Do happier pregnancies make healthier babies?Stress and the medicalization of maternal emotion

Elizabeth Mitchell ArmstrongPrinceton University

• “All of us want happy children. Happy children grow out of happy babies. Happy babies are born to happy mothers.”– Dr. Vijai Sharma

Psychological stress may kill the fetus

Imagined effects of prenatal stress

• Stillbirth• Spontaneous abortion• Preterm birth• Low birthweight

Imagined effects of prenatal stress,cont’d

• Fetal heart rate• Fetal movement• Fetal behavior– “direct link between antenatal maternal mood

and fetal behavior”• Fetal habituation to stimuli• Fetal neurodevelopment

Imagined effects of prenatal stress,cont’d

• Infant stress reactivity• Infant fear reactivity• Infant cardiorespiratory reactivity• Stress-induced salivary cortisol responses in infants• Infant sleep disturbance• Excessive infant crying• Infant affective reactivity to novelty• Infant temperament• Taste neophobia

Imagined effects of prenatal stress,cont’d

• Infant stress reactivity• Infant fear reactivity• Infant cardiorespiratory reactivity• Stress-induced salivary cortisol responses in infants• Infant sleep disturbance• Excessive infant crying• Infant affective reactivity to novelty• Infant temperament• Taste neophobia

Imagined effects of prenatal stress,cont’d

• Apgar score• Congenital malformations– Cranial-neural crest

• Head circumference at birth• Colic• Neural tube defects• Infantile pyloric stenosis• Cord-blood immunoglobulin-E

Imagined effects of prenatal stress,cont’d

• ADHD• Autism• Child behavioral and cognitive problems• Child fearfulness• Language delay• Febrile seizures• Eczema• Asthma and allergy• Diabetes-related autoimmunity at age 2.5 yrs• Problem behavior in 27-mos. old toddlers• 4-6 yo’s reaction to vaccination• Childhood psychopathology

Imagined effects of prenatal stress,cont’d

• ADHD• Autism• Child behavioral and cognitive problems• Child fearfulness• Language delay• Febrile seizures• Eczema• Asthma and allergy• Diabetes-related autoimmunity at age 2.5 yrs• Problem behavior in 27-mos. old toddlers• 4-6 yo’s reaction to vaccination• Childhood psychopathology

Imagined effects of prenatal stress,cont’d

• Schizophrenia• post-pubertal immune incompetence• Mixed-handedness

– Brain asymmetry• Dermatoglyphic asymmetry• Distress symptoms in adulthood• Insulin resistance in young adults• HPA axis regulation in young adults• Working memory performance in young women• Cancer

– Bereavement • Sexual orientation

Imagined effects of prenatal stress,cont’d

• Sex ratio at birth

What is stress?

• Physiologic response to psychological and physical demands and threats (“stressors”)

• Person-environment interaction– Not everyone responds to same stressor in the

same way

Stress & health

• Stress linked to disease• Immediate causation• Accumulation/weathering• “Allostatic load”– Stress adaptive in acute situations; maladaptive

when chronic– Wear and tear caused by exposure to chronic

stress

Stress in pregnancy

• 1950s & 60s• Animal studies• Sustained attention late 60s, early 70s– Early emphasis on work-related stress

Conceptualizations of stress

• Anxiety• “Daily hassles”• Self-reported “nervousness”• Work• Discrimination/racism• Negative life events– Bereavement– Divorce/separation– Serious accident or illness episode

Prenatal stressors

• Abuse/intimate partner violence• Involuntary job loss or incarceration• Food insecurity• Poverty• Lack of social support• Partner deployment• “negative feelings about household role”

Characterizations of stress

• “Psychologic distress”• “Negative maternal emotions”

Dimensions of stress

• State vs. trait• Acute vs. chronic

Subfields

• Stress and disparities in birth outcomes in the U.S.

• Stress and the experience of infertility

Disasters as population stressors• May 1940 invasion of the

Netherlands• Dutch famine• Chernobyl• the French Revolution• 1999 bombing of Belgrade• The first Gulf War• 9/11 terrorist attacks on the

WTC• Swedish PM’s murder &

ferry sinking– “communal bereavement”

• 1998 ice storm in Quebec• Hurricanes and tropical

storms• Various flood disasters• 1976 earthquake in

Tangshan, China

Hypothesized mechanisms

• Hormonal– Corticotropin-releasing hormone (CRH) effect on

labor– Programming of fetal HPA axis– Exposure to testosterone

• Immune system functioningmaternal infection

• Reduced blood flow to placenta & uterus

Hypothesized mechanisms

• Stresscoping via smoking, substance use• Stresspoor nutrition• StressPIH

Stress and fetal programming

• Fetus’ physiological adaptation to intrauterine environment within which it is developing

