Ambulatory assessments of psychological and peripheral stress-markers predict birth outcomes in teen pregnancy

Feasibility and utility of ecological momentary assessment to measure mental health issues in perinatal women: Scoping review

BACKGROUND

Ecological Momentary Assessment (EMA) allows real-time, repeated evaluations of emotions and thoughts in natural settings, effectively avoiding retrospective bias associated with traditional surveys and capturing the dynamic nature of psychological variables. However, its feasibility, utility, and methodological details for studying or monitoring maternal mental health remain unclear.

OBJECTIVES

This review aims to assess the feasibility and utility of EMA in perinatal women with mental health issues, identify application gaps, and explore future directions for its development.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines for systematic reviews. Both the feasibility and utility of the extracted data were analyzed. Feasibility was evaluated using response-related results, study design, and data collection methods, while utility was assessed based on evaluation outcomes.

RESULTS

Of the 27 studies meeting inclusion criteria, EMA protocols demonstrated an average compliance rate of 80% (ranging from 63% to 96%), indicating strong feasibility for assessing diverse outcome variables. EMA proved useful in predicting or evaluating trends in maternal psychological symptoms and exploring relationships between variables. However, several gaps were identified, including limited sample representation, high participant burden, and insufficient development of ecological momentary interventions to support maternal mental health.

CONCLUSION

EMA is both feasible and useful for addressing maternal mental health issues. Future improvements to EMA protocols should focus on reducing participant burden, addressing response-related challenges, and enhancing their application in perinatal mental health management.

A Preliminary Investigation of Associations Between Traumatic Events Experienced During Pregnancy and Salivary Diurnal Cortisol Levels of Brazilian Adolescent Mothers and Infants

INTRODUCTION

Interpersonal violence against women is a major global health problem that may have intergenerational effects. This study investigated associations between maternal experiences of interpersonal violence and other traumatic events and maternal and infant salivary diurnal cortisol in a cohort of adolescent mothers in São Paulo, Brazil.

METHOD

Adolescent mothers (14-19 years) participating in a home-visiting intervention were interviewed retrospectively about lifetime and pregnancy violence and trauma exposure. Mothers collected saliva at waking and before bedtime from themselves (n = 23) and their infants (n = 32) at 12 months postpartum. Multivariable regression models were used to examine associations between trauma history variables and salivary diurnal cortisol.

RESULTS

Adjusting for the intervention group, infant sex, maternal age, non-supplement medication use, and sample collection time, we found that higher-than-average lifetime trauma exposure was associated with maternal evening cortisol (b = 0.472, p-value = 0.028). Lifetime assaultive violence exposure was also associated with maternal evening cortisol (b = 0.196, p-value = 0.02). Maternal exposure to traumatic events in pregnancy was positively associated with bedtime cortisol levels of infants (b = 0.21, p = 0.01). Trauma variables were not associated with maternal or infant morning cortisol levels.

CONCLUSION

Results suggest that maternal trauma history influences both maternal and infant postnatal cortisol regulation as indexed by evening cortisol levels. These results are consistent with models of fetal programming; however, future studies should investigate potential postnatal psychobiological pathways. Lifetime trauma exposure may also become embedded in the maternal hypothalamic-adrenal-pituitary axis regulation. Future studies are needed to consider other biological pathways in the intergenerational transmission of trauma.

Enduring impact of childhood adversity: Affective modulation of acoustic startle response during pregnancy and postpartum

BACKGROUND

Women with a history of adverse childhood experiences (ACEs) enter pregnancy and the postpartum with a physiologic system programmed by early life stress, potentially reflected in psychophysiologic reactivity.

METHODS

We enrolled pregnant, psychiatrically healthy women ≥18 years old. Using the ACE Questionnaire, women were categorized as high (≥2 ACEs; n = 77) or low ACE (<2 ACEs; n = 72). Participants completed an affective modulation of acoustic startle response (ASR) task during pregnancy and postpartum, in which ASR magnitude was measured while participants viewed pleasant, unpleasant, and neutral pictures. Two types of control trials were included (habituation trials presented at baseline and intertrial interval trials presented when no picture was present).

