Indian Journal of PsychiatryIndian Journal of Psychiatry
Home | About us | Current Issue | Archives | Ahead of Print | Submission | Instructions | Subscribe | Advertise | Contact | Login 
    Users online: 1630 Small font sizeDefault font sizeIncrease font size Print this article Email this article Bookmark this page


    Advanced search

    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  

    Antenatal Mental...
    Postnatal Mental...
    Antenatal Distre...
    Maternal Mental ...
    Mediators of Mat...
    Directions for F...
    Article Tables

 Article Access Statistics
    PDF Downloaded1243    
    Comments [Add]    
    Cited by others 32    

Recommend this journal


 Table of Contents    
Year : 2011  |  Volume : 53  |  Issue : 4  |  Page : 351-361
Maternal mental health in pregnancy and child behavior

Mental Health and Maternal and Child Health Divisions, St. John's Research Institute, Bangalore, Karnataka, India

Click here for correspondence address and email

Date of Web Publication16-Jan-2012


Maternal mental health research is a public health priority due to its impact on both maternal and child health. Despite the growing number of empirical studies in this area, particularly from developing countries, there is a paucity of synthetic review articles. Therefore, attempting to synthesize the existing literature in this area seems relevant to appraise the readers of the field's progress and to infer directions for future research. The present review aims to provide an overview of the literature on maternal mental health and its association with birth outcomes and child behavior. Specifically, the literature on mental health during pregnancy and in the postpartum period and its influence on birth outcomes and child behavior have been reviewed. Further, a conceptual and methodological evaluation of the existing literature has been provided to identify gaps in the literature and to suggest directions for future research.

Keywords: Antenatal depression, birth outcomes, child emotional-behavior problems, mental health, postnatal depression

How to cite this article:
Satyanarayana VA, Lukose A, Srinivasan K. Maternal mental health in pregnancy and child behavior. Indian J Psychiatry 2011;53:351-61

How to cite this URL:
Satyanarayana VA, Lukose A, Srinivasan K. Maternal mental health in pregnancy and child behavior. Indian J Psychiatry [serial online] 2011 [cited 2022 Oct 2];53:351-61. Available from:

   Introduction Top

With declining rates of maternal mortality worldwide, researchers are recognizing the importance of addressing morbidity as well. The contribution of maternal mental health to maternal morbidity however has not been well ascertained. [1] In recent decades, psychological morbidity in child-bearing women in particular has received increasing research attention because of its ramifications on the mother as well as her child.

Once considered a time of emotional wellbeing, and "protecting" women against psychiatric disorders, it is now well established that several psychiatric disorders are common during pregnancy, with depression being the most common. [2] Violence during pregnancy or intimate partner violence has also received research attention due to its lasting consequences on the mental health and wellbeing of the mother and her child. Further, motherhood is often glorified, which makes the pregnant woman or mother feel guilty about experiencing negative emotions.

For the purpose of the present review, we limit our focus to reviewing published reports on common mental disorders, such as depression and anxiety disorders, and general psychological distress during pregnancy and in the postpartum period. Research has indicated that risk factors for poor mental health during pregnancy include past personal or family history of psychiatric illness or substance abuse, past personal history of sexual, physical or emotional abuse, current exposure to intimate partner violence or coercion, current social adversity and coincidental adverse life events. Psychological disturbances during pregnancy are associated with inadequate antenatal care, low-birth weight and preterm delivery, while in the postpartum, it is associated with diminished emotional involvement, neglect and hostility towards the newborn. While the bulk of literature in this area is from the developed world, particularly, the United States, Canada, Europe and Australia, the last decade has seen some interesting publications from developing countries as well where gender disadvantage, poverty and limited access to resources further complicate the issue.

An attempt has been made to synthesize literature on maternal mental health and child behavior in the last 5 years. Although mental health of mothers in the postpartum period is relatively well researched compared with mental health during pregnancy, empirical studies on the impact of either on infant/child behavior and development is still in its infancy. Cultural preferences and culture-specific issues in the manifestation of psychological distress during pregnancy have been elucidated as well.

   Antenatal Mental Health Top

The perinatal period, which includes both antenatal and postnatal phases, is very significant both for the mother as well as for her child. Although the impact of maternal mental health on child development starts from conception, research in the area of antenatal mental health has gained momentum only in recent years. The existing literature has largely focused on common mental disorders, such as depression and anxiety. Growing evidence also suggests that antenatal mental health problems can be a precursor for subsequent mental health problems in a woman's life.

Prevalence of antenatal psychological distress

The prevalence rates of antenatal psychological problems are estimated to be high world over [Table 1]. Studies have indicated that the prevalence of antenatal depression (AD) and/or anxiety ranges from 8% to 30%. [3],[4] The prevalence rates are likely to vary across studies and cultures due to choice of measures and sociocultural determinants. Studies have used either screening measures such as the Edinburgh Post Natal Depression Scale (EPDS) or structured interview schedules that yield a clinical diagnosis.
Table 1: Prevalence estimates of antenatal distress*

Click here to view

Prevalence estimates from developed countries

A systematic review showed that of the 18% of women reporting depressed mood during pregnancy, 13% met the DSM-IV diagnostic criteria for a major depressive episode. [5] In a Japanese study, women (n=290) were assessed both antenatally and postnatally for the presence of DSM-III-R psychiatric disorders. About 12% of the women at pregnancy and postpartum, respectively, met the criteria for one of the following psychiatric disorders: major depressive disorder, manic episode, generalized anxiety disorder, social phobia, specific phobia and obsessive compulsive disorder. [6]

A United States population study (n=1662) investigated AD using EPDS during mid pregnancy and found that the prevalence of depressive symptoms during the antenatal period was 9%. Minority groups in the US, such as Black and Hispanic mothers, had a higher prevalence of depressive symptoms compared with non-Hispanic white mothers. [7]

Swedish studies indicated that the point prevalence of depression in pregnant women ranged from 13.7% [8] to 29.2%. [9] A recent study (n=1522) reported that antenatal stress (78% low-moderate, 6% high) not amounting to a disorder was highly prevalent. About 43% (n=658) of the sample completed screening at both time points during pregnancy (mean GA=22.1±6.0 weeks and 36.3±1.8 weeks), with stress scores being significantly higher at the first screening (14.8±3.9 vs. 14.2±3.8). [10]

Mental health problems during the antenatal period are also known to vary across trimesters. While one study found the prevalence of antenatal anxiety and AD as assessed on the Hospital and Anxiety Depression Scale (HADS) to be similar across the three trimesters, [11] others have noted a much higher prevalence of antenatal depressive disorder at 12-16 weeks (6.1%) as opposed to the third trimester (4.4%) of pregnancy. [12]

Prevalence estimates from developing countries

In the recent decade, there has been an increasing number of studies on antenatal mental health from developing countries. A Brazilian cross-sectional study (n=432) reported the prevalence of state and trait antenatal anxiety (AA) to be 59.5% and 45.3%, respectively. The prevalence of AD assessed on the Beck Depression Inventory was 19.6%. [13]

A study from Pakistan (n=1368) reported prevalence rates of anxiety and/or depression at 20-26 weeks gestation to be 18%. [14] Others have noted a much higher prevalence for AD among women from developing countries. In a study from Pakistan, 42.7% of the women (n=213) had AD, assessed on EPDS. [15] Among Bangladeshi women (n=361), the prevalence of AD assessed on EPDS was 33%. [16] Thus, studies from developing countries indicate that the prevalence of antenatal distress is higher compared with those from developed countries. [17] This may be attributed to limited access to health care and a broad range of sociocultural correlates that are reviewed below.

Correlates of antenatal psychological distress

A host of salient risk factors for antenatal psychological distress have been identified in the literature. Rich-Edwards et al. (2006) in a US population study (n=1662) found that the strongest predictor for antenatal depressive symptoms was a past history of depression. [7] These findings were corroborated by studies from Canada [18] and Brazil. [19] Another cross-sectional analysis on a US sample (n=1522) found that domestic violence, drug use and medical problems was associated with a 3-4-fold increase in the odds of reporting stress during pregnancy. [10] A study from Japan [20] found that 15 of the 279 respondents (5.4%) who reported domestic violence during pregnancy experienced significant sleep disturbances, anxiety and depression.

There is also a reported dose-effect relationship between the numbers of stressful life events experienced in the year prior to pregnancy and depressive symptoms during pregnancy. Women who reported two or more stressful life events were 3.7-times more likely to report depressive symptoms during pregnancy. [8] A qualitative study in England (n=24) found that adjustment to motherhood, sense of loss when social activities were curtailed, past history of fetal loss, history of distress in pregnancy and current concerns about pregnancy were primary risk factors for distress during pregnancy. [21] Another qualitative study from UK reported lack of partner support to be the most significant contributor of distress during pregnancy. [22] A study in Nigeria found that being single, polygamous, having previous history of still birth and perceived lack of social support were associated with depression. [23] Further, quality of marital relationship is also known to influence antenatal psychological distress, [11],[24],[25] again a consistent finding across cultures.

