In a recent prospective study published in the journal Pediatric Research, researchers investigated the effect of acetaminophen, an analgesic considered safe during pregnancy, on language development in children. They found that an increased use of acetaminophen during pregnancy is potentially associated with language development issues in children.
The widespread use of acetaminophen (paracetamol) during pregnancy, perceived to be safe for decades, is now raising concerns about potential adverse neurodevelopmental effects. Epidemiological evidence links prenatal acetaminophen exposure to attention problems, motor delay, behavioral issues, and language development delay, highlighting the need for further investigation into its safety during pregnancy.
The few previous studies on prenatal use of acetaminophen and language development have been limited by infrequent self-report measures, hindering accurate assessment of timing and potential impacts. The Illinois Kids Development Study (IKIDS) improved upon this by assessing acetaminophen use in six distinct pregnancy periods, allowing for better evaluation. In the present study, researchers evaluated the impact of acetaminophen use on language development using the data from IKIDS and specific questionnaires.
About the study
IKIDS is a prospective pregnancy and birth cohort in the United States of America aimed at investigating the impact of gestational exposure to phenols and phthalates on neurodevelopment. Participants were recruited at 8–14 weeks gestation between 2013 and 2020. The inclusion criteria were <15 weeks of singleton pregnancy, age 18–40 years, willingness to provide samples, and residing close to the University of Illinois. They reported the number of times they consumed acetaminophen during the three trimesters of pregnancy. They also provided demographic, health, medication, pregnancy, and lifestyle-related data through interviews.
Data from 532 children born during the study were collected between 2016 and 2022. MacArthur-Bates Communicative Development Inventories (CDI) were filled by participants when their children (n = 298, 147 males) reached the age of 26.5–28.5 months. It is a parental form measuring expressive vocabulary, language complexity, and mean length of the longest three utterances (M3L). At 36–38 months, they filled the Speech and Language Assessment Scale (SLAS), a short questionnaire (n = 254, 121 males). It assesses responsiveness, semantics, assertiveness, syntax, and articulation. Socio-demographic factors and maternal stress and depression scores were considered as covariates, with child sex included as a potential modifier in continuous outcome models. Statistical analysis involved the use of multivariable generalized linear regression models and sensitivity analysis.
Results and discussion
Most participants consuming acetaminophen were found to be white and non-Hispanic. Demographic and exposure data were found to be similar among those filling the CDI and SLAS. About 70.9% of participants reportedly used acetaminophen-containing medications at least once during pregnancy, a higher proportion compared to previous studies. Few participants reported using other analgesics. Acetaminophen use was most common during the first trimester, with most participants using it for pain relief. There was no difference in acetaminophen use between subsets with CDI or SLAS data and the full sample. As per the CDI analysis, females demonstrated more advanced language development compared to males. Similarly, as per the SLAS analysis, females showed higher scores than males, but without statistical significance.
At 26.5–28.5 months, higher acetaminophen intake during pregnancy, especially in the second and third trimesters, was linked to reduced vocabulary size and M3L in children, with consistent effects across genders. Specifically, each increase in acetaminophen use during these trimesters was associated with a decrease in vocabulary size by 0.58 and 1.83 words, respectively, and a slight decrease in M3L. At 36–38 months of age, increased acetaminophen use during pregnancy, especially in the second and third trimesters, was found to correlate with lower total SLAS scores across genders. Males showed significantly lower SLAS scores with third-trimester exposure. Sensitivity analyses confirmed both these results.
Strengths of the study include its utilization of data from an ongoing, prospective birth cohort, multiple assessments of acetaminophen use during pregnancy, robustness to sensitivity analyses, and the use of comprehensive measures of language development in children. On the other hand, the study is limited by potential inaccuracies due to lack of correction for multiple comparisons, homogeneity of the cohort, loss to follow-up, potential error in self-reporting, lack of dosage information, and inability to assess the indications for acetaminophen use.
Conclusion
This is the first study to use a standardized measure of language development to evaluate the effect of prenatal acetaminophen exposure on neurodevelopmental outcomes in children. In conclusion, evidence from the present study links increased acetaminophen use during pregnancy to poorer language development. The study warrants further research to understand this association’s mechanisms and potentially establish causality. The researchers emphasize the importance of more extensive and more diverse cohort studies in the future to investigate prenatal acetaminophen exposure and its impact on neurodevelopment.
Although several studies have linked smoking during pregnancy with neurodevelopmental disorders, the results of behavioral experiments in mice prenatally exposed to nicotine have been inconsistent. In a recent study, scientists from Japan developed a deep learning-based framework to automatically observe and classify mice behavior in such experiments, producing more accurate and unbiased results. They show that prenatal exposure to nicotine could increase the risk of autism spectrum- and attention deficit/hyperactivity disorders in newborns.
The fact that smoking is a risk factor for several diseases, including cancer, stroke, and diabetes, has been known for approximately half a century. However, over the past few decades, scientists have brought to light many of the detrimental effects of smoking during pregnancy, linking this habit to high infant mortality, failed delivery, and low body weight at birth. In addition, recent studies suggest that prenatal nicotine exposure (PNE) may be related to neurodevelopmental disorders, such as attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD).
For a long time now, scientists have used animal models (like rodents) to understand how PNE leads to neurodevelopmental disorders. By carefully analyzing the behavior of rodents, they can infer whether PNE is causing neurological changes and the brain regions affected by it; this can later be confirmed through histological analyses.
