoking in pregnancy may contribute directly or through epigenetic mechanisms to children's symptoms of hyperactivity/inattention.

Predictors of positive and negative parenting behaviours: evidence from the ALSPAC cohort

BACKGROUND

This study aimed to establish the predictors of positive and negative parenting behaviours in a United Kingdom population. The majority of previous research has focused on specific risk factors and has used a variety of outcome measures. This study used a single assessment of parenting behaviours and started with a wide range of potential pre- and post-natal variables; such an approach might be used to identify families who might benefit from parenting interventions.

METHODS

Using a case-control subsample of 160 subjects from the Avon Longitudinal Study of Parents and Children (ALSPAC), regression analysis was undertaken to model parenting behaviours at 12 months as measured by the Mellow Parenting Observational System.

RESULTS

Positive parenting increased with maternal age at delivery, levels of education and with prenatal anxiety. More negative interactions were observed among younger mothers, mothers with male infants, with prenatal non-smokers and among mothers who perceived they had a poor support structure.

CONCLUSIONS

This study indicates two factors which may be important in identifying families most at risk of negative parenting: younger maternal age at delivery and lack of social support during pregnancy. Such factors could be taken into account when planning provision of services such as parenting interventions. We also established that male children were significantly more likely to be negatively parented, a novel finding which may suggest an area for future research. However the findings have to be accepted cautiously and have to be replicated, as the measures used do not have established psychometric validity and reliability data.

Cohort Profile: the Avon Longitudinal Study of Parents and Children: ALSPAC mothers cohort

Summary The Avon Longitudinal Study of Children and Parents (ALSPAC) was established to understand how genetic and environmental characteristics influence health and development in parents and children. All pregnant women resident in a defined area in the South West of England, with an expected date of delivery between 1st April 1991 and 31st December 1992, were eligible and 13761 women (contributing 13867 pregnancies) were recruited. These women have been followed over the last 19-22 years and have completed up to 20 questionnaires, have had detailed data abstracted from their medical records and have information on any cancer diagnoses and deaths through record linkage. A follow-up assessment was completed 17-18 years postnatal at which anthropometry, blood pressure, fat, lean and bone mass and carotid intima media thickness were assessed, and a fasting blood sample taken. The second follow-up clinic, which additionally measures cognitive function, physical capability, physical activity (with accelerometer) and wrist bone architecture, is underway and two further assessments with similar measurements will take place over the next 5 years. There is a detailed biobank that includes DNA, with genome-wide data available on >10000, stored serum and plasma taken repeatedly since pregnancy and other samples; a wide range of data on completed biospecimen assays are available. Details of how to access these data are provided in this cohort profile.

Psychological differences between smokers who spontaneously quit during pregnancy and those who do not: a review of observational studies and directions for future research

INTRODUCTION

Although remarkable interindividual differences among pregnant smokers' decision/ability to quit have been documented, the psychological factors that may account for these differences have received less attention and comprised the primary aim of this review.

METHODS

We searched the medical and behavioral sciences literature from 1996 to November 2011 using PubMed and PsycINFO(®). Fifty-one articles were identified based on titles or abstracts. These articles were reviewed in full and searched for quantitative observational studies of population-based or clinical samples, with the main topic of comparing smokers who quit spontaneously during pregnancy with those who did not, utilizing multivariable analyses.

RESULTS

The eight pertinent studies reviewed herein included four longitudinal studies and four cross-sectional analyses. Amidst significant variability among measures used, social support, depressive symptoms, and anxiety appeared unrelated to smoking cessation during pregnancy. Furthermore, when severity of nicotine dependence was controlled, maternal history of attention-deficit/hyperactivity disorder, depression, bipolar disorder, and schizophrenia all showed no independent relationship with smoking cessation during pregnancy, whereas maternal history of conduct disorder did. Secure attachment, prosocial personality, self-esteem, and perceived parenting competence were additional predictors of cessation during pregnancy.

CONCLUSIONS

A greater understanding of psychological factors that differentiate smokers who spontaneously quit during pregnancy from those who do not is crucial to the design of more effective prenatal smoking cessation interventions and also may elucidate causal mechanisms that underlie the well-established link between maternal smoking during pregnancy and offspring behavioral problems. Directions for future research and public health and policy implications are discussed.