RESULTS

Among high ACE women, ASR was significantly higher postpartum compared with pregnancy in the unpleasant (p = 0.002, β = 0.46, 95% CI [0.18, 0.74], χ2 = 10.12, z = 3.18) and intertrial interval trials (p = 0.002, β = 0.44, 95% CI [0.16, 0.73], χ2 = 9.25, z = 3.04), accounting for multiple comparisons using a Bonferroni correction at p < 0.005. Among low ACE women, ASR was similar in pregnancy and postpartum.

CONCLUSIONS

Physiological reactivity increased in high ACE women from pregnancy to postpartum, but no change was observed in low ACE women.

Associations between childhood maltreatment, poor sleep, and prenatal distress in pregnant adolescents

Childhood maltreatment (CM) is a known risk factor for adolescent pregnancy. Sleep disturbances and psychological distress, both common negative sequelae of CM, often co-occur during pregnancy, although directionality remains unclear. Furthermore, little is known about how CM affects sleep-distress associations during pregnancy. In pregnant adolescents, we examined: (a) whether there are significant predictive associations from CM to sleep quality and distress and (b) bidirectional influences of distress and sleep quality. Healthy pregnant adolescents (n = 204) were recruited before or during the 2nd trimester. CM was assessed at enrollment; sleep quality and distress were assessed in the 2nd and 3rd trimesters. Hypotheses were tested using path analysis. Findings revealed that CM was associated with worse 2nd trimester sleep quality and distress (β = .19, p < .05 for sleep; β = .30, p < .001 for distress). Higher levels of 2nd trimester distress were associated with lower 3rd trimester sleep quality (β = .19, p < .05). Findings provide novel information about (a) associations from CM to prenatal mood and sleep in pregnant adolescents, and (b) sleep-distress directionality over the course of pregnancy. These results have implications for better understanding the ways in which CM potentially exerts influences later in life, and for targeting interventions to address physical and mental health during pregnancy.

Associations Between Maternal Distress, Cortisol Levels, and Perinatal Outcomes

OBJECTIVE

Stress during pregnancy may decrease gestational age at birth and birth size. We aimed to investigate the associations between maternal subjective stress measures, salivary cortisol, and perinatal outcomes.

METHODS

A cohort of pregnant women (n = 1693) was recruited from eight antenatal care clinics in Stockholm, Sweden. Questionnaires on subjective distress (perceived stress, worry, depression symptoms, sleep quality) and saliva samples for cortisol measurement (morning and evening) were collected in early and late pregnancy. Perinatal outcomes were birth weight, birth length, gestational age, and birth weight for gestational age. We used linear regression to estimate associations adjusted for maternal characteristics.

RESULTS

All associations between subjective distress and cortisol levels were close to null and nonsignificant, for example, exp(β) = 1.001 (95% confidence interval = 0.995 to 1.006) for the morning cortisol level and perceived stress in early pregnancy. Likewise, most associations between distress (subjective and cortisol) and perinatal outcomes were weak and not statistically significant, for example, β = 1.95 (95% confidence interval = -4.16 to 8.06) for perceived stress in early pregnancy and birth weight. An exception was a statistically significant association between birth weight for gestational age and depression symptoms in early pregnancy, with somewhat higher weight with more symptoms (β = 0.08; 95% CI = 0.04 to 0.13). The results were similar for stress in early and late pregnancy.

CONCLUSIONS

We found no association between subjective distress and cortisol measures irrespective of when in pregnancy the measures were taken. Furthermore, we found no evidence for a longitudinal association between psychological measures of stress or cortisol with lower birth weight, birth weight for gestational age, or gestational age.

