Psychological trauma associated with the World Trade Center attacks and its effect on pregnancy outcome

Maternal anxiety, depression and posttraumatic stress disorder (PTSD) after natural disasters: a systematic review

OBJECTIVE

To measure the prevalence of maternal anxiety, depression and posttraumatic stress disorder (PTSD) in those exposed to natural disasters.

METHODS

A literature search of the PubMed database and www.clinicaltrials.gov from January 1990 through June 2020 was conducted. A PRISMA review of the available literature regarding the incidence and prevalence of maternal anxiety, depression and posttraumatic stress disorder (PTSD) following natural disasters was performed. A natural disaster was defined as one of the following: pandemic, hurricane, earthquake and post-political conflict/displacement of people. Studies were selected that were population-based, prospective or retrospective. Case reports and case series were not used. The primary outcome was the prevalence of maternal anxiety, depression and PTSD in the post-disaster setting. Two independent extractors (I.F. & H.G.) assessed study quality using an adapted version of the Effective Public Health Practice Project Quality Assessment tool. Given the small number of studies that met inclusion criteria, all 22 studies were included, regardless of rating. Data were extracted and aggregate rates of depression, anxiety, and PTSD were calculated to provide synthesized rates of maternal mental health conditions among participants.

RESULTS

Twenty-two studies met the inclusion criteria. A total of 8357 pregnant or birthing persons in the antepartum and postpartum periods were studied. The prevalence of post-pandemic anxiety, depression and PTSD were calculated to be 48.2%, 27.3%, and 22.9%. Post-earthquake depression and PTSD rates were 38.8% and 22.4%. The prevalence of post-hurricane anxiety, depression and PTSD were 17.4%, 22.5%, and 8.2%. The rates of post-political conflict anxiety, depression and PTSD were 48.8%, 31.6% and 18.5%.

CONCLUSION

Given the high rates of anxiety, depression and PTSD among pregnant and birthing persons living through the challenges of natural disasters, obstetrician-gynecologists must be able to recognize this group of patients, and provide a greater degree of psychosocial support.

Childbirth-related post-traumatic stress disorder symptoms and mother-infant neurophysiological and behavioral co-regulation during dyadic interaction: study protocol

BACKGROUND

Mother's childbirth-related posttraumatic stress disorder (PTSD) symptoms have a negative impact on mother and infant's behaviors during dyadic interactions which may increase mother-infant neurophysiological and behavioral co-regulation difficulties, leading to dysregulated mother-infant interactions. This study was specifically designed to analyze: (1) the sociodemographic and obstetric factors associated with mother's childbirth-related PTSD symptoms; (2) mother-infant neurophysiological functioning and behavioral co-regulation during dyadic interaction; (3) the impact of mother's childbirth-related PTSD symptoms on neurophysiological and behavioral mother-infant co-regulation during dyadic interaction; (4) the moderator role of previous trauma on the impact of mother's childbirth-related PTSD symptoms on neurophysiological and behavioral mother-infant co-regulation during dyadic interaction; and (5) the moderator role of comorbid symptoms of anxiety and depression on the impact of mother's childbirth-related PTSD symptoms on neurophysiological and behavioral mother-infant co-regulation during dyadic interaction.

METHODS

At least 250 mothers will be contacted in order to account for refusals and dropouts and guarantee at least 100 participating mother-infant dyads with all the assessment waves completed. The study has a longitudinal design with three assessment waves: (1) 1-3 days postpartum, (2) 8 weeks postpartum, and (3) 22 weeks postpartum. Between 1 and 3 days postpartum, mothers will report on-site on their sociodemographic and obstetric characteristics. At 8 weeks postpartum, mothers will complete online self-reported measures of birth trauma, previous trauma, childbirth-related PTSD, anxiety, and depressive symptoms. At 22 weeks postpartum, mothers will complete online self-reported measures of childbirth-related PTSD, anxiety, and depressive symptoms. Mothers and infants will then be home-visited to observe and record their neurophysiological, neuroimaging and behavioral data during dyadic interactions using the Still-face Paradigm. Activation patterns in the prefrontal cortices of mother and infant will be recorded simultaneously using hyperscanning acquisition devices. Unadjusted and adjusted multilevel linear regression models will be performed to analyze objectives 1 to 3. Moderation models will be performed to analyze objectives 4 and 5.

DISCUSSION

Data from this study will inform psychological interventions targeting mother-infant interaction, co-regulation, and infant development. Moreover, these results can contribute to designing effective screenings to identify mothers at risk of perinatal mental health problems and those who may need specialized perinatal mental health care.

Exploring the experiences of pregnant women in the U.S. during the first year of the Covid-19 pandemic

In this paper, we integrate the stress process model with symbolic interactionism to frame our analysis of interviews with 35 women who were pregnant and/or gave birth during the first year of the Covid-19 pandemic. We detail three stressors, highlight their variation, and discuss how they coped with these stressors. Women reported having to navigate contradictory information about the public health crisis, but Black participants simultaneously endured added strain from a heightened awareness of racialized violence. To cope with an overabundance of precarious and contradictory messages, some women sought out information (i.e., information gatherers), others eschewed information (i.e., information avoiders), and most established protective "bubbles." Next, women experienced disruptions in pregnancy rituals but coped by reframing their expectations. This stressor, however, was less acute for women with a prior birth. Third, women shared feelings of social isolation and reduced social support, which were intensified if pregnancy complications occurred. Women coped by relying on telecommunication and at-home monitoring devices. Our study shows how pregnant women experienced and coped through adversity to mitigate stressors amid pandemonium.

Are Brain and Cognitive Reserve Shaped by Early Life Circumstances?

When growing older, many people are faced with cognitive deterioration, which may even amount to a form of dementia at some point in time. Although neuropathological signs of dementia disorders can often be demonstrated in brains of patients, the degree to which clinical symptoms are present does mostly not accurately reflect the amount of neuropathology that is present. Sometimes existent pathology even goes without any obvious clinical presentation. An explanation for this phenomenon may be found in the concept of reserve capacity. Reserve capacity refers to the ability of the brain to effectively buffer changes that are associated with normal aging processes and to cope with pathological damage. A larger reserve capacity has been suggested to increase resilience against age-associated cognitive deterioration and dementia disorders. Traditionally, a division has been made between brain reserve, which is based on morphological characteristics of the brain, and cognitive reserve, which is based on functional characteristics of the brain. The present review discusses the premises that brain and cognitive reserve capacity are shaped by prenatal and early postnatal factors. Evidence is accumulating that circumstances during the first 1,000 days of life are of the utmost importance for the lifelong health of an individual. Cognitive deterioration and dementia disorders may also have their origin in early life and a potentially important pathway by which the early environment affects the risk for neurodegenerative diseases is by developmental programming of the reserve capacity of the brain. The basic idea behind developmental programming of brain and cognitive reserve is explained and an overview of studies that support this idea is presented. The review is concluded by a discussion of potential mechanisms, synthesis of the evidence and relevance and future directions in the field of developmental origins of reserve capacity.

The Intersect of Pregnancy Loss, Trauma, and Spirituality: A Dyadic Perspective

OBJECTIVES

Pregnancy loss and trauma are unexpected yet frequent occurrences for females in the United States, however little research exists on the role of pregnancy loss and trauma with both partners in couple relationships. The purpose of this study was to use dyadic analyses to better understand the role of trauma, spirituality, and pregnancy loss in the context of the couple relationship.

METHOD

Drawn from a secondary data set, the dyadic sample included survey responses from (n = 97) matched, pregnant heterosexual couples. Couples responded to questions related to traumatic experiences, previous pregnancy history, relationship satisfaction, and spirituality. Actor-partner independence models were conducted to explore pregnancy loss, trauma, and spirituality on relationship satisfaction.

RESULTS

Female partner's experience of trauma and loss predicted relationship satisfaction, but the male partner's experience did not. In addition, spirituality moderated the effects of loss and trauma for female partners but not for male partners.

CONCLUSION

The outcomes from this study punctuated the importance of learning about relational dynamics (e.g., pregnancy and interpersonal traumas) through dyadic samples and analyses. Implications include research and clinical recommendations to incorporate biopsychosocial-spiritual metrics into research designs with diverse samples and dyads.