Unfortunately, thus far, studies on behavioral changes induced by PNE in mice have shown varied results, some of which are contradictory. Although there could be multiple reasons behind these discrepancies, human error and bias are prime suspects. In general, the assessment of complex animal behaviors, especially social interactions, relies on the efforts of human observers, which introduces a baseline level of subjectivity that is hard to dispel. But what if we can leverage artificial intelligence (AI) to produce more accurate and unbiased results from observations of PNE mice behavior?
In a recent study published in Cells on 1 February 2024, researchers from the Department of Molecular and Cellular Physiology at the Shinshu University School of Medicine, including graduate student Mengyun Zhou, Assistant Professor Takuma Mori, and Professor Katsuhiko Tabuchi, developed and trained a deep learning-based system to automatically analyze footage from behavioral experiments on mice. They used this tool to explore the behavioral changes induced by PNE in mice without observer biases, seeking to shed light on the link between nicotine and neurodevelopmental disorders.
The proposed AI-based framework relied on a combination of two well-established open-source toolkits, namely DeepLabCut and Simple Behavioral Analysis (SimBA). “AI tools can label the body parts of animals in a markerless video footage and precisely estimate their poses using supervised machine learning,” explains Prof. Tabuchi. “Since animal behaviors are defined as a specific arrangement of body parts over a short period of time, deep-learning toolkits like SimBA can use the pose estimations obtained with DeepLabCut to classify different types of animal behaviors.”
After reaching an optimal training protocol for their framework using manually labeled data, the researchers conducted several experiments using PNE and control mice, looking for indicators of ADHD- and ASD-like behaviors. First, they carried out cliff avoidance reaction tests, which are used to test impulsivity. In these tests, they placed the subject mouse on top of a slightly elevated platform and took note-;both manually and with the AI system-;of how long the mouse waited before jumping down the platform. The test results suggested that PNE mice are more impulsive, a behavioral feature of ADHD in humans.
They also tested the working memory of mice using a Y-shaped maze and counted the number of times each mouse spontaneously switched from one arm of the maze to another. “We observed a decrease in the spontaneous alteration in PNE mice, suggesting that their working memory was altered, which is another behavioral feature of ADHD,” comments Mengyun Zhou. “These results suggest prenatal exposure to nicotine may cause ADHD in mice, which is consistent with clinical reports in humans.“
Finally, the researchers conducted open-field and social-interaction experiments, which represented the main challenge for their AI-based system. In these experiments, the researchers observed either one or two mice behaving freely in a large enclosure and looked for indicators of anxiety and social behaviors, such as grooming and following. Interestingly, PNE mice exhibited social behavioral deficits and increased anxiety which are features of ASD. Subsequent histological analysis of hippocampal brain tissue confirmed decreased neurogenesis, a hallmark of ASD. Thus, it appears that smoking may not only increase the risk of ADHD, but also ASD.
Worth noting, the results obtained using the AI-based system were highly reliable, as Prof. Tabuchi highlights: “We validated the accuracy of our behavioral analysis framework by drawing a careful comparison between the results generated by the model and behavior assessments made by multiple human annotators, which is considered the gold standard.” These analyses cement the potential of the proposed approach and showcase its capabilities for many types of behavioral studies.
With any luck, further efforts will pave the way to a solid understanding of mechanisms behind neurodevelopmental disorders like ASD and ADHD, ultimately leading to better diagnostic tools and therapeutic methods.
Source:
Journal reference:
Zhou, M., et al. (2024). Deep-Learning-Based Analysis Reveals a Social Behavior Deficit in Mice Exposed Prenatally to Nicotine. Cells. doi.org/10.3390/cells13030275.
In 2023, Rhode Island, Massachusetts and Minnesota joined a growing list of states that allow undocumented immigrants to obtain driver’s licenses if an applicant can provide certain documentation, such as a foreign birth certificate or passport and evidence of current residency in the state. Altogether, 19 states and the District of Columbia have similar legislation in place. And lawmakers in other states, such as Michigan and Oklahoma, have introduced similar legislation.
In many cases, these laws were passed based on the premise that they would keep the roads safer by allowing undocumented immigrants to drive legally and obtain insurance. But new research from Washington University in St. Louis provides evidence that these laws also indirectly improve the overall health and well-being of immigrant mothers and their babies.
The research, published Feb. 26 in the Journal of Health and Social Behavior, found that implementing license laws is associated with improvements in birth weight -; a critical measure of early development with long-term health implications -; for babies born to Mexican and Central American immigrants.
The authors also noted a decline in preterm birth rates between 2008-2021 in states that enacted license laws compared with those that did not, though rates in both groups declined over time.
Our study’s findings underscore how states’ extension of legal rights to immigrants can improve the health of the next generation.”
Margot Moinester, study co-author and assistant professor of sociology in Arts & Sciences at WashU
“Previous research has demonstrated that restrictive immigration policies and practices contribute to poor health outcomes for immigrant families, but our study is among the first to demonstrate a positive relationship between inclusive immigration policies and improved health.”
Connecting the dots
To study the connection between license laws and birth outcomes, Moinester and co-author Kaitlyn K. Stanhope, at Emory University, examined birth records for more than 4 million singleton births born to Mexican and Central American immigrants between 2008-2021 living in states that adopted these laws during the study period. They also tracked how many months prior to conception the law was implemented to assess how the relationship between the implementation of a license law and changes in perinatal health -; that of pregnant people and their babies before, during and after birth -; over time.
Finally, as a control measure, they compared their findings with outcomes for U.S.-born, non-Hispanic white pregnant people living in these states, but found no correlation between the implementation of a license law and birth weight in this population.