Toledo-Corral C, Chavez TA, Naya CH, Johnson M, Eckel SP, Lerner D, Grubbs BH, Farzan SF, Dunton GF, Bastain TM, Breton CV. Prenatal Maternal Cortisol Levels and Infant Birth Weight in a Predominately Low-Income Hispanic Cohort

Infant birth weight influences numerous health outcomes throughout the life course including childhood obesity and metabolic morbidities. Maternal experience of stress, both before and during pregnancy, has been hypothesized to influence fetal growth and birth outcomes. However, these associations currently are not fully understood, due to conflicting results in the published literature. Salivary cortisol is often used as a biological biomarker to assess the diurnal pattern of the hypothalamic-pituitary-adrenal axis (HPA-axis) functioning. Cortisol metrics include both the total cortisol concentration secreted during waking hours, reflected by the area under the curve (AUC), and cortisol dynamics, which include the diurnal cortisol slope (DCS) and the cortisol awakening response (CAR). This study examined the association of these cortisol metrics measured during the third trimester of pregnancy and infant birth weight among 240 mother-infant dyads participating in the Maternal and Developmental Risks from Environmental and Social Stressors (MADRES) pregnancy cohort study, which is predominately comprised of Hispanic low-income women. There were no significant associations with the maternal biological stress response and infant birth weight in this study. More research is needed in larger studies to better understand how the biological stress response influences birth weight in populations facing health disparities.

Healthcare professionals' views on supporting young mothers with eating and moving during and after pregnancy: An interview study using the COM-B framework

Young mothers under the age of 20 often have poor nutrition and low levels of physical activity, adversely affecting outcomes for themselves and their babies. The aim of this qualitative study was to explore the experiences of healthcare professionals in supporting young women around eating and moving during and after pregnancy. Seventeen semi-structured interviews were conducted with midwives, family nurse practitioners and health visitors involved in the care of pregnant and post-natal mothers under the age of 20 in England and Wales. Data were analysed using thematic analysis and coded within the theoretical framework of the COM-B model to three areas of capability, motivation and opportunity. For capability, participants were broadly divided between those who had specialist knowledge and training in communication skills to support health behaviours in this population and professionals reliant on tacit knowledge. For opportunity, having enough time was seen as critical because young women's difficult social contexts meant supporting improved health behaviours required relationships of trust to be built. For motivation, participants reported that supporting young women with eating and moving was part of their role. However, the decision to prioritise this support sometimes related to perceived need based on BMI and this was complicated as young women were still growing. Motivation was additionally connected to professionals' own body experiences and health behaviours. Moving habits were less frequently discussed than eating as professionals described how young women tended to walk a lot in their daily lives or found that young women were not interested. Results suggest that to support eating and moving behaviours with young women, professionals need to be trained in communication techniques, enabled with the time to hold space for young women and be able to reflect on their own attitudes and beliefs to support a rounded model of health and wellbeing.

Quantitative meta-analysis of maternal prenatal salivary cortisol and newborn birthweight does not identify effect of fetal sex

BACKGROUND

Heightened concentration of maternal cortisol is a frequently proposed mechanism linking adverse maternal environments with poor birth outcomes, including birth weight. It is commonly hypothesized that prenatal exposures have sexually dimorphic effects on fetal development, however few studies have assessed the effects of fetal sex on the relationship between maternal cortisol and birth outcomes.

METHODS

In a previous systematic review and meta-analysis we obtained data from authors of included studies to calculate trimester-specific correlations between maternal prenatal salivary cortisol and newborn birth weight. Given that this data was well-poised to address the unknown effects of fetal sex on the relationship between maternal cortisol and birth outcomes, we contacted authors a second time with request to unblind sex into the correlations. An updated database search was conducted to identify potentially relevant articles published within 2018 and two additional articles were included.

RESULTS AND DISCUSSION

Eleven studies with a total of 2236 maternal-fetal dyads demonstrated negative correlations for both males, -0.15 (95% CI -0.24 to -0.06, I² = 98.5%, p < 0.001) and females -0.21 (95% CI -0.25 to -0.17, I² = 93.3%, p < 0.001). Sex difference were not statistically significant, p = 0.62. Despite greater exposure to cortisol and lower birth weight among females, the association did not differ by sex.

