Impact of perinatal maternal depression on child development.

Background: As India reduced maternal mortality by 50% in the last decade, the mental health of mothers has slowly started catching our attention. Increased participation of women in the economic sector and awareness of women's rights has added to this process. Perinatal depression has been associated with negative birth outcomes and poor child development. The paucity of research from eastern India poses challenges for physicians and hinders effective medical interventions. Aim: To investigate the effect of antenatal and postnatal depression on child development at 12 months of age. Method: In total, 174 mothers were administered Bengali Edinburgh Postnatal Depression Scale (EPDS-B) for assessment of antenatal and postnatal depression. Developmental Assessment Scale in Indian Infants (DASII) was administered to assess the motor and cognitive development of their children (n = 153) at 12 months. Result: The prevalence of antenatal and postnatal depression was 28.7% and 16.7%, respectively. Antenatal depression predicted postnatal depression (b = 0.631). Mothers with AD scored significantly low on family support measures (P = 0.012). Children of mothers with AD had low motor and cognitive attainment at the age of 12 months (P = 0.022).
Conclusion: Screening and treatment of mental health need to be included in the antenatal care routine to facilitate appropriate child development. Copyright:

INTRODUCTION

Pregnancy brings about a huge transition in women’s life. Traditionally, it is presumed to be uniquely fulfilling and emotionally satisfying—so much so that women may feel pressured to be happy.[1] However, harsh social and material realities can force women into mental distress during pregnancy.[12] Coping with the physical[3] and physiological[4] changes that take place to accommodate the growing fetus can also bring about unprecedented emotional distress.[345] Consequently, non-psychotic mental disorders such as stress, anxiety, and depression are quite common in the antenatal as well as postnatal stages.[67] According to a recent review, psychiatric illness in Indian women has escalated in general and in the perinatal period in particular.[8]

Both antenatal[9] and postnatal[10] emotional distress can result in negative birth outcomes and poor developmental attainment.[91011] However, while postnatal mental health issues have received significant attention, antenatal mental health problems remain far less explored[12] despite it being no less common than postnatal mental health illnesses.[1314] The medical myth regarding hormonal protection against psychological distress during pregnancy,[15] coupled with social expectations from expecting mothers may cumulate to disregard and suppress the personal experience of emotional distress. Consequently, the effect of antenatal emotional distress on birth outcomes and development of children remains relatively unexplored.

So far, no study from eastern India has been conducted to investigate how non-psychotic mental disorders in pregnant women might influence the growth and development of their children. A systematic review of Indian studies on antenatal depression (AD) draws attention toward the dearth of studies from the eastern part (n = 0).[14] The paucity of research from eastern India (n = 3) has also been noted in a systematic review and meta-analysis of postpartum depression (PND) in India.[16]

Perinatal depression, defined as depression occurring in a woman anytime during her pregnancy and within 12 months of delivery, has a wide variability in prevalence, predictors, and impacts in different populations.[17] Consequently, population-specific data can help plan effective intervention measures. In this study, we investigated the effect of AD and PND on children’s developmental parameters. We also explored the association between AD and PND.

METHODS

Participants: Literate mothers between 12 and 36 weeks of pregnancy attending the antenatal clinic at the Institute of Post Graduate Medical Education and Research and SSKM Hospital, Kolkata between March 1 and April 30, 2019 were invited to participate in this study. Mothers with twin pregnancies or with chronic medical or psychotic illnesses were excluded from the study. Participants signed an informed consent form approved by the institutional ethics committee. In total, 174 mothers and their babies (male: 93, female: 81) participated in this study [Table1]. Only 153 mothers turned up with their babies for the third session, which was conducted 1 year after delivery.

Table 1

Demographic details of participants

	n>	Range>	Minimum>	Maximum>	Mean>	SD>
Age	174	24	18	42	25.73	4.279
Education	174	17	0	17	10.39	4.315
Socioeconomic status	174	5	1	6	3.74	0.711
Family support	174	32	0	32	5.90	3.627

Materials: A semi-structured questionnaire was used to record the age, literacy, occupation, and family income of the participants. Modified Kuppuswamy socioeconomic scale[18] was used to evaluate socioeconomic status. Family support scale (FSS)[19] was used to find out the extent of support these mothers received from spouse, family members, relatives, friends, neighbors, and community in the perinatal period.