The research established a correlation between these laws and improved birth outcomes among babies born to Mexican and Central American immigrants, but stopped short of explaining why the correlation exists. According to Moinester and Stanhope, these laws likely influence perinatal health by lessening deportation fears and stress. It’s well known that stress prior to and during pregnancy can increase risk of adverse birth outcomes, including low birth weight and preterm birth.
“By reducing the criminalization of immigrants, driver’s license laws may lessen deportation fears and subsequent stress, potentially improving birth outcomes,” Stanhope said.
Because stress prior to conception -; not just during pregnancy -; can affect birth outcomes, it’s likely that the strength of the association would increase over time, she added.
“While we see stress as one key mechanism through which these license laws may improve perinatal health, we also think it is possible that the laws could lead to improved birth outcomes by increasing immigrants’ access to financial resources, including better-paying jobs and more weekly work hours,” Moinester said.
The authors also hypothesized that the laws would improve immigrants’ perinatal health by making it easier to access timely prenatal care. However, contrary to their hypothesis, they observed a slightly lower probability of first-trimester entry into care for individuals in states with license laws. According to the authors, one possible explanation could be that immigrants living in these states already had high rates of early prenatal care, meaning there was little room for improvement. Another possible explanation could be that access to a driver’s license was not enough to counteract other barriers, such as a lack of insurance, language differences and distance to care.
Changing immigration landscape
Over the past two decades, states have emerged as important players in the immigration policy arena, passing immigration legislation at a scale not seen in over a century, the authors said.
“There’s been a lot of focus on the extreme measures taken by some states to keep immigrants out and limit their access to services and benefits, but many states have responded by affirming their support for immigrants,” Moinester said.
“In fact, more than half of the states that have enacted license laws did so after 2015, when Donald Trump began his first campaign and made immigration enforcement a key issue.”
According to Moinester, the findings from this study highlight the potential of an individual state policy to positively shape the lives of Mexican and Central American immigrants and their children amid a highly conflictual federal and state immigration policy climate.
Because government-issued IDs are required to access a range of economic and material resources critical to health, including bank accounts, utilities, prescription medications, housing and safety net programs -; plus more job opportunities -; it’s likely these laws have other important health implications, Moinester said. More research is needed to better understand the health implications of these policies and to inform future policy decisions.
Standing in front of the concrete steps of her home in Midway, Texas, Collier, initially barefoot and wearing a baggy gray T-shirt, told officers she planned to see a doctor in the morning because she had been bleeding.
Police body camera footage obtained by KFF Health News through an open records request shows that the officers then told Collier — who was 29 at the time and enrolled in online classes to study psychology — to turn around.
Instead of taking her to get medical care, they handcuffed and arrested her because she had outstanding warrants in a neighboring county for failing to appear in court to face misdemeanor drug charges three weeks earlier. She had missed that court date, medical records show, because she was at a hospital receiving treatment for pregnancy complications.
Despite her symptoms and being about 13 weeks pregnant, Collier spent the next day and a half in the Walker County Jail, about 80 miles north of Houston. She said her bleeding worsened there and she begged repeatedly for medical attention that she didn’t receive, according to a formal complaint she filed with the Texas Commission on Jail Standards.
“There wasn’t anything I could do,” she said, but “just lay there and be scared and not know what was going to happen.”
Welfare Check Turns Into Arrest for Pregnant Texan
Collier’s experience highlights the limited oversight and absence of federal standards for reproductive care for pregnant women in the criminal justice system. Incarcerated people have a constitutional right to health care, yet only a half-dozen states have passed laws guaranteeing access to prenatal or postpartum medical care for people in custody, according to a review of reproductive health care legislation for incarcerated people by a research group at Johns Hopkins School of Medicine. And now abortion restrictions might be putting care further out of reach.
Collier’s arrest was “shocking and disturbing” because officers “blithely” took her to jail despite her miscarriage concerns, said Wanda Bertram, a spokesperson for the Prison Policy Initiative, a nonprofit organization that studies incarceration. Bertram reviewed the body cam footage and Collier’s complaint.
“Police arrest people who are in medical emergencies all the time,” she said. “And they do that regardless of the fact that the jail is often not equipped to care for those people in the way an emergency room might be.”
After a decline during the first year of the pandemic, the number of women in U.S. jails is once again rising, hitting nearly 93,000 in June 2022, a 33% increase over 2020, according to the Department of Justice. Tens of thousands of pregnant women enter U.S. jails each year, according to estimates by Carolyn Sufrin, an associate professor of gynecology and obstetrics at Johns Hopkins School of Medicine, who researches pregnancy care in jails and prisons.
The health care needs of incarcerated women have “always been an afterthought,” said Dana Sussman, deputy executive director at Pregnancy Justice, an organization that defends women who have been charged with crimes related to their pregnancy, such as substance use. For example, about half of states don’t provide free menstrual products in jails and prisons. “And then the needs of pregnant women are an afterthought beyond that,” Sussman said.
Researchers and advocates worry that confusion over recent abortion restrictions may further complicate the situation. A nurse cited Texas’ abortion laws as one reason Collier didn’t need care, according to her statement to the standards commission.
Texas law allows treatment of miscarriage and ectopic pregnancies, a life-threatening condition in which a fertilized egg implants outside the uterus. However, different interpretations of the law can create confusion.
A nurse told Collier that “hospitals no longer did dilation and curettage,” Collier told the commission. “Since I wasn’t hemorrhaging to the point of completely soaking my pants, there wasn’t anything that could be done for me,” she said.