Ambulatory Blood Pressure Trajectory and Perceived Stress in Relation to Birth Outcomes in Healthy Pregnant Adolescents

OBJECTIVE

An early decline in resting blood pressure (BP), followed by an upward climb, is well documented and indicative of a healthy pregnancy course. Although BP is considered both an effector of stress and a clinically meaningful measurement in pregnancy, little is known about its trajectory in association with birth outcomes compared with other stress effectors. The current prospective longitudinal study examined BP trajectory and perceived stress in association with birth outcomes (gestational age (GA) at birth and birth weight (BW) percentile corrected for GA) in pregnant adolescents, a group at risk for stress-associated poor birth outcomes.

METHODS

Healthy pregnant nulliparous adolescents (n = 139) were followed from early pregnancy through birth. At three time points (13-16, 24-27, and 34-37 gestational weeks ±1 week), the Perceived Stress Scale was collected along with 24-hour ambulatory BP (systolic and diastolic) and electronic diary reporting of posture. GA at birth and BW were abstracted from medical records.

RESULTS

After adjustment for posture and pre-pregnancy body mass index, hierarchical mixed-model linear regression showed the expected early decline (B = -0.18, p = .023) and then increase (B = 0.01, p < .001) of diastolic BP approximating a U-shape; however, systolic BP displayed only an increase (B = 0.01, p = .010). In addition, the models indicated a stronger systolic and diastolic BP U-shape for early GA at birth and lower BW percentile and an inverted U-shape for late GA at birth and higher BW percentile. No effects of perceived stress were observed.

CONCLUSIONS

These results replicate the pregnancy BP trajectory from previous studies of adults and indicate that the degree to which the trajectory emerges in adolescence may be associated with variation in birth outcomes, with a moderate U-shape indicating the healthiest outcomes.

The effect of gestational period on the association between maternal prenatal salivary cortisol and birth weight: A systematic review and meta-analysis

BACKGROUND

Studies exploring the relations between maternal stress and fetal development show an association between increased maternal stress and adverse birth outcomes. A frequently proposed mechanism linking maternal prenatal stress and adverse birth outcomes is heightened concentrations of maternal cortisol. To date, studies exploring this association have reported conflicting results because of the diverse approaches taken to measuring cortisol and the wide variety of possible birth outcomes explored. To add clarity to the growing body of literature, this systematic review and meta-analysis reports empirical findings on the association between maternal prenatal salivary cortisol and newborn birth weight.

METHODS

Searches for relevant papers published up until November 2017 were run in MEDLINE, EMBASE, PsycINFO, and CINAHL. Non-English language papers were included and experts were contacted when necessary. We included data from human observational studies that were designed or had an underlying intention to measure maternal prenatal salivary cortisol and newborn birth weight. We only included data from measurements of salivary cortisol to prevent rendering of the review unsuitable for meta-analysis. Two independent reviewers assessed study eligibility and quality. For every maternal-fetal dyad, an area under the curve with respect to ground (AUCg) of maternal cortisol was calculated to determine a Pearson's correlation coefficient with a continuous measure of newborn birth weight. Correlation coefficients were then pooled across all stages of gestation. To examine if there are critical gestational periods in which the fetus may be more susceptible to elevated concentration of maternal salivary cortisol, a meta-analysis was performed on separate correlations calculated from gestational trimesters.

RESULTS

Nine studies with a total of 1606 maternal-fetal dyads demonstrated a negative correlation between pooled maternal salivary cortisol and birth weight (-0.24, 95% CI -0.28 to -0.20), but there was a high degree of heterogeneity between studies (I² = 88.9%). To investigate heterogeneity, subgroup analysis by trimester of the pooled correlation between salivary cortisol and birth weight was performed with the following correlations found: first trimester, -0.18 (95% CI -0.32 to -0.03, I² = 97.3%); second trimester, -0.20 (95% CI -0.28 to -0.12, I² = 98.3%); and third trimester, -0.30 (95% CI -0.33 to -0.26, I² = 85.4%).

