Cumulative psychosocial stress, coping resources, and preterm birth

The Association Between Adverse Childhood Experiences and Preterm Delivery: A Latent Class Approach

Background: Racial and socioeconomic status (SES) disparities in preterm delivery (PTD) have existed in the United States for decades. Disproportionate maternal exposures to adverse childhood experiences (ACEs) may increase the risk for adverse birth outcomes. Moreover, racial and SES disparities exist in the prevalence of ACEs, underscoring the need for research that examines whether ACEs contribute to racial and SES disparities in PTD. Methods: We examined the relationship between ACEs and PTD in a longitudinal sample of N = 3,884 women from the National Longitudinal Study of Adolescent to Adult Health (1994-2018). We applied latent class analysis to (1) identify subgroups of women characterized by patterns of ACE occurrence; (2) estimate the association between latent class membership (LCM) and PTD, and (3) examine whether race and SES influence LCM or the association between LCM and PTD. Results: Two latent classes were identified, with women in the high ACEs class characterized by a higher probability of emotional abuse, physical abuse, sexual abuse, and foster care placement compared with the low ACEs class, but neither class was associated with PTD. Race and SES did not predict LCM. Conclusions: Our findings suggest that ACEs may not impact PTD risk in previously hypothesized ways. Future research should assess the impact of ACEs on the probability of having live birth pregnancies as well as the role of potential protective factors in mitigating the impact of ACEs on PTD.

Factors associated with stress among pregnant women with a second child in Hunan province under China's two-child policy: a mixed-method study

OBJECTIVE

The purpose of the study was to investigate the status of pregnancy stress and to explore factors associated with pregnancy stress among women by China's two-child policy.

METHODS

A mixed-method study involving both quantitative and qualitative methods was conducted using questionnaires and semi-structured interviews. The questionnaires encompassed socio-demographic and obstetric characteristics, as well as the Pregnancy Stress Rating Scale (PSRS) and the Social Support Rating Scale (SSRS). Initially, the participants were required to complete the questionnaires, enabling us to assess their respective pregnancy stress statuses. Subsequently, we selectively interviewed pregnant women with a second child and exhibited at least mild pregnancy stress. The qualitative study sought to uncover the factors contributing to their stress during pregnancy.

RESULTS

A total of 463 subjects were enrolled; of the subjects, 22 (4.8%) had no stress, 407 (87.9%) had mild stress, 34 (7.3%) had moderate stress. Generalized linear regression analysis revealed significant factors (P<0.05) related to pregnancy stress, including family financial burden, subjective support, fertility desire, gender of the first child, and gender preference. Additionally, 16 subjects were interviewed, and through analysis, three major themes emerged, each comprising 12 sub-themes associated with pregnancy stress. These themes were identified as fertility factors (worry about maternal and child health, birth experience, and parenting stress), family factors ( financial burden, second child care problems, first child's acceptance of the second child, family concerns, fertility desire, and gender preference) and social factors (involving life events, career development and workload).

CONCLUSION

The diver factors contribute to pregnancy stress among pregnant women under China's two-child policy. Our study could be used to develop appropriate interventions to reduce pregnancy stress and to enhance the mental health of women pregnant with a second child.

Investigating associations between maternal stress, smoking and adverse birth outcomes: evidence from the All Our Families cohort

BACKGROUND

Independently, active maternal and environmental tobacco smoke exposure and maternal stress have been linked to an increased risk of preterm birth and low birth weight. An understudied relationship is the potential for interactive effects between these risk factors.

METHODS

Data was obtained from the All Our Families cohort, a study of 3,388 pregnant women < 25 weeks gestation recruited from those receiving prenatal care in Calgary, Canada between May 2008 and December 2010. We investigated the joint effects of active maternal smoking, total smoke exposure (active maternal smoking plus environmental tobacco smoke) and prenatal stress (Perceived Stress Scale, Spielberger State-Trait Anxiety Inventory), measured at two time points (< 25 weeks and 34-36 weeks gestation), on preterm birth and low birth weight.

RESULTS

A marginally significant association was observed with the interaction active maternal smoking and Spielberger State-Trait Anxiety Inventory scores in relation to low birth weight, after imputation (aOR = 1.02, 95%CI: 1.00-1.03, p = 0.06). No significant joint effects of maternal stress and either active maternal smoking or total smoke exposure with preterm birth were observed. Active maternal smoking, total smoke exposure, Perceived Stress Scores, and Spielberger State-Trait Anxiety Inventory scores were independently associated with preterm birth and/or low birth weight.

CONCLUSIONS

Findings indicate the role of independent effects of smoking and stress in terms of preterm birth and low birthweight. However, the etiology of preterm birth and low birth weight is complex and multifactorial. Further investigations of potential interactive effects may be useful in helping to identify women experiencing vulnerability and inform the development of targeted interventions.

Positive maternal mental health attenuates the associations between prenatal stress and children's internalizing and externalizing symptoms

Positive maternal mental health can improve perceptions of stressful situations and promote the use of adaptive coping strategies. However, few studies have examined how positive maternal mental health affects children's development. The aims of this study were to examine the associations between positive maternal mental health and children's internalizing and externalizing symptoms, and to ascertain whether positive maternal mental health moderated the associations between prenatal stress and children's internalizing and externalizing symptoms. This study is based on the Norwegian Mother, Father, and Child Cohort Study (MoBa), and comprised 36,584 mother-child dyads. Prenatal stress was assessed using 41 self-reported items measured during pregnancy. Positive maternal mental health (self-efficacy, self-esteem, and enjoyment) was assessed by maternal report during pregnancy and postpartum. Child internalizing and externalizing symptoms were assessed by maternal report at age 5. Structural equation modeling was used for analysis. Maternal self-efficacy, self-esteem, and enjoyment were negatively associated with internalizing and externalizing symptoms in males and females. The association between prenatal stress and internalizing symptoms in males was stronger at low than at high levels of maternal self-esteem and enjoyment, whereas for females, the association was stronger at low than at high levels of maternal self-esteem and self-efficacy. This study provides evidence of associations between positive maternal mental health and children's mental health, and suggests that higher positive maternal mental health may buffer against the impacts of prenatal stress. Positive maternal mental health may represent an important intervention target to improve maternal-child well-being and foster intergenerational resilience.

Addressing Adverse Childhood and Adult Experiences During Prenatal Care

Adverse childhood and adult experiences can affect health outcomes throughout life and across generations. The perinatal period offers a critical opportunity for obstetric clinicians to partner with patients to provide support and improve outcomes. This article draws on stakeholder input, expert opinion, and available evidence to provide recommendations for obstetric clinicians' inquiry about and response to pregnant patients' past and present adversity and trauma during prenatal care encounters. Trauma-informed care is a universal intervention that can proactively address adversity and trauma and support healing, even if a patient does not explicitly disclose past or present adversity. Inquiry about past and present adversity and trauma provides an avenue to offer support and to create individualized care plans. Preparatory steps to adopting a trauma-informed approach to prenatal care include initiating education and training for practice staff, prioritizing addressing racism and health disparities, and establishing patient safety and trust. Inquiry about adversity and trauma, as well as resilience factors, can be implemented gradually over time through open-ended questions, structured survey measures, or a combination of both techniques. A range of evidence-based educational resources, prevention and intervention programs, and community-based initiatives can be included within individualized care plans to improve perinatal health outcomes. These practices will be further developed and improved by increased clinical training and research, as well as through broad adoption of a trauma-informed approach and collaboration across specialty areas.

The Level of Stress and Anxiety in Pregnant Women Depending on Social Support and Physical Activity

Social support and physical activity are mentioned among the numerous factors affecting the emotional state of pregnant women. Therefore, the aim of the study was to assess the level of perceived stress and anxiety in pregnant women depending on social support and their physical activity both before and during pregnancy and find the factors that affected the level of perceived stress.

METHODS

A total of 373 pregnant women were qualified for the study. The Perceived Stress Scale (PSS-10), the State-Trait Anxiety Inventory (STAI), and a self-administered questionnaire were used.

RESULTS

In the study group, a high level of stress and anxiety were noted. A comparative analysis showed that physically active women before pregnancy, women attending childbirth classes and remaining in a relationship, were characterized by a lower level of stress and anxiety compared to physically inactive women, women who did not participate in childbirth classes and were single. A multiple linear regression analysis showed that participation in childbirth classes, physical activity before pregnancy, the level of anxiety as a trait, and women's age had the most significant impact on the stress level of surveyed women.

CONCLUSIONS

Further research among pregnant women and women in the postpartum period is needed to confirm the benefits of physical activity and to identify as many factors as possible that may affect the emotional state of pregnant women.

