Child Psych and Dev - Prenatal and Postpartum Maternal Psychological Distress and Infant Development

Child Psychiatry Hum Dev (2012) 43:683714
DOI 10.1007/s10578-012-0291-4
REVIEW PAPER
Prenatal and Postpartum Maternal Psychological

Distress and Infant Development: A Systematic Review
Dawn Kingston Suzanne Tough Heather Whitfield
Published online: 10 March 2012

Springer Science+Business Media, LLC 2012
Abstract Infant development plays a foundational role in optimal child development and
health. Some studies have demonstrated an association between maternal psychological
distress and infant outcomes, although the main emphasis has been on postpartum
depression and infant-maternal attachment. Prevention and early intervention strategies
would benefit from an understanding of the influence of both prenatal and postpartum
maternal distress on a broader spectrum of infant developmental outcomes. We conducted
a systematic review of studies assessing the effect of prenatal and postpartum maternal
psychological distress on five aspects of infant development: global; cognitive; behavioral;
socio-emotional; and psychomotor. These findings suggest that prenatal distress can have
an adverse effect on cognitive, behavioral, and psychomotor development, and that post-
partum distress contributes to cognitive and socio-emotional development.
Keywords Infant development Maternal psychological distress

Systematic review Maternal psychosocial care
Background
Healthy child development has been viewed as a necessary foundation for reducing health
and social inequities across the life course [1, 2]. Early years programming has been an
important strategy for the prevention of developmental problems, largely influenced by an
increasing understanding of environmental influences on the neuroplasticity of the young
D. Kingston (&)
Faculty of Nursing, Rm 5-258 Edmonton Clinic Health Academy, University of Alberta,
11405-87th Avenue, Edmonton, AB T6G 1C9, Canada
e-mail: Dawn.Kingston@ualberta.ca
S. Tough
Faculty of Paediatrics and Community Health Sciences, Centre for Child, Family,
and Community Research, University of Calgary, Calgary, AB, Canada
H. Whitfield
McMaster University, Hamilton, ON, Canada
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684 Child Psychiatry Hum Dev (2012) 43:683714
brain [2]. From an economic standpoint, investment in the early years in the form of quality
education, child development, and parenting programs has shown greater return than
investments allocated post-kindergarten [2]. Yet, based on the Early Development Index
(EDI), 2530% of children in Canada enter school with some form of physical, socio-
emotional, or cognitive-language delay, and Canadian trends reveal an increase in
developmental vulnerability in several provinces over the past decade [2, 3]. Advocates
suggest that the decline in healthy child development at a time when there has been
increased attention in this area implies that greater investment in early years services is
required [2]. However, it also compels us to consider earlier influences in a childs life that
have not been sufficiently addressed to date.
Tandem to the movement to develop and enhance universal services to support healthy
early years development has been a growing interest in the long-term effects of risks that
occur during pregnancy and the postpartum period on child development. Although
maternal health may represent a key point of early, upstream intervention, the evidence
surrounding early life factors has not been translated into prevention/intervention strategies
or policy. The recently released Marmot Review, Fair Society, Healthy Lives, proposed a
second revolution in the early years to increase the support of parents starting in
pregnancy and continuing through primary school [4]. This report recommended giving
priority to pre- and post-natal interventions that reduce adverse outcomes of pregnancy and
infancy (p. 16) [4]. An earlier report by the World Health Organizations Commission of
Social Determinants stated, Implementing a more comprehensive approach to early life
includescomprehensive support to and care of mother before, during, and after preg-
nancyincluding interventions that help to address prenatal and postnatal maternal mental
health problems (p. 53) [5]. These documents formally acknowledge the important
influence of maternal health during the prenatal and postpartum periods in child health and
development.
Given that maternal psychological distress (e.g., stress, anxiety, depression) in preg-
nancy is common [6, 7], and a substantial proportion of women who experience distress in
pregnancy or during the postpartum period continue to have symptoms into their childs
early years [810], maternal psychological distress represents a prevalent, enduring, and
modifiable influence that may significantly impact fetal and child development. Interest in
the effect of maternal psychological distress on infant outcomes and its underlying
mechanisms has surged over the past two decades. While much of the early research in this
field focused on studying the impact of postpartum depression (PPD) on outcomes such as
maternal-infant interaction and infant temperament, more recent studies have explored the
effects of different forms of maternal psychological distress and their timing on a broader
array of infant outcomes, including infant development. Some key findings of this body of
evidence suggest that: (a) developmental delay in infancy is associated with delay in later
childhood stages [11]; (b) predictors of neurodevelopmental delay can be detected during
the first 10 months of life [12, 13]; (c) infant developmental delay and its causes are
amenable to early intervention targeted at the infant and its family [14, 15]; and
(d) intervention aimed at reducing maternal psychological distress can lower the risk of
adverse infant developmental outcomes [16].
Very few reviews have synthesized evidence relating prenatal and postpartum maternal
psychological distress to infant development. Of these, few are methodologically rigorous,
systematic reviews; most address a single form of maternal distress during the prenatal or
postpartum period; and, the majority focus on older children. Given the importance of the
role of infant development in future child development and health, a substantive review of
the impact and magnitude of effect of maternal prenatal and postpartum psychological