While few studies have examined protective factors associated with antenatal distress, an Australian study (n=421) showed that social support and self-confidence protected women from experiencing distress. [26]

Interestingly, these findings were replicated in a developing country - Jamaica (n=452), using a similar methodology. [27]

The above findings suggest that a host of psychosocial risk factors are associated with distress during pregnancy. Past history of depression, domestic violence, stressful life events, marital disharmony and lack of social support emerged as the most salient risk factors.

   Postnatal Mental Health Top

Women's mental health in the postnatal period has received greater emphasis in research compared with that in the antenatal period. Existing estimates indicate that approximately 12-16% of women experience postpartum depression (PPD). Depression and anxiety of postpartum onset can be either acute or chronic. [28] Like antenatal distress, postnatal distress is also known to be associated with various psychosocial risk factors.

Prevalence of postnatal psychological distress

While most women following delivery experience postpartum blues, postnatal psychological distress is also highly prevalent across cultures [Table 2].
Table 2: Prevalence estimates of postnatal distress*

Click here to view

Prevalence estimates from developed countries

A Swedish sample (n=1580) reported the point prevalence of depression on EPDS to be 12.5% at 8 weeks and 8.3% at 12 weeks postpartum. The period prevalence for 8-12 weeks postpartum was 4.5%. [29] In a study from Australia, 7.5% of the women (n=12,361) reported a high likelihood of depression between 6 and 8 weeks postpartum. [30] PPD varies across time; an Italian study (n=167) found a higher percentage (13.8%) of women meeting the criteria for depression on EPDS at 3 months postpartum compared to 4.8% of women both at 9 and 18 months. The stability of depressive symptoms throughout the three periods was also studied using EPDS. About 23% reported depressive symptoms on at least one of the assessments; specifically, 16.2% reported depression once, 6% twice and 1.2% showed persistent or recurrent symptomatology across all the three assessments. [31]

Prevalence estimates from developing countries

Klainin and Arthur (2009) reviewed 64 studies from 17 Asian countries and found that PPD ranged from 3.5% to 63.3%, with Malaysia reporting the lowest rates and Pakistan the highest. [32] A review of the literature in the African continent showed the prevalence of postnatal depression and anxiety to be 18.3% and 14.0%, respectively. [33] A cohort study of Thai women (n=610) reported the prevalence of postpartum depressive mood on EPDS to be 16.8%, [34] while a study from Nepal reported a 4.9% prevalence on EPDS. [35] In a Moroccan study (n=100), 17% of the mothers reported depression on MINI International Neuropsychiatric Interview (MINI) and EPDS. [36] A study from Brazil (n=271) reported the prevalence of depression to be 20.7% between the 6 th and 8 th week postpartum. [37]

Edwards et al. (2006) examined the severity of PPD in Indonesia, and found that of the 22% women with depression, the majority had mild levels of depression (82.5%). [38] A Moroccan study (n=144) reported that the prevalence of depression varied across the postpartum period; 18.7% women met the diagnostic criteria for depression at 2 weeks after delivery and 6.9% at 6 weeks after delivery. At the 6th month, the prevalence increased to 11.8% and, subsequently, decreased to 5.6% in the 9 th month. [39] The estimated prevalence of PPD in studies from India ranged from 11% to 26.3%. [17],[40],[41]

Correlates of postnatal psychological distress

Correlates of PPD consistently found in research are past history of depression, AD, stressful life events and inadequate partner support. [33],[42] In a study from Sweden, significantly increased risk was found for single women for postnatal depression. [29] Others have corroborated these findings. [17],[43],[44]

A population-based study in Pakistan (n=149) found that at 12 weeks, the PPD score was associated with lower social support, increased stressful life events in the preceding year and higher levels of psychological distress in the antenatal period. [45] In another study from Pakistan, Rahman et al. (2007) found that poverty, having five or more children, lower education level of spouse and lack of a confidant was associated with persistence of depression in the postnatal period. [46] Other investigators from developing countries have also reported an association between disadvantaged socioeconomic status and postnatal depression. [37],[38],[44] A recent population-based study from South India found that birth of a girl child when a boy was preferred was a major risk factor for postnatal depression, [40] a finding replicated in other studies from India. [17],[41] Several researchers have examined the temporal stability of antenatal distress. Studies have found that the strongest risk factor for developing postnatal depression was a history of depression in the antenatal period. [7] These findings were consistent across cultures: Japan, [6] Sweden, [9] Australia, [42] Canada, [47] Iran [48] and India. [17],[44]

A Chinese population study found that women with persistent AA or depression in the antenatal period had a higher likelihood of developing PPD. [11] Austin et al. (2007) found that women with high AA were 2.6-times more likely to have probable postnatal depression compared with women with low scores. [49] A study from China showed that women with depressive symptoms (EPDS>14) in the second trimester were 11.78-times and 7.15-times more likely to report depressive symptoms at the 3 rd trimester and 6 weeks postpartum, respectively. [50]

Researchers have identified factors that protect the mother from developing depression in the postnatal period. Ramchandani et al. (2009) in a study of mothers in South Africa found that literate mothers are less likely to develop postnatal depression. [51] Zelkowitz et al. (2008) found that women (n=106) with relatively few somatic complaints, low levels of perinatal stress and satisfactory marital relations were less likely to exhibit mental health problems during pregnancy and in the postpartum period. [47] Among other factors that protect mothers from PPD is breastfeeding. [52],[53] Additionally, breastfeeding contributes to mother-infant attachment, mother's sense of wellbeing and enhances self- esteem. [54],[55] The mediating role of breastfeeding in the link between maternal distress and child mental health is briefly discussed later in this paper.

A recent review of studies in Asia classified major risk factors for PPD as biological, psychological, obstetric, economic and cultural factors. Biological risk included a history of medical conditions, severe premenstrual symptoms and poor physical health. Psychological risk factors were depressive symptoms, anxiety, past psychiatric history, stressful life events, child care stress, low self-esteem, poor self-image and an insecure attachment style. Obstetric correlates were problems during pregnancy, previous abortion, previous loss of baby, unplanned pregnancy and the absence of breastfeeding. Economic and cultural variables were being an immigrant, being hungry in the past month, being a home maker, having an unemployed and uneducated husband, spouse's history of psychiatric disorder, polygamy, domestic violence, dissatisfaction with living conditions and lack of emotional support from husband and in-laws. [32]

Findings indicate that a wide range of psychosocial risk factors and past history of depression are associated with PPD. In addition, association between culture-specific risk factors (such as birth of a female child when a male child was preferred) and PPD merits further study.

   Antenatal Distress and Birth Outcomes Top

Antenatal psychological distress or maternal psychopathology during the antenatal period is known to impact obstetric/neonatal outcomes. A study from Pakistan compared 147 physically healthy mothers with 147 mothers diagnosed with ICD-10 depression of similar gestational age and found that infants of depressed mothers had lower birth weight (LBW; mean 2910 g) than infants of nondepressed mothers (mean 3022 g). The relative risk for LBW (≤2500 g) in infants of depressed mothers was significant (RR=1.9), even after adjusting for confounders in multivariate analyses. [56] Another study [57] compared three groups of pregnant women: those with actual psychiatric disorder, psychological distress and healthy controls. They found that infants of women with psychiatric disorders had LBW, and 30% of the infants had birth weight below the 10th centile for gestational age compared with 5% of infants of healthy mothers.

In a prospective cohort study of 681 women in France, the authors found that the rate of spontaneous preterm birth was significantly higher among women with high-depression scores (9.7%) even after adjusting for potential confounding factors. Anxiety, unlike depression, was not significantly associated with preterm birth. [58] Further, a study from Pakistan also showed that the negative effects of maternal AD on infant growth continued for at least 1 year after birth. [56]

Studies from India have described an association between psychological morbidity during pregnancy and LBW (<2.5 kg). [59] A cohort of mothers (n=270) recruited from a district hospital was interviewed with a screening questionnaire for psychological morbidity and their infants were assessed at birth. Excluding five premature babies, they found that maternal psychological morbidity was independently associated with LBW. Studies from low-income countries in South Asia have also indicated that maternal depression in the postnatal period interferes with infant growth and failure to thrive. [60],[61] A recent review identified elevated fetal activity, delayed prenatal growth, prematurity and LBW as common consequences of prenatal maternal depression. [62] While enhanced levels of depression and anxiety symptoms during pregnancy contributed independently of other biomedical risk factors to adverse obstetric, fetal and neonatal outcomes, however, this cannot be generalized to women meeting diagnostic criteria for mood or anxiety disorders during pregnancy. [63]

Researchers have also questioned whether it is depression per se or exposure to antidepressant medication during pregnancy that affects neonatal birth weight. A recent study [64] showed no association between maternal depression and birth weight. The authors, however, showed that exposure to antidepressant medication during pregnancy was associated with an eightfold increase in infants of LBW and prematurity. In addition, infants exposed to antidepressants during pregnancy were smaller in length and had a smaller head circumference at birth. Using linked population health data, a study [65] found that prenatal SSRI exposure was associated with an increased risk of LBW and respiratory distress, even when maternal illness severity was accounted for.