Contributors to Preterm Birth: Data from a Single Polish Perinatal Center

Preterm birth may result from overlapping causes including maternal age, health, previous obstetric history and a variety of social factors. We aimed to identify factors contributing to preterm birth in respect to new social and environmental changes in the reproductive patterns. Our cross-sectional study included 495 mother–infant pairs and was based on maternal self-reporting in an originally developed questionnaire. Neonates were divided into two groups: 72 premature babies (study group) and 423 full-term babies (control group). We analyzed maternal, sociodemographic and economic characteristics, habits, chronic diseases, previous obstetric history and pregnancy complications. For statistical analysis, Pearson’s Chi-squared independence test was used with a statistical significance level of 0.05. Preterm births were more common among mothers living in villages (p < 0.001) and with lower education level (p = 0.01). Premature births were also positively associated with mothers who were running their own businesses (p = 0.031). Mothers with a history of previous miscarriages gave birth at a significantly older age (p < 0.001). The most frequent pregnancy complications were hypothyroidism (41.4%), pregestational and gestational diabetes mellitus (DM; 17.8%) and hypertension (8.1%). Pregestational DM significantly influenced the occurrence of prematurity (p < 0.05). Pregestational DM, being professionally active, a lower education level and living outside cities are important risk factors of prematurity.

The social predictors of paternal antenatal mental health and their associations with maternal mental health in the Queensland Family Cohort prospective study

Antenatal depression (AND) affects 1 in 10 fathers, potentially negatively impacting maternal mental health and well-being during and after the transition to parenthood. However, few studies have assessed the social predictors of paternal AND or their possible associations with maternal mental health. We analysed data from 180 couples participating in the Queensland Family Cohort longitudinal study. Both parents completed surveys measuring mental health, relationship quality, social support, and sleep quality at 24 weeks of pregnancy. Mothers also completed the same surveys 6 weeks' postpartum. Antenatal depression, stress, and anxiety were highest among fathers reporting lower social support and higher sleep impairment. Maternal AND, stress, and anxiety were higher among mothers reporting higher physical pain and poor sleep quality. Postnatally, mothers reporting lower social support also reported higher depression, anxiety, stress, and psycho-social well-being. While there were no significant associations between AND among fathers and maternal antenatal or postnatal depression, an exploratory analysis revealed that mothers whose partners reported lower antenatal social support also reported lower postnatal social support and higher postnatal depression. Our findings highlight the importance of including data among fathers to achieve a whole family approach to well-being during the transition to parenthood.

The amniotic fluid proteome predicts imminent preterm delivery in asymptomatic women with a short cervix

Preterm birth, the leading cause of perinatal morbidity and mortality, is associated with increased risk of short- and long-term adverse outcomes. For women identified as at risk for preterm birth attributable to a sonographic short cervix, the determination of imminent delivery is crucial for patient management. The current study aimed to identify amniotic fluid (AF) proteins that could predict imminent delivery in asymptomatic patients with a short cervix. This retrospective cohort study included women enrolled between May 2002 and September 2015 who were diagnosed with a sonographic short cervix (< 25 mm) at 16–32 weeks of gestation. Amniocenteses were performed to exclude intra-amniotic infection; none of the women included had clinical signs of infection or labor at the time of amniocentesis. An aptamer-based multiplex platform was used to profile 1310 AF proteins, and the differential protein abundance between women who delivered within two weeks from amniocentesis, and those who did not, was determined. The analysis included adjustment for quantitative cervical length and control of the false-positive rate at 10%. The area under the receiver operating characteristic curve was calculated to determine whether protein abundance in combination with cervical length improved the prediction of imminent preterm delivery as compared to cervical length alone. Of the 1,310 proteins profiled in AF, 17 were differentially abundant in women destined to deliver within two weeks of amniocentesis independently of the cervical length (adjusted p-value < 0.10). The decreased abundance of SNAP25 and the increased abundance of GPI, PTPN11, OLR1, ENO1, GAPDH, CHI3L1, RETN, CSF3, LCN2, CXCL1, CXCL8, PGLYRP1, LDHB, IL6, MMP8, and PRTN3 were associated with an increased risk of imminent delivery (odds ratio > 1.5 for each). The sensitivity at a 10% false-positive rate for the prediction of imminent delivery by a quantitative cervical length alone was 38%, yet it increased to 79% when combined with the abundance of four AF proteins (CXCL8, SNAP25, PTPN11, and MMP8). Neutrophil-mediated immunity, neutrophil activation, granulocyte activation, myeloid leukocyte activation, and myeloid leukocyte-mediated immunity were biological processes impacted by protein dysregulation in women destined to deliver within two weeks of diagnosis. The combination of AF protein abundance and quantitative cervical length improves prediction of the timing of delivery compared to cervical length alone, among women with a sonographic short cervix.

Effect of individual or comorbid antenatal depression and anxiety on birth outcomes and moderation by maternal traumatic experiences and resilience

Background

Although antenatal depression and anxiety (e.g., negative antenatal mental health; NAMH) are individually associated with preterm birth (PTB) and infant neurological impairment, few studies account for comorbidity. Understanding how NAMH impacts PTB and infant neurological functioning by either singular (depression or anxiety) or comorbid status, as well as the way in which these effects can be moderated by additional risk or protective factors (traumatic experiences and trait resiliency) can contribute further understanding of NAMH effects on birth outcomes.

Methods

The sample included 3042 mother-infant dyads from U.S. and South Africa cohorts of the Safe Passage Study (N = 3042). A four-category NAMH variable was created to categorize depression-only, anxiety-only, comorbid, or no NAMH statuses.

Results

There were no NAMH main effects on PTB, however, anxiety-only and comorbid NAMH increased odds of PTB for mothers with higher rates of traumatic life experiences. Anxiety-only and comorbid NAMH were associated with increased odds of newborn neurological impairment, and the effect of comorbid NAMH was stronger for mothers with higher rates of traumatic experiences. Resiliency decreased odds of neurological impairment for mothers who reported depression-only or anxiety-only NAMH.

Limitations

Limitations included potential artefacts of two cohorts that differed in rates of almost all variables, a single time point for measuring NAMH, and lack of pregnancy-specific NAMH measures.

Conclusions

Especially when compared to mothers with no NAMH, comorbidity or singular-condition NAMH statuses associate with negative birth outcomes in nuanced ways, especially when considering additional contexts that may foster or protect against NAMH.

Potential differences in occurrence of preterm births according to quality of relationship between mothers and fathers of the children

OBJECTIVES

Premature birth is a serious pregnancy complication that is affected by many biological as well as psychosocial factors. Several studies have shown that a mother's positive relationship with her child's father reduces the mother's stress, anxiety and depression during pregnancy, promotes a healthier mother's lifestyle and thus has a positive effect on pregnancy as such. This research was therefore aimed at identifying possible differences in the incidence of premature births in mothers depending on the quality of the relationship with the father of their child.

METHODS

The research involved 210 mothers after childbirth in the period from October 2020 to September 2021. A questionnaire aimed at obtaining descriptive data about the mother and her child and a questionnaire aimed at determining the quality of the relationship - Quality of Relationship Inventory (QRI) were distributed. Mann-Whitney U tests were used to determine differences between groups.

RESULTS

Of 210 children, 44 (21%) were born prematurely, 154 (73.3%) mothers were married and 176 (83.8%) lived with the father of their child in the same household. The results showed that the degree of quality of the mother's relationship with the child's father is approximately the same for mothers who gave birth prematurely and for those who gave birth at term, so there were no differences in this factor between the two groups of mothers.

CONCLUSION

The results of other researchers have shown the positive impact of partners on pregnancy and the overall well-being of the mothers. However, our research has not confirmed the positive effect of the quality of the relationship between mother and father of her child on reducing the incidence of premature births. Further research is needed to clarify how specifically and whether the quality of the relationship between parents can affect the incidence of premature births at all.

The Mediating Role of Dispositional Optimism in the Relationship between Health Locus of Control and Self-Efficacy in Pregnant Women at Risk of Preterm Delivery

Difficult situations during pregnancy, such as threatened preterm labor, trigger negative experiences in women. The levels of stress experienced and the way individuals cope with it depend on their personal resources, such as optimism, internal health locus of control, and self-efficacy, among other factors. The purpose of this paper was to determine the role of dispositional optimism in the relationship between health locus of control and self-efficacy in pregnant women with threatened preterm labor. Dispositional optimism plays the role of mediator in relationships between: (1) internal health control and self-efficacy; and (2) impact of random events on one's health and self-efficacy. Dispositional optimism does not mediate the relationship between the perceived impact of others on one's health and self-efficacy. For women with a high-risk pregnancy, dispositional optimism is a significant resource for coping with the problems they encounter. It changes the direction (from negative to positive) of the association between experiencing the impact of external factors (random events) on one's health and perceived self-efficacy. It prevents the cycle of loss caused by the interpretation of random events as having an impact on one's health, and acts as a mediator to initiate a cycle of gains that leads to greater perceived self-efficacy. Optimistic pregnant women maintain a positive outlook, even when confronted with difficult, negative experiences such as threatened preterm labor.