Collier testified that she saw a nurse only once during her stay in jail, even after she repeatedly asked jail staffers for help. The nurse checked her temperature and blood pressure and told her to put in a formal request for Tylenol. Collier said she completed her miscarriage shortly after being released.
Collier’s case is a “canary in a coal mine” for what is happening in jails; abortion restrictions are “going to have a huge ripple effect on a system already unequipped to handle obstetric emergencies,” Sufrin said.
‘There are no consequences’
Jail and prison health policies vary widely around the country and often fall far short of the American College of Obstetricians and Gynecologists’ guidelines for reproductive health care for incarcerated people. ACOG and other groups recommend that incarcerated women have access to unscheduled or emergency obstetric visits on a 24-hour basis and that on-site health care providers should be better trained to recognize pregnancy problems.
In Alabama, where women have been jailed for substance use during pregnancy, the state offers pregnancy tests in jail. But it doesn’t guarantee a minimum standard of prenatal care, such as access to extra food and medical visits, according to Johns Hopkins’ review.
Policies for pregnant women at federal facilities also don’t align with national standards for nutrition, safe housing, and access to medical care, according to a 2021 report from the Government Accountability Office.
Even when laws exist to ensure that incarcerated pregnant women have access to care, the language is often vague, leaving discretion to jail personnel.
Since 2020, Tennessee law has required that jails and prisons provide pregnant women “regular prenatal and postpartum care, as necessary.” But last August a woman gave birth in a jail cell after seeking medical attention for more than an hour, according to the Montgomery County Sheriff’s Office.
Pregnancy complications can quickly escalate into life-threatening situations, requiring more timely and specialized care than jails can often provide, said Sufrin. And when jails fail to comply with laws on the books, little oversight or enforcement may exist.
In Louisiana, many jails didn’t consistently follow laws that aimed to improve access to reproductive health care, such as providing free menstrual items, according to a May 2023 report commissioned by state lawmakers. The report also said jails weren’t transparent about whether they followed other laws, such as prohibiting the use of solitary confinement for pregnant women.
Krishnaveni Gundu, as co-founder of the Texas Jail Project, which advocates for people held in county jails, has lobbied for more than a decade to strengthen state protections for pregnant incarcerated people.
In 2019, Texas became one of the few states to require that jails’ health policies include obstetrical and gynecological care. The law requires jails to promptly transport a pregnant person in labor to a hospital, and additional regulations mandate access to medical and mental health care for miscarriages and other pregnancy complications.
But Gundu said lack of oversight and meaningful enforcement mechanisms, along with “apathy” among jail employees, have undermined regulatory protections.
“All those reforms feel futile,” said Gundu, who helped Collier prepare for her testimony. “There are no consequences.”
Before her arrest, Collier had been to the hospital twice that month experiencing pregnancy complications, including a bladder infection, her medical records show. Yet the commission found that Walker County Jail didn’t violate minimum standards. The commission did not consider the police body cam footage or Collier’s personal medical records, which support her assertions of pregnancy complications, according to investigation documents obtained by KFF Health News via an open records request.
In making its determination, the commission relied mainly on the jail’s medical records, which note that Collier asked for medical attention for a miscarriage once, in the morning on the day she was released, and refused Tylenol.
“Your complaint of no medical care is unfounded,” the commission concluded, “and no further action will be taken.”
Collier’s miscarriage had ended before she entered the jail, argued Lt. Keith DeHart, jail lieutenant for the Walker County Sheriff’s Office. “I believe there was some misunderstanding,” he said.
Brandon Wood, executive director of the commission, wouldn’t comment on Collier’s case but defends the group’s investigation as thorough. Jails “have a duty to ensure that those records are accurate and truthful,” he said. And most Texas jails are complying with heightened standards, he said.
Bertram disagrees, saying the fact that care was denied to someone who was begging for it speaks volumes. “That should tell you something about what these standards are worth,” she said.
Last year, Chiree Harley spent six weeks in a Comal County, Texas, jail shortly after discovering she was pregnant and before she could get prenatal care, she said.
I was “thinking that I was going to be well taken care of,” said Harley, 37, who also struggled with substance use.
Jail officials put her in the infirmary, Harley said, but she saw only a jail doctor and never visited an OB-GYN, even though she had previous pregnancy complications including losing multiple pregnancies at around 21 weeks. This time she had no idea how far along she was.
She said that she started leaking amniotic fluid and having contractions on Nov. 1, but that jail officials waited nearly two days to take her to a hospital. Harley said officers forced her to sign papers releasing her from jail custody while she was having contractions in the hospital. Harley delivered at 23 weeks; the baby boy died less than a day later in her arms.
The whole experience was “very scary,” Harley said. “Afterwards we were all very, very devastated.”
Comal County declined to send Harley’s medical and other records in response to an open records request. Michael Shaunessy, a partner at McGinnis Lochridge who represents Comal County, said in a statement that, “at all times, the Comal County Jail provided Chiree Harley with all appropriate and necessary medical treatment for her and her unborn child.” He did not respond to questions about whether Harley was provided specialized obstetric care.
‘I trusted those people’
In states like Idaho, Mississippi, and Louisiana that installed near-total abortion bans after the Supreme Court eliminated the constitutional right to abortion in 2022, some patients might have to wait until no fetal cardiac activity is detected before they can get care, said Kari White, the executive and scientific director of Resound Research for Reproductive Health.
White co-authored a recent study that documented 50 cases in which pregnancy care deviated from the standard because of abortion restrictions even outside of jails and prisons. Health care providers who worry about running afoul of strict laws might tell patients to go home and wait until their situations worsen.