Stewart, in a recent review, [66] highlighted the findings that the effect of depression as an independent risk factor for poor infant growth typically occurred in mothers/infants living in conditions of socioeconomic deprivation and among relatively deprived social groups in the economically developed world. One of the most replicated findings is the poorer birth outcomes for African-American women compared with non-Hispanic white women. [67]

Studies examining obstetric and neonatal complications in depressed mothers should be interpreted with caution because it is difficult to tease out the consequences of untreated depression from the consequences of exposure to antidepressant medication. In addition, most of the effects of antenatal psychological distress on birth outcomes have occurred in a setting of socioeconomic deprivation. Studies so far have shown that anxiety and depression influence obstetric/neonatal outcomes. However, the comorbid nature of the two conditions makes it difficult to examine their differential effects on birth outcomes. Furthermore, we expect a dose-response relationship; clinical diagnosis of anxiety or depression is likely to have a greater impact than the presence of symptoms alone, but there is little empirical research on this to date. However, findings from various studies indicate that screening and treatment for psychological distress, particularly depression, should begin in the antenatal period itself. Engel [68] highlighted that maternal mental health problems should ideally be an integral component of primary health care systems the world over.

   Maternal Mental Health and Child Emotional-Behavioral Outcomes Top

Maternal-fetal attachment

Maternal mental health significantly influences Maternal-fetal attachment (MFA), and infant-caregiver bonding begins fairly early in pregnancy. [69] In a recent metaanalysis, [70] 183 studies published between 1981 and 2006 were reviewed to examine predictors of MFA. Perceived social support predicted MFA to a greater extent when compared with other predictors such as anxiety, self-esteem and depression. Gestational age, however, had the highest effect size. Di Pietro [71] opined that while there is a fairly substantial literature on the development and moderation of psychological features of the maternal-fetal relationship, including the role of ultrasound imaging, relatively little is known about the manner in which maternal psychological functioning influences the fetus. Higher AA symptoms were related to less-optimal maternal-fetal quality of attachment, more negative attitudes toward self as mother and motherhood on the whole. [72] Similar trends were found for depressive symptoms as well. [69] A review of 22 studies on MFA found that the factors associated with higher levels of MFA included family support, greater psychological wellbeing and having an ultrasound performed. Factors such as depression, substance abuse and higher anxiety levels were associated with lower levels of MFA. [73]

Infant temperament

Parental psychological stress and psychopathology during pregnancy not only increased across their transition into parenthood but was also associated with difficult child temperament at 12 months postpartum. [74] In a large cohort study (Avon Longitudinal Study of Parents and Children; n=14,663), maternal depression at time 1 (6-8 months after child's birth) was found to predict difficult child temperament (child mood and temperament) at time 2 (21-24 months after child's birth). Paternal depression at time 1 also seemed to influence child temperament (child mood and intensity) at time 2, but the effects were more significant for male children than for female children. [75] Trait anxiety in mothers predicted difficult infant temperament, such as clinging behavior, frequent crying and irritability, independent of comorbid depression, sociodemographic and obstetric risk factors. [76] Treating maternal antenatal distress increased the likelihood of the child having an easy temperament, [77] a finding endorsed by a recent review that demonstrated that treating parental psychopathology resulted in significantly improved outcomes in child symptomatology and functioning. [78]

Child cognitive-emotional-behavior problems

While some studies have indicated an association between maternal depression and subsequent cognitive and language difficulties in the child, [79],[80] other studies have found no evidence to suggest such a relationship. [81] A recent study [82] showed that poverty and maternal depression independently and collectively decreased cognitive and emotional wellbeing in children. A recent review of papers published in the last year [83] suggested that psychological distress and mental illness, including depression and anxiety, influence a child's emotional, cognitive, and behavior development in addition to impacting birth outcomes and physical growth.

In the Raine study, a prospective cohort study of pregnant women (n=2979) recruited at 18 weeks gestation behavioral problems as assessed on the Child Behavior Check List, were predicted by maternal experience of multiple stressful events during pregnancy. [84] Kaplan et al. [85] reported that maternal sensitivity rather than antenatal psychiatric diagnosis or postnatal psychiatric status modulated infant responsiveness. Werner et al. [86] found that physiological markers of individual differences in infant temperament are identifiable in the fetal period, and possibly shaped by the prenatal environment. Antenatal psychiatric diagnosis was also associated with a fourfold increase in cry reactivity in infants.

In a study from Sub-Saharan Africa on 431 children aged 3-24 months, Hadley et al. [87] found that maternal mental health problems were associated with both global and specific developmental problems. Studies from New Zealand [88],[89] reported that the prevalence rates of internalizing problems were significantly higher in children of mothers who had self-reported symptoms of psychological disorder. The adjusted odds ratio of a child having internalizing problems was 1.38 (95% CI: 0.79-2.43) in mothers reporting early symptoms of postnatal depression, 1.45 (95% CI: 0.85-2.49) in late symptoms of psychological disorder and 2.93 (95% CI: 1.54-5.57) in persistent or recurrent symptoms relative to the nonsymptomatic group. There was no association between maternal psychological disorder and externalizing symptoms.

Studies have also indicated an association between maternal AA and ADHD. [90],[91],[92] A review [93] based on independent prospective studies showed that if a mother is stressed while pregnant, her child is substantially more likely to have emotional or cognitive problems, including an increased risk of attentional deficit/hyperactivity, anxiety and language delay and, interestingly, the associations were independent of maternal postnatal depression and anxiety. The magnitude of these effects is clinically significant as the attributable load of emotional/behavioral problems due to antenatal stress and/or anxiety is approximately 15%. A large birth cohort (n=3982) of children born in Brisbane found that maternal anxiety during or after pregnancy was associated with child attentional problems at ages 5 and 14. Children of mothers with chronic anxiety problems were more likely to have persistent attention difficulties. [94]

Paternal psychopathology

Antenatal and postnatal depression in fathers has only recently received research attention. Ramchandani and colleagues [51],[95],[96],[97] found that depression in fathers during the postnatal period was associated with adverse emotional and behavioral outcomes in children, such as oppositional defiant disorder/conduct problems in boys and psychiatric disorder in their children 7 years later. They also found that most psychiatric disorders that affect fathers are associated with an increased risk of behavioral and emotional difficulties in their children, similar in magnitude to that due to maternal psychiatric disorders. Some findings indicate that boys are at a greater risk than girls, and that paternal disorders compared with maternal disorders might be associated with an increased risk of behavioral rather than emotional problems.

The above review suggests that both antenatal and postnatal psychological distress and/or disorder is likely to impact multiple facets of child growth and development. Therefore, appropriate screening and referral services during the antenatal and postnatal periods should be integrated with routine obstetrics and gynecology services.

   Mediators of Maternal Mental Health and Child Development Top

Psychological distress and psychopathology in the perinatal period are known to impact child development and behavior. The pioneering theory and research-based framework linking maternal depression and adverse child outcomes was proposed by Goodman and Gotlib. [98] According to this model, factors that mediate the relationship between maternal depression and child outcomes are heritability of depression, innate dysfunctional neuroregulatory mechanisms, exposure to negative maternal cognitions, behaviors and affect and exposure to a stressful environment. Hence, a depressed mother who experienced one or more of the above mediating factors is more likely to have a child with psychological problems. All of these factors create a predisposition/vulnerability (physiological, such as Hypothalamic-pituitary-adrenal (HPA) axis and/or psychological, such as cognition, behavior, affect and interpersonal) in the child that may then lead to impaired psychological functioning in the child.

Physiological mediators

Among the physiological mechanisms underpinning the association between maternal anxiety and depression and, later, development of behavioral problems in children, the research has focused on the mediating role of cortisol. [99],[100],[101]

Animal studies have shown that prenatal stress can reprogram the function of the HPA axis in the offspring. However, the effects on the HPA axis are very variable depending on the nature of the stress, its timing in gestation, the genetic strain of the animal and the sex and age of the offspring. Recent studies in humans suggest long-term effects of prenatal stress on basal cortisol levels, or cortisol responses to stress. Evidence suggests that an altered function of the HPA axis in the child mediates behavioral or cognitive alterations observed to be associated with prenatal stress. [99] Further, a recent review found support for the "fetal origins hypothesis" that prenatal environmental exposures, including maternal psychological state-based alterations in in utero physiology, can have sustained effects across the lifespan. [102]

In a recent study that followed-up 125 mothers from pregnancy to 17 months postnatal, prenatal cortisol exposure, indexed by amniotic fluid levels, negatively predicted cognitive ability in the infant, independent of prenatal, obstetric and socioeconomic factors. This association was moderated by child-mother attachment: children with an insecure attachment had higher levels of cortisol and lower cognitive ability compared with those with a secure attachment style. [103]

Elevated maternal cortisol at 30-32 weeks of gestation, but not earlier in pregnancy, was significantly associated with greater maternal report of infant negative reactivity. Prenatal maternal anxiety and depression additionally predicted infant temperament. The associations between maternal cortisol and maternal depression remained after controlling for postnatal maternal psychological state. [104] Perceived maternal stress during pregnancy and neonatal cortisol reactivity each remained stable across the first 10 months of postnatal life. Maternal stress during pregnancy predicted infant cortisol reactivity at 2 days and 10 months after birth as well as behavioral reactivity at 10 months. Neonatal cortisol reactivity predicted 10-month behavioral reactivity. [105] In another study, infant's salivary cortisol level and cry reactivity in response to inoculation at 8 weeks was found to be greatest in mothers who had assisted delivery and least in mothers who had cesarean delivery. [106] Because studies have recommended assessing the cortisol-DHEA ratio as a measure of functional hypercortisolemia, [107] rather than cortisol alone, future studies examining stress response in mothers and infants may benefit from using the same.