Differences in Psychosocial Protective Factors by Race/Ethnicity and Socioeconomic Status and Their Relationship to Preterm Delivery

Background: Non-Hispanic Black (“Black”) women in the United States deliver preterm at persistently higher rates than non-Hispanic White (“White”) women, and disparities in preterm delivery (PTD) also exist by socioeconomic factors. Research is needed to identify and understand factors that are protective against PTD for Black women and low socioeconomic status (SES) women.

Methods: We examined seven potential protective factors at the individual, interpersonal, and neighborhood levels during pregnancy to determine if they (1) differed in prevalence by race/ethnicity and SES and (2) were associated with risk of PTD overall or within specific race/ethnicity and SES groups. We used prospectively collected data from n = 2474 women who were enrolled in the Pregnancy Outcomes and Community Health Study conducted in Michigan (1998–2004).

Results: White women reported higher levels of self-esteem, mastery, perceived social support, instrumental social support, and reciprocity compared to Black women (all p < 0.01), while Black women reported higher levels of religiosity compared to white women (p < 0.01). High SES women reported higher levels of all protective factors compared to middle and low SES women (all p < 0.01). While protective factors were not independently associated with PTD, religiosity was associated with lower odds of PTD among low SES women (OR 0.6, 95% CI 0.4-0.9) and among Black women (OR 0.6, 95% CI 0.4–1.0), respectively.

Conclusions: Our findings highlight the importance of assessing how protective factors may operate differently across race/ethnicity and SES to promote healthy pregnancy outcomes. Future studies should examine mechanisms that elucidate potential causal pathways between religiosity and PTD for Black women and low SES women.

Effects of maternal exposure to acute stress on birth outcomes: a quasi-experiment study

Numerous studies have shown associations between maternal stress and poor birth outcomes, but evidence is unclear for causal inference. Natural disasters provide an opportunity to study effects of quasi-randomized hardship with an accurate measure of onset and duration. In a population-based quasi-experimental study, we examined the effect of maternal exposure to the January 1998 Québec ice storm on birth outcomes by comparing pregnant mothers who lived in an area hard hit by the ice storm with those in two unaffected regions. In a total of 147,349 singleton births between 1995 and 2001, we used a difference-in-differences method to estimate the effects of the ice storm on gestational age at delivery (GA), preterm birth (PTB), weight-for-gestational-age z-scores (BWZ), large for gestational age (LGA), and small for gestational age (SGA). After adjusting for maternal and sociodemographic characteristics, there were no differences between the exposed and the unexposed mothers for birth outcomes. The estimated differences (exposed vs. unexposed) were 0.01 SDs (95% CI: -0.02, 0.05) for BWZ; 0.10% point (95% CI: -0.95%, 1.16%) for SGA; 0.25% point (95% CI: -0.78%, 1.28%) for LGA; -0.01 week (95% CI: -0.07, 0.05) for GA; and 0.16% point (95% CI: -0.66%, 0.97%) for PTB. Neither trimester-specific nor dose-response associations were observed. Overall, exposure to the 1998 Québec ice storm as a proxy for acute maternal stress in pregnancy was not associated with poor birth outcomes. Our results suggest that acute maternal hardship may not have a substantial effect on adverse birth outcomes.

Adverse birth outcomes among women exposed to intimate partner violence in pregnancy in Ikere-Ekiti, South-west Nigeria: A prospective cohort study

OBJECTIVE

Studies on birth outcomes associated with intimate partner violence in pregnancy in Nigeria are scarce. We aimed to evaluate adverse birth outcomes among women exposed to intimate partner violence in pregnancy in a Nigerian population.

STUDY DESIGN

We performed a prospective cohort study involving 363 women with singleton pregnancies presenting for antenatal care between March 2019 and September 2019. Intimate partner violence was assessed with a validated self-administered questionnaire- ongoing abuse screen. We compared adverse birth outcomes between women that experienced intimate partner violence in pregnancy and those that did not. Multivariate logistic regression was used to adjust for confounders.

RESULTS

Of the 363 pregnant women that completed the study, 56(15.4%) experienced intimate partner violence in pregnancy. Women who experienced intimate partner violence in pregnancy were significantly more likely to experience composite adverse birth outcome (53.6% compared with 20.2%,adjusted OR 4.72, 95% CI: 2.43-9.19, p < 0.001) preterm delivery (26.8% compared with 13.4%,adjusted OR 2.96, 95% CI: 1.34-6.50, p = 0.007), stillbirths(17.9% compared with 3.3%,adjusted OR 9.52, 95% CI: 3.96-22.90, p < 0.001) and neonatal intensive care unit admission (32.1% compared with 19.9%, adjusted OR 1.93, 95% CI: 1.19-10.60, p = 0.03). Mode of delivery and low birth weight did not differ significantly between the two groups.

CONCLUSION

Intimate partner violence is associated with increased risk of preterm delivery, stillbirth and neonatal intensive care unit admission. There is a need to evaluate the effect of interventions on these adverse birth outcomes.

Determinants of Psychosocial Resilience Resources in Obese Pregnant Women with Threatened Preterm Labor-A Cross-Sectional Study

Background: The purpose of the study was to assess the level of such psychosocial resilience resources as self-efficacy, dispositional optimism, and health locus of control in pregnant women with obesity with threatened premature labor. Methods: The study was performed in the years 2017-2020 in a group of 328 pregnant women hospitalized due to threatened preterm labor and diagnosed with obesity before the pregnancy. The following instruments were applied: the Life Orientation Test, the Generalized Self-Efficacy Scale, and the Multidimensional Health Locus of Control Scale. Results: Obese pregnant women with threatened premature labor have a moderate level of generalized self-efficacy (28.02) and a moderate level of dispositional optimism (16.20). Out of the three health locus of control dimensions, the highest scores were recorded in the "internal control" subscale (26.08). Statistically significant predictors for the self-efficacy variable model included: satisfactory socio-economic standing (ß = 0.156; p = 0.004), being nulliparous (ß = -0.191; p = 0.002), and the absence of comorbidities (ß = -0.145; p = 0.008). Higher levels of dispositional optimism were found in women who were married (ß = 0.381; p = 0.000), reported a satisfactory socio-economic standing (ß = 0.137; p = 0.005), were between 23 and 27 weeks pregnant (ß = -0.231; p = 0.000), and had no comorbidities (ß = -0.129; p = 0.009). Conclusions: Generalized self-efficacy in obese women with threatened preterm labor is associated with satisfactory socio-economic standing, being nulliparous, and the absence of chronic disease. Dispositional optimism in obese pregnant women with threatened preterm labor is determined by their marital status, socio-economic standing, gestational age, and the absence of comorbidities.

A Strategic Program for Risk Assessment and Intervention to Mitigate Environmental Stressor-Related Adverse Pregnancy Outcomes in the Indian Population

The Problem: Global environmental stressors of human health include, but are not limited to, conflict, migration, war, natural disasters, climate change, pollution, trauma, and pandemics. In combination with other factors, these stressors influence physical and mental as well as reproductive health. Maternal stress is a known factor for adverse pregnancy outcomes such as preterm birth (PTB); however, environmental stressors are less well-understood in this context and the problem is relatively under-researched. According to the WHO, major Indian cities including New Delhi are among the world's 20 most polluted cities. It is known that maternal exposure to environmental pollution increases the risk of premature births and other adverse pregnancy outcomes which is evident in this population.

Response to the Problem: Considering the seriousness of this problem, an international and interdisciplinary group of researchers, physicians, and organizations dedicated to the welfare of women at risk of adverse pregnancy outcomes launched an international program named Optimal Pregnancy Environment Risk Assessment (OPERA). The program aims to discover and disseminate inexpensive, accessible tools to diagnose women at risk for PTB and other adverse pregnancy outcomes due to risky environmental factors as early as possible and to promote effective interventions to mitigate these risks. OPERA has been supported by the Worldwide Universities Network, World Health Organization (WHO) and March of Dimes USA.

Addressing the Problem: This review article addresses the influence of environmental stressors on maternal-fetal health focusing on India as a model population and describes the role of OPERA in helping local practitioners by sharing with them the latest risk prediction and mitigation tools. The consequences of these environmental stressors can be partially mitigated by experience-based interventions that build resilience and break the cycle of inter- and-transgenerational transmission. The shared knowledge and experience from this collaboration are intended to guide and facilitate efforts at the local level in India and other LMIC to develop strategies appropriate for the jurisdiction for improving pregnancy outcomes in vulnerable populations.