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Child Psychiatry Hum Dev (2012) 43:683714 685
distress on infant development would inform prevention, early intervention, and policy
strategies for reducing the risks of developmental delay that occur in a childs earliest
environment.
Objectives
The objectives of this systematic review were to: (a) assess the relationship between
prenatal and postnatal maternal psychological distress and infant development from birth
to 12 months; (b) estimate the magnitude of effect of the relationship between various
forms of maternal psychological distress and infant developmental outcomes; (c) describe
the quality of the evidence for the relationship between maternal psychological distress and
infant development; (d) identify gaps in the existing evidence; (e) describe the implications
of the review findings; and (f) formulate research, clinical, and policy related
recommendations.
Methods
Inclusion and Exclusion Criteria and Definitions
Studies were included in this review if the: (a) exposure was any form of maternal psy-
chological distress (e.g., anxiety, depression, stress, psychological distress) occurring
during pregnancy or the postpartum period (i.e., 1 year following birth); (b) outcome was a
measure of child development that was assessed from birth up to and including 12 months
and included global indices of development, behavior, cognitive development, socio
socio-emotional development, and psychomotor development; (c) study recruited women
and children from developed countries; (d) study was published in English; and, (e) study
was a primary study that was published between 1990 and 2010. Studies were excluded
from this review if: (a) maternal distress during the prenatal or postpartum period was part
of a composite variable that extended beyond 1 year postpartum; (b) the exposure was a
pharmacologic treatment for maternal distress; or, (c) the study did not have a comparison
group.
The categorization of infant outcomes (e.g., as cognitive or behavioral) was based on
the investigators own descriptions. A global index of development combined a number of
developmental components (e.g., socio-emotional, behavioral, cognitive development) into
a single index (e.g., Child Behavior Checklist Total Score; Bayley Scales of Infant
Development). Trimesters of pregnancy were categorized as first (013 weeks gestation),
second ([1326 weeks), and third ([2640? weeks). Effect sizes were based on Cohens
guidelines (trivial when r \ 0.10; small when d = 0.20 or r = 0.100.30; medium when
d = 0.50 or r = 0.300.50; and, large when d = 0.80 or r C 0.50) [17]. Odds ratios (ORs)
of \1.7 were defined as small, [1.72.5 were medium, and [2.5 were large [17].
Search Strategy, Title and Abstract Review, Critical Appraisal, Data Extraction,
Analysis
The search strategy was developed in consultation with a university-based librarian. Five
electronic databases were searched, including Embase, CINAHL, Eric, PsycInfo, and
Medline. Reference lists were reviewed and key journals were hand-searched. The search
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encompassed the period from January 1, 1990, to August 10, 2010. The detailed search
strategy is available from the authors. The titles and/or abstracts of each article were
reviewed independently by 2 individuals based on the a priori inclusion and exclusion
criteria. Disagreements related to inclusion or exclusion were resolved by discussion and
consensus. In cases where decisions could not be reached based on title or abstract review,
the full-text version of the article was retrieved and reviewed. A modified version of the
critical appraisal form for observational studies developed by the Scottish Intercollegiate
Guideline Network (http://www.sign.ac.uk/methodology/checklists.html) was used to
assess the quality of each article. Each study was appraised based on its study design,
potential for selection bias, confounders, withdrawals and dropouts, follow-up, blinding,
and measurement of exposures and outcomes. The quality of the articles was assessed by 2
independent reviewers with experience in critical appraisal. Disagreements were resolved
by consensus. Data were extracted by one reviewer using a standardized data extraction
form that was developed for this review. Studies were also reviewed for the potential to
conduct a meta-analysis.
Results: Overview
The search strategy yielded a total of 17,792 studies with 18 studies having infant out-
comes (Fig. 1). These studies recruited participants from a variety of different countries
(e.g., New Zealand, Finland, Netherlands, US, Australia, Sweden, Israel). The majority of
these studies were published in the past decade (n = 16) with over 60% of these being
published in the past 5 years (20052010). All but 2 studies were longitudinal and the
majority (n = 12) represented community-based samples. Among these 18 studies, most
evaluated the effect of maternal distress on infant cognitive (n = 7) or psychomotor
(n = 7) development, with fewer assessing the effects on global indices of infant devel-
opment (n = 2), behavior (n = 2), and socio-emotional development (n = 4). There was a
fairly even distribution of the number of studies that assessed prenatal (n = 7) and post-
partum maternal distress (n = 8), with 3 studies addressing both.
We examined each infant outcome for the potential to conduct a meta-analysis. The
diversity of the outcomes (e.g., dichotomous and continuous measures) precluded meta-
analysis. We also reviewed the studies for the potential to calculate mean differences
where outcomes were dichotomized, but insufficient data were available. As such, a
thorough qualitative analysis was conducted. We included all studies in our qualitative
analysis because few studies met the inclusion criteria (n = 18), particularly across the
various forms of infant development; in addition, their inclusion enabled us to qualitatively
describe the heterogeneity that existed between weak and moderate/strong studies [18].
Results: Infant Development
Global Indices of Infant Development (Table 1)
General Overview of Studies (n = 2)
Two longitudinal studies from Finland and New Zealand evaluated the influence of maternal
distress on global indices of infant development at 12 months [19, 20]. One study was
community-based with half of the mothers having term, small for gestational age infants [20],
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*Articles retrieved through search