Skin-to-skin contact for 25-120 minutes after birth, early suckling or both positively influenced mother-infant interaction 1 year later when compared with routines involving separation of mother and infant. [108] A recent Cochrane review of 30 studies showed a relationship between early skin-to-skin contact and shorter cry duration and better attachment behavior. [109] Another study [110] reported a relationship between breastfeeding and attachment security in the child. Further, prenatal breast feeding intent and attachment security was mediated by maternal sensitivity. Several studies have indicated that maternal depression is correlated positively with cessation of breastfeeding. [111],[112] Studies have also highlighted the protective role of breastfeeding in improving maternal distress and child outcomes. [113],[114] A recent review highlighted the concurrent effects of PPD and breast feeding: PPD can lead to not initiating or early cessation of breast feeding, and breast feeding can alter or influence the course of PPD. Studies reviewed here were not methodologically sound and hence it is difficult to make definitive conclusions. [115]

Psychological mediators

Prenatal stress predicted both mental development and observed fearfulness in the child; the effect persisted even after controlling for maternal education and psychological state, exposures to medications and substances during pregnancy and birth outcomes. Prenatal stress accounted for 17% of the variance in cognitive ability and 10% of the variance in observed fearfulness. Relationship strain with the partner accounted for 73.5% and 75.0% of the prenatal stress-related variance on infant cognitive and fearfulness scores, respectively. [116] Another study [117] demonstrated the moderating role of child-parent attachment in the relationship between antenatal stress and infant fearfulness. This finding that attachment experiences during the postnatal period can attenuate the adverse effects of antenatal stress has important clinical implications. Perceived stress during pregnancy was a predictor of lower levels of restless/disruptive temperament, more total behavioral problems and more externalizing behavioral problems in 2-year-olds. Fear of bearing a handicapped child in the mother was a predictor of higher levels of restless/disruptive temperament and more attention regulation problems in toddlers. [118],[119] Another study [120] found that maternal life events measured during the first part of pregnancy were negatively associated with the child's attention/concentration index, while controlling for overall IQ, gender and postnatal stress. No associations were found between prenatal maternal cortisol and the offspring's learning and memory.

Thus, a number of both physiological and psychosocial factors have been identified as possible mediators or moderators of the link between maternal mental health and child behavior.

   Evaluation Top

Literature on maternal mental health and child behavior over the last 5 years indicates that the prevalence of both antenatal and postnatal psychological distress is considerably high the world over, with higher prevalence rates reported in developing countries. A host of demographic, psychosocial and culture-specific risk factors (male child preference) have been identified for antenatal and postnatal distress. Socioeconomic deprivation and maternal psychological distress tend to co-occur; examining the differential effect of risk factors is therefore a challenge.

Antenatal distress is known to persist through the postnatal period as well. Studies have also suggested a positive association between antenatal distress and birth outcomes and antenatal/postnatal distress on MFA, temperament and cognitive-emotional and behavioral problems in the child. The impact of maternal mental health is also known to have lasting implications on child/adolescent behavior.

While research on prevalence and correlates of antenatal/postnatal depression have used cross-sectional designs, studies on mother-child interactions have been typically inferred from studies using longitudinal designs and prospective birth cohorts that provide a valuable opportunity to study mother-child dyads across time. While some papers are based on large population-based samples, others have conducted formative research on modest and convenience samples. As in most behavioral sciences research, the issue of measurement haunts this area as well. A number of measures have been used to assess psychological distress and disorders, which makes comparison difficult. They range from screening instruments such as the GHQ and EPDS to structured diagnostic interview schedules such as the MINI, SCID and the like. STAI is commonly used to assess maternal anxiety, while CBCL is commonly used to ascertain child emotional-behavioral problems.

Although studies correlating maternal distress and child behavior are disproportionately higher than paternal distress and child behavior, it is interesting to note that there is a meta analytic study in JAMA on the latter [121] but none in the former. Further, longitudinal studies examining the effects of psychosocial interventions in improving maternal and child mental health outcomes are few.

   Directions for Furure Research Top

Literature review in this area clearly indicates that studies from India on the impact of antenatal distress on birth outcomes and antenatal/postnatal distress on infant temperament and child behavior (cognitive, emotional and behavioral) problems are few. Sociocultural factors, such as preference for a male child, domestic violence and a lack of social support further accentuates a woman's risk for psychopathology in our culture and merits further study. Future research is expected to highlight the biological underpinnings of the association between antenatal and postnatal psychological distress on birth outcomes and later behavioral difficulties in children and provide neurobiological explanation for interventions aimed at improving child and maternal mental health.

While there are intervention studies and reviews on the effects of cognitive-behavior therapy (CBT) in reducing postnatal depression, [122] not many studies have examined its effects on the child. Recently, Lancet papers have demonstrated the effectiveness of community-based women's participatory groups in improving maternal and neonatal outcomes using clustered randomized trials in poor rural communities in India, [123] Bangladesh [124],[125] and Nepal. [126] Similar intervention studies may further explore the question - Does reduction in maternal distress result in improved birth outcomes and child behavior?

It is apparent that certain societal/technological transitions have also impacted pregnancy in ways that are both positive and negative. Although technological advancements in the industrialized world have rendered pregnancy and child birth safer, introduction of various assisted reproductive procedures for the treatment of infertility have resulted in hope as well as psychological turmoil prior to and during pregnancy. Assisted conception is now being shown to result in adverse psychological problems - maternal anxiety and depression and difficulties in mother-child bonding. Adolescent or teen pregnancy is also associated with adverse health outcomes for mothers and their children. There may be merit in exploring this area further.