Risk of Preterm Birth and Newborn Low Birthweight in Military Women with Increased Pregnancy-Specific Anxiety

INTRODUCTION

Prenatal maternal anxiety and depression have been implicated as possible risk factors for preterm birth (PTB) and other poor birth outcomes. Within the military, maternal conditions account for 15.3% of all hospital bed days, and it is the most common diagnostic code for active duty females after mental disorders. The majority of women (97.6%) serving on active duty are women of childbearing potential. Understanding the impact that prenatal maternal anxiety and depression can have on PTB and low birthweight (LBW) in a military population is critical to providing insight into biological pathways that alter fetal development and growth. The purpose of the study was to determine the impact of pregnancy-specific anxiety and depression on PTB and LBW within a military population.

MATERIAL AND METHODS

Pregnancy-specific anxiety and depression were measured for 246 pregnant women in each trimester. Individual slopes for seven different measures of pregnancy anxiety and one depression scale were calculated using linear mixed models. Logistic regression, adjusted and unadjusted models, were applied to determine the impact on PTB and LBW.

RESULTS

For each 1/10 unit increase in the anxiety slope as it related to well-being, the risk of LBW increased by 83% after controlling for parity, PTB, and active duty status. Similarly, a 1/10 unit rise in the anxiety slope related to accepting pregnancy, labor fears, and helplessness increased the risk of PTB by 37%, 60%, and 54%, respectively.

CONCLUSIONS

Pregnancy-specific anxiety was found to significantly increase the risk of PTB and LBW in a military population. Understanding this relationship is essential in developing effective assessments and interventions. Results emphasize the importance of prenatal maternal mental health to fetal health and birth outcomes. Further research is needed to determine the specific physiological pathways that link prenatal anxiety and depression with poor birth outcomes.

Effect of a Nonoptimal Cervicovaginal Microbiota and Psychosocial Stress on Recurrent Spontaneous Preterm Birth

OBJECTIVE

While select cervicovaginal microbiota and psychosocial factors have been associated with spontaneous preterm birth, their effect on the risk of recurrence remains unclear. It is also unknown whether psychosocial factors amplify underlying biologic risk. This study sought to determine the effect of nonoptimal cervicovaginal microbiota and perceived stress on the risk of recurrent spontaneous preterm birth.

STUDY DESIGN

This was a secondary analysis of a prospective pregnancy cohort, Motherhood and Microbiome. The Cohen's Perceived Stress Scale (PSS-14) was administered and cervical swabs were obtained between 16 and 20 weeks of gestation. PSS-14 scores ≥30 reflected high perceived stress. We analyzed cervicovaginal microbiota using 16S rRNA sequencing and classified microbial communities into community state types (CSTs). CST IV is a nonoptimal cervicovaginal microbial community characterized by anaerobes and a lack of Lactobacillus. The final cohort included a predominantly non-Hispanic Black population of women with prior spontaneous preterm birth who had recurrent spontaneous preterm birth or term birth and had stress measurements (n = 181). A subanalysis was performed in the subset of these women with cervicovaginal microbiota data (n = 74). Multivariable logistic regression modeled adjusted associations between CST IV and recurrent spontaneous preterm birth, high stress and recurrent spontaneous preterm birth, as well as high stress and CST IV.

RESULTS

Among the 181 women with prior spontaneous preterm birth, 45 (24.9%) had high perceived stress. We did not detect a significant association between high stress and recurrent spontaneous preterm birth (adjusted odds ratio [aOR] 1.67, 95% confidence interval [CI]: 0.73-3.85). Among the 74 women with prior spontaneous preterm birth and cervicovaginal microbiota analyzed, 29 (39.2%) had CST IV; this proportion differed significantly among women with recurrent spontaneous preterm birth (51.4%) compared with women with term birth (28.2%) (p = 0.04). In models adjusted for race and marital status, the association between CST IV and recurrent spontaneous preterm birth persisted (aOR 3.58, 95% CI: 1.25-10.24). There was no significant interaction between stress and CST IV on the odds of spontaneous preterm birth (p = 0.328). When both stress and CST IV were introduced into the model, their associations with recurrent spontaneous preterm birth were slightly stronger than when they were in the model alone. The aOR for stress with recurrent spontaneous preterm birth was 2.02 (95% CI: 0.61-6.71) and for CST IV the aOR was 3.83 (95% CI: 1.30-11.33). Compared to women with neither of the two exposures, women with both high stress and CST IV had the highest odds of recurrent spontaneous preterm birth (aOR = 6.01, 95% CI: 1.002-36.03).

CONCLUSION

Among a predominantly non-Hispanic Black cohort of women with a prior spontaneous preterm birth, a nonoptimal cervicovaginal microbiota is associated with increased odds of recurrent spontaneous preterm birth. Adjustment for perceived stress may amplify associations between CST IV and recurrent spontaneous preterm birth. Identification of modifiable social or behavioral factors may unveil novel nonpharmacologic interventions to decrease recurrent spontaneous preterm birth among women with underlying biologic risk.

KEY POINTS

· CST IV, a nonoptimal microbiota, is associated with increased odds of recurrent spontaneous preterm birth.. · Adjustment for perceived stress amplified associations between CST IV and recurrent spontaneous preterm birth.. · Identification of modifiable psychosocial factors may unveil novel nonpharmacologic interventions to decrease recurrent preterm birth..

Racial/ethnic differences in maternal resilience and associations with low birthweight

OBJECTIVE

Evaluate racial/ethnic differences in maternal resilience and its associations with low birthweight (LBW).

STUDY DESIGN

Retrospective cohort study of 3244 women surveyed in the Longitudinal Study of Adolescent to Adult Health. The Add Health Resilience Instrument assessed resilience. Logistic regression models explored associations between women's resilience and risk of LBW.

RESULT

Resilience scores were lowest in American Indian women. Women with the lowest resilience scores were more likely to deliver a LBW infant than highly resilient women, after adjusting for demographic and health-related factors (aOR 1.58 95% CI 1.05-2.38). The risk-adjusted rate of LBW among highly resilient Black women (15.6%) was significantly higher than the risk-adjusted rate of LBW among highly resilient white women (9.1%, p = 0.01) and highly resilient Hispanic women (8.6%, p = 0.04).

CONCLUSION

Resilience scores differ significantly among women of different race and ethnicity but do not appear to entirely account for racial/ethnic disparities in LBW.

The contribution of group prenatal care to maternal psychological health outcomes: A systematic review

PROBLEM

Poor mental health remains a significant cause of morbidity for childbearing women globally.

BACKGROUND

Group care has been shown to be effective in reducing select clinical outcomes, e.g., the rate of preterm birth, but less is known about the effect of Group Prenatal Care (GPC) on mental health outcomes of stress, depression and anxiety in pregnant women.

AIM

To conduct a systematic review of the current evidence of the effect of group pregnancy care on mental health and wellbeing outcomes (i.e., stress, depression and/or anxiety) in childbearing women.

METHODS

A comprehensive search of published studies in Medline, PsychInfo, CINAHL, ProQuest databases, ClinicalTrials.gov and Google Scholar. Databases were systematically searched without publication period restriction until Feb 2020. Inclusion criteria were randomized controlled trials (including quasi-experimental) and observational studies comparing group care with standard pregnancy care. Included were studies published in English, whose primary outcome measures were stress, depression and/or anxiety.

RESULTS

Nine studies met the inclusion criteria, five randomized controlled trials and four observational studies, involving 1585 women (39%) in GPC and 2456 women (61%) in standard (individual) pregnancy care. Although evidence is limited, where targeted education was integrated into the group pregnancy care model, significant reductions in depressive symptoms were observed. In addition, secondary analysis across several studies identified a subset of GPC women, i.e., higher risk for psychological symptoms, who reported a decrease in their depression, stress and anxiety symptoms, postpartum. Due to the diversity of group care structure and content and the lack of outcomes measures universally reported, a comprehensive meta-analysis could not be performed.

CONCLUSION

The evidence suggests improvements in some markers of psychological health outcomes with group pregnancy care. Future research should involve larger well-designed studies encompassing cross-population data using a validated scale that is comparable across diverse childbearing populations and clinical settings to better understand the impact of group pregnancy care.