Bengali version of the Edinburgh Postnatal Depression Scale (EPDS-B)[2021] was administered to assess AD and PND. It is an adaptation of the original English version of EPDS. The EPDS is a self-rated questionnaire where participants are asked to respond to 10 questions that assess objectively how they felt in the last 7 days. The responses are coded from 0 to 3, with 0 meaning no distress and 3 meaning severe distress. A summed-up figure is the final score. The minimum score is 0 and the maximum 30. In this study, a score of 13 was considered as the threshold.[21]

EPDS has proved to be an effective tool for assessing PND in the Indian population.[22] Although EPDS was designed to assess PND, several studies have used it to measure AD as well.[2324] Hence, we used EPDS-B to assess both AD and PND.

Developmental Assessment Scale in Indian Infants (DASII)[25] was administered to the children at 12 months to test their motor and cognitive development. DASII was adapted from the Bayley Scale of Infant Development (BSID).[26] The DASII is an effective and comprehensive tool that has been standardized on Indian babies by Dr. Phatak. It is applicable for infants between 0 and 30 months. It involves guided play activity using play material designed for the purpose. Independent motor and mental developmental quotients are generated based on the performance of the babies during the test.

Procedure: The study was conducted in three sessions. In the first session, participants (pregnant mothers between 12 and 36 weeks of pregnancy) completed the demographic datasheet and EPDS-B in a quiet room of the hospital. The second session was conducted 3–6 months after delivery. The EPDS and FSS were administered to all the participating mothers in this session. The third session was conducted 1 year after the delivery. Developmental Assessment Scale in Indian Infants (DASII) was administered to the infants of the participating mothers in this session. A psychologist trained and certified in DASII collected the data in the designated room of the early intervention clinic.

Statistical analysis

Data were analyzed using SPSS Statistics 21.0 (IBM Corp., Armonk, NY, US). Descriptive statistics and t tests were used to characterize the demographic parameters. One-way MANCOVA was conducted with motor and cognitive scores of the babies as the dependent variables, group (mothers with and without AD) as the independent variable, and PND as the covariate. Another one-way MANCOVA was conducted with motor and cognitive scores of the babies as the dependent variables, group (mothers with and without PND) as the independent variable, and AD as the covariate. Linear regression was also carried out to investigate if there exists a linear relationship between AD and PND.

RESULT

It was found that 28.7% (50/174) of the mothers had AD and 16.7% (29/174) had PND. In total, 31.6% (55/174) had perinatal depression [Figure 1].

Figure 1

Prevalence of AD, PD, and perinatal depression

AD (b = 0.631, t = 10.663, P < 0.001) predicted PND in pregnant women (F (1, 172) = 113.7, P < 0.001, R2 = 0.398, Cohen’s f2 = 0.661).

There was no significant difference between mothers with and without AD in age (P = 0.830), education (P = 0.655), and socioeconomic status (P = 0.987). However, mothers with AD scored significantly low on family support measures (P = 0.012) [Table 2]. Mothers with and without PND were comparable in age (P = 0.339), education (P = 0.294), socioeconomic status (P = 0.476), and family support measures (P = 0.145).

Table 2

Details of women with and without perinatal depression and their babies

	Perinatal depression	n	Mean	Sth. Deviation	t	P
Age	No perinatal depression	119	25.78	3.981	0.233	0.816
	Perinatal depression	55	25.62	4.901
Education	No perinatal depression	119	10.71	4.251	1.459	0.146
	Perinatal depression	55	9.69	4.409
Socioeconomic status	No perinatal depression	119	3.73	0.756	−0.280	0.780
	Perinatal depression	55	3.76	0.607
Family support	No perinatal depression	119	6.36	3.864	2.525	0.012
	Perinatal depression	55	4.89	2.833
Gestation age in weeks	No perinatal depression	119	36.07	3.124	−1.123	0.263
	Perinatal depression	55	38.67	3.672
Birth weight in g	No perinatal depression	119	2431.71	775.164	0.686	0.494
	Perinatal depression	55	2342.38	848.944

There was a statistically significant difference between the children of mothers with and without AD on the combined developmental parameters after controlling for PND, F (2, 149) = 3.899, P = 0.022, Wilks’ L = 0.950, and partial h2 = 0.050. Pairwise comparisons with Bonferroni correction indicated that the mean cognitive development scores of children of mothers without AD (M = 93.9, SD = 11.3) was significantly higher than the children of mothers with AD (M = 86.9, SD = 11.6) (P = 0.006, Cohen’s d = 0.61) [Figure 2]. The mean motor development scoresof children of mothers without AD (M = 95.7, SD = 12.4) were higher than those of the children of mothers with AD (M = 90.4, SD = 12.5). This difference was not statistically significant (P = 0.325), but the effect size was not insignificant (Cohen’s d = 0.427).

Figure 2

Cognition and motor development with or without antenatal depression

There was no statistically significant difference between the children of mothers with and without PND on the combined developmental parameters after controlling for AD, F (2, 149) = 1.450, P = 0.238, Wilks’ L = 0.981, and partial h2 = 0.019.