   References Top

1.Fisher J, deMello MC, Izutsu T. Mental health aspects of pregnancy, childbirth and the postpartum period. In: Chandra PS, Herman H, Fisher J, Kastrup M, Niaz U, Rondon MB, et al., editors. Contemporary Topics in Womens Mental Health-Global Perspectives. United Kingdom: John Wiley and Sons Ltd; 2009. p. 197-226.   Back to cited text no. 1
2.Chandra PS. The interface between reproductive health and psychiatry. In: Chandra PS, Herman H, Fisher J, Kastrup M, Niaz U, Rondon MB, et al., editors. Contemporary topics in womens mental health-Global perspectives. United Kingdom: John Wiley and Sons Ltd; 2009. p. 189-96.  Back to cited text no. 2
3.Bowen A, Muhajarine N. Prevalence of antenatal depression in women enrolled in an outreach program in Canada. J Obstet Gynecol Neonatal Nurs 2006;35:491-8.  Back to cited text no. 3
4.van Bussel JC, Spitz B, Demyttenaere K. Women's mental health before, during, and after pregnancy: A population-based controlled cohort study. Birth 2006;33:297-302.   Back to cited text no. 4
5.Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, Swinson T. Perinatal depression: A systematic review of prevalence and incidence. Obstet Gynecol 2005;106:1071-83.  Back to cited text no. 5
6.Kitamura T, Yoshida K, Okano T, Kinoshita K, Hayashi M, Toyoda N, et al. Multicentre prospective study of perinatal depression in Japan: Incidence and correlates of antenatal and postnatal depression. Arch Womens Ment Health 2006;9:121-30.   Back to cited text no. 6
7.Rich-Edwards JW, Kleinman K, Abrams A, Harlow BL, McLaughlin TJ, Joffe H, et al. Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice. J Epidemiol Community Health 2006;60:221-7.  Back to cited text no. 7
8.Rubertsson C, Wickberg B, Gustavsson P, Rådestad I. Depressive symptoms in early pregnancy, two months and one year postpartum-prevalence and psychosocial risk factors in a national Swedish sample. Arch Womens Ment Health 2005;8:97-104.   Back to cited text no. 8
9.Andersson L, Sundström-Poromaa I, Wulff M, Aström M, Bixo M. Depression and anxiety during pregnancy and six months postpartum: A follow-up study. Acta Obstet Gynecol Scand 2006;85:937-44.  Back to cited text no. 9
10.Woods SM, Melville JL, Guo Y, Fan MY, Gavin A. Psychosocial stress during pregnancy. Am J Obstet Gynecol 2010;202:61.e1-7.  Back to cited text no. 10
11.Lee AM, Lam SK, Sze Mun Lau SM, Chong CS, Chui HW, Fong DY. Prevalence, course, and risk factors for antenatal anxiety and depression. Obstet Gynecol 2007;110:1102-12.  Back to cited text no. 11
12.Bunevicius R, Kusminskas L, Bunevicius A, Nadisauskiene RJ, Jureniene K, Pop VJ. Psychosocial risk factors for depression during pregnancy. Acta Obstet Gynecol Scand 2009;88:599-605.  Back to cited text no. 12
13.Faisal-Cury A, Rossi Menezes P. Prevalence of anxiety and depression during pregnancy in a private setting sample. Arch Womens Ment Health 2007;10:25-32.  Back to cited text no. 13
14.Karmaliani R, Asad N, Bann CM, Moss N, Mcclure EM, Pasha O, et al. Prevalence of anxiety, depression and associated factors among pregnant women of Hyderabad, Pakistan. Int J Soc Psychiatry 2009;55:414-24.   Back to cited text no. 14
15.Imran N. Screening of antenatal depression in Pakistan: Risk factors and effects on obstetric and neonatal outcomes. Asia-Pacific Psychiatry 2009;2:26-32.  Back to cited text no. 15
16.Gausia K, Fisher C, Ali M, Oosthuizen J. Antenatal depression and suicidal ideation among rural Bangladeshi women: A community-based study. Arch Womens Ment Health 2009;12:351-8.  Back to cited text no. 16
17.Patel V, Rodrigues M, DeSouza N. Gender, poverty, and postnatal depression: A study of mothers in Goa, India. Am J Psychiatry 2002;159:43-7.  Back to cited text no. 17
18.Bowen A, Stewart N, Baetz M, Muhajarine N. Antenatal depression in socially high-risk women in Canada. J Epidemiol Community Health 2009;63:414-6.   Back to cited text no. 18
19.Lovisi GM, López JR, Coutinho ES, Patel V. Poverty, violence and depression during pregnancy: A survey of mothers attending a public hospital in Brazil. Psychol Med 2005;35:1485-92.  Back to cited text no. 19
20.Kataoka Y, Yaju Y, Eto H, Horiuchi S. Domestic violence against women during pregnancy. Nippon Koshu Eisei Zasshi 2005;52:785-95.  Back to cited text no. 20
21.Furber CM, Garrod D, Maloney E, Lovell K, McGowan L. A qualitative study of mild to moderate psychological distress during pregnancy. Int J Nurs Stud 2009;46:669-77.  Back to cited text no. 21
22.Raymond JE. 'Creating a safety net': Women's experiences of antenatal depression and their identification of helpful community support and services during pregnancy. Midwifery 2009;25:39-49.   Back to cited text no. 22
23.Adewuya AO, Ola BA, Aloba OO, Dada AO, Fasoto OO. Prevalence and correlates of depression in late pregnancy among Nigerian women. Depress Anxiety 2007;24:15-21.  Back to cited text no. 23
24.Bilszta LC, Tang M, Meyer D, Milgrom J, Ericksen J, Buist AE. Single motherhood versus poor partner relationship: Outcomes for antenatal mental health. Aust N Z J Psychiatry 2008;42:56-65.  Back to cited text no. 24
25.Fottrell E, Kanhonou L, Goufodji S, Béhague DP, Marshall T, Patel V, et al. Risk of psychological distress following severe obstetric complications in Benin: The role of economics, physical health and spousal abuse. Br J Psychiatry 2010;196:18-25.  Back to cited text no. 25
26.Edwards B, Galletly C, Semmler-Booth T, Dekker G. Antenatal psychosocial risk factors and depression among women living in socioeconomically disadvantaged suburbs in Adelaide, South Australia. Aust N Z J Psychiatry 2008;42:45-50.  Back to cited text no. 26
27.Pottinger AM, Trotman-Edwards H, Younger N. Detecting depression during pregnancy and associated lifestyle practices and concerns among women in a hospital-based obstetric clinic in Jamaica. Gen Hosp Psychiatry 2009;31:254-61.   Back to cited text no. 27
28.Leung BM, Kaplan BJ. Perinatal depression: Prevalence, risks, and the nutrition link-A Review of the Literature. J Am Diet Assoc 2009;109:1566-75.  Back to cited text no. 28
29.Massoudi P, Wickberg B, Hwang P. Screening for postnatal depression in Swedish child health care. Acta Paediatr 2007;96:897-901.  Back to cited text no. 29
30.Buist AE, Austin MP, Hayes BA, Speelman C, Bilszta JL, Gemmill AW, et al. Postnatal mental health of women giving birth in Australia 2002-2004: Findings from the beyondblue National Postnatal Depression Program. Aust N Z J Psychiatry 2008;42:66-73.  Back to cited text no. 30
31.Monti F, Agostini F, Marano G, Lupi F. The course of maternal depressive symptomatology during the first 18 months postpartum in an Italian sample. Arch Womens Ment Health 2008;11:231-8.  Back to cited text no. 31
32.Klainin P, Arthur DG. Postpartum depression in Asian cultures: A literature review. Int J Nurs Stud 2009;46:1355-73.   Back to cited text no. 32
33.Sawyer A, Ayers S, Smith H. Pre- and postnatal psychological wellbeing in Africa: A systematic review. J Affect Disord 2010;123:17-29.   Back to cited text no. 33
34.Limlomwongse N, Liabsuetrakul T. Cohort study of depressive moods in Thai women during late pregnancy and 6-8 weeks of postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Arch Womens Ment Health 2006;9:131-8.  Back to cited text no. 34
35.Ho-Yen SD, Bondevik GT, Eberhard-Gran M, Bjorvatn B. The prevalence of depressive symptoms in the postnatal period in Lalitpur district, Nepal. Acta Obstet Gynecol Scand 2006;85:1186-92.  Back to cited text no. 35
36.Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Womens Ment Health 2006;9:343-6.  Back to cited text no. 36
37.Tannous L, Gigante LP, Fuchs SC, Busnello ED. Postnatal depression in Southern Brazil: Prevalence and its demographic and socioeconomic determinants. BMC Psychiatry 2008;8:1.  Back to cited text no. 37
38.Edwards GD, Shinfuku N, Gittelman M, Ghozali EW, Haniman F, Wibisono S, et al. Postnatal depression in Surabaya, Indonesia. Int J Ment Health 2006;35:62-74.  Back to cited text no. 38
39.Agoub M, Moussaoui D, Battas O. Prevalence of postpartum depression in a Moroccan sample. Arch Womens Ment Health 2005;8:37-43.   Back to cited text no. 39
40.Chandran M, Tharyan P, Muliyil J, Abraham S. Post-partum depression in a cohort of women from a rural area of Tamil Nadu, India. Incidence and risk factors. Br J Psychiatry 2002;181:499-504.  Back to cited text no. 40
41.Savarimuthu RJ, Ezhilarasu P, Charles H, Antonisamy B, Kurian S, Jacob KS. Post-partum depression in the community: A qualitative study from rural South India. Int J Soc Psychiatry 2010;56:94-102.  Back to cited text no. 41
42.Milgrom J, Gemmill AW, Bilszta JL, Hayes B, Barnett B, Brooks J, et al. Antenatal risk factors for postnatal depression: A large prospective study. J Affect Disord 2008;108:147-57.  Back to cited text no. 42