Effects of psychological stress on adverse pregnancy outcomes and nonpharmacologic approaches for reduction: an expert review

Both acute and chronic stress can cause allostatic overload, or long-term imbalance in mediators of homeostasis, that results in disruptions in the maternal-placental-fetal endocrine and immune system responses. During pregnancy, disruptions in homeostasis may increase the likelihood of preterm birth and preeclampsia. Expectant mothers traditionally have high rates of anxiety and depressive disorders, and many are susceptible to a variety of stressors during pregnancy. These common life stressors include financial concerns and relationship challenges and may be exacerbated by the biological, social, and psychological changes occurring during pregnancy. In addition, external stressors such as major weather events (eg, hurricanes, tornados, floods) and other global phenomena (eg, the coronavirus disease 2019 pandemic) may contribute to stress during pregnancy. This review investigates recent literature published about the use of nonpharmacologic modalities for stress relief in pregnancy and examines the interplay between psychiatric diagnoses and stressors, with the purpose of evaluating the feasibility of implementing nonpharmacologic interventions as sole therapies or in conjunction with psychotherapy or psychiatric medication therapy. Further, the effectiveness of each nonpharmacologic therapy in reducing symptoms of maternal stress is reviewed. Mindfulness meditation and biofeedback have shown effectiveness in improving one's mental health, such as depressive symptoms and anxiety. Exercise, including yoga, may improve both depressive symptoms and birth outcomes. Expressive writing has successfully been applied postpartum and in response to pregnancy challenges. Although some of these nonpharmacologic interventions can be convenient and low cost, there is a trend toward inconsistent implementation of these modalities. Future investigations should focus on methods to increase ease of uptake, ensure each option is available at home, and provide a standardized way to evaluate whether combinations of different interventions may provide added benefit.

Birth Observation Among African American Women Prior to Pregnancy

A focused ethnography among African American college students who had observed a live birth prior to their own pregnancy was pursued. Women described two reasons to attend births: curiosity about birth, or a desire to support the birth mother. Women attended the births of friends, family members, or saw their mother give birth to a younger sibling. Themes included pain, operative or traumatic birth, and surprise at the length and/or stages of labor. Some language suggested lingering trauma. Future expectations included painful labor, operative birth or damage, or traumatic labor and birth. Other women felt closer to the infant, or felt more prepared for their own births after observing birth. Prior personal experiences at birth should be explored prenatally.

[Visualization of unstructured personal narratives of perterm birth using text network analysis]

PURPOSE

This study aimed to identify the components of preterm birth (PTB) through women's personal narratives and to visualize clinical symptom expressions (CSEs).

METHODS

The participants were 11 women who gave birth before 37 weeks of gestational age. Personal narratives were collected by interactive unstructured storytelling via individual interviews, from August 8 to December 4, 2019 after receiving approval of the Institutional Review Board. The textual data were converted to PDF and analyzed using the MAXQDA program (VERBI Software).

RESULTS

The participants' mean age was 34.6 (±2.98) years, and five participants had a spontaneous vaginal birth. The following nine components of PTB were identified: obstetric condition, emotional condition, physical condition, medical condition, hospital environment, life-related stress, pregnancy-related stress, spousal support, and informational support. The top three codes were preterm labor, personal characteristics, and premature rupture of membrane, and the codes found for more than half of the participants were short cervix, fear of PTB, concern about fetal well-being, sleep difficulty, insufficient spousal and informational support, and physical difficulties. The top six CSEs were stress, hydramnios, false labor, concern about fetal wellbeing, true labor pain, and uterine contraction. "Stress" was ranked first in terms of frequency and "uterine contraction" had individual attributes.

CONCLUSION

The text network analysis of narratives from women who gave birth preterm yielded nine PTB components and six CSEs. These nine components should be included for developing a reliable and valid scale for PTB risk and stress. The CSEs can be applied for assessing preterm labor, as well as considered as strategies for students in women's health nursing practicum.

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.

Periconceptional stressors and social support and risk for adverse birth outcomes

Background

The prevalence of preterm birth and low birth weight has been increasing slightly in recent years. A few studies have suggested that psychosocial stress during pregnancy may increase risk for these adverse birth outcomes. To extend those observations, we analyzed various major life event stressors separately and cumulatively as potential risk factors for preterm birth and low birth weight using granular categories of each outcome in a large, population-based study. Additionally, we assessed if greater social support buffered any effects.

Methods

Data were from a nested prevalence study of 4395 women in the National Birth Defects Prevention Study who delivered live-born non-malformed infants (controls) between 2006 and 2011. Participants completed a standardized, computer-assisted interview between 6 weeks and 24 months after delivery that included questions on stress and social support from 3 months before pregnancy to the 3rd month of pregnancy. Cumulative stress and support indices were also calculated. Preterm birth was divided into “early preterm” (< 32 weeks), “late preterm” (32–36 weeks) and “term.” Low birthweight was divided into “very low birth weight” (< 1500 g), “low birth weight” (1500–2499 g) and “normal birth weight” (≥2500 g). Relative risks and 95% confidence intervals (95% CI) were calculated using Poisson regression.

Results

For women reporting relationship difficulties, there was a suggestive risk of early preterm birth (RR: 1.9, 95%CI: 0.9–3.9) and very low birthweight (RR: 2.0, 95%CI: 0.9–4.4). For women reporting that they or someone close to them were victims of abuse, violence, or crime, there was an increased risk of low birthweight (RR: 1.8, 95%CI: 1.1–2.7) and late preterm birth (RR: 1.5, 95%CI: 1.0–2.2). There were no strong associations observed between social support questions and the various outcomes.

Conclusions

Our results add some support to prior evidence that certain stressors may be associated with increase selected adverse birth outcomes risk. We did not find strong evidence that social support buffered the observed risks in our study.

Efficacy of psychotherapy for anxiety reduction in hospital management of women successfully treated for preterm labor: a randomized controlled trial

Preterm labor (PTL) is associated with high anxiety and stress in pregnant women. The study investigated the effect of adding psychotherapy to hospital management of pregnant women with successfully treated for PTLon improving anxiety, pregnancy stress, and perceived control. In a randomized controlled trial study, sixty pregnant women with gestational ages of 24 to 37 weeks and successfully treated forPTL were randomly divided into the experimental (n = 30) and control group (n = 30). The experimental group received psychotherapy along with medical care in individual face-to-facesessions, 1 h per day for 6 consecutive days.The control group received medical care for PTL. Objective outcomes were assessed via the State-Anxiety Inventory, Prenatal Distress Questionnaire (NuPDQ), and Perceived Pregnancy Control at pre-trial and post-trial. The results revealed that psychotherapy significantly improved mean pregnancy distress (45.80 ± 2.29 vs. 43.80 ± 1.93), state anxiety (47.46 ± 5.92 vs. 41.60 ± 5.46), and perceived control (2.86 ± 1.59 vs. 5.26 ± 1.38) in women with PTL from beginning to end of the intervention. The findings suggest that adding psychotherapy to hospital management of women successfully treated for PTLcan be considered a potential method to reduce anxiety and pregnancy-specific stress.

Impact of individual and neighborhood social capital on the physical and mental health of pregnant women: the Japan Environment and Children's Study (JECS)

Background

Previous studies revealed positive, negative, and no influence of social capital on the health outcomes of pregnant women. It was considered that such differences were caused by the disparities of outcome measures and sample sizes between studies. Our chief aim was to verify the positive influence of social capital on the health condition of pregnant women using established health outcome measures and large-scale nationwide survey data.

Methods

We employed questionnaire survey data from 79,210 respondents to the Japan Environment and Children’s Study, and physical and mental component summary scores from the 8-Item Short-Form Health Survey as outcome measures. We estimated the effect of individual and neighborhood social capitals on physical and mental component summary scores. To consider the property that the richness of social capital would be generally determined by individual characteristics, and to estimate the causal influence of social capital on health without bias caused by said property, we adopted average treatment effect estimation with inverse probability weighting. Generally, average treatment effects are based on the difference of average outcomes between treated and untreated groups in an intervention. In this research, we reckoned individuals’ different levels of social capital as a kind of non-randomized treatment for respective individuals, and we applied average treatment effect estimation. The analysis regarded pregnant women with the lowest level of social capital as untreated samples and women with other levels of social capitals as treated samples.

Results

For mental component summary score, the maximum average treatment effects in the comparison between the lowest and highest levels of social capital were approximately 4.4 and 1.6 for individual and neighborhood social capital, respectively. The average treatment effects for the physical component summary score were negligible for both social capital types.

Conclusions

Social capital particularly contributes to improving mental component summary score in pregnant women. The likelihood of a mentally healthy pregnancy may be increased by enhancing social capital.

Paternal violent criminality and preterm birth: a Swedish national cohort study

Background

Fathers may affect expectant mothers’ daily living situations, which in turn might influence pregnancy outcomes. We investigated the association between paternal violent criminality and risk of preterm birth (≤36 weeks).