• HPA axis functioning• “The fetus is involved in a dynamic

communication with the mother over the course of gestation.”– Ellman et al. 2008

Why prenatal stress matters• Stress as “a social pollutant.”• Often likened to a teratogen• Stress as “developmental toxin”• “Maternal psychosocial processes in pregnancy are at

least as important and warrant the same degree of further consideration and study as other established obstetric risk factors, because the overall magnitude of their independent effect size on prematurity-related outcomes is comparable to that of most other obstetric risk factors.”– Wadhwa 2005

Prenatal stress is prevalent

• Prenatal stress commonly reported• 65% of pregnant women say they are

concerned about the impact that stress during pregnancy is having on themselves and the health of their baby.– CIGNA Health Care/March of Dimes survey

• “Five months to go until I give birth to our first child, and the trials of life and work are starting to get to me. If that weren’t enough, the onslaught of news stories about stress during pregnancy is enough to raise my blood pressure still further.”– “Bumpology: a weekly column on the science

behind pregnancy”

Evidence?

In popular understanding• Pregnancy stress ‘passed to baby’

– BBC News 2005• Stress in womb can alter life later

– LiveScience 2010• Mother’s stress may affect fetus

– Washington Post 2006• Less stress for healthier mom, baby• Unborn babies face emotional stress during pregnancy,

research shows• Fetus to mom: You’re stressing me out!

– WebMD• Anxiety for two

– Newsweek 2008

Fetus to mom: You’re stressing me out!

• “the fetus builds itself permanently to deal with this kind of high-stress environment, and once it’s born may be at greater risk for a whole bunch of stress-related pathologies.”– Dr. Pathik Wadwha, quoted on WebMD

• “Who you are and what you’re like when you’re pregnant will affect who that baby is. Women’s psychological functioning during pregnancy—their anxiety level, stress, personality—ultimately affects the temperament of their babies. It has to…the baby is awash in all the chemicals produced by the mom.”– Dr. Janet DiPietro, quoted on WebMD

Pregnancy advice• Take an occasional chill pill. Too much stress isn’t

good for you or your baby.– WTEWYE 2002 ed.

• Be positive. Your baby deserves all the good vibes you can muster up.– “Build a Better Baby” Roizen and Oz 2010

• Stress can however be particularly harmful during pregnancy, thus it is important that you work to reduce your stress and anxiety levels during pregnancy as much as possible.

• Remember that just as what you eat affects your baby, so too does your stress level and your emotional health. It is important that you minimize your stress and anxiety during pregnancy to provide your baby with an optimal environment in which to grow.– Womenshealthcaretopics.com

• The bad news is that stress during pregnancy is more than just an inconvenience; it’s actually unhealthy for you and your baby.

• “Cutting down on stress—or learning how to manage it—makes for a healthier pregnancy.”– www.babycenter.com

Maternal emotions in historical perspective• “What a mother is thinking can transmute the fetus

in different ways.”– Hippocrates

• “An expectant mother should think it important to keep calm and cheerful and sweet-tempered throughout her pregnancy.”– Plato

• “The pregnant woman’s imagination can distort and deform the child in the womb.”– Paracelsus

Des Monstres et Prodiges, 1573Ambroise Paré

• 13 causes of birth defects• “The imagination” being the 5th

• “If she ought to govern herself well in the observation of what we have lately mentioned, she ought no less to be careful to overcome and moderate her passions as not to be excessively angry; and above all, that she be not affrighted, nor that any melancholy news be suddenly told her; for these passions, when violent, are capable to make a woman miscarry at the moment, even at any time of her going with child.”– Mauriceau (trans. Chamberlen) 1716

Maternal impressions

• “A curious fact associated with pregnancy is the apparent influence of the emotions of the mother on the child in the uterus.”– Gould and Pyle

• “An encounter by the pregnant woman with some gruesome person or object, the hearing of some startling news, or the seeing of some tragedy”– Tye

Mary Toft

2 forms of maternal impression

• Photographic or mimetic effect on fetus• Strong emotions (fright, shock, disgust) that

have non-specific effects

“Psychophysiology of the maternal-fetal relationship” (DiPietro 2004)• “Women’s acute emotional reactivity during

pregnancy can influence fetal HR patterns.”– Monk et al. 2000

• “The importance of a good quality of psycho-affective communication between mother and child has been shown to be decisive for fetal growth.”– Relier 2001

• “Fetal neurobehavioral regulation is routinely disrupted by maternal environmental intrusions.”

Modern maternal impressions?

• Paradox of maternal effect • Social management of female emotion• Cultural management of uncertainty• Maternal management of emotion

What about men and stress?

• “The effect of a man’s daily life psychologic stress on his semen quality is small or non-existent.”– Hjollund et al. 2004