43.Bågedahl-Strindlund M, Monsen Börjesson K. Postnatal depression: A hidden illness. Acta Psychiatr Scand 1998;98:272-5.  Back to cited text no. 43
44.Mariam KA, Srinivasan K. Antenatal psychological distress and postnatal depression: A prospective study from an urban clinic. Asian J Psychiatry 2009;2:71-3.  Back to cited text no. 44
45.Husain N, Bevc I, Husain M, Chaudhry IB, Atif N, Rahman A. Prevalence and social correlates of postnatal depression in a low income country. Arch Womens Ment Health 2006;9:197-202.  Back to cited text no. 45
46.Rahman A, Creed F. Outcome of prenatal depression and risk factors associated with persistence in the first postnatal year: Prospective study from Rawalpindi, Pakistan. J Affect Disord 2007;100:115-21.  Back to cited text no. 46
47.Zelkowitz P, Saucier JF, Wang T, Katofsky L, Valenzuela M, Westreich R. Stability and change in depressive symptoms from pregnancy to two months postpartum in childbearing immigrant women. Arch Womens Ment Health 2008;11:1-11.  Back to cited text no. 47
48.Kheirabadi GR, Maracy MR, Barekatain M, Salehi M, Sadri GH, Kelishadi M, et al. Risk factors of postpartum depression in rural areas of Isfahan Province, Iran. Arch Iran Med 2009;12:461-7.  Back to cited text no. 48
49.Austin MP, Tully L, Parker G. Examining the relationship between antenatal anxiety and postnatal depression. J Affect Disord 2007;101:169-74.  Back to cited text no. 49
50.Lau Y, Wong DF, Chan KS. The utility of screening for perinatal depression in the second trimester among Chinese: A three-wave prospective longitudinal study. Arch Womens Ment Health 2010;13:153-64.  Back to cited text no. 50
51.Ramchandani PG, Richter LM, Stein A, Norris SA. Predictors of postnatal depression in an urban South African cohort. J Affect Disord 2009;113:279-84.  Back to cited text no. 51
52.Flores DL, Hendrick VC. Etiology and treatment of postpartum depression. Curr Psychiatry Rep 2002;4:461-6.  Back to cited text no. 52
53.McCoy SJ, Beal JM, Shipman SB, Payton ME, Watson GH. Risk factors for postpartum depression: A retrospective investigation at 4-weeks postnatal and a review of the literature. J Am Osteopath Assoc 2006;106:193-8.  Back to cited text no. 53
54.Kendall-Tackett K. A new paradigm for depression in new mothers: The central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. Int Breastfeed J 2007;2:6.  Back to cited text no. 54
55.Labbok MH. Effects of breastfeeding on the mother. Pediatr Clin North Am 2001;48:143-58.  Back to cited text no. 55
56.Rahman A, Bunn J, Lovel H, Creed F. Association between antenatal depression and low birthweight in a developing country. Acta Psychiatr Scand 2007;115:481-6.  Back to cited text no. 56
57.Maina G, Saracco P, Giolito MR, Danelon D, Bogetto F, Todros T. Impact of maternal psychological distress on fetal weight, prematurity and intrauterine growth retardation. J Affect Disord 2008;111:214-20.   Back to cited text no. 57
58.Dayan J, Creveuil C, Marks MN, Conroy S, Herlicoviez M, Dreyfus M, et al. Prenatal depression, prenatal anxiety, and spontaneous preterm birth: A prospective cohort study among women with early and regular care. Psychosom Med 2006;68:938-46.  Back to cited text no. 58
59.Patel V, Prince M. Maternal psychological morbidity and low birth weight in India. Br J Psychiatry 2006;188:284-5.  Back to cited text no. 59
60.Patel V, DeSouza N, Rodrigues M. Postnatal depression and infant growth and development in low income countries: A cohort study from Goa, India. Arch Dis Child 2003;88:34-7.  Back to cited text no. 60
61.Patel V, Rahman A, Jacob KS, Hughes M. Effect of maternal mental health on infant growth in low income countries: New evidence from South Asia. BMJ 2004;328:820-3.   Back to cited text no. 61
62.Field T, Diego M, Hernandez-Reif M. Prenatal depression effects on the fetus and newborn: A review. Infant Behav Dev 2006;29:445-55.  Back to cited text no. 62
63.Alder J, Fink N, Bitzer J, Hosli I, Holzgreve W. Depression and anxiety during pregnancy: A risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. J Matern Fetal Neonatal Med 2007;20:189-209.  Back to cited text no. 63
64.Lewis AJ, Galbally M, Opie G, Buist A. Neonatal growth outcomes at birth and one month postpartum following in utero exposure to antidepressant medication. Aust N Z J Psychiatry 2010;44:482-7.  Back to cited text no. 64
65.Oberlander TF, Warburton W, Misri S, Aghajanian J, Hertzman C. Neonatal outcomes after prenatal exposure to selective serotonin reuptake inhibitor antidepressants and maternal depression using population-based linked health data. Arch Gen Psychiatry 2006;63:898-906.  Back to cited text no. 65
66.Stewart RC. Maternal depression and infant growth: A review of recent evidence. Matern Child Nutr 2007;3:94-107.  Back to cited text no. 66
67.O'Keane V, Marsh MS. Depression during pregnancy. BMJ 2007;334:1003-5.   Back to cited text no. 67
68.Engle PL. Maternal mental health: Program and policy implications. Am J Clin Nutr 2009;89:963S-6S.  Back to cited text no. 68
69.Sedgmen B, McMahon C, Cairns D, Benzie RJ, Woodfield RL. The impact of two-dimensional versus three-dimensional ultrasound exposure on maternal-fetal attachment and maternal health behavior in pregnancy. Ultrasound Obstet Gynecol 2006;27:245-51.  Back to cited text no. 69
70.Yarcheski A, Mahon NE, Yarcheski TJ, Hanks MM, Cannella BL. A meta-analytic study of predictors of maternal-fetal attachment. Int J Nurs Stud 2009;46:708-15.   Back to cited text no. 70
71.Dipietro JA. Psychological and psychophysiological considerations regarding the maternal-fetal relationship. Infant Child Dev 2010;19:27-38.  Back to cited text no. 71
72.Hart R, McMahon CA. Mood state and psychological adjustment to pregnancy. Arch Womens Ment Health 2006;9:329-37.   Back to cited text no. 72
73.Alhusen JL. A literature update on maternal-fetal attachment. J Obstet Gynecol Neonatal Nurs 2008;37:315-28.  Back to cited text no. 73
74.Perren S, von Wyl A, Bürgin D, Simoni H, von Klitzing K. Depressive symptoms and psychosocial stress across the transition to parenthood: Associations with parental psychopathology and child difficulty. J Psychosom Obstet Gynaecol 2005;26:173-83.  Back to cited text no. 74
75.Hanington L, Ramchandani P, Stein A. Parental depression and child temperament: Assessing child to parent effects in a longitudinal population study. Infant Behav Dev 2010;33:88-95.   Back to cited text no. 75
76.Austin MP, Hadzi-Pavlovic D, Leader L, Saint K, Parker G. Maternal trait anxiety, depression and life event stress in pregnancy: Relationships with infant temperament. Early Hum Dev 2005;81:183-90.  Back to cited text no. 76
77.Yang J, Shi SX, Chen Y, Yu W, Zhu YY, Tang YF, et al. Effect of maternal antepartum psychological therapy upon early infant temperament. Zhonghua Yi Xue Za Zhi 2009;89:2038-41.  Back to cited text no. 77
78.Gunlicks ML, Weissman MM. Change in child psychopathology with improvement in parental depression: A systematic review. J Am Acad Child Adolesc Psychiatry 2008;47:379-89.  Back to cited text no. 78
79.Sohr-Preston SL, Scaramella LV. Implications of timing of maternal depressive symptoms for early cognitive and language development. Clin Child Fam Psychol Rev 2006;9:65-83.  Back to cited text no. 79
80.Stein A, Malmberg LE, Sylva K, Barnes J, Leach P; FCCC team. The influence of maternal depression, caregiving, and socioeconomic status in the post-natal year on children's language development. Child Care Health Dev 2008;34:603-12.  Back to cited text no. 80
81.Tse AC, Rich-Edwards JW, Rifas-Shiman SL, Gillman MW, Oken E. Association of maternal prenatal depressive symptoms with child cognition at age 3 years. Paediatr Perinat Epidemiol 2010;24:232-40.  Back to cited text no. 81
82.Kiernan KE, Huerta MC. Economic deprivation, maternal depression, parenting and children's cognitive and emotional development in early childhood. Br J Sociol 2008;59:783-806.  Back to cited text no. 82
83.Hollins K. Consequences of antenatal mental health problems for child health and development. Curr Opin Obstet Gynecol 2007;19:568-72.   Back to cited text no. 83
84.Robinson M, Oddy WH, Li J, Kendall GE, de Klerk NH, Silburn SR, et al. Pre- and post-natal influences on preschool mental health: A large-scale cohort study. J Child Psychol Psychiatry 2008;49:1118-28.  Back to cited text no. 84
85.Kaplan LA, Evans L, Monk C. Effects of mothers' prenatal psychiatric status and postnatal caregiving on infant biobehavioral regulation: Can prenatal programming be modified? Early Hum Dev 2008;84:249-56.  Back to cited text no. 85