DISCUSSION

We investigated the impact of maternal depression on the motor and cognitive development of children. The prevalence of perinatal depression was found to be 31.6%. This rate is higher than that found in the studies from north India (14%)[27] and central India (12.4%).[17]

The prevalence of AD in this study was found to be 28.7%. The result is quite consistent with that reported by Maheshwari et al.[28] (AD = 24.8%) and Rehman et al.[29] (AD = 26%), who studied pregnant women attending antenatal clinics of urban/tertiary health care centers in Bangalore and Srinagar, respectively. Another study done in a tertiary care center of Karnataka reported a higher prevalence of AD (36.75%).[30] However, this study investigated a wider age range of pregnant women (15–45) than ours (18–42). A higher prevalence of AD (65%) was reported in a study from south India which investigated rural women near Chennai.[31] It may be noted that living in rural areas has been associated with an increased risk of perinatal mental illness.[32] The prevalence rate was low in Indian studies that used the Beck Depression Inventory Scale (BDI) to assess AD.[3334] The prevalence rate found in our study (28.7%) is close to the one reported for Southeast Asian women (22.6%) in a recent meta-analysis study that used pooled samples, but it is higher than the country average (17.74%) reported in the same study.[35]

The prevalence of PND was found to be 16.7% in this study. This is lower than the pooled prevalence of PND in eastern India (23%) and the pooled prevalence of PND calculated for Indian women (22%).[16] However, two of the three studies from eastern India that were included in the meta-analysis had assessed PND within 2 weeks of delivery. Thus, the prevalence of PND in eastern India may be higher as the researchers had conflated baby blues with PND. AD predicted PND. This is consistent with the findings reported by Cury and Menezes, who investigated the association between AD and PND in the Brazilian population.[36] This is also consistent with the results by Kingston et al.,[37] who reviewed 2448 studies to investigate the association between antenatal and postnatal psychological distress.

Mothers with AD scored significantly low on family support measures. Though we measured AD during pregnancy and family support during the first 3–6 months postpartum, we anticipated that support from family and friends would remain the same in both antenatal and postnatal periods. This is consistent with several other studies that suggest the importance of family support in improving the mental health of pregnant women.[121438] Lack of social and partner support was identified as the second most commonly associated risk factor for antenatal depression in four systematic reviews encompassing 47 primary studies consisting of around 226,000 participants.[39]

Children of mothers with AD had low motor and cognitive attainment at the age of 12 months. The difference in cognitive development was statistically significant. This is again quite in line with Kingston et al.[37] The authors stated that most studies obtained medium effect sizes for the association between antenatal psychological distress and cognitive development.

Our result is consistent with a growing body of literature that reports altered uterine physiology in response to maternal psychological state.[40] Maternal depression and anxiety can affect intrauterine artery blood flow. Increased uterine artery resistance restricts uterine blood flow, cutting down the supply of oxygen and nutrients to the growing fetus. This may affect the growth and development of the fetus. Also, maternal stress during pregnancy may increase the levels of cortisol and corticotrophin-releasing hormone in the mother and subsequently in fetal circulation. These hormones may contribute to behavior disorders and cognitive deficits, including attention and learning disorders.

There was no significant effect of PND on the developmental attainments of children when the effect of AD was controlled. It may be noted that the effect of PDD on developmental parameters has been reported to be inconclusive. Variable effect sizes were reported for the association between postnatal mental distress and cognitive development by Kingston et al.[37] However, further research is needed to confirm the long-term effects of PND on motor and cognitive development. A strong correlation between AD and PND suggests that the effect of PND on child development observed by some researchers may be primarily due to AD.

Small sample size, using a screening tool instead of a diagnostic test, and having the same cut-off scores for antenatal and PND were some of the limitations of the present study. Moreover, we did not consider all the factors such as planned versus unplanned pregnancy, multigravidity, history of abortion, phase of pregnancy, employment status, gender preference, domestic violence, and medication, which could affect maternal depression. We did not assess other non-psychotic mental health parameters such as anxiety and stress, which are reported to affect developmental attainments. Despite these limitations, this study provides much-needed preliminary information on perinatal mental illness among women in eastern India and its impact on child development. Future investigations on larger samples including all the important risk factors will help lend further insight.

CONCLUSION

The high prevalence of AD, its adverse effect on developmental attainments of children, and its positive correlation with PND indicate a pressing need to include mental health screening in antenatal care routine. An adequate and timely intervention of AD can help ameliorate the burden of postpartum depression and adverse child developmental attainments associated with perinatal depression.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.