Effects of ambient air pollution, fresh fruit and vegetable intakes as well as maternal psychosocial stress on the outcome of newborn otoacoustic emission hearing screening

BACKGROUND

Newborn hearing screening results indicated that more than 40% of the detected infants had no recognized risk factors. To determine whether maternal exposure to ambient air pollutants and experience of stressful life event, as well as lack of fresh fruit and vegetable during pregnancy are associated with the abnormal hearing development among newborns.

METHODS

A total of 1193 newborns and their mothers were recruited in this study. Personal information and covariates were collected by face to face interview. Medical examination results of newborns and their mothers were extracted from medical record. We estimated personal air pollutant exposure level through inverse distance weighted method based on data from air quality monitoring stations and assessed the auditory development of newborns via distortion product otoacoustic emission (DPOAE). Unconditional logistic regression model was used to estimate the relationship between DPOAE screening result and the potential influential factors as well as the combined effect.

RESULTS

The results indicated that PM₁₀ exposure during the second trimester and stressful life event during the third trimester could increase the risk of not passing DPOAE test among newborns. However, frequent intakes of fruit and vegetable significantly reduced the risk. There was a synergetic interaction between PM₁₀ exposure and stressful life event on neonatal hearing development.

CONCLUSIONS

To alleviate abnormal auditory development among fetus, pregnant woman should decrease the exposures to ambient air pollutant and negative life event and at the same time, intake sufficient fresh fruit and vegetable.

Racial Inequities in Birth Weight by Maternal Age Among College-Educated Mothers: The Role of Early Disadvantage

INTRODUCTION

Non-Hispanic Black infants experience disproportionately high risks of low birth weight compared with non-Hispanic White infants, particularly among mothers with high educational attainment and greater socioeconomic advantage. This study investigates how maternal early-life disadvantage contributes to ongoing racial birth weight inequities among U.S. college‒educated mothers, specifically declining birth weights with age among non-Hispanic Black mothers.

METHODS

Study analyses used cohort data from the National Longitudinal Study of Adolescent to Adult Health. Racial inequities in birth weight by maternal age and early-life disadvantage were assessed using completed reproductive histories among college-educated mothers at ages 33-44 years collected in 2016‒2018 and regression-based marginal standardization techniques. Early-life disadvantage was measured using a study-based composite measure of early-life concentrated poverty and social disadvantage in homes, neighborhoods, and schools, collected in previous waves. Primary analyses were completed in 2020‒2021.

RESULTS

Among non-Hispanic Black mothers who experienced high early-life disadvantage, a 1-year increase in maternal age at delivery was associated with lower birth weight by 26.07 g (95% CI= -48.74, -3.40). Similar declines were not found among non-Hispanic Black mothers with low early-life disadvantage. Non-Hispanic White mothers experienced increased birth weight with maternal age, 6.85 g (95% CI= -1.12, 14.82) per year, which did not significantly vary by early-life disadvantage.

CONCLUSIONS

Early-life disadvantage modifies whether and how college-educated mothers experience birth weight decline with older age. The effects of early-life contexts and embedded racial inequities on maternal health inequities and differential weathering warrant further public health attention.

Understanding the Role of Persistent Organic Pollutants and Stress in the Association between Proximity to the World Trade Center Disaster and Birth Outcomes

Fetal growth is affected by exposure to both prenatal stress and environmental contaminants. The attacks on the World Trade Center (WTC) resulted in exposure to chemicals and psychological stress amongst New York City residents. We measured prenatal maternal stress and exposure to persistent organic pollutants (polybrominated diphenyl ethers, polychlorinated biphenyls, and polychlorinated dibenzo-p-dioxins (PCDDs)) in 108 participants from a Columbia University WTC birth cohort. Principal component (PC) analyses were conducted to characterize the mixture of exposure to the three groups of chemicals. We evaluated the associations between geographical exposures (proximity to the WTC disaster) and both chemical exposures (PCs) and stress (demoralization). We then evaluated the effect these exposures (PCs and stress) had on previously reported associations between geographical WTC exposure and birth outcomes (birth weight and birth length) in this study population to understand their individual roles in the observed associations. Geographical exposure via proximity to the WTC was associated with the PC reflecting higher PCDD exposure (PC3) (β = 0.60, 95% CI: 0.03, 1.18 for living/working within 2 miles of the WTC; and β = 0.73, 95% CI = 0.08, 1.38 for living within 2 miles of WTC). Previously reported reductions in birth weight and length associated with WTC proximity (β = −215.2, 95% CI: −416.2, −14.3 and β = −1.47, 95% CI: −2.6, −0.34, respectively) were attenuated and no longer significant for birth weight (β = −156.4, 95% CI: −358.2, 45.4) after adjusting for PC3, suggesting that PCDDs may act as partial mediators in this previously observed association. The results of this study can help focus future research on the long-term health effects of these prenatally exposed populations.

Pregnancy and posttraumatic stress disorder: associations with infant outcomes and prenatal care utilization

BACKGROUND

Posttraumatic stress disorder (PTSD) affects 3.6-9.7% of women, and has been associated with adverse outcomes in pregnancy; however, associations with prenatal care (PNC) utilization are not clear.

OBJECTIVE

To evaluate associations of PTSD in pregnancy with PNC utilization and adverse infant outcomes in an active-duty military population (a population with universal health insurance).

METHODS

This was a retrospective cohort study of pregnant active-duty service members in Department of Defense Birth and Infant Health Research program data from 2007 to 2014. Administrative medical encounter data were used to define PTSD cases and outcomes of interest. Descriptive statistics and multivariable log-binomial regression compared PNC utilization and adverse infant outcomes (preterm birth, small for gestational age [SGA], major birth defects) among service members with current PTSD (defined as PTSD in the year prior to pregnancy or during pregnancy) to those without current PTSD.

RESULTS

Of the 103,221 singleton live births identified, 1657 (1.6%) were born to active-duty service members diagnosed with current PTSD. Service members with PTSD were more likely to initiate PNC in the first trimester (93.5% vs. 90.2%) and score adequate plus on the Adequacy of Prenatal Care Utilization Index (63.2% vs. 40.0%) compared to service members without PTSD. PTSD case status was not associated with preterm birth, SGA, or major birth defects, regardless of the adjustment set used (fully adjusted RR 0.96, 95% CI 0.82-1.13; RR 1.08, 95% CI 0.79-1.48; and RR 1.03, 95% CI 0.79-1.34, respectively).

CONCLUSION

For pregnant service members with current PTSD, no associations with adverse infant outcomes were noted, and these patients initiated care earlier and had higher PNC utilization scores compared to pregnant service members without current PTSD. Universal health care coverage and utilization of PNC in this population may mitigate adverse pregnancy outcomes observed in civilian populations of patients with PTSD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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

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

Self-reported oil spill exposure and birth outcomes among southern Louisiana women at the time of the Gulf oil spill: The GROWH study

BACKGROUND

The chemical, physical, economic, and social effects of a major oil spill might adversely affect pregnancy health.

OBJECTIVES

To examine the relationship between oil spill exposure and birth outcomes in a cohort of women living near the Gulf of Mexico at the time of the 2010 oil spill.

METHODS

Between 2012 and 2016, 1375 women reported their exposure to the oil spill, and at least one livebirth. Five hundred and three had births both before and after the oil spill. Indicators of oil spill exposure included self-reported financial consequences, direct contact with oil, traumatic experiences, loss of use of the coast, and involvement in litigation. Birth outcomes were low birthweight (LBW; birthweight <2500 g) and preterm birth (PTB; >3 weeks early). Women who were not pregnant at the time of the interview (n = 1001) self-reported outcomes, while women who were pregnant (n = 374) primarily had them abstracted from medical records (n = 374). All pregnancies prior to the oil spill were considered unexposed; those after the oil spill were considered exposed or unexposed depending on interview responses. Generalized estimating equations were used to control for clustering within women, with control for confounders.

RESULTS

The most common type of exposure was economic (49%), but 302 women (22.0%) reported some degree of direct contact with the oil. Associations between most indicators of oil spill exposure and pregnancy outcomes were null, although when all pregnancies were examined, associations were seen with high levels of contact with oil for LBW (adjusted Odds Ratio [aOR] 2.19, 95% CI, 1.29-3.71) and PTB (aOR 2.27, 1.34-3.87).