Methods

We conducted a register-based study with all live singleton births in the Swedish Medical Birth Register from 1992 to 2012, linked with records of paternal violent crime convictions from the National Crime Register from 1973 to 2012.

Results

Paternal violent criminality was associated with increased risk of preterm birth and lower gestational age. The association was especially pronounced among infants of reoffenders: men convicted of three or more violent crimes (adjusted odds ratio [aOR] 1.23 [95% CI 1.17, 1.29]). Maternal half sibling-comparisons, an analytic approach controlling for maternal factors stable across pregnancies, also suggested increased risk of preterm birth and lower gestational age when exposed to a violently reoffending father compared to a father without violent criminal convictions (aOR 1.30 [0.99, 1.72], adjusted mean difference − 1.07 [− 1.78, − 0.36]).

Conclusions

Persistent paternal violent criminality was associated with increased risk of preterm birth, even after controlling for maternal characteristics that did not change between pregnancies.

Optimism during pregnancy and obstetrical outcomes: A systematic review

OBJECTIVE

To ascertain the strength of association between dispositional optimism, assessed with the Revised Life Orientation Test (LOT-R), and obstetrical outcomes, and to evaluate women's social characteristics that may lead to low dispositional optimism during pregnancy.

STUDY DESIGN

The research was conducted using MEDLINE, EMBASE, Scopus, Web of Sciences, Cochrane Database, and ClinicalTrial.gov as electronic databases. The articles were identified with the use of a combination of the relevant heading term, key words, and word variants for: "optimism" or "happiness" and "pregnancy" or "obstetrical outcomes", from the inception of each database to June 2019. Review of articles also included the abstracts of all references retrieved from the search. Randomized, cohort, case-control, or case series were all accepted study designs. Only studies reporting obstetrical outcomes in women undergone LOT-R to assess dispositional optimism during pregnancy were included. Obstetrical outcomes included preterm birth, pre-eclampsia and small for gestational age fetuses. All analyses were carried out using the random effects model. Dichotomous variables were analyzed using the odds ratio (OR) with a 95 % confidence interval (95 % CI). No continuous variables were compared in the analysis. Significance level was set at P < 0.05. Heterogeneity was measured using I-squared (Higgins I²).

RESULTS

Two prospective cohort studies, including 3,570 pregnancies undergone LOT-R - mostly during the second trimester - were included in the systematic review. Out of the 3,570 pregnancies included, 411 were in the lowest quartile of optimism, according to LOT-R score. Dispositional optimism showed a trend towards lower incidence of preterm birth (7.6 % vs 9.7 %; OR 0.76, CI 0.53-1.09); no difference between women at higher levels and women in the lowest quartile of optimism was found in preeclampsia and small for gestational age. Women at higher levels of dispositional optimism were significantly associated with: age ≥ 30 years; marriage or "marriage-like status"; lower rates of public assistance and smoking; white ethnicity; higher rates of higher education.

CONCLUSION

There are limited data on optimism and obstetric outcomes. Higher levels of optimism, evaluated by the LOT-R tool in two studies, are associated with a non-significant decrease in preterm birth.

Childhood maltreatment affects adolescent sensitivity to parenting and close friendships in predicting growth in externalizing behavior

Childhood maltreatment robustly predicts adolescent externalizing behaviors (EB; e.g., violence, delinquency, substance use) and may crystalize patterns of EB by influencing sensitivity to the social environment (e.g., parenting, friendships). In a nationally representative sample of 9,421 adolescents, we modeled latent growth curves of EB from age 13 to 32 years. Next, we explored whether maltreated youth differed from nonmaltreated youth in their sensitivity to parental closeness, friendship involvement, and polymorphisms from dopamine genes linked to EB (dopamine receptors D2 and D4, dopamine transporter). Overall, maltreated youth had significantly higher levels of EB across adolescence and adulthood; however, maltreated and nonmaltreated youth showed similar patterns of EB change over time: violent behavior decreased in adolescence before stabilizing in adulthood, whereas nonviolent delinquency and substance use increased in adolescence before decreasing in the transition to adulthood. Maltreatment reduced sensitivity to parental closeness and friendship involvement, although patterns varied based on type of EB outcome. Finally, none of the environmental effects on EB were significantly moderated by the dopamine polygenic risk score after accounting for multiple testing. These findings underline the enduring effects of early maltreatment and implicate that maltreatment may contribute to long-term risk for EB by influencing children's sensitivity to social relationship factors in adolescence.

Medical and Psychosocial Risk Profiles for Low Birthweight and Preterm Birth

OBJECTIVES

Low birthweight and preterm birth are risk factors for infant mortality and persistent problems. This study uses representative data to assess whether distinct latent profiles of co-occurring medical and psychosocial factors have implications for preterm birth and low birthweight.

METHODS

Data are from the Pregnancy Risk Assessment Monitoring System, a cross-sectional survey constituting representative data on pregnancies from 2012 to 2013. Latent class analysis derived classes of pregnant women potentially at risk for low birthweight and/or preterm birth.

RESULTS

Latent class analysis identified five homogenous profiles of interrelated psychosocial and medical factors. Risk was greatest for the profile marked by high rates of medical factors, followed by a high risk for a profile marked by a combination of very low income and psychosocial factors. Two profiles involving low income and very low income also indicated greater risk for adverse birth outcomes related to socioeconomic status.

CONCLUSIONS

More attention should be paid to screening for and addressing psychosocial risk in concert with prenatal care. Women who show high-risk profiles can be monitored and supported by an interdisciplinary care team, when warranted.

Maternal postpartum stress and toddler developmental delays: Results from a multisite study of racially diverse families

Maternal psychosocial stress during pregnancy can adversely influence child development, but few studies have investigated psychosocial stress during the postpartum period and its association with risk of toddler developmental delays. Moreover, given the expanding diversity of the U.S. population, and well-documented health and stress disparities for racial and ethnic minorities, research examining the effect of postpartum stress on risk of developmental delays in diverse populations is of critical importance. In this study, data from the Community Child Health Network provided the opportunity to test maternal postpartum stress as a predictor of toddler risk of developmental delay in a sample of African American, Latina and non-Hispanic White women and their toddlers (N = 1537) recruited in urban, suburban, and rural communities. Postpartum maternal stress over 1 year was operationalized as perceived stress, life events, and negative impact of life events. Regression results revealed higher risk of developmental delays in toddlers whose mothers experienced more negative life events, greater negative impact of events, and higher perceived stress over the year. Prenatal stress, pregnancy/birth complications, and postpartum depression did not explain these associations. Maternal postpartum stress may contribute to increased risk for developmental delays and is an important target for psychosocial intervention.

Perceived Psychological Traumatic Childbirth in Iranian Mothers: Diagnostic Value of Coping Strategies

Objectives

The aim of this study was to investigate the diagnostic value of a stress coping scale for predicting perceived psychological traumatic childbirth in mothers.

Methods

This cross-sectional study was performed on 400 new mothers (within 48 hours of childbirth). Psychological traumatic childbirth was evaluated using the 4 diagnostic criteria of Diagnostic and Statistical Manual of Mental Disorders. Coping was measured using Moss and Billings' Stress Coping Strategies Scale.

Results

The overall mean score of stress coping was 29 ± 14.2. There were 193 (43.8%) mothers that had experienced a psychological traumatic childbirth. A stress coping score ≤ 30, with a sensitivity of 90.16 (95% CI = 85.1-94.0), and a specificity of 87.44 (95% CI = 82.1-91.6), was determined as a predictor of psychological traumatic childbirth. So that among mothers with stress coping scores ≤ 30, 87% had experienced a psychological traumatic childbirth.

Conclusion

Investigating the degree of coping with stress can be used as an accurate diagnostic tool for psychological traumatic childbirth. It is recommended that during pregnancy, problem-solving and stress management training programs be used as psychological interventions for mothers with low levels of stress control. This will ensure that they can better cope with traumatic childbirth and post-traumatic stress in the postpartum stage.

Mental health and worries of pregnant women living through disaster recovery

The health and well-being of pregnant women during and after natural disasters remains an international concern. In this mixed methods study we described pregnant women's mental health, psychosocial concerns and sources of stress living in New Orleans during long term recovery from Hurricane Katrina. Our survey of 402 pregnant women indicated poor social support was associated with higher levels of depression symptomology, post-traumatic stress disorder, anxiety, and stress. Women were interviewed and described seven common areas of worry. We concluded that pregnant women living in post-disaster communities have stressful lives years after the event, needing innovative models of care to build resilience.