“Obviously, it’s much trickier for people who are in jail or in prison, because they are not going to necessarily be able to leave again,” she said.
Advocates argue that boosting oversight and standards is a start, but that states need to find other ways to manage pregnant women who get caught in the justice system.
For many pregnant people, even a short stay in jail can cause lasting trauma and interrupt crucial prenatal care.
Collier remembers being in “disbelief” when she was first arrested but said she was not “distraught.”
“I figured I would be taken care of, that nothing bad was gonna happen to me,” she said. As it became clear that she wouldn’t get care, she grew distressed.
After her miscarriage, Collier saw a mental health specialist and started medication to treat depression. She hasn’t returned to her studies, she said.
“I trusted those people,” Collier said about the jail staff. “The whole experience really messed my head up.”
This article was reprinted from khn.org, a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF – the independent source for health policy research, polling, and journalism.
BGI Europe A/S, a wholly owned subsidiary of BGI Genomics, announced its NIFTY® non-invasive prenatal testing kit and software (CE-IVDD List B) were granted an extension under its existing CE-IVDD certification to include the DNBSEQ-G99 model to meet the European Union regulations for medical devices.
In January 2024, BGI Genomics unveiled the NIFTY® ultra-fast non-invasive prenatal genetic testing product, utilizing the innovative DNBSEQ-G99 platform. Designed for both small and medium throughput, this platform ensures top-notch testing performance and quality. It enables clinical laboratories to provide quicker and more accurate prenatal genetic testing results. This advancement is crucial for timely genetic counseling and further prenatal diagnosis, enhancing prenatal care options.
Key features of the DNBSEQ-G99 platform:
Speed: The DNBSEQ-G99 platform dramatically reduces sequencing time to just 3 hours, with the entire process from sample collection to report generation taking only 14 hours. This efficiency significantly reduces the anxious wait for expecting families.
Flexibility: It allows for the processing of varying sample sizes in a single run, accommodating a minimum of 12 samples. This flexibility helps in minimizing reagent waste and cutting costs.
Versatility: The platform supports various sequencing modes and is suitable for a wide range of tests, including pre-embryo transplantation chromosome testing and monogenic disease carrier screening.
Simplicity: Featuring a cassette flow cell and an innovative pre-injected reagent design, the DNBSEQ-G99 simplifies the sequencing process, making it user-friendly for operators.
BGI Genomics has been a pioneer in non-invasive prenatal genetic testing since 2010. NIFTY® has received medical device qualifications in various countries, including the United Kingdom, Australia, Saudi Arabia, Turkey, India, and Thailand. BGI Genomics continues to upgrade its prenatal and neonatal tests, contributing to better public health systems and outcomes.
Guided by the vision of “Omics for all,” BGI Genomics is dedicated to enhancing genetic testing technologies, thereby advancing global precision medicine and improving lives.
Painting a sobering picture, a research team led by Children’s National Hospital culled years of data demonstrating that maternal mental illness is an under-recognized contributor to the death of new mothers. They are calling for urgent action to address this public health crisis in the latest edition of JAMA Psychiatry.
Backed by dozens of peer-reviewed studies and health policy sources, the journal’s special communication comes as maternal mortality soars in the United States to as much as three times the rate of other high-income countries.
The contribution of mental health conditions to the maternal morbidity and mortality crisis that we have in America is not widely recognized. We need to bring this to the attention of the public and policymakers to demand action to address the mental health crisis that is contributing to the demise of mothers in America.”
Katherine L. Wisner, M.D., associate chief of Perinatal Mental Health and member of the Center for Prenatal, Neonatal & Maternal Health Research at Children’s National
The evidence review laid out the risks facing new mothers: More than 80% of maternal deaths in the United States are preventable, particularly the nearly 1 in 4 maternal fatalities that are attributable to mental health disorders. Overdose and other maternal mental health conditions are taking the lives of more than twice as many women as postpartum hemorrhage, the second leading cause of maternal death. For non-Hispanic Black mothers, the mortality rate is a striking 2.6 times higher than non-Hispanic White mothers.
Yet the research team found that recent national efforts to combat maternal mortality have failed to address maternal mental health as “the public health crisis that it represents.” Even methodologies to measure maternal health statistics are inconsistent, which challenges efforts to shape health policy.
In examining 30 recent studies and another 15 historical references, the team – which included Caitlin Murphy, MPA, PNP, research scientist at the Milken School of Public Health at George Washington University, and Megan Thomas, M.D., FACOG, obstetrician at the University of Kansas School of Medicine – found ample data to support the need to elevate maternal mental health as a priority. Some examples:
Multiple studies show that the perinatal period puts women at higher risk for new and recurrent psychiatric disorders, with 14.5% of pregnant mothers having a new episode of depression and another 14.5% developing an episode three months after birth.
Nationwide, more than 400 maternity healthcare centers closed between 2006 and 2020, creating “maternity care deserts” that left nearly 6 million women with limited or no access to maternity care.
Mental health conditions such as suicide or opioid overdose are to blame for nearly 23% of maternal deaths in America, according to reports from three dozen Maternal Morbidity and Mortality Review Committees, which are state-based organizations that review each maternal death within a year of pregnancy. That’s followed by hemorrhage (13.7%), cardiac conditions (12.8%) and infection (9.2%).
Even with these sobering statistics, Dr. Wisner says that only 20 percent of women are screened for depression postpartum. “Given that this is a time that many mothers have contact with healthcare professionals, it’s critically important that all mothers are screened and offered treatment,” she said. “Mental health is fundamental to health – of the mother, the child and the entire family.”