DISCUSSION

In this community-based cohort, we did not find associations between report of exposure to the oil spill, with the possible exception of high oil contact in some analyses, and birth outcomes. Research incorporating specific biomarkers of oil spill exposure and stress biomarkers would be valuable, to allow for assessing both perceived and actual exposure, especially when direct toxicant exposure is minimal.

Investigation on the mental health status of pregnant women in China during the Pandemic of COVID-19

Purpose

To evaluate the anxiety and depression in pregnant women in China, and its influencing factors during the corona virus disease 2019 (COVID-19) pandemic.

Methods

From February 22 to February 27, a questionnaire survey was conducted on 156 pregnant women, including demographic characteristics, a self-rating anxiety scale (SAS), and a self-depression rating scale (SDS).

Results

A total of 13 non-homologous end-joining (8.3%, 13/156) patients were anxious, 79 patients (50.6%, 79/156) were depressed, and 13 patients (8.3%, 13/156) suffered from both anxiety and depression. The SAS score of pregnant women was 40.55 ± 6.09, and the SDS score was 50.42 ± 11.64. For the SAS score, only 8.3% of all patients (13/156) were in a light anxiety state. For the SDS score, 46.79% (73/156) of patients was normal, 23.72% of patients (37/156) showed mild depression, 22.44% (35/156) showed moderate depression, and 4.49% (7/156) showed severe depression. No significant changes were observed in SAS and SDS scores between patients from different regions within China, health state, gestational week, educational background, and living condition (P > 0.05). Moreover, no significant differences were observed between diagnosed/suspected patients and the normal control group (P > 0.05), and between pregnant women in Wuhan compared to other regions (P > 0.05).

Conclusion

During the COVID-19 epidemic, the anxiety level of pregnant women was the same as that before the epidemic, while the level of depression was significantly higher. Pregnant women who lived in Wuhan, the epicenter of the epidemic, were not more anxious or depressed compared to pregnant women in other regions during the COVID-19 epidemic. Furthermore, the mental health status of pregnant women with COVID-19 was not more severe.

Electronic supplementary material

The online version of this article (10.1007/s00404-020-05805-x) contains supplementary material, which is available to authorized users.

Risk for Depressive Symptoms among Hospitalized Women in High-Risk Pregnancy Units during the COVID-19 Pandemic

Objective: Higher rates of mental disorders, specifically depression, were found among affected people in previous epidemiological studies taken after disasters. The aim of the current study was to assess risk for depression among pregnant women hospitalized during the “coronavirus disease 2019” (COVID-19) pandemic, as compared to women hospitalized before the COVID-19 pandemic. Study design: A cross-sectional study was performed among women hospitalized in the high-risk pregnancy units of the Soroka University Medical Center (SUMC). All participating women completed the Edinburgh Postnatal Depression Scale (EPDS), and the results were compared between women hospitalized during the COVID-19 strict isolation period (19 March 2020 and 26 May 2020) and women hospitalized before the COVID-19 pandemic. Multivariable logistic regression models were constructed to control for potential confounders. Results: Women hospitalized during the COVID-19 strict isolation period (n = 84) had a comparable risk of having a high (>10) EPDS score as compared to women hospitalized before the COVID-19 pandemic (n = 279; 25.0% vs. 29.0%, p = 0.498). These results remained similar in the multivariable logistic regression model, while controlling for maternal age, ethnicity and known mood disorder (adjusted odds ratio (OR) 1.0, 95% CI 0.52–1.93, p = 0.985). Conclusion: Women hospitalized at the high-risk pregnancy unit during the COVID-19 strict isolation period were not at increased risk for depression, as compared to women hospitalized before the COVID-19 pandemic.

The Intergenerational Impact of Terror: Did the 9/11 Tragedy Impact the Initial Human Capital of the Next Generation?

Given the unexpected nature of the terrorist attacks of September 11, 2001, a specific cohort of children were exogenously exposed to increased maternal psychological stress in utero. Rich administrative data and the precise timing of the event allow this study to uniquely provide insights into the health effects of exposure to maternal psychological stress across gestation. Results suggest that children exposed in utero were born significantly smaller and earlier than previous cohorts. The timing of the effect provides evidence that intrauterine growth is specifically restricted by first trimester exposure to stress; reductions in gestational age and increases in the likelihood of being born at low (<2,500 grams) or very low (<1,500 grams) birth weight are induced by increased maternal psychological stress mid-pregnancy. This study also documents a positively selected post-attack fertility response, which would bias an evaluation that includes cohorts conceived after September 11, 2001, in the control group.

Prenatal Stress, Mood, and Gray Matter Volume in Young Adulthood

This study aimed to determine whether prenatal stress, measured by the number of stressful life events during the first 20 weeks of pregnancy, might relate to mood dysregulation and altered brain structure in young adulthood. Participants included 93 young adults from a community-based birth cohort from the Czech Republic. Information on prenatal stress exposure was collected from their mothers in 1990-1992. Magnetic resonance imaging (MRI) and mood-related data were collected from the young adults in 2015. MRI analyses focused on overall gray matter (GM) volume and GM volume of cortical regions previously associated with major depression. Higher prenatal stress predicted more mood dysregulation, lower overall GM volume, and lower GM volume in mid-dorsolateral frontal cortex, anterior cingulate cortex, and precuneus in young adulthood. We observed no prenatal stress by sex interactions for any of the relations. We conclude that prenatal stress is an important risk factor that relates to worse mood states and altered brain structure in young adulthood irrespective of sex. Our results point to the importance and long-lasting effects of prenatal programming and suggest that offspring of mothers who went through substantial stress during pregnancy might benefit from early intervention that would reduce the odds of mental illness in later life.

Post-traumatic stress disorder and association with low birth weight in displaced population following conflict in Malakand division, Pakistan: a case control study

Background

The northern part of the province of Khyber Pakhtunkhwa in Pakistan experienced armed conflict since September 2007 till the autumn of 2011. Conflict involved widespread insurgency activity and military intervention including in 2009 internally displacing the 2.5 million people of the valley of Swat to live in camps, with relatives, or in rented accommodation across the region for approximately 4 months. It was during this period the current study was conducted to determine whether Post-Traumatic Stress Disorder in pregnant women was independently associated with Low Birth Weight (LBW) in an area affected by conflict and militancy.

Methods

A case control study was conducted in tertiary care hospitals of district Peshawar, Khyber Pakhtunkhwa. Two hundred twenty-five cases (neonates with birth weight <  2.5 kg) and 225 controls (neonates with birth weight of > 2.5 kg) were enrolled within 24 h of delivery. Post-Traumatic Stress Disorder was assessed through the MINI Neuropsychiatric Interview 5.0, a validated questionnaire along with the birth weight of the newborn. Maternal anthropometry, anemia and other sociodemographic details were also obtained during data collection. Data was analyzed using statistical package (STATA version 14). Logistic regression analysis of the association between LBW and all variables collected with a p-value of < 0.25 on uni-variate analysis were entered.

Results

A total of 450 newborn and mother pairs participated in the study with 225 cases and 225 controls. On univariate analysis factors significantly associated with LBW include: less than 5 years of paternal schooling and PTSD. On logistic regression, PTSD was independently associated with low birth weight in the presence of other factors like maternal/paternal schooling, gravida, history of preterm, BMI of the mother and maternal anemia.

Conclusion

PTSD was found to be independently associated with LBW. In light of the current findings and other similar literature, intervention programs should be considered for pregnant women exposed to traumatic events.

Risk for probable post-partum depression among women during the COVID-19 pandemic

The aim of the current study was to assess the risk for post-partum depression among women delivering during the COVID-19 pandemic as compared to the risk among women delivering before the COVID-19 pandemic. A cohort study was performed among women delivering singletons at term which were recruited in the maternity wards of the Soroka University Medical Center. Recruitment was done during the COVID-19 strict isolation period (March 18 and April 29, 2020). Women delivering during the COVID-19 pandemic completed the Edinburgh Postnatal Depression Scale (EPDS), and the results were compared to women delivering at the same medical center before the COVID-19 pandemic. Multivariable logistic regression models were constructed to control for potential confounders. A total of 223 women who delivered during the COVID-19 strict isolation period were recruited. Women delivering during the COVID-19 pandemic had lower risk of having a high (> 10) or very high (≥ 13) EPDS score as compared with women delivering before the COVID-19 pandemic (16.7% vs 31.3%, p = 0.002, and 6.8% vs 15.2%, p = 0.014, for EPDS ≥ 10 and EPDS ≥ 13, respectively). These results remained similar in the multivariable logistic regression models, for both EPDS score ≥ 10 and EPDS score ≥ 13, while controlling for maternal age, ethnicity, marital status, and adverse pregnancy outcomes (adjusted OR 0.4, 95% CI 0.23-0.70, p = 0.001 and adjusted OR 0.3, 95% CI 0.15-0.74, p = 0.007 for EPDS score > 10 and > 13, respectively). In our population, delivering during the COVID-19 pandemic was independently associated with lower risk of post-partum depression.