DISCUSSION

A consistently negative association was observed between maternal cortisol and infant birth weight. The review highlights specific gaps in the literature on the relationship between maternal prenatal salivary cortisol and newborn birth weight. Although a significant negative correlation was found, substantial heterogeneity of effects and the likelihood of publication bias exist. The third trimester was revealed as a possible critical gestational period for heightened maternal cortisol concentration to affect birth weight. Challenges faced in this body of research and recommendations for future research are discussed.

Outcomes of Care for 1,892 Doula-Supported Adolescent Births in the United States: The DONA International Data Project, 2000 to 2013

This is the largest study to-date to report on outcomes of care for a national sample of doula-supported adolescent births (n = 1,892, birth years 2000 to 2013). Descriptive statistics were calculated for maternal demographics, risk profiles, labor/birth interventions and occurrences, and birth outcomes. In this national sample, childbearing adolescents and their neonates experienced improved health outcomes and lower rates of intervention relative to national statistics for adolescent deliveries in the United States. Key findings are consistent with previous studies on the effects of doula care for marginalized and medically underserved communities. Results strengthen the case for doulas as a perinatal care strategy for improving maternal and infant health outcomes and decreasing inequities among childbearing adolescents.

Maternal abuse history and reduced fetal heart rate variability: Abuse-related sleep disturbance is a mediator

The consequences of childhood maltreatment are profound and long lasting. Not only does the victim of abuse suffer as a child, but there is mounting evidence that a history of maltreatment places the next generation at risk for significant psychopathology. Research identifies postnatal factors as affecting this intergenerational transmission of trauma. However, emerging evidence suggests that part of this risk may be transmitted before birth, passed on via abuse-related alterations in the in utero environment that are as yet largely unidentified. To date, no study has directly assessed the influence of pregnant women's abuse history on fetal neurobehavioral development, nor considered trauma-associated poor sleep quality as a mediator reflecting established physiological dysregulation. Using data from 262 pregnant adolescents (ages 14-19), a population at elevated risk for childhood maltreatment, the current study examined maternal emotional abuse history and sleep quality in relation to third-trimester fetal resting heart rate variability, an index of parasympathetic nervous system functioning. The results indicate that maternal emotional abuse history is indirectly associated with lower fetal heart rate variability via abuse-related sleep disturbances. These data demonstrate an association between maternal abuse histories and fetal development, showing that at least part of the intergenerational transmission of risk occurs during pregnancy.

Associations Among Child Abuse, Depression, and Interleukin-6 in Pregnant Adolescents: Paradoxical Findings

OBJECTIVE

Limited data exist on child abuse-related immune variation during pregnancy, despite implications for maternal and infant health and extensive data showing that abuse history and depression are related to increased inflammation in other populations. This study examined associations among child abuse, depression, circulating levels of inflammatory markers, and perinatal health in pregnant adolescents, a group at high risk for childhood abuse and poor birth outcomes.

METHODS

Pregnant teenagers (n = 133; 14-19 years; 89.5% Latina) reported on abuse and depression and had two blood draws (24-27 and 34-37 gestational weeks, second and third trimesters, respectively) for interleukin-6 (IL-6) and C-reactive protein; birth outcomes were collected.

RESULTS

Abuse and depression interacted to predict higher IL-6 at second trimester (B = 0.006, p = .011) such that severely abused adolescents with high depression had higher IL-6 relative to severely abused adolescents with low depression; depression did not differentiate IL-6 levels for those with low abuse severity. Abuse and IL-6 also interacted to predict gestational age at birth (B = 0.004, p = .040) such that those with low abuse and high IL-6 and those with high abuse and low IL-6 had infants with earlier gestational age at birth. Cortisol at the second trimester mediated the association between IL-6 and gestational age at birth (indirect effect estimate=-0.143, p < .039).

CONCLUSIONS

Depression severity distinguished IL-6 levels among more severely abused pregnant Latina adolescents, but it was unrelated to IL-6 among less severely abused adolescents. Cortisol explained the relationship between IL-6 and earlier gestational age at birth. Multiple adversities and inflammation may influence birth outcomes and potentially affect intergenerational health.