Predictors of Postpartum Depression: A Comprehensive Review of the Last Decade of Evidence

Postpartum depression (PPD) is one of the most frequent complications of childbirth affecting ~500,000 women annually (prevalence 10% to 15%). Despite the documented adverse outcomes for mother and child, there remains a great need to develop prospective approaches to identify women at risk. This review examines some of the best-characterized molecular and clinical risk factors for PPD. We illustrate that this is a growing literature but there remains a lack of reliable molecular predictors for PPD. Current best predictors are clinical assessments for psychiatric history and adverse life events, highlighting the need for increased depression screening across the perinatal period.

Relationships between stress, demographics and dietary intake behaviours among low-income pregnant women with overweight or obesity

OBJECTIVE

To identify demographic risk factors associated with high stress and examine the relationships between levels of stress, demographics and dietary fat, fruit and vegetable intakes in low-income pregnant women with overweight or obesity.

DESIGN

A cross-sectional study.

SETTING

Participants were recruited from the Special Supplemental Nutrition Program for Women, Infants, and Children in Michigan, USA.ParticipantsParticipants (n 353) were non-Hispanic Black (black) or White (white).

RESULTS

Women aged 35 years or older (OR=4·09; 95% CI 1·45, 11·51) and who had high school or less education (OR=1·88; 95% CI 1·22, 2·89) or were unemployed (OR=1·89; 95% CI 1·15, 3·12) were significantly more likely to report high stress than women who were younger, had at least some college education or were employed/homemakers. However, race and smoking status were not associated with level of stress. Women with high stress reported significantly lower fruit and vegetable intakes but not fat intake than women with low stress. Women aged 35 years or older reported significantly higher vegetable but not fat or fruit intake than women who were 18-24 years old. Black women reported significantly higher fat but not fruit or vegetable intake than white women. Education, employment and smoking status were not significantly associated with dietary intake of fat, fruits and vegetables.

CONCLUSIONS

Nutrition counselling on reducing fat and increasing fruit and vegetable intakes may consider targeting women who are black or younger or who report high stress, respectively.

Epigenetic Signature of Chronic Maternal Stress Load During Pregnancy Might be a Potential Biomarker for Spontaneous Preterm Birth

Preterm birth is the leading cause of mortality in newborn infants and can lead to significant neonatal morbidities. Spontaneous preterm birth accounts for at least 50.0% of all preterm births. We argue that chronic maternal stress load, which is an important risk factor for spontaneous preterm birth, could be represented by epigenetic signature of several specific genetic loci in the mother’s blood. A literature search was done in PubMed with the following keywords: “DNA methylation,” “epigenetics,” “maternal stress” and “preterm birth” from year 2000 to 2017. We suggest that these genetic loci might be related to vulnerability and hypersensibility of stress response during pregnancy in women with preterm births. The mother’s epi-genetic stress bioprofile was supposed to be a result of chronic maternal stress load since her birth. This epigenetic bioprofile might also be a potential biomarker for spontaneous preterm birth. DNA methylation changes are tissue-specific and human stress response manifests mostly through the central nervous system (CNS). Nevertheless, we found evidence that methylation changes of DNA isolated from blood leucocytes might be a reliable measure of stress-related epigenetic changes that occur in the CNS. Evaluating biological mechanisms through the development of simple assays based on epigenetic changes to measure chronic stress loads in expectant mothers can lead to our ability to prepare more effective measures for the prevention of preterm births, as well as leading to more effective treatment strategies for both expectant mothers and their newborns.

Factor Structure for Chronic Stress Before and During Pregnancy by Racial/Ethnic Group

This study aimed to explore race/ethnicity-specific dimensionalities of chronic stress before and during pregnancy for non-Hispanic (N-H) White, N-H Black, Hispanic, and Asian women in the United States. This study analyzed the data among 6,850 women from the New York City and Washington State Pregnancy Risk Assessment Monitoring System (2004-2007) linked with birth certificates. Separate exploratory factor analysis was conducted by race/ethnicity using a maximum-likelihood extraction method with 26 chronic stress items before and during pregnancy. Correlations and internal consistency reliabilities among items and latent factors determined race/ethnicity-specific factor structures of chronic stress. Chronic stress was race/ethnicity-distinctive and multidimensional with low correlations among the factors ( r = .07-.28, p < .05). Despite financial hardship, perceived isolation, and physical violence underlying chronic stress among the racial/ethnic groups, intergroup variations existed under each group's cultural or sociopolitical contexts. This study could help develop targeted strategies to intervene with women's chronic stressors before childbirth.

The associations between maternal lifestyles and antenatal stress and anxiety in Chinese pregnant women: A cross-sectional study

The study aimed to investigate the associations between maternal lifestyles and antenatal stress and anxiety. 1491 pregnant women were drawn from the Guangxi birth cohort study (GBCS). A base line questionnaire was used to collect demographic information and maternal lifestyles. The Pregnancy Stress Rating Scale (PSRS) and Self-Rating Anxiety Scale (SAS) were used to assess prenatal stress and anxiety, respectively. Regression analyses identified the relationship between maternal lifestyles and prenatal stress and anxiety: (1) Hours of phone use per day was positively correlated to prenatal stress and anxiety and increased with stress and anxiety levels (all P trend < 0.05). In addition, not having baby at home was positively correlated to prenatal stress. (2) Self-reported sleep quality was negative with prenatal stress and anxiety, and decreased with stress and anxiety levels (all P trend < 0.01). Moreover, not frequent cooking was negatively correlated to prenatal stress and having pets was negatively correlated to prenatal anxiety (P < 0.05). However, having pets was not correlated to prenatal stress (P > 0.05). Our results showed that adverse lifestyles increase the risk of antenatal stress and anxiety, a regular routine and a variety of enjoyable activities decreases the risk of prenatal stress and anxiety.

Examining the Psychometric Properties of Three Standardized Screening Tools in a Pregnant and Parenting Population

Significance Although standardized tools such as the Speilberger State Anxiety scale (1970) and Cohen's Perceived Stress Index (1983) have often been used in pregnant and postpartum populations to evaluate psychosocial risk, there exists very little literature on the reliability of these scales in this population. Given the potentially grave consequences of undiagnosed pre and postpartum mental distress, it is of paramount importance that the tools that are commonly used are evaluated for their psychometric properties within the pregnant and parenting population. Methods The psychometric properties of three mental health scales were evaluated using the All Our Babies data. The All Our Babies cohort is a prospective longitudinal study based in Calgary, Alberta. A total of 3300 women were recruited from prenatal care sites from all four quadrants of the city. Participants were mailed questionnaires at 24-26 weeks gestation, 34-36 weeks and at 4 months postpartum. Reliability for the Speilberger State Anxiety Scale, the Perceived Stress Index and the Life Optimism Test-revised were evaluated by calculating Cronbach's alphas. Validity with related constructs were tested for the State Anxiety Scale and the Perceived Stress Index by calculating Pearson Correlation Coefficients with closely related constructs. Sample size varied from 2670 to 3376, according to the response rate and time point. Depression as a related construct was evaluated using the Edinburgh Postpartum Depression Scale. Results The Cronbach's Alphas for the Speilberger State Anxiety scale were 0.92, 0.92 and 0.93 for 24-26 weeks, 34-36 weeks and 4 months postpartum respectively. The Alpha's for the Perceived Stress index were 0.88, 0.88 and 0.89 respectively. The Life Optimism Test Revised was only measured in the third trimester and the Cronbach's alpha was 0.83. The Pearson Correlation Coefficient for Anxiety with depression were r = 0.73, r = 0.72 and r = 0.77 respectively. The coefficients for stress and depression were r = 0.75, r = 0.75 and r = 0.77 respectively. Discussion/Conclusion The psychometric properties for all three scales were strong, with alphas that were comparable or higher to literature values. These data provide evidence that the use of these scales, previously validated in other populations are appropriate for use in among pregnant and parenting women at risk for mental distress.

Can support from the father of the baby buffer the adverse effects of depressive symptoms on risk of preterm birth in Black families?

BACKGROUND

While maternal depressive symptoms during pregnancy have been linked to preterm birth (PTB; birth before 37 completed weeks of gestation), little has been reported on potential buffering factors, particularly specific to Black women who are at much higher risk. We examined the association between depressive symptoms and PTB in pregnant Black women, with father of the baby (FOB) support as a potential buffering factor.

METHODS

Data were obtained from the life-course influences on fetal environments study (2009-2011), a cohort of 1,410 Black women in metropolitan Detroit, Michigan (71% response rate) using maternal interviews and medical record abstraction collected during the postpartum hospitalization. The 20-item Center for Epidemiologic Studies Depression (CES-D) scale was used to measure depressive symptoms. The 14-item social networks in adult relations questionnaire was used to assess the mother's relationship with the FOB. Logistic regression was used to explore the interaction between CES-D and FOB support with regard to PTB risk. We adjusted for maternal advanced age, income, education level, smoking status, hypertension, prenatal care and BMI.