Prenatal stress and elevated seizure susceptibility: Molecular inheritable changes

Stressful episodes are common during early-life and may have a wide range of negative effects on both physical and mental status of the offspring. In addition to various neurobehavioral complications induced by prenatal stress (PS), seizure is a common complication with no fully explained cause. In this study, the association between PS and seizure susceptibility was reviewed focusing on sex differences and various underlying mechanisms. The role of drugs in the initiation of seizure and the effects of PS on the nervous system that prone the brain for seizure, especially the hypothalamic-pituitary-adrenal (HPA) axis, are also discussed in detail by reviewing the papers studying the effect of PS on glutamatergic, gamma-aminobutyric acid (GABA)ergic, and adrenergic systems in the context of seizure and epilepsy. Finally, epigenetic changes in epilepsy are described, and the underlying mechanisms of this change are expanded. As the effects of PS may be life-lasting, it is possible to prevent future psychiatric and behavioral disorders including epilepsy by preventing avoidable PS risk factors.

Post-traumatic stress disorder and hypertensive disorders of pregnancy among military women

BACKGROUND

Women are more likely to develop post-traumatic stress disorder (PTSD) than men. Limited research exists evaluating the risk of hypertensive disorders of pregnancy (HDP) among military women with PTSD.

METHODS

We conducted a retrospective cohort study using US Department of Defense (DoD) data comprised of all active-duty women giving birth to their first, liveborn singleton infant using DoD-sponsored health insurance from 1 January 2004 to 31 December 2008 (n = 34 176). Birth hospitalisation records, maternal mental health visits, and Post-Deployment Health Assessment (PDHA) and Reassessment (PDHRA) screenings were included. The HDP outcome (yes vs no) was defined using ICD-9-CM codes in the maternal birth hospitalisation record. Women fit into one of four PTSD exposure categories (confirmed, probable, possible, none). Confirmed cases had a PTSD ICD-9-CM diagnosis code. Probable/possible cases were classified using PDHA screening items. We used multiple log-linear regression to assess PTSD (confirmed, any vs none) and the risk of HDP overall, and then explored effect modification by military service and demographic variables. We assessed the risk of HDP among deployed mothers with PTSD (confirmed, probable/possible vs none) who completed a PDHA, and explored effect modification by race/ethnicity. We also assessed risk of HDP with differing PTSD lead times.

RESULTS

Overall, PTSD was not associated with HDP except among mothers whose PTSD was diagnosed ≥1 year prior to conception (RR 1.42, 95% CI 1.06, 1.90).

CONCLUSIONS

Post-traumatic stress disorder preceding conception by at least a year appeared to confer an increased risk of HDP, but further research is needed using more thorough PTSD assessment.

Maternal experience of their infants' crying in the context of war trauma: Determinants and consequences

We examined, first, how prenatal maternal mental health and war trauma predicted mothers' experience of their infant crying, indicated by emotions, cognitions, and behavior; and second, how these experiences influenced the mother-infant interaction and infant development. Participants were 511 Palestinian mothers from the Gaza Strip, reporting their war trauma, symptoms of posttraumatic stress disorder (PTSD), depression, and perceived stress during pregnancy (Time 1). They reported experiences of infant crying at 4 months (Time 2), and the mother-infant interaction and infant sensorimotor and language development at 12 months of infants' age (Time 3). Results revealed that maternal mental health problems, but not war trauma, were important to experiences of infant crying. A high level of PTSD symptoms predicted negative emotions evoked by infant crying, and high depressive symptoms predicted low active and positive responses to crying. Unexpectedly, high prenatal perceived stress predicted high active and positive responsiveness. Concerning the consequences, mothers' sensitive interpretation of infant crying predicted optimal infant sensorimotor development, and mothers' active and positive responses predicted high emotional availability in mother-infant interaction. Crying is the first communication tool for infants, and mothers' sensitive responses to crying contribute to infant well-being. Therefore, reinforcing mother's optimal responses is important when helping war-affected dyads.

Priority focus areas for a sub-national response to climate change and health: A South African provincial case study

INTRODUCTION

The intersection of health and climate change is often absent or under-represented in sub-national government strategies. This analysis of the literature, using a new methodological framework, highlights priority focus areas for a sub-national government response to health and climate change, using the Western Cape (WC) province of South Africa as a case study.

METHODS

A methodological framework was created to conduct a review of priority focus areas relevant for sub-national governments. The framework encompassed the establishment of a Project Steering Group consisting of relevant, sub-national stakeholders (e.g. provincial officials, public and environmental health specialists and academics); an analysis of local climatic projections as well as an analysis of global, national and sub-national health risk factors and impacts.

RESULTS

Globally, the discussion of health and climate change adaptation strategies in sub-national, or provincial government is often limited. For the case study presented, multiple health risk factors were identified. WC climatic projections include a warmer and potentially drier future with an increased frequency and intensity of extreme weather events. WC government priority focus areas requiring further research on health risk factors include: population migration and environmental refugees, land use change, violence and human conflict and vulnerable groups. WC government priority focus areas for further research on health impacts include: mental ill-health, non-communicable diseases, injuries, poisonings (e.g. pesticides), food and nutrition insecurity-related diseases, water- and food-borne diseases and reproductive health. These areas are currently under-addressed, or not addressed at all, in the current provincial climate change strategy.

CONCLUSIONS

Sub-national government adaptation strategies often display limited discussion on the health and climate change intersect. The methodological framework presented in this case study can be globally utilized by other sub-national governments for decision-making and development of climate change and health adaptation strategies. Additionally, due to the broad range of sectoral issues identified, a primary recommendation from this study is that sub-national governments internationally should consider a "health and climate change in all policies" approach when developing adaptation and mitigation strategies to address climate change.

Allostatic load: A theoretical model for understanding the relationship between maternal posttraumatic stress disorder and adverse birth outcomes

BACKGROUND

Adverse birth outcomes such as preterm birth and low birth weight are significant public health concerns and contribute to neonatal morbidity and mortality. Studies have increasingly been exploring the predictive effects of maternal posttraumatic stress disorder (PTSD) on adverse birth outcomes. However, the biological mechanisms by which maternal PTSD affects birth outcomes are not well understood. Allostatic load refers to the cumulative dysregulations of the multiple physiological systems as a response to multiple social-ecological levels of chronic stress. Allostatic load has been well documented in relation to both chronic stress and adverse health outcomes in non-pregnant populations. However, the mediating role of allostatic load is less understood when it comes to maternal PTSD and adverse birth outcomes.

OBJECTIVE

To propose a theoretical model that depicts how allostatic load could mediate the impact of maternal PTSD on birth outcomes.

METHOD

We followed the procedures for theory synthesis approach described by Walker and Avant (2011), including specifying focal concepts, identifying related factors and relationships, and constructing an integrated representation. We first present a theoretical overview of the allostatic load theory and the other 4 relevant theoretical models. Then we provide a brief narrative review of literature that empirically supports the propositions of the integrated model. Finally, we describe our theoretical model.

FINDINGS/CONCLUSIONS

The theoretical model synthesized has the potential to advance perinatal research by delineating multiple biomarkers to be used in future. After it is well validated, it could be utilized as the theoretical basis for health care professionals to identify high-risk women by evaluating their experiences of psychosocial and traumatic stress and to develop and evaluate service delivery and clinical interventions that might modify maternal perceptions or experiences of stress and eliminate their impacts on adverse birth outcomes.