A UCLA-led team of researchers has found a correlation between early signs of adrenal puberty in first-born daughters and their mothers’ having experienced high levels of prenatal stress. They did not find the same result in boys or daughters who were not first-born.
The 15-year longitudinal study’s findings were published in the February issue of Psychoneuroendocrinology.
The study was the first to identify earlier patterns of adrenal puberty as a result of prenatal stress. Adrenal puberty is marked by changes like the growth of body hair, pimples and aspects of cognitive maturation, but does not include breast development or the onset of menstruation for girls or testicular enlargement for boys.
The finding adds to research in the field of fetal programming, studies that explore the impact that stress and other factors affecting pregnant mothers can have on fetuses and children long after birth.
“This is a first-of-its-kind finding and is fascinating to look at through an evolutionary lens,” said UCLA anthropologist Molly Fox, who led the study with colleagues from UC Irvine, UC Merced, Chapman University and the University of Denver.
Fox explains that a first-born daughter’s maturation, but not early onset of menstruation, may enable her to help her mother rear her other children successfully. The daughter becomes mature enough to help take care of children while not yet able to produce her own children, who would require her attention.
The finding also provides insights into the so-called “eldest daughter syndrome,” the socio-cultural phenomenon discussed online that refers to the childcare and other domestic labor that first-born females often take on, consciously or unconsciously, to help with the traditional parental or adult responsibilities required to run a household. The online discussions focus on oldest daughters feeling an overwhelming sense of responsibility for their family’s well-being.
Researchers recruited participants for the study from two obstetric clinics in Southern California during routine first trimester prenatal care visits. The women were 30 years old on average, all 18 or older, and experiencing singleton pregnancies. For about half of them, this was their first pregnancy. All were English-speaking, 45% were white/non-Latina and 30% were Latina. All were nonsmoking and not using steroid medications, tobacco, alcohol or other recreational drugs during pregnancy. Of the children born to these mothers, 48% were female and 52% were male.
Women’s stress, depression and anxiety levels were measured at 15-, 19-, 25-, 31- and 37-weeks’ gestation to create a prenatal psychological distress composite score. They were also assessed at two to three months postpartum to assign a postnatal distress composite score. The depression assessment asked respondents to rate the truth of statements such as “I felt lonely.” An example of an anxiety question was how often they felt particular symptoms, such as “jittery.”
At ages 8–10, 11–12 and 13–16, children’s biomarkers of adrenal and gonadal puberty were separately measured, including body hair, skin changes, growth in height or growth spurts, breast development and the onset of menstruation (in females), voice changes and facial hair growth (in males). Hormone levels that are indicators of adrenal and gonadal puberty were measured through saliva samples at all assessment stages.
The study also measured childhood adversity to account for other factors known to correlate to early maturation or signs of puberty in children and adolescents. These included the death of a parent or parental separation before age 5, the absence of the father and low income-to-needs ratios experienced at ages 7–9.
This research adds to the body of knowledge in our field showing the significant and lifelong impacts to women and their offspring when it comes to prenatal emotional, environmental and other factors. This is important as we continue to come up with practical and policy solutions that contribute to greater access to healthcare and the general wellbeing of pregnant mothers.”
Fox, M. M., et al. (2024). Mothers’ prenatal distress accelerates adrenal pubertal development in daughters. Psychoneuroendocrinology. doi.org/10.1016/j.psyneuen.2023.106671.
In a recent study published in Nutrients, researchers determined the relationship between maternal Mediterranean diet (MedDiet) adherence during gestation and overweight or obese offspring risk at four years.
The childhood obesity epidemic is a global health concern affecting millions of children under five, causing psychological comorbidities, low self-esteem, behavioral and emotional disorders, and long-term cardiovascular morbidity and cancer.
In addition, the World Health Organization’s (WHO) report emphasizes the importance of antenatal nutritional balance in preventing childhood obesity.
Close maternal adherence to a Mediterranean-style diet during gestation could be a promising strategy for determining potential obesity risks in childhood. Greater adherence to the diet has multiple health benefits for both mother and child.
However, studies examining the impact of prenatal diet on offspring obesity are scarce and yield varied results, warranting further research.
About the study
In the present study, researchers investigated whether maternal MedDiet adherence was associated with offspring obesity at four years and evaluated the impact of maternal factors on the association.
The team included 272 mother-child dyads from the Ensayo CLInico Para Suplementar con Hierro a EmbarazadaS (ECLIPSES) study for analysis.
The primary study outcome was offspring overweight or obese based on sex- and age-specific body mass index (BMI) z-scores above the 85th percentile using the WHO child growth standards.
The researchers obtained baseline maternal data from questionnaires during face-to-face interviews at recruitment, including medical history, age, educational level, socioeconomic status, physical activity, smoking status, and alcohol intake.
In addition to the gestational age at birth and delivery type, they obtained data on child-related variables, including sex, length, and weight at birth.
The team assessed prenatal diet using standardized 45-component food-frequency questionnaires (FFQs) at gestational weeks 12, 24, and 36 and calculated relative MedDiet (rMedDiet) scores. They measured offspring height and weight at four years.
They estimated the total daily calorie intake using the REGAL food table and determined household socioeconomic status using the Catalan classification of occupations (CCO-2011).
The researchers assessed physical exercise using the International Physical Activity Questionnaire (IPAQ) and categorized gestational weight gain (GWG) using the 2009 Institute of Medicine (IOM) recommendations.