RESULTS

The PTB rate in this cohort was 17.7%. Among women with FOB scale < 60 (less support), the odd ratio (OR) of PTB for women with CES-D scores ≥ 23 (severe depressive symptoms) as compared to CES-D scores < 23 (no severe depressive symptoms) was 2.57 [95% confidence interval (CI): 1.68, 3.94; p < 0.001]. Among women with FOB scores ≥ 60 (more support), the odds of PTB in women with CES-D scores ≥ 23 did not significantly differ from the odds of PTB in women with CES-D scores < 23 (OR = 1.34; 95% CI: 0.74, 2.44; p = 0.3). After adjustment for covariates, among women with FOB scores < 60, the OR of PTB for women with CES-D scores ≥ 23 compared to < 23 was 2.79 (95% CI: 1.75, 4.45; p < 0.001). Among women with FOB scores ≥ 60, the odds of PTB in women with CES-D scores ≥ 23 was not statistically significantly different compared to the odds of PTB in women with CES-D scores < 23 (OR = 1.21; 95% CI: 0.62, 2.35; p = 0.6). The interaction term was statistically significant (p = 0.04).

DISCUSSION/CONCLUSIONS

The adverse effect of depressive symptoms on risk of PTB may be buffered by factors such as a supportive relationship with the FOB.

The Relationships of Health Behaviour and Psychological Characteristics with Spontaneous Preterm Birth in Nulliparous Women

Objectives Preterm birth is the leading pregnancy outcome associated with perinatal morbidity and mortality and remains difficult to prevent. There is evidence that some modifiable maternal health characteristics may influence the risk of preterm birth. Our aim was to investigate the relationships of self-reported maternal health behaviour and psychological characteristics in nulliparous women with spontaneous preterm birth in prenatal primary care. Methods The data of our prospective study was obtained from the nationwide DELIVER multicentre cohort study (September 2009–March 2011), which was designed to examine perinatal primary care in the Netherlands. In our study, consisting of 2768 nulliparous women, we estimated the relationships of various self-reported health behaviours (smoking, alcohol consumption, folic acid supplementation, daily fruit, daily fresh vegetables, daily hot meal and daily breakfast consumption) and psychological characteristics (anxious/depressed mood and health control beliefs) with spontaneous preterm birth as a dichotomous outcome. Due to the clustering of clients within midwife practices, Generalized Estimating Equations was used for these analyses. Results Low health control beliefs was the sole characteristic significantly associated with spontaneous preterm birth (odds ratio 2.26; 95 % confidence interval 1.51, 3.39) after being adjusted for socio-demographics, anthropometrics and the remaining health behaviour and psychological characteristics. The other characteristics were not significantly associated with spontaneous preterm birth. Conclusions for Practice Maternal low health control beliefs need to be explored further as a possible marker for women at risk for preterm birth, and as a potentially modifiable characteristic to be used in interventions which are designed to reduce the risk of spontaneous preterm birth.

Deconstructing a disparity: explaining excess preterm birth among U.S.-born black women

PURPOSE

To determine components of excess preterm birth (PTB) rates for U.S.-born black women relative to both foreign-born black women and U.S.-born white women attributable to differences in observed sociodemographic, behavioral, and medical risk factors.

METHODS

Using the 2013 U.S. natality files, we used Oaxaca-Blinder decomposition on the absolute scale to estimate the contribution of the group differences in the prevalence of PTB predictors between U.S.- and foreign-born black women and U.S.-born black and U.S.-born white women.

RESULTS

U.S.-born blacks had a 3.2 (95% confidence interval: 3.0-3.5) and 4.4 (95% confidence interval: 4.3-4.5) percentage point higher risk of PTB than foreign-born blacks and U.S.-born whites, respectively. The variables in the models explained between 18% and 27% of the PTB disparities. Differences in paternal acknowledgment (about 12%), maternal hypertension (about 7%-11%), and maternal education (about 6%-10%) explained the largest proportion of these disparities.

CONCLUSIONS

Programs and policies that address both distal and proximate factors, including the social determinants of health and the prevention and management of hypertension, may reduce the higher rates of PTB among U.S.-born black women compared to foreign-born black women and U.S.-born white women.

Worry about racial discrimination: A missing piece of the puzzle of Black-White disparities in preterm birth?

OBJECTIVES

The causes of the large and persistent Black-White disparity in preterm birth (PTB) are unknown. It is biologically plausible that chronic stress across a woman's life course could be a contributor. Prior research suggests that chronic worry about experiencing racial discrimination could affect PTB through neuroendocrine, vascular, or immune mechanisms involved in both responses to stress and the initiation of labor. This study aimed to examine the role of chronic worry about racial discrimination in Black-White disparities in PTB.

METHODS

The data source was cross-sectional California statewide-representative surveys of 2,201 Black and 8,122 White, non-Latino, U.S.-born postpartum women with singleton live births during 2011-2014. Chronic worry about racial discrimination (chronic worry) was defined as responses of "very often" or "somewhat often" (vs. "not very often" or "never") to the question: "Overall during your life until now, how often have you worried that you might be treated or viewed unfairly because of your race or ethnic group?" Prevalence ratios (PRs) with 95% Confidence Intervals (CI) were calculated from sequential logistic regression models, before and after adjustment for multiple social/demographic, behavioral, and medical factors, to estimate the magnitude of: (a) PTB risks associated with chronic worry among Black women and among White women; and (b) Black-White disparities in PTB, before and after adjustment for chronic worry.

RESULTS

Among Black and White women respectively, 36.9 (95% CI 32.9-40.9) % and 5.5 (95% CI 4.5-6.5) % reported chronic worry about racial discrimination; rates were highest among Black women of higher income and education levels. Chronic worry was significantly associated with PTB among Black women before (PR 1.73, 95% CI 1.12-2.67) and after (PR 2.00, 95% CI 1.33-3.01) adjustment for covariates. The unadjusted Black-White disparity in PTB (PR 1.59, 95%CI 1.21-2.09) appeared attenuated and became non-significant after adjustment for chronic worry (PR 1.30, 95% CI 0.93-1.81); it appeared further attenuated after adding the covariates (PR 1.17, 95% CI 0.85-1.63).

CONCLUSIONS

Chronic worry about racial discrimination may play an important role in Black-White disparities in PTB and may help explain the puzzling and repeatedly observed greater PTB disparities among more socioeconomically-advantaged women. Although the single measure of experiences of racial discrimination used in this study precluded examination of the role of other experiences of racial discrimination, such as overt incidents, it is likely that our findings reflect an association between one or more experiences of racial discrimination and PTB. Further research should examine a range of experiences of racial discrimination, including not only chronic worry but other psychological and emotional states and both subtle and overt incidents as well. These dramatic results from a large statewide-representative study add to a growing-but not widely known-literature linking racism-related stress with physical health in general, and shed light on the links between racism-related stress and PTB specifically. Without being causally definitive, this study's findings should stimulate further research and heighten awareness of the potential role of unmeasured social variables, such as diverse experiences of racial discrimination, in racial disparities in health.

Acculturation and Adverse Birth Outcomes in a Predominantly Puerto Rican Population

Introduction Latinas in the United States on average have poorer birth outcomes than Whites, yet considerable heterogeneity exists within Latinas. Puerto Ricans have some of the highest rates of adverse outcomes and are understudied. The goal of this study was to determine if acculturation was associated with adverse birth outcomes in a predominantly Puerto Rican population. Methods We conducted a secondary analysis of Proyecto Buena Salud, a prospective cohort study conducted from 2006 to 2011. A convenience sample of pregnant Latina women were recruited from a tertiary care hospital in Massachusetts. Acculturation was measured in early pregnancy; directly via the Psychological Acculturation Scale, and via proxies of language preference and generation in the United States. Birth outcomes (gestational age and birthweight) were abstracted from medical records (n = 1362). Results After adjustment, psychological acculturation, language preference, and generation was not associated with odds of preterm birth. However, every unit increase in psychological acculturation score was associated with an increase in gestational age of 0.22 weeks (SE = 0.1, p = 0.04) among all births. Women who preferred to speak Spanish (β = -0.39, SE = 0.2, p = 0.02) and who were first generation in the US (β = -0.33, SE = 0.1, p = 0.02) had significantly lower gestational ages than women who preferred English or who were later generation, respectively. Similarly, women who were first generation had babies who weighed 76.11 g less (SE = 35.2, p = 0.03) than women who were later generation. Discussion We observed a small, but statistically significant adverse impact of low acculturation on gestational age and birthweight in this predominantly Puerto Rican population.