Perinatal stress and human hippocampal volume: Findings from typically developing young adults

The main objective of this study was to investigate the impact of prenatal and early postnatal stress on hippocampal volume in young adulthood. In sharp contrast to numerous results in animal models, our data from a neuroimaging follow-up (n = 131) of a community-based birth cohort from the Czech Republic (European Longitudinal Study of Pregnancy and Childhood) showed that in typically developing young adults, hippocampal volume was not associated with birth weight, stressful life events during the prenatal or early postnatal period, or dysregulated mood and wellbeing in the mother during the early postnatal period. Interestingly, mother’s anxiety/co-dependence during the first weeks after birth did show long-lasting effects on the hippocampal volume in young adult offspring irrespective of sex. Further analyses revealed that these effects were subfield-specific; present in CA1, CA2/3, CA4, GC-DG, subiculum, molecular layer, and HATA, hippocampal subfields identified by translational research as most stress- and glucocorticoid-sensitive, but not in the remaining subfields. Our findings provide evidence that the type of early stress is critical when studying its effects on the human brain.

Maternal posttraumatic stress disorder during the perinatal period and child outcomes: A systematic review

BACKGROUND

Approximately 3.3% of women in pregnancy have posttraumatic stress disorder (PTSD) and 4% of women postpartum PTSD. The impact of maternal PTSD during the perinatal period (from conception until one year postpartum) on child outcomes has not been systematically examined.

METHOD

A systematic review was conducted to synthesize and critically evaluate quantitative research investigating the association between perinatal PTSD and child outcomes. Databases EMBASE, BNI, Medline, PsycInfo and CINAHL were searched using specific inclusion and exclusion criteria.

RESULTS

26 papers reporting 21 studies were identified that examined associations between perinatal PTSD and postpartum birth outcomes, child development, and mother-infant relationship. Studies reviewed were heterogeneous, with poor-to-medium scores of methodological quality. Results showed that maternal postpartum PTSD is associated with low birth weight and lower rates of breastfeeding. Evidence for an association between maternal PTSD and preterm birth, fetal growth, head circumference, mother-infant interaction, the mother-infant relationship or child development is contradictory. Associations between maternal PTSD and infant salivary cortisol levels, and eating/sleeping difficulties are based on single studies, so require replication.

LIMITATIONS

Methodological weaknesses of the studies included insufficient sample size, use of invalidated measures, and limited external validity.

CONCLUSION

Findings suggest that perinatal PTSD is linked with some negative child outcomes. Early screening for PTSD during the perinatal period may be advisable and onward referral for effective treatment, if appropriate. Future research using larger sample sizes, validated and reliable clinical interviews to assess PTSD, and validated measures to assess a range of child outcomes, is needed.

Prenatal stress potentiates febrile seizure and leads to long-lasting increase in cortisol blood levels in children under 2years old

Neurological disorders can be exacerbated in an offspring that is exposed to stress prenatally. This study is aimed to investigate the severity of febrile seizures (FS) in the offspring under 2years old that were prenatally stressed. In this study, 158 children below 2years old with FS were selected. Information about convulsion including seizure lasting, recurrence of seizure, age of the first seizure and type of FS was gathered. Blood samples were obtained from the offspring to measure the cortisol blood levels. Questionnaire was filled in to evaluate the perceived stress and exposure or non-exposure to major stresses during pregnancy. Results of this study showed that both high Perceived Stress Scores (PSS) during pregnancy and exposure to major stresses during pregnancy significantly increased seizure duration and seizure intensity. Also, the appearance of complex FS was significantly higher in prenatally stressed children than the unexposed ones. Further, cortisol blood levels were significantly higher in prenatally stressed subjects. It can be concluded that both higher PSS and/or exposure to major stresses during pregnancy potentiate FS parameters and lead to long lasting increase in cortisol blood levels in the offspring.

Post-traumatic stress disorder symptoms in pregnant Australian Indigenous women residing in rural and remote New South Wales: A cross-sectional descriptive study

BACKGROUND

Pregnancy can be a stressful time for many women. There is ample evidence of numerous physical and mental health inequities for Indigenous Australians. For those Indigenous women who are pregnant, it is established that there is a higher incidence of poor physical perinatal outcomes when compared with non-Indigenous Australians. However, little evidence exists that examines stressful events and post-traumatic stress disorder (PTSD) symptoms in pregnant women who are members of this community.

AIMS

To quantify the rates of stressful events and PTSD symptoms in pregnant Indigenous women.

METHODS

One hundred and fifty rural and remote Indigenous women were invited to complete a survey during each trimester of their pregnancy. The survey measures were the stressful life events and the Impact of Events Scale.

RESULTS

Extremely high rates of PTSD symptoms were reported by participants. Approximately 40% of this group exhibited PTSD symptoms during their pregnancy with mean score 33.38 (SD = 14.37) significantly higher than a study of European victims of crisis, including terrorism attacks (20.6, SD = 18.5).

CONCLUSIONS

The extreme levels of PTSD symptoms found in the women participating in this study are likely to result in negative implications for both mother and infant. An urgent response must be mounted at government, health, community development and research levels to address these findings. Immediate attention needs to focus on the development of interventions to address the high levels of PTSD symptoms that pregnant Australian Indigenous women experience.

Maternal PTSD following Exposure to the Wenchuan Earthquake Is Associated with Impaired Mental Development of Children

The purpose of this study was to explore whether earthquake-related maternal Post-Traumatic Stress Disorder (PTSD) is associated with impaired development of infants. Participants included 86 women who were pregnant during or after the earthquake in Ningqiang county, and their children. Data were collected from February to March of 2012. PTSD questionnaire (PTSD Checklist, Civilian Version (PCL-C)) was used to measure the effect of the earthquake on mothers, and that the scores greater than 50 were used to indicate presence of PTSD. Each child was assessed using the mental Developmental Screening Test (DST) according to age. Among the 86 women, PTSD scores equal to or greater than 50 accounted for 20.93%. Among the 86 children, 25.60% of development quotient (DQ) scores and 19.80% of mental index (MI) scores were less than 85. The correlation coefficient analysis showed that PTSD scores were inversely related to DQ and MI scores. Maternal PTSD following earthquake exposure is associated with relatively lower intellectual development in children age 0–3 years. Further research is needed to assess the persistent effects of this influence on offspring of mothers exposed to earthquake.

Does prenatal stress alter the developing connectome?

Human neurodevelopment requires the organization of neural elements into complex structural and functional networks called the connectome. Emerging data suggest that prenatal exposure to maternal stress plays a role in the wiring, or miswiring, of the developing connectome. Stress-related symptoms are common in women during pregnancy and are risk factors for neurobehavioral disorders ranging from autism spectrum disorder, attention deficit hyperactivity disorder, and addiction, to major depression and schizophrenia. This review focuses on structural and functional connectivity imaging to assess the impact of changes in women's stress-based physiology on the dynamic development of the human connectome in the fetal brain.

Reproductive Outcomes Following Maternal Exposure to the Events of September 11, 2001, at the World Trade Center, in New York City

OBJECTIVES

To estimate associations between exposure to the events of September 11, 2001, (9/11) and low birth weight (LBW), preterm delivery (PD), and small size for gestational age (SGA).

METHODS

We matched birth certificates filed in New York City for singleton births between 9/11 and the end of 2010 to 9/11-related exposure data provided by mothers who were World Trade Center Health Registry enrollees. Generalized estimating equations estimated associations between exposures and LBW, PD, and SGA.

RESULTS

Among 3360 births, 5.8% were LBW, 6.5% were PD, and 9% were SGA. Having incurred at least 2 of 4 exposures, having performed rescue or recovery work, and probable 9/11-related posttraumatic stress disorder 2 to 3 years after 9/11 were associated with PD and LBW during the early study period.

CONCLUSIONS

Disasters on the magnitude of 9/11 may exert effects on reproductive outcomes for several years. Women who are pregnant during and after a disaster should be closely monitored for physical and psychological sequelae.

PUBLIC HEALTH IMPLICATIONS

In utero and maternal disaster exposure may affect birth outcomes. Researchers studying effects of individual disasters should identify commonalities that may inform postdisaster responses to minimize disaster-related adverse birth outcomes.