They performed multivariate logistic regression modeling to determine the odds ratios (OR) for the association between prenatal diet and childhood obesity.
The ECLIPSES randomized clinical trial was conducted in Tarragona, Spain, from 2013 to 2017 to evaluate the efficacy of maternal iron supplementation in different dosages, adjusting for the initial hemoglobin levels during early gestation, on maternal iron status at the end of gestation.
Primary care midwives recruited 791 expecting women aged ≥18 years for the study during the initial prenatal visit (before week 12 of gestation).
Results
The mean maternal age was 32; 70% were aged ≥30, and 42% were obese or overweight, with body mass index values ≥25 kg m-2.
Most (86%) mothers were from Spain, 44% received university-level education, 22% had high socioeconomic status, and 17% practiced smoking during pregnancy. Among the mothers, 29% showed low MedDiet adherence, whereas 23% were highly adherent.
The mean prenatal rMedDiet score was 9.80, and 26% of offspring were overweight or obese at four years, with a higher obesity prevalence among males (63%) than females (37%).
The team found significant anthropometric differences (height, weight, and body mass index) by sex. The mean body mass index and body weight of offspring at four years were 16 kg m-2 and 18 kg, respectively.
Males had higher weight (19 versus 17 kg), BMI (16 versus 15.6), weight-for-age z scores (0.5 versus 0.1), and body mass index z-scores (0.7 versus 0.2) than females.
Overweight/obesity was less prevalent among offspring of mothers with university-level education, higher socioeconomic status, and higher gestational rMedDiet scores.
After adjusting for potential confounding variables, the team found higher prenatal MedDiet adherence related to a reduced risk of offspring being overweight or obese (OR for the highest versus lowest quartile, 0.3).
They obtained similar findings, stratifying by maternal age, early gestational BMI, educational attainment, smoking status, socioeconomic status, and GWG.
After confounder adjustment, the team found that each point increase in the prenatal MedDiet was associated with a 19% lower risk of children being overweight or obese at four years (OR, 0.8).
Smoking (OR, 2.5), pre-pregnancy overweight (OR, 2.5) or obesity (OR, 2.6), and excessive GWG (OR, 2.9) were considerably associated with offspring overweight or obese at four years.
The protective effects of MedDiet on offspring weight were higher among expecting women aged below 30 years with overweight or obese during initial gestation, those who did not smoke, and those with low socioeconomic status.
Conclusion
Overall, the study findings showed higher prenatal MedDiet adherence associated with lower reduced offspring overweight/obesity at four years, especially among university-educated mothers aged below 30 years from low socioeconomic backgrounds who did not smoke. Future studies could investigate whether the association persists across life stages.
A study published in the journal The Lancet Planetary Health reveals that prenatal exposure to phthalate metabolites can increase the risk of preterm birth and low birth weight.
Preterm birth and low birth weight are associated with many adverse consequences, including infant and childhood mortality, psychological, behavioral, and educational adversities in young adulthood, and cardiometabolic diseases in adulthood. In the United States, about 8% and 10% of infants suffered low birthweight and preterm birth, respectively, in 2020.
Many risk factors are associated with adverse birth outcomes, including maternal age, poor socioeconomic status, pre-eclampsia, and lack of prenatal care. Various synthetic chemicals, such as phthalates, are also known to increase the risk of birth adversities.
Phthalate and its metabolites are used in personal care products and food packaging. These chemicals have pro-inflammatory, pro-oxidative, and endocrine-disrupting activities. The crosstalk between these pathways can potentially disrupt hormonal regulation in pregnancy and induce placental insufficiency, pre-eclampsia, and premature membrane rupture.
In this study, scientists investigated the effects of prenatal phthalate exposure on birthweight and gestational age at birth. They also estimated phthalate-attributable adverse birth outcomes and associated costs.
Study design
The scientists collected data from the National Institutes of Health Environmental influences on Child Health Outcomes (ECHO) Program, which includes 69 unique pediatric cohorts from across the USA to identify environmental and preventable factors associated with low birthweight, preterm birth, and other birth complications.
The concentrations of 20 phthalate metabolites were measured in maternal urinary samples. The associations of these metabolites with gestational age at birth, birthweight, birth length, and birthweight for gestational age z-scores (age-independent assessment of a fetus growth) were analyzed in the study.
Important observations
The study was conducted on 5006 mother-child dyads identified from 13 cohorts in the ECHO program. The concentrations of phthalate metabolites in these mothers were similar to those detected in women of childbearing age in national surveys. A similar distribution of phthalates was observed across trimesters. The metabolites of di-2-ethylhexyl phthalate (DEHP) showed a strong correlation with one another. Mono-ethyl phthalate and phthalic acid showed the highest concentrations in maternal urinary samples.
Higher concentrations of multiple phthalate metabolites were observed in non-Hispanic Black mothers. In contrast, Hispanic mothers showed higher concentrations of low-molecular-weight metabolites and lower concentrations of high-molecular-weight metabolites, DEHP, and phthalic acid.
An inverse association was observed between maternal age and concentrations of all metabolites. Moreover, a positive association was observed between maternal age, birth weight and length.
Impact of phthalates on birth outcomes
The study analysis revealed strong associations of phthalic acid, diisodecyl phthalate (DiDP), di-n-octyl phthalate (DnOP), and diisononyl phthalate (DiNP) with gestational age, birth length, and birth weight. These associations were stronger than that observed for low- and high-molecular-weight metabolites and DEHP.