Guided Imagery and Stress in Pregnant Adolescents

OBJECTIVE

We examined the effects of a guided imagery intervention on perceived stress in pregnant adolescents.

METHOD

Thirty-five pregnant adolescents recruited from a local alternative education program participated in a guided imagery intervention. Participants listened to a pregnancy-specific guided imagery recording on four separate occasions during their pregnancies. Perceived stress was measured immediately before and after each session using the Perceived Stress Measure-9 (PSM-9).

RESULTS

Participants' pre- and postsession PSM-9 scores for three of the four sessions demonstrated a significant reduction in stress. Participants' baseline stress levels also decreased significantly across the four listening sessions. The greatest reductions in stress within and between sessions occurred in the early sessions, with effects diminishing over time.

CONCLUSION

Pregnant teens experienced initial short- and long-term stress reduction during a guided imagery intervention, supporting the use of guided imagery to reduce stress in pregnant adolescents.

The Role of Sexual Abuse and Dysfunctional Attitudes in Perceived Stress and Negative Mood in Pregnant Adolescents: An Ecological Momentary Assessment Study

STUDY OBJECTIVE

Latinas have the highest rates of adolescent pregnancy in the United States. Identifying means to improve the well-being of these young women is critical. The current study examined whether a history of child sexual abuse-itself a risk factor for adolescent pregnancy-was associated with more perceived stress and negative mood over the course of pregnancy and whether dysfunctional attitudes explained these associations.

DESIGN AND SETTING

This mixed methods study involved laboratory-based assessments of perceived stress, sexual abuse history, and dysfunctional attitudes, as well as Ecological Momentary Assessments (EMA) of mood states every 30 minutes during a 24-hour period once during each trimester of pregnancy.

PARTICIPANTS

Pregnant adolescents (N = 204, 85% Latina).

MAIN OUTCOME MEASURES

EMA mood states and laboratory-based retrospective self-reports of perceived stress.

RESULTS

One in 4 pregnant adolescents had a history of sexual abuse. Sexually abused adolescents reported greater perceived stress during the first trimester relative to those without, though the groups did not differ on EMA negative mood ratings. Dysfunctional attitudes explained associations between sexual abuse and perceived stress. Sexual abuse was indirectly associated with the intercept and slope of negative mood through dysfunctional attitudes. Findings were circumscribed to sexual abuse and not other types of child abuse.

CONCLUSIONS

Identifying sexually abused pregnant adolescents and providing support and cognitive therapy to target dysfunctional beliefs may decrease stress during the first trimester as well as negative affect throughout pregnancy.

Pregnancy distress gets under fetal skin: Maternal ambulatory assessment & sex differences in prenatal development

Prenatal maternal distress is associated with an at-risk developmental profile, yet there is little fetal evidence of this putative in utero process. Moreover, the biological transmission for these maternal effects remains uncertain. In a study of n = 125 pregnant adolescents (ages 14-19), ambulatory assessments of daily negative mood (anger, frustration, irritation, stress), physical activity, blood pressure, heart rate (every 30 min over 24 hr), and salivary cortisol (six samples) were collected at 13-16, 24-27, 34-37 gestational weeks. Corticotropin-releasing hormone, C-reactive protein, and interleukin 6 from blood draws and 20 min assessments of fetal heart rate (FHR) and movement were acquired at the latter two sessions. On average, fetuses showed development in the expected direction (decrease in FHR, increase in SD of FHR and in the correlation of movement and FHR ("coupling")). Maternal distress characteristics were associated with variations in the level and trajectory of fetal measures, and results often differed by sex. For males, greater maternal 1st and 2nd session negative mood and 2nd session physical activity were associated with lower overall FHR (p < .01), while 1st session cortisol was associated with a smaller increase in coupling (p < .01), and overall higher levels (p = .05)-findings suggesting accelerated development. For females, negative mood, cortisol, and diastolic blood pressure were associated with indications of relatively less advanced and accelerated outcomes. There were no associations between negative mood and biological variables. These data indicate that maternal psychobiological status influences fetal development, with females possibly more variously responsive to different exposures.