Impact of the Great East Japan Earthquake on feeding methods and newborn growth at 1 month postpartum: results from the Fukushima Health Management Survey

This study examined the effects of three disasters (the Great East Japan Earthquake of March 11, 2011, followed by a tsunami and the Fukushima Daiichi Nuclear Power Plant accident) on feeding methods and growth in infants born after the disasters. Using results from the Fukushima Health Management Survey, Soso District (the affected area where the damaged nuclear power plant is located) and Aizu District (a less-affected area located farthest from the plant) were compared. In this study, newborn and maternal background characteristics were examined, as well as feeding methods, and other factors for newborn growth at the first postpartum examination for 1706 newborns born after the disaster in the affected (n = 836) and less-affected (n = 870) areas. Postpartum examinations took place 1 month after birth. Feeding method trends were examined, and multivariate regression analyses were used to investigate effects on newborn mass gain. There were no significant differences in background characteristics among newborns in these areas. When birth dates were divided into four periods to assess trends, no significant change in the exclusive breastfeeding rate was found, while the exclusive formula-feeding rate was significantly different across time periods in the affected area (p = 0.02). Multivariate analyses revealed no significant independent associations of maternal depression and change in medical facilities (possible disaster effects) with other newborn growth factors in either area. No area differences in newborn growth at the first postpartum examination or in exclusive breastfeeding rates were found during any period. Exclusive formula-feeding rates varied across time periods in the affected, but not in the less-affected area. It is concluded that effective guidance to promote breast-feeding and prevent exclusive use of formula is important for women in post-disaster circumstances.

Prenatal depression and adverse birth outcomes: an updated systematic review

Complications related to preterm birth (PTB) and low birth weight (LBW) are leading causes of infant morbidity and mortality. Prenatal depression is a hypothesized psychosocial risk factor for both birth outcomes. The purpose of this systematic review was to examine evidence published between 1977 and 2013 on prenatal depression and risks of these primary adverse birth outcomes. A systematic search of the PUBMED and PsycINFO databases was conducted to identify studies testing the associations between prenatal depressive symptoms, or diagnoses of depression, and risk of PTB or LBW. We systematically selected 50 published reports on PTB and length of gestation, and 33 reports on LBW and BW. Results were reviewed by two independent reviewers and we evaluated the quality of the evidence with an established systematic review method, the Newcastle Ottawa Scale. We then undertook a narrative synthesis of the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Less than a quarter of 50 published reports found that prenatal depression was significantly associated with PTB or gestational age. In contrast, slightly more than half of the 33 reports found that prenatal depression was associated with LBW or BW. When weighing methodological features, we determined that the effects of prenatal depression on LBW are more consistent than effects on length of gestation or PTB. Although the evidence may not be strong enough to support routine depression screening for risk of adverse outcomes, screening to enable detection and timely treatment to reduce risk of postpartum depression is warranted. Further rigorous research on prenatal depression and adverse birth outcomes is needed.

Psychological trauma and posttraumatic stress disorder: risk factors and associations with birth outcomes in the Drakenstein Child Health Study

BACKGROUND

Prenatal and peripartum trauma may be associated with poor maternal-fetal outcomes. However, relatively few data on these associations exist from low-middle income countries, and populations in transition.

OBJECTIVE

We investigated the prevalence and risk factors for maternal trauma and posttraumatic stress disorder (PTSD), and their association with adverse birth outcomes in the Drakenstein Child Health Study, a South African birth cohort study.

METHODS

Pregnant women were recruited from two clinics in a peri-urban community outside Cape Town. Trauma exposure and PTSD were assessed using diagnostic interviews; validated self-report questionnaires measured other psychosocial characteristics. Gestational age at delivery was calculated and birth outcomes were assessed by trained staff. Multiple logistic regression explored risk factors for trauma and PTSD; associations with birth outcomes were investigated using linear regression. Potential confounders included study site, socioeconomic status (SES), and depression.

RESULTS

A total of 544 mother-infant dyads were included. Lifetime trauma was reported in approximately two-thirds of mothers, with about a third exposed to past-year intimate partner violence (IPV). The prevalence of current/lifetime PTSD was 19%. In multiple logistic regression, recent life stressors were significantly associated with lifetime trauma, when controlling for SES, study site, and recent IPV. Childhood trauma and recent stressors were significantly associated with PTSD, controlling for SES and study site. While no association was observed between maternal PTSD and birth outcomes, maternal trauma was significantly associated with a 0.3 unit reduction (95% CI: 0.1; 0.5) in infant head-circumference-for-age z-scores (HCAZ scores) at birth in crude analysis, which remained significant when adjusted for study site and recent stressors in a multivariate regression model.

CONCLUSIONS

In this exploratory study, maternal trauma and PTSD were found to be highly prevalent, and preliminary evidence suggested that trauma may adversely affect fetal growth, as measured by birth head circumference. However, these findings are limited by a number of methodological weaknesses, and further studies are required to extend findings and delineate causal links and mechanisms of association.

Extreme Weather-driven Disasters and Children’s Health

Extreme weather events such as heat waves, extreme precipitation, and storm surges are likely to become more frequent and intense with climate change. Extreme weather-driven disasters (EWDDs) cause a substantial burden of childhood mortality and morbidity worldwide. We reviewed the published literature on EWDDs and their health impacts on children, and developed a conceptual model based on complex systems thinking to identify the health risks, vulnerabilities, and capacities of children in the context of EWDDs as a means of informing areas for adaptive intervention. We found that direct and indirect physical and mental impacts of EWDDs on child health are abundant and interrelate in complex ways. The literature review and modeling demonstrated the centrality of resilience at the level of the child and his or her direct environment, suggesting that mental health status may play a key role in a child’s experience of numerous other health outcomes of EWDDs. EWDDs interact with environmental and social systems and with individual children and their contexts in complex ways, the impacts of which are nonlinear and difficult to predict. Traditional perspectives on climate change-driven health impacts often overlook complex bio-psychosocial interactions, suggesting a need to work on preventive strategies to reduce vulnerability and build individual child resilience.

Perinatal distress in women in low- and middle-income countries: allostatic load as a framework to examine the effect of perinatal distress on preterm birth and infant health

In low- and middle-income countries (LMIC), determinants of women’s and children’s health are complex and differential vulnerability may exist to risk factors of perinatal distress and preterm birth. We examined the contribution of maternal perinatal distress on preterm birth and infant health in terms of infant survival and mother–infant interaction. A critical narrative and interpretive literature review was conducted. Peer-reviewed electronic databases (MEDLINE, Embase, Global Health, CINHAL), grey literature, and reference lists were searched, followed by a consultation exercise. The literature was predominantly from high-income countries. We identify determinants of perinatal distress and explicate changes in the hypothalamic–pituitary–adrenal axis, sympathetic, immune and cardiovascular systems, and behavioral responses resulting in pathophysiological effects. We suggest cultural–neutral composite measures of allostatic mediators (i.e., several biomarkers) of maternal perinatal distress as objective indicators of dysregulation in body systems in pregnant women in LMIC. Understanding causal links of maternal perinatal distress to preterm birth in women in LMIC should be a priority. The roles of allostasis and allostatic load are considered within the context of the health of pregnant women and fetuses/newborns in LMIC with emphasis on identifying objective indicators of the level of perinatal distress and protective factors or processes contributing to resilience while facing toxic stress. We propose a prospective study design with multiple measures across pregnancy and postpartum requiring complex statistical modeling. Building research capacity through partnering researchers in high-income countries and LMIC and reflecting on unique ethical challenges will be important to generating new knowledge in LMIC.

Post-disaster health indicators for pregnant and postpartum women and infants

United States (U.S.) pregnant and postpartum (P/PP) women and their infants may be particularly vulnerable to effects from disasters. In an effort to guide post-disaster assessment and surveillance, we initiated a collaborative process with nationwide expert partners to identify post-disaster epidemiologic indicators for these at-risk groups. This 12 month process began with conversations with partners at two national conferences to identify critical topics for P/PP women and infants affected by disaster. Next we hosted teleconferences with a 23 member Indicator Development Working Group (IDWG) to review and prioritize the topics. We then divided the IDWG into three population subgroups (pregnant women, postpartum women, and infants) that conducted at least three teleconferences to discuss the proposed topics and identify/develop critical indicators, measures for each indicator, and relevant questions for each measure for their respective population subgroup. Lastly, we hosted a full IDWG teleconference to review and approve the indicators, measures, and questions. The final 25 indicators and measures with questions (available online) are organized by population subgroup: pregnant women (indicators = 9; measures = 24); postpartum women (indicators = 10; measures = 36); and infants (indicators = 6; measures = 30). We encourage our partners in disaster-affected areas to test these indicators and measures for relevancy and completeness. In post-disaster surveillance, we envision that users will not use all indicators and measures but will select ones appropriate for their setting. These proposed indicators and measures promote uniformity of measurement of disaster effects among U.S. P/PP women and their infants and assist public health practitioners to identify their post-disaster needs.