Overall, phthalate metabolites showed an association with low birth weight. The strongest associations were observed between the concentrations of phthalic acid, DiNP, DiDP, and DnOP and preterm birth and low birth weight. The magnitude of these associations was stronger in the third trimester compared to that in the first and second trimesters.
The findings of sensitive analysis revealed that the association between DnOP and preterm birth is stronger for female infants than male infants. Moreover, the associations of phthalic acid, DiNP, and DnOP with many birth outcomes were stronger among non-Hispanic White mothers and college-educated mothers.
Regarding phthalate-attributable adverse birth outcomes and associated costs, the study estimated 56,595 preterm birth cases in 2018, with associated costs of 3.84 billion USD. A sensitive analysis considering DiDP exposure revealed 57,017 to 79,947 attributable cases with associated costs of 3.86 billion USD to 5.42 billion USD. Similarly, for DiNP exposure, the analysis showed 76,838 to 120,116 attributable cases with associated costs of 5.21 billion USD to 8.14 billion USD.
Study significance
The study finds that prenatal exposure to phthalate metabolites can increase the risk of preterm birth and low birth weight. The pattern of associations observed in the study indicates that phthalate metabolites replacing DHEP in food packaging are responsible for the increase in preterm birth. This suggests a need to regulate chemicals with similar properties as a class.
A new study in the journal Nature Mental Health explores how a mother’s positive state of mind during pregnancy affects the structure and function of the developing fetal brain by measuring these parameters by 7.5 years of age.
How does the maternal emotional state affect fetal development?
During pregnancy, which is a time of significant physical, mental, and social change, anxiety, depression, and other stress-related mental health disorders are frequently reported. These mental health issues have been associated with a durable and adverse effect on fetal brain development.
For example, previous research has shown that these mental disorders can lead to changes in the growth rate of the fetal hippocampus and a lower density of gray matter in the prefrontal and medial temporal lobes in early childhood. These children may also exhibit altered structure and function of emotion-regulating cortico-limbic networks, which are important for stress management.
At certain stages, these changes appear to be more significant in girls than boys. Notably, it is not necessary that the mother be clinically anxious or depressed for these alterations to manifest.
As a key component of mental health, positive maternal emotions like happiness can affect multiple outcomes, including maternal-infant bonding, parenting approaches, and child development. Furthermore, maternal happiness during pregnancy also impacts the long-term health of both the mother and child; however, it remains unclear how positive maternal emotions affect prenatal development.
About the study
The current study used data from the Growing Up in Singapore Towards Health Outcomes (GUSTO) cohort. Both structural and functional magnetic resonance imaging (MRI) were performed on children to explore the association of maternal happiness during pregnancy with brain development.
The researchers developed their own tool to measure positive maternal mental health during pregnancy. This was based on a mental health questionnaire given to pregnant women at 26-28 weeks.
What did the study show?
At 7.5 years of age, children are experiencing a vital phase of development during which the brain shifts towards different patterns of activity and cognitive processes develop in new ways. As a result, this period was chosen as the focus of the study.
Brain areas involved in perceiving and regulating emotions include the hippocampus and amygdala, as well as various functional networks like the visual networks, default mode network (DMN), and functional network. These regions of the brain have also been directly correlated with how the mother cares for the child.
A composite measure from multiple mental health scales was used for assessing positive maternal emotions during pregnancy. Other potential contributing factors such as socioeconomic status, stress levels, family and friend relationships, and death of close relatives in the two years before and after pregnancy were also recorded to determine a socio-environmental adversity factor. Maternal parenting stress was also assessed when the child was six years of age.
Interestingly, girls born to mothers who reported feeling happy during pregnancy had larger hippocampus volumes, whereas both boys and girls born to happy mothers exhibited altered functional connectivity of multiple networks.
When categorized by task-negative and task-positive networks, reduced connectivity between task-negative networks was observed among girls born to mothers with increased positive emotions during pregnancy. Conversely, increased connectivity between task-positive networks was associated with greater maternal happiness during pregnancy.
Since these findings were absent when explored in relation to depression or anxiety in the mother during pregnancy, the observed changes in functional connectivity may occur specifically with greater maternal positive emotion in pregnancy. This may indicate that maternal happiness transmits to the developing child’s brain through neural changes.
What are the implications?
The study findings suggest that feeling happy during pregnancy not only reduces the risk of psychiatric illness in the mother but also potentially acts as a protective factor for fetal brain development.
Previous studies have shown that anxious and stressed mothers are more likely to have children with hippocampal changes, which may affect the developing brain and lead to impaired stress responses in the future. By encouraging mothers to have positive emotions during pregnancy, hippocampal development in the offspring may be promoted, with better structure and functional networks during the time when children typically begin to attend school.
Importantly, better hippocampal development is associated with greater childhood resilience, thus serving as an early marker for psychological vulnerability and greater potential for behavioral and emotional problems when encountering stressful circumstances. However, the period of fetal development at which maternal positive emotions occur may modify the impact.
Future studies are needed to establish and extend these findings, especially to understand the neural basis of prenatal-maternal interactions during psychoneurological development. These studies could support the development of preventive strategies to help mothers feel happy during pregnancy and ultimately promote the mental health of their children.
Journal reference:
Qiu, A., Shen, C., Lopez-Vicente, M., et al. (2024). Maternal positive mental health during pregnancy impacts the hippocampus and functional brain networks in children. Nature Mental Health. doi:10.1038/s44220-024-00202-8.
Study: Examining the relationship of acetaminophen use during pregnancy with early language development in children. Image Credit: luchschenF / Shutterstock