86.Werner EA, Myers MM, Fifer WP, Cheng B, Fang Y, Allen R, et al. Prenatal predictors of infant temperament. Dev Psychobiol 2007;49:474-84.  Back to cited text no. 86
87.Hadley C, Tegegn A, Tessema F, Asefa M, Galea S. Parental symptoms of common mental disorders and children's social, motor, and language development in sub-Saharan Africa. Ann Hum Biol 2008;35:259-75.  Back to cited text no. 87
88.Gao W, Paterson J, Abbott M, Carter S, Iusitini L. Maternal mental health and child behaviour problems at 2 years: Findings from the Pacific Islands Families Study. Aust N Z J Psychiatry 2007;41:885-95.  Back to cited text no. 88
89.Paterson J, Carter S, Gao W, Perese L. Pacific Islands families study: Behavioral problems among two-year-old Pacific children living in New Zealand. J Child Psychol Psychiatry 2007;48:514-22.  Back to cited text no. 89
90.Van den Bergh BR, Mennes M, Oosterlaan J, Stevens V, Stiers P, Marcoen A, et al. High antenatal maternal anxiety is related to impulsivity during performance on cognitive tasks in 14- and 15-year-olds. Neurosci Biobehav Rev 2005;29:259-69.   Back to cited text no. 90
91.van den Bergh BR, Mulder EJ, Mennes M, Glover V. Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: Links and possible mechanisms. A review. Neurosci Biobehav Rev 2005;29:237-58.   Back to cited text no. 91
92.van den Bergh BR, Mennes M, Stevens V, van der Meere J, Börger N, Stiers P, et al. ADHD deficit as measured in adolescent boys with a continuous performance task is related to antenatal maternal anxiety. Pediatr Res 2006;59:78-82.  Back to cited text no. 92
93.Clavarino AM, Mamun AA, O'Callaghan M, Aird R, Bor W, O'Callaghan F, et al. Maternal anxiety and attention problems in children at 5 and 14 years. J Atten Disord 2010;13:658-67.   Back to cited text no. 93
94.Sabet F, Richter LM, Ramchandani PG, Stein A, Quigley MA, Norris SA. Low birth weight and subsequent emotional and behavioural outcomes in 12-year-old children in Soweto, South Africa: Findings from Birth to Twenty. Int J Epidemiol 2009;38:944-54.   Back to cited text no. 94
95.Ramchandani PG, Hotopf M, Sandhu B, Stein A; ALSPAC Study Team. The epidemiology of recurrent abdominal pain from 2 to 6 years of age: Results of a large, population-based study. Pediatrics 2005;116:46-50.  Back to cited text no. 95
96.Ramchandani PG, O'Connor TG, Evans J, Heron J, Murray L, Stein A. The effects of pre- and postnatal depression in fathers: A natural experiment comparing the effects of exposure to depression on offspring. J Child Psychol Psychiatry 2008;49:1069-78.  Back to cited text no. 96
97.Ramchandani PG, Stein A, O'Connor TG, Heron J, Murray L, Evans J. Depression in men in the postnatal period and later child psychopathology: A population cohort study. J Am Acad Child Adolesc Psychiatry 2008;47:390-8.   Back to cited text no. 97
98.Goodman SH, Gotlib IH. Risk for psychopathology in the children of depressed parents: A developmental approach to the understanding of mechanisms of transmission. Psychol Rev 1999;106:458-90.  Back to cited text no. 98
99.Glover V, O'Connor TG, O'Donnell K. Prenatal stress and the programming of the HPA axis. Neurosci Biobehav Rev 2010;35:17-22.  Back to cited text no. 99
100.Kammerer M, Taylor A, Glover V. The HPA axis and perinatal depression: A hypothesis. Arch Womens Ment Health 2006;9:187-96.  Back to cited text no. 100
101.O'Donnell K, O'Connor TG, Glover V. Prenatal stress and neurodevelopment of the child: Focus on the HPA axis and role of the placenta. Dev Neurosci 2009;31:285-92.  Back to cited text no. 101
102.Kinsella MT, Monk C. Impact of maternal stress, depression and anxiety on fetal neurobehavioral development. Clin Obstet Gynecol 2009;52:425-40.  Back to cited text no. 102
103.Bergman K, Sarkar P, Glover V, O'Connor TG. Maternal prenatal cortisol and infant cognitive development: Moderation by infant-mother attachment. Biol Psychiatry 2010;67:1026-32.  Back to cited text no. 103
104.Davis EP, Glynn LM, Schetter CD, Hobel C, Chicz-Demet A, Sandman CA. Prenatal exposure to maternal depression and cortisol influences infant temperament. J Am Acad Child Adolesc Psychiatry 2007;46:737-46.   Back to cited text no. 104
105.Leung E, Tasker SL, Atkinson L, Vaillancourt T, Schulkin J, Schmidt LA. Perceived maternal stress during pregnancy and its relation to infant stress reactivity at 2 days and 10 months of postnatal life. Clin Pediatr (Phila) 2010;49:158-65.  Back to cited text no. 105
106.Taylor A, Fisk NM, Glover V. Mode of delivery and subsequent stress response. Lancet 2000;355:120.   Back to cited text no. 106
107.Young AH, Gallagher P, Porter RJ. Elevation of the cortisoldehydroepiandrosterone ratio in drug-free depressed patients. Am J Psychiatry 2002;159:1237-9.  Back to cited text no. 107
108.Bystrova K, Ivanova V, Edhborg M, Matthiesen AS, Ransjö-Arvidson AB, Mukhamedrakhimov R, et al. Early contact versus separation: Effects on mother-infant interaction one year later. Birth 2009;36:97-109.  Back to cited text no. 108
109.Moore ER, Anderson GC, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2007;3:CD003519.  Back to cited text no. 109
110.Kramer MS, Fombonne E, Igumnov S, Vanilovich I, Matush L, Mironova E, et al. Effects of prolonged and exclusive breastfeeding on child behavior and maternal adjustment: Evidence from a large, randomized trial. Pediatrics 2008;121:e435-40.  Back to cited text no. 110
111.Britton JR, Britton HL, Gronwaldt V. Breastfeeding, sensitivity, and attachment. Pediatrics 2006;118:e1436-43.  Back to cited text no. 111
112.Bogen DL, Hanusa BH, Moses-Kolko E, Wisner KL. Are maternal depression or symptom severity associated with breastfeeding intention or outcomes? J Clin Psychiatry 2010;71:1069-78.  Back to cited text no. 112
113.Lau Y, Chan KS. Perinatal depressive symptoms, sociodemographic correlates, and breast-feeding among Chinese women. J Perinat Neonatal Nurs 2009;23:335-45.  Back to cited text no. 113
114.Bener A, Ehlayel MS, Alsowaidi S, Sabbah A. Role of breast feeding in primary prevention of asthma and allergic diseases in a traditional society. Eur Ann Allergy Clin Immunol 2007;39:337-43.  Back to cited text no. 114
115.Ip S, Chung M, Raman G, Chew P, Magula N, DeVine D, et al. Breastfeeding and maternal and infant health outcomes in developed countries. Evid Rep Technol Assess (Full Rep) 2007;153:1-186.  Back to cited text no. 115
116.Bergman K, Sarkar P, O'Connor TG, Modi N, Glover V. Maternal stress during pregnancy predicts cognitive ability and fearfulness in infancy. J Am Acad Child Adolesc Psychiatry 2007;46:1454-63.  Back to cited text no. 116
117.Bergman K, Sarkar P, Glover V, O'Connor TG. Quality of child-parent attachment moderates the impact of antenatal stress on child fearfulness. J Child Psychol Psychiatry 2008;49:1089-98.  Back to cited text no. 117
118.Gutteling BM, de Weerth C, Willemsen-Swinkels SH, Huizink AC, Mulder EJ, Visser GH, et al. The effects of prenatal stress on temperament and problem behavior of 27-month-old toddlers. Eur Child Adolesc Psychiatry 2005;14:41-51.  Back to cited text no. 118
119.Gutteling BM, de Weerth C, Buitelaar JK. Prenatal stress and children's cortisol reaction to the first day of school. Psychoneuroendocrinology 2005;30:541-9.  Back to cited text no. 119
120.Gutteling BM, de Weerth C, Zandbelt N, Mulder EJ, Visser GH, Buitelaar JK. Does maternal prenatal stress adversely affect the child's learning and memory at age six? J Abnorm Child Psychol 2006;34:789-98.   Back to cited text no. 120
121.Paulson JF, Bazemore SD. Prenatal and postpartum depression in fathers and its association with maternal depression: A meta-analysis. JAMA 2010;303:1961-9.  Back to cited text no. 121
122.Milgrom J, Negri LM, Gemmill AW, McNeil M, Martin PR. A randomized controlled trial of psychological interventions for postnatal depression. Br J Clin Psychol 2005;44:529-42.  Back to cited text no. 122
123.Tripathy P, Nair N, Barnett S, Mahapatra R, Borghi J, Rath S, et al. Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India: A cluster-randomised controlled trial. Lancet 2010;375:1182-92.   Back to cited text no. 123
124.Azad K, Barnett S, Banerjee B, Shaha S, Khan K, Rego AR, et al. Effect of scaling up women's groups on birth outcomes in three rural districts in Bangladesh: A cluster-randomised controlled trial. Lancet 2010;375:1193-202.   Back to cited text no. 124
125.Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, Williams EK, Seraji HR, et al. Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: A cluster-randomised controlled trial. Lancet 2008;371:1936-44.  Back to cited text no. 125
126.Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM, et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: Cluster-randomised controlled trial. Lancet 2004;364:970-9.  Back to cited text no. 126