Methylation of NR3C1 is related to maternal PTSD, parenting stress and maternal medial prefrontal cortical activity in response to child separation among mothers with histories of violence exposure

Prior research has shown that mothers with Interpersonal violence-related posttraumatic stress disorder (IPV-PTSD) report greater difficulty in parenting their toddlers. Relative to their frequent early exposure to violence and maltreatment, these mothers display dysregulation of their hypothalamic pituitary adrenal axis (HPA-axis), characterized by hypocortisolism. Considering methylation of the promoter region of the glucocorticoid receptor gene NR3C1 as a marker for HPA-axis functioning, with less methylation likely being associated with less circulating cortisol, the present study tested the hypothesis that the degree of methylation of this gene would be negatively correlated with maternal IPV-PTSD severity and parenting stress, and positively correlated with medial prefrontal cortical (mPFC) activity in response to video-stimuli of stressful versus non-stressful mother–child interactions. Following a mental health assessment, 45 mothers and their children (ages 12–42 months) participated in a behavioral protocol involving free-play and laboratory stressors such as mother–child separation. Maternal DNA was extracted from saliva. Interactive behavior was rated on the CARE-Index. During subsequent fMRI scanning, mothers were shown films of free-play and separation drawn from this protocol. Maternal PTSD severity and parenting stress were negatively correlated with the mean percentage of methylation of NR3C1. Maternal mPFC activity in response to video-stimuli of mother–child separation versus play correlated positively to NR3C1 methylation, and negatively to maternal IPV-PTSD and parenting stress. Among interactive behavior variables, child cooperativeness in play was positively correlated with NR3C1 methylation. Thus, the present study is the first published report to our knowledge, suggesting convergence of behavioral, epigenetic, and neuroimaging data that form a psychobiological signature of parenting-risk in the context of early life stress and PTSD.

Stressful events during pregnancy and postpartum depressive symptoms

BACKGROUND

Understanding the influence of perinatal stressors on the prevalence of postpartum depressive symptoms (PDS) and help-seeking for PDS using surveillance data can inform service provision and improve health outcomes.

METHODS

We used Massachusetts Pregnancy Risk Assessment Monitoring System (MA-PRAMS) 2007-2010 data to evaluate associations between selected perinatal stressors and PDS and with subsequent help-seeking behaviors. We categorized 12 stressors into 4 groups: partner, traumatic, financial, and emotional. We defined PDS as reporting "always" or "often" to any depressive symptoms on PRAMS Phase 5, or to a composite score ≥10 on PRAMS Phase 6 depression questions, compared with women reporting "sometimes," "rarely" or "never" to all depressive symptoms. The median response time to MA-PRAMS survey was 3.2 months (interquartile range, 2.9-4.0 months). We estimated prevalence ratios (PRs) and 95% confidence intervals (95% CIs) using modified Poisson regression models, controlling for socioeconomic status indicators, pregnancy intention and prior mental health visits.

RESULTS

Among 5,395 participants, 58% reported ≥1 stressor (partner=26%, traumatic=16%, financial=29% and emotional=30%). Reporting of ≥1 stressor was associated with increased prevalence of PDS (PR=1.68, 95% CI: 1.42-1.98). The strongest association was observed for partner stress (PR=1.90, 95% CI: 1.51-2.38). Thirty-eight percent of mothers with PDS sought help. Mothers with partner-related stressors were less likely to seek help, compared with mothers with other grouped stressors.

CONCLUSIONS

Women who reported perinatal common stressors-particularly partner-related stressors-had an increased prevalence of PDS. These data suggest that women should be routinely screened during pregnancy for a range of stressors and encouraged to seek help for PDS.

Excess prenatal corticosterone exposure results in albuminuria, sex-specific hypotension, and altered heart rate responses to restraint stress in aged adult mice

Exposure to excess glucocorticoids programs susceptibility to cardiovascular and renal dysfunction in later life although the mechanisms have not been clearly elucidated. We administered corticosterone (CORT; 33 μg·kg(-1)·h(-1)) to pregnant mice for 60 h from embryonic day (E) 12.5. Prenatal CORT resulted in postnatal growth restriction and reduced nephron endowment at postnatal day 30 in both male and female offspring. The reduction in nephron number was associated with increased expression of apoptotic markers in the kidney at E14.5. In offspring of both sexes at 12 mo of age, there were no differences in kidney weights, urine output, or urinary sodium excretion; however, prenatal CORT exposure increased the urinary albumin/creatinine ratio and 24-h urinary albumin excretion. Surprisingly, at 12 mo male but not female offspring exposed to prenatal CORT were hypotensive, with mean arterial blood pressures ∼10 mmHg lower than untreated controls (P < 0.001). Finally, we examined how offspring responded to a renal or cardiovascular challenge (saline load or restraint stress). When given 0.9% NaCl as drinking water for 7 days, there were no differences in blood pressures or urinary parameters between groups. Restraint stress (15 min) caused a tachycardic response in all animals; however the increase in heart rate was not sustained in male offspring exposed to CORT (P < 0.01), suggesting that autonomic control of cardiovascular function may be altered. These data demonstrate that excess prenatal CORT impairs kidney development and increases the risk of cardiovascular dysfunction especially in males.

Pregnant women with posttraumatic stress disorder and risk of preterm birth

IMPORTANCE

Posttraumatic stress disorder (PTSD) occurs in about 8% of pregnant women. Stressful conditions, including PTSD, are inconsistently linked to preterm birth. Psychotropic treatment has been frequently associated with preterm birth. Identifying whether the psychiatric illness or its treatment is independently associated with preterm birth may help clinicians and patients when making management decisions.

OBJECTIVE

To determine whether a likely diagnosis of PTSD or antidepressant and benzodiazepine treatment during pregnancy is associated with risk of preterm birth. We hypothesized that pregnant women who likely had PTSD and women receiving antidepressant or anxiolytic treatment would be more likely to experience preterm birth.

DESIGN, SETTING, AND PARTICIPANTS

Longitudinal, prospective cohort study of 2654 women who were recruited before 17 completed weeks of pregnancy from 137 obstetrical practices in Connecticut and Western Massachusetts.

EXPOSURES

Posttraumatic stress disorder, major depressive episode, and use of antidepressant and benzodiazepine medications.

MAIN OUTCOMES AND MEASURES

Preterm birth, operationalized as delivery prior to 37 completed weeks of pregnancy. Likely psychiatric diagnoses were generated through administration of the Composite International Diagnostic Interview and the Modified PTSD Symptom Scale. Data on medication use were gathered at each participant interview.

RESULTS

Recursive partitioning analysis showed elevated rates of preterm birth among women with PTSD. A further split of the PTSD node showed high rates for women who met criteria for a major depressive episode, which suggests an interaction between these 2 exposures. Logistic regression analysis confirmed risk for women who likely had both conditions (odds ratio [OR], 4.08 [95% CI, 1.27-13.15]). For each point increase on the Modified PTSD Symptom Scale (range, 0-110), the risk of preterm birth increased by 1% to 2%. The odds of preterm birth are high for women who used a serotonin reuptake inhibitor (OR, 1.55 [95% CI, 1.02-2.36]) and women who used a benzodiazepine medication (OR, 1.99 [95% CI, 0.98-4.03]).

CONCLUSIONS AND RELEVANCE

Women with likely diagnoses of both PTSD and a major depressive episode are at a 4-fold increased risk of preterm birth; this risk is greater than, and independent of, antidepressant and benzodiazepine use and is not simply a function of mood or anxiety symptoms.

Depression during gestation in adolescent mothers interferes with neonatal neurobehavior

OBJECTIVE

To compare the neurobehavior of neonates born to adolescent mothers with and without depression during gestation.

METHODS

This prospective cross-sectional study included healthy term neonates born to adolescent mothers with untreated depression during gestation, without exposure to legal or illicit drugs, and compared them with infants born to adolescent mothers without psychiatric disorders. Maternal psychiatric diagnoses were assessed by the Composite International Diagnostic Interview (CIDI 2.1) and neonatal neurobehavior by the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) at 24 to 72 hours of life. Neurobehavioral outcomes were analyzed by ANOVA adjusted for confounders.

