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A mother’s mental health can have substantial impacts on her pregnancy, delivery and her baby’s health.  Previous studies have demonstrated a link between depression and/or anxiety and higher rates of preterm birth and lower birth weight. Most studies, however, do not systematically assess traumatic life events.   This is a significant oversight given that depression and anxiety often occur together, and may be a direct consequence of trauma exposure.   Childhood maltreatment, in particular, is associated with an increased risk for concurrent depression and anxiety disorders in adulthood (Putnam, Harris, Putnam, 2013).  There is also evidence that childhood trauma may alter the development of neuroendocrine systems that are relevant for pregnancy and delivery as well as a healthy mother-infant attachment. 
Previous studies have focused on a single type of trauma, used cross-sectional designs, or failed to control for confounding factors such as depression or anxiety.  In this study, we used a longitudinal design, assessed multiple types of trauma exposure and their onset, and controlled for common confounding factors.   We hypothesized that women with a trauma history would be more likely to experience adverse obstetric outcomes, defined as lower birth weight, earlier gestational age and delivery complications.   We also wanted to examine if the number of traumas experienced and the age of first trauma predicted adverse labor and delivery. 
We enrolled 358 pregnant women during the first trimester of pregnancy; these women received their obstetrical care from a university hospital-based practice serving a predominantly low-income, inner-city population.  The women were medically healthy, of low to medium obstetric risk, but were considered to be high psychosocial risk.   We used consecutive sampling to enroll an approximately equal numbers of women with and without affective symptoms, defined as scoring above standard cut-offs for depression or anxiety from widely used questionnaires. 
Participants were assessed by interviewers twice in pregnancy at 18 weeks (n=358) and 32 weeks gestation (n=348) when they completed a battery of health and psychosocial questionnaires as well a psychiatric clinical diagnostic interview (SCID).  Detailed medical, clinical and sociodemographic data were collected via interview and medical records. 
Traumatic events were elicited through the PTSD section of the SCID.  We collected a description of each event that a woman had experienced throughout her life and the age at which is occurred.  Diagnoses of lifetime and current episodes of depression and anxiety were made according to DSM-IV TR and continuous symptoms of depression and anxiety were assessed from the widely used questionnaires. 
Over a third of the sample (n=139, 38.8%) reported experiencing at least one traumatic event in their lifetime.  This rate of trauma is similar to previous studies of low-income pregnant women (29% - 61%), providing further evidence that a history of trauma is common among impoverished pregnant women. 
Similar to prior studies, we also found that a lifetime trauma history, especially childhood trauma, was significantly associated with adverse or potentially adverse reproductive outcomes, including younger age at first pregnancy, greater number of pregnancies and history of miscarriage compared to women who were not trauma exposed.  Trauma significantly increased the risk of lifetime and prenatal depression and anxiety, which are independently associated with a range of adverse biological and psychiatric maternal and child outcomes. 
In our study, depression and anxiety predicted significantly lower birth weight but trauma did not have a direct effect on birth weight, gestational age or obstetric complications. Results from a hierarchical regression analysis, however, found that lifetime trauma history and, in particular, having a first trauma exposure during childhood (< 18 years of age) magnified the risk of have a low birth weight baby if the mother was depressed or anxious.  This indicates that childhood trauma, which increases a woman’s lifetime risk for a depressive or anxiety disorder (Putnam, Harris, Putnam, 2013), also synergistically interacts with a mother’s anxiety and/or depression to increase her risk for a low birth weight baby. 
A growing body of evidence indicates that trauma, depression and anxiety are complexly interconnected to produce adverse obstetric outcomes.  Current practice guidelines encourage screening pregnant women for depression, anxiety and intimate partner violence (ACOG, 2015, ACOG, 2012).  In order to reduce the time and effort required to add a third screen for early trauma exposure it should be possible to add childhood trauma questions to the domestic violence questionnaire.  Ideally, a single screening questionnaire covering the essential anxiety, depression and trauma items could be developed that would reduce the response burden on patients, OB GYN practitioners, and other primary care providers.  Positive screens for any or all of the above would be referred to mental health providers for further evaluation and treatment as warranted. 
Our findings supports a life course perspective to obstetric health and suggests possible mechanisms including the involvement of neuroendocrine systems such as dysregulation of the HPA axis and/or reduction in oxytocin secretion (Noll et al., 2007;Ditzen, Bradley & Heim, 2012).  They also support a broader public health approach to the screening and prevention of childhood trauma (IOM and NRC, 2016).

Reference Article

Blackmore ER, Putnam FW, Pressman EK, et al. The Effects of Trauma History and Prenatal Affective Symptoms on Obstetric Outcomes. Journal of Traumatic Stress. 2016;29(3):245-252 

Author Biographies

Emma Robertson Blackmore, PhD
is an Assistant Professor at the University of Florida, Jacksonville.  Her research focuses on the biological and clinical correlates of perinatal mood disorders.
Frank W. Putnam, MD is a child and adolescent psychiatrist, Professor of Psychiatry at the University of North Carolina at Chapel Hill, and Professor Emeritus of Pediatrics at Cincinnati Children’s Hospital, who has devoted his 35-year career to understanding, treating and preventing child maltreatment. The author/co-author of over 200 scientific articles and three books, his current research interests include developing implementation strategies for the large-scale dissemination of evidence-based interventions for child maltreatment and maternal depression and investigating the contribution of childhood trauma to the symptomatic heterogeneity of mental disorders.  

Thomas G. O'Connor, PhD is Professor in the Department of Psychiatry and is Director of the Wynne Center for Family Research at the University of Rochester Medical Center, New York.  His research focuses on the mechanisms by which early stress exposures, including prenatal maternal anxiety and caregiving stress, may persistently shape children's behavioral and biological health. His work encompasses epidemiological, observational and experimental designs and incorporates behavioral, physiological, genetic, and immunological methods.

References Cited

Ditzen, B., Bradley, B., Heim, CM (2012).  Oxytocin and pair bonding: on possible influences during the life course. Biological Psychiatry, 72(3),e3-4. doi: 10.1016/j.biopsych.2012.01.029.
IOM (Institute of Medicine) and NRC (National Research Council). (2014).  New
directions in child abuse and neglect research.  Washington, DC: The National Academies Press.
Putnam, K.T., Harris, W.H., Putnam, F.W. (2013).  Synergistic Childhood Adversities and Complex Adult Psychopathology.  Journal of Traumatic Stress26, 435-442.  doi: 10.1002/jts.21833.
Noll, J.G., Schulkin, J., Trickett, P.K., Susman, E.J., Breech, L., & Putnam, F.W. (2007). Differential pathways to preterm delivery in sexually abused and comparison women.  Journal of Pediatric Psychology, 32, 10, 1238-1248.