Correspondence Address:
K Srinivasan
St. Johns Research Institute, Opp Koramangala BDA Complex, Bangalore - 560 034, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5545.91911

Rights and Permissions


  [Table 1], [Table 2]

This article has been cited by
1 Vulnerabilidad a los problemas de salud mental: Percepción de las mujeres embarazadas y de sus maridos en Surakarta, Indonesia
Yuli Kusumawati, Widyawati Widyawati, Fatwa Sari Tetra Dewi
Enfermería Clínica (English Edition). 2022; 32(5): 334
[Pubmed] | [DOI]
2 Vulnerable to mental health problems: Pregnant women and husband's perception in Surakarta, Indonesia
Yuli Kusumawati, Widyawati Widyawati, Fatwa Sari Tetra Dewi
Enfermería Clínica. 2022;
[Pubmed] | [DOI]
3 Does poor quality housing impact on child health? Evidence from the social housing sector in Avon, UK
Bilal Nasim
Journal of Environmental Psychology. 2022; : 101811
[Pubmed] | [DOI]
Inönü Üniversitesi Saglik Hizmetleri Meslek Yüksek Okulu Dergisi. 2022;
[Pubmed] | [DOI]
5 Mobile Phone Use and Acceptability for the Delivery of Mental Health Information Among Perinatal Adolescents in Nigeria: Survey Study
Lola Kola, Dolapo Abiona, Adeyinka Olufolake Adefolarin, Dror Ben-Zeev
JMIR Mental Health. 2021; 8(1): e20314
[Pubmed] | [DOI]
6 Predicting Next-Day Perceived and Physiological Stress of Pregnant Women Using Machine Learning and Explainability: Algorithm Development and Validation (Preprint)
Ada Ng, Boyang Wei, Jaya Jain, Erin Ward, Darius Tandon, Judith Moskowitz, Sheila Krogh-Jespersen, Lauren S Wakschlag, Nabil Alshurafa
JMIR mHealth and uHealth. 2021;
[Pubmed] | [DOI]
7 Management of maternal depression: Qualitative exploration of perceptions of healthcare professionals from a public tertiary care hospital, Karachi, Pakistan
Makkiya Jawed, Nousheen Akber Pradhan, Rozina Mistry, Amirah Nazir, Sualeha Shekhani, Tazeen Saeed Ali, Syed Khurram Azmat
PLOS ONE. 2021; 16(7): e0254212
[Pubmed] | [DOI]
8 Biopsychosocial Factors during the Perinatal Period: Risks, Preventative Factors, and Implications for Healthcare Professionals
Ashley J. Blount, Charmayne R. Adams, Ann L. Anderson-Berry, Corrine Hanson, Kara Schneider, Gurudutt Pendyala
International Journal of Environmental Research and Public Health. 2021; 18(15): 8206
[Pubmed] | [DOI]
Babitha E K, Geethakumary. V P, Harish. M Tharayil
[Pubmed] | [DOI]
10 Developing Biopsychosocial Research on Maternal Mental Health in Malawi: Community Perspectives and Concerns
Lucinda Manda-Taylor, Eric Umar, Robert C. Stewart, Macdonald Kufankomwe, Genesis Chorwe-Sungani, Owen C. Mwale, Demoubly Kokota, Joyce Nyirenda, Kazione Kulisewa, Martyn Pickersgill
Ethics & Human Research. 2021; 43(4): 11
[Pubmed] | [DOI]
11 The Price of Pre-adolescent Abuse: Effects of Sexual Abuse on Perinatal Depression and Anxiety
Tanitoluwa Demilade Akinbode, Cort Pedersen, Sandraluz Lara-Cinisomo
Maternal and Child Health Journal. 2021; 25(7): 1083
[Pubmed] | [DOI]
12 Evaluation of role of maternal antenatal cardiac autonomic and biochemical stress markers in prediction of psychological stress levels during postpartum period
Ashwini Kishan, Shailaja S. Moodithaya, Prasanna Kumar Shetty, Shrinivasa Bhat U.
Current Psychology. 2021;
[Pubmed] | [DOI]
13 Can lifetime exposure to intimate partner violence predict suicidality in a sample of Egyptian pregnant women: a cross-sectional study?
M. Abdelghani, A. Saad, Y. Khalil, M.A. Ibrahem, M.S. Badr, Y. Saraya, M.S. Hassan
The European Journal of Psychiatry. 2021; 35(2): 83
[Pubmed] | [DOI]
14 Early life risk and resiliency factors and their influences on developmental outcomes and disease pathways: a rapid evidence review of systematic reviews and meta-analyses
Ayah Abdul-Hussein, Ayesha Kareem, Shrankhala Tewari, Julie Bergeron, Laurent Briollais, John R. G. Challis, Sandra T. Davidge, Claudio Delrieux, Isabel Fortier, Daniel Goldowitz, Pablo Nepomnaschy, Ashley Wazana, Kristin L. Connor
Journal of Developmental Origins of Health and Disease. 2021; 12(3): 357
[Pubmed] | [DOI]
15 Cultural adaptation and psychometric validation of the Pregnancy Experience Scale–Brief version (PES-Brief) in Pakistani women with antenatal anxiety symptoms
Ahmed Zaidi, Aasia Khan, Armaan Rowther, Huma Nazir, Jamie Perin, Nida Rauf, Sidra Mumtaz, Hina Naseem, Najia Atif, Atif Rahman, Pamela Surkan, Abid Malik
SSM - Mental Health. 2021; : 100055
[Pubmed] | [DOI]
16 Maternal mental health and infant and young child undernutrition: protocol for a systematic review
Manisha Singh, Tomasina Stacey, Julie Abayomi, Padam Simkhada
BMJ Open. 2021; 11(9): e044989
[Pubmed] | [DOI]
17 Parent-reported early sleep problems and internalising, externalising and dysregulation symptoms in toddlers
Isabel Morales-Muñoz, Sakari Lemola, Outi Saarenpää-Heikkilä, Anneli Kylliäinen, Pirjo Pölkki, Tiina Paunio, Matthew R Broome, E. Juulia Paavonen
BMJ Paediatrics Open. 2020; 4(1): e000622
[Pubmed] | [DOI]
18 Psychological aspects of COVID-19
Caroline Stamu-O’Brien, Simona Carniciu, Elizabeth Halvorsen, Mohammad Jafferany
Journal of Cosmetic Dermatology. 2020; 19(9): 2169
[Pubmed] | [DOI]
19 Maternal nutritional status mediates the association between maternal age and birth outcomes
Abdulhalik Workicho, Tefera Belachew, Alemayehu Argaw, Alemzewed Roba, Shibani Ghosh, Meghan Kershaw, Carl Lachat, Patrick Kolsteren
Maternal & Child Nutrition. 2020; 16(4)
[Pubmed] | [DOI]
20 Childhood and adolescent mental health of NICU graduates: an observational study
Andreea Chiorean, Calan Savoy, Karen Beattie, Salhab el Helou, Maysoon Silmi, Ryan J Van Lieshout
Archives of Disease in Childhood. 2020; 105(7): 684
[Pubmed] | [DOI]
21 Vaginal delivery or caesarean section – Severity of early symptoms of postpartum depression and assessment of pain in Polish women in the early puerperium
Michalina Ilska, Ewa Banas, Katarzyna Gregor, Anna Brandt-Salmeri, Aleksander Ilski, Wojciech Cnota
Midwifery. 2020; 87: 102731
[Pubmed] | [DOI]
22 Enhanced Doula Support to Improve Pregnancy Outcomes Among African American Women With Disabilities
Christan Horton, Susan Hall
The Journal of Perinatal Education. 2020; 29(4): 188
[Pubmed] | [DOI]
23 ‘Good health means being mentally, socially, emotionally and physically fit’: women’s understanding of health and ill health during and after pregnancy in India and Pakistan: a qualitative study
Mary McCauley, Ayesha Rasheeda Avais, Ritu Agrawal, Shumaila Saleem, Shamsa Zafar, Nynke van den Broek
BMJ Open. 2020; 10(1): e028760
[Pubmed] | [DOI]
24 A systematic review regarding women’s emotional and psychological experiences of high-risk pregnancies
Nazeema Zainura Isaacs, Michelle Glenda Andipatin
BMC Psychology. 2020; 8(1)
[Pubmed] | [DOI]
25 Healthy mothers, happy children. Prenatal assessment for psychosocial factors in public hospitals of the Republic of Cyprus
Eleni Hadjigeorgiou, Yianna Koliandri, Andria Spyridou
Minerva Psichiatrica. 2020; 61(4)
[Pubmed] | [DOI]
26 Antenatal Depressive Symptoms and Neurodevelopment Outcomes in Children at 30 Months. A Study From South India
Susan Thomas, Emelia Vigil, Tinku Thomas, David C. Bellinger, Asha Ramthal, Anura V. Kurpad, Christopher P. Duggan, Krishnamachari Srinivasan
Frontiers in Psychiatry. 2020; 11
[Pubmed] | [DOI]
27 Comorbid Anxiety and Depression among Pregnant Pakistani Women: Higher Rates, Different Vulnerability Characteristics, and the Role of Perceived Stress
Shahirose Sadrudin Premji, Sharifa Lalani, Kiran Shaikh, Ayesha Mian, Ntonghanwah Forcheh, Aliyah Dosani, Nicole Letourneau, Ilona S. Yim, Shireen Shehzad Bhamani
International Journal of Environmental Research and Public Health. 2020; 17(19): 7295
[Pubmed] | [DOI]
28 Cohort Profile: Perinatal depression and child socioemotional development ; the Bachpan cohort study from rural Pakistan
Siham Sikander, Ikhlaq Ahmad, Lisa M Bates, John Gallis, Ashley Hagaman, Karen O’Donnell, Elizabeth Louise Turner, Ahmed Zaidi, Atif Rahman, Joanna Maselko
BMJ Open. 2019; 9(5): e025644
[Pubmed] | [DOI]
29 The intergenerational effects of war on the health of children
Delan Devakumar,Marion Birch,David Osrin,Egbert Sondorp,Jonathan CK Wells
BMC Medicine. 2014; 12(1): 57
[Pubmed] | [DOI]
30 Depression, anxiety and stress among pregnant Migraineurs in a pacific-northwest cohort
Olivia R. Orta,Bizu Gelaye,Chungfang Qiu,Lee Stoner,Michelle A. Williams
Journal of Affective Disorders. 2014;
[Pubmed] | [DOI]
31 Nutritional Factors Associated with Antenatal Depressive Symptoms in the Early Stage of Pregnancy Among Urban South Indian Women
Ammu Lukose,Asha Ramthal,Tinku Thomas,Ronald Bosch,Anura V. Kurpad,Christopher Duggan,Krishnamachari Srinivasan
Maternal and Child Health Journal. 2013;
[Pubmed] | [DOI]
32 Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?
Zulfiqar A Bhutta,Jai K Das,Arjumand Rizvi,Michelle F Gaffey,Neff Walker,Susan Horton,Patrick Webb,Anna Lartey,Robert E Black
The Lancet. 2013; 382(9890): 452
[Pubmed] | [DOI]