RESULTS

37 infants born to mothers with depression during gestation were compared to 332 infants born to mothers without psychiatric disorders. Infants of mothers with depression had smaller head circumferences. Significant interactions of maternal depression and male gender, gestational age > 40 weeks, regional anesthesia during delivery, vaginal delivery, and infant head circumference ≥ 34 cm were found. Worse performance was noted in the following neonatal neurobehavioral parameters: arousal, excitability, lethargy, hypotonicity, and signs of stress and abstinence.

CONCLUSION

Infants born to adolescent mothers with depression exhibit some behavioral changes in the first days of life. These changes are associated with infant sex, gestational age, type of anesthesia, mode of delivery, and head circumference.

Post-disaster reproductive health outcomes

We examined methodological issues in studies of disaster-related effects on reproductive health outcomes and fertility among women of reproductive age and infants in the United States (US). We conducted a systematic literature review of 1,635 articles and reports published in peer-reviewed journals or by the government from January 1981 through December 2010. We classified the studies using three exposure types: (1) physical exposure to toxicants; (2) psychological trauma; and (3) general exposure to disaster. Fifteen articles met our inclusion criteria concerning research focus and design. Overall studies pertained to eight different disasters, with most (n = 6) focused on the World Trade Center attack. Only one study examined pregnancy loss, i.e., occurrence of spontaneous abortions post-disaster. Most studies focused on associations between disaster and adverse birth outcomes, but two studies pertained only to post-disaster fertility while another two examined it in addition to adverse birth outcomes. In most studies disaster-affected populations were assumed to have experienced psychological trauma, but exposure to trauma was measured in only four studies. Furthermore, effects of both physical exposure to toxicants and psychological trauma on disaster-affected populations were examined in only one study. Effects on birth outcomes were not consistently demonstrated, and study methodologies varied widely. Even so, these studies suggest an association between disasters and reproductive health and highlight the need for further studies to clarify associations. We postulate that post-disaster surveillance among pregnant women could improve our understanding of effects of disaster on the reproductive health of US pregnant women.

Short- and long-term effects of exposure to natural and synthetic glucocorticoids during development

1.Glucocorticoids (GCs) are necessary for fetal development, but clinical and experimental studies suggest that excess exposure may be detrimental to health in both the short and longer term. 2.Exposure of the fetus to synthetic GCs can occur if the mother has a medical condition requiring GC therapy (e.g. asthma) or if she threatens to deliver her baby prematurely. Synthetic GCs can readily cross the placenta and treatment is beneficial, at least in the short term, for maternal health and fetal survival. 3.Maternal stress during pregnancy can raise endogenous levels of the natural GC cortisol. A significant proportion of the cortisol is inactivated by the placental 'GC barrier'. However, exposure to severe stress during pregnancy can result in increased risk of miscarriage, low birth weight and behavioural deficits in children. 4.Animal studies have shown that excess exposure to both synthetic and natural GCs can alter normal organ development, including that of the heart, brain and kidney. The nature and severity of the organ impairment is dependent upon the timing of exposure and, in some cases, the type of GC used and the sex of the fetus. 5.In animal models, exposure to elevated GCs during pregnancy has been associated with adult-onset diseases, including elevated blood pressure, impaired cardiac and vascular function and altered metabolic function.

Public health consequences of terrorism on maternal-child health in New York City and Madrid

Past research provides evidence for trajectories of health and wellness among individuals following disasters that follow specific pathways of resilience, resistance, recovery, or continued dysfunction. These individual responses are influenced by event type and pre-event capacities. This study was designed to utilize the trajectories of health model to determine if it translates to population health. We identified terrorist attacks that could potentially impact population health rather than only selected individuals within the areas of the attacks. We chose to examine a time series of population birth outcomes before and after the terrorist events of the New York City (NYC) World Trade Center (WTC) attacks of 2001 and the Madrid, Spain train bombings of 2004 to determine if the events affected maternal-child health of those cities and, if so, for how long. For percentages of low birth weight (LBW) and preterm births, we found no significant effects from the WTC attacks in NYC and transient but significant effects on rates of LBW and preterm births following the bombings in Madrid. We did find a significant positive and sustained effect on infant mortality rate in NYC following the WTC attacks but no similar effect in Madrid. There were no effects on any of the indicator variables in the comparison regions of New York state and the remainder of Spain. Thus, population maternal-health in New York and Madrid showed unique adverse effects after the terrorist attacks in those cities. Short-term effects on LBW and preterm birth rates in Madrid and long-term effects on infant mortality rates in NYC were found when quarterly data were analyzed from 1990 through 2008/2009. These findings raise questions about chronic changes in the population's quality of life following catastrophic terrorist attacks. Public health should be monitored and interventions designed to address chronic stress, environmental, and socioeconomic threats beyond the acute aftermath of events.

Quercetin alleviates predator stress-induced anxiety-like and brain oxidative signs in pregnant rats and immune count disturbance in their offspring

This study was performed in rats to investigate the effect of a psychogenic stress during late gestation on the immediate behavior and brain oxidative status in dams as well as on the immune cell counts in their offspring up to weaning. Besides, the ability of quercetin (a natural flavonoid) to prevent stress effects was evaluated. Quercetin was orally administered for 6 consecutive days before the pregnant rats were acutely exposed to predator stress on gestational day 19. Post-stress corticosterone level, brain oxidative stress parameters and anxiety-like behavior were assessed in dams, whereas immune cell counts were postnatally determined in both male and female pups. Predator stress caused an oxidative stress in the brain and elicited an elevation in plasma corticosterone with concomitant behavioral impairment in dams. Prenatally-stressed pups mainly showed a decrease in total leukocytes and lymphocytes along with monocytosis and granulocytosis, but these changes were sex-dependent throughout the postnatal period studied. Quercetin pretreatment blocked the stress-induced corticosterone release and alleviated the brain oxidative stress with the maternal anxiety measures being slightly attenuated, whereas its effects on the offspring immune cell counts were mostly revealed at birth. Our findings suggest that late gestational exposure to traumatic events may cause anxiety symptoms in dams, in which corticosterone and brain oxidative stress play a certain role, and trigger negative immune changes in the early postnatal life of progeny. Notably, quercetin intake before such adverse events seems to be beneficial against negative outcomes in both dams and offspring.

The interplay of variants near LEKR and CCNL1 and social stress in relation to birth size

BACKGROUND

We previously identified via a genome wide association study variants near LEKR and CCNL1 and in the ADCY5 genes lead to lower birthweight. Here, we study the impact of these variants and social stress during pregnancy, defined as social adversity and neighborhood disparity, on infant birth size. We aimed to determine whether the addition of genetic variance magnified the observed associations.

METHODOLOGY/PRINCIPAL FINDINGS

We analyzed data from the Northern Finland Birth Cohort 1986 (n=5369). Social adversity was defined by young maternal age (<20 years), low maternal education (<11 years), and/or single marital status. Neighborhood social disparity was assessed by discrepancy between neighborhoods relative to personal socio-economic status. These variables are indicative of social and socioeconomic stress, but also of biological risk. The adjusted multiple regression analysis showed smaller birth size in both infants of mothers who experienced social adversity (birthweight by -40.4 g, 95%CI -61.4, -19.5; birth length -0.14 cm, 95%CI -0.23, -0.05; head circumference -0.09 cm 95%CI -0.15, -0.02) and neighborhood disparity (birthweight -28.8 g, 95%CI -47.7, -10.0; birth length -0.12 cm, 95%CI -0.20, -0.05). The birthweight-lowering risk allele (SNP rs900400 near LEKR and CCNL1) magnified this association in an additive manner. However, likely due to sample size restriction, this association was not significant for the SNP rs9883204 in ADCY5. Birth size difference due to social stress was greater in the presence of birthweight-lowering alleles.

CONCLUSIONS/SIGNIFICANCE

Social adversity, neighborhood disparity, and genetic variants have independent associations with infant birth size in the mutually adjusted analyses. If the newborn carried a risk allele rs900400 near LEKR/CCNL1, the impact of stress on birth size was stronger. These observations give support to the hypothesis that individuals with genetic or other biological risk are more vulnerable to environmental influences. Our study indicates the need for further research to understand the mechanisms by which genes impact individual vulnerability to environmental insults.