strategy; title and abstract review
(n=17,792)
Studies excluded (n=17,620) due to: (a) not a primary study or a case study
(n=5,753); (b) wrong exposure and outcome (n=8,684); (c) wrong exposure
(n=2,660); (d) wrong outcome (n=473); (e) correct exposure and outcome but in
older population (n=50)
Studies retrieved for more

detailed evaluation (n=172)
Studies excluded due to recruitment in developing countries; maternal distress

measured after 12 months postpartum; maternal and paternal measures of distress
not analyzed separately; children <8 years combined with older group (n=108)
Studies included in the

comprehensive review (n=64)
Studies involving outcomes of children aged 13 months to 8 years (n=46)
Studies summarized in this paper

(n=18) (e.g., outcomes included
global indices of infant
development, behaviour, socio-
emotional development, cognitive
development, and psychomotor
development for infants aged birth to
12 months)
Fig. 1 Flow diagram of included and excluded studies. *Note The findings presented in this paper were part
of a larger systematic review of studies that examined maternal distress on childrens development from
birth to age 8. Forty-six studies involved children aged 13 months to 8 years, and this paper summarized the
findings of 18 studies of children from birth to 12 months
whereas the other recruited half of its participants from infertility clinics [19]. The follow-up
sample sizes were 520 [19] and 744 [20] (total N = 1,264).These studies assessed the effect
of prenatal trait anxiety in the second trimester (1820 weeks) [19], prenatal/postnatal per-
ceived stress in late gestation through to the immediate postpartum period [20], parenting
stress at 12 months (maternal report) [20], and PPD at 2 and 12 months [19].
Quality
The overall quality rating was weak for the Punamaki et al. [19] and moderate for
Slykerman et al. [20]. Attrition rates were similar at 25% [20] and 30.2% [19]. The main
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688
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Table 1 Key aspects of studies of global indices of infant development (n = 2)
Citation/ Study design and sample Measure and timing of Infant outcome (assessor) Results (effect size)a Adjusted for key potential
Quality exposure confounders
rating
Punamaki Longitudinal (Finland) Prenatal anxiety (Spielberger Developmental NS (prenatal anxiety, Current distress; PPD; neonatal
200619 Community (subsample Trait Anxiety Inventory; achievement at depression; PPD) health (S); birth complications;
(n = 520) of women with/without General Health 12 months (maternal Neonatal health a significant child characteristics
Quality: ART) Questionnaire) and report of infants sleep, mediator (prenatal
weak Mean age 33.0 depression (Beck standing, walking, words) anxiety ? poor neonatal
10.413.1% unskilled Depression Inventory) (2nd health ? infant
work trimester) development)
PPD (Beck) (2 and
12 months)
Slykerman Longitudinal Prenatal perceived stress Developmental milestones NS perceived stress (AOR Education; marital status (S);
200720 Community (half SGA) (Perceived Stress Scale) at 12 months (Revised 1.45, CI 0.922.29); NS occupation; gestational age;
(n = 744) (New Zealand) (assessed after delivery for Denver Prescreening parenting stress (AOR 1.47, birthweight; smoking in
Quality: Mean age 31.3 (no delay) past month, 3rd trimester); Developmental CI 0.932.31) pregnancy (S); smoking in first
moderate versus 31.6 years parenting stress at Questionnaire) (mother) In high perceived stress group, year; pregnancy hypertension;
(delay) 12 months (single item) 37.6% infants had parity; social support at 1 year;
Low SES 64.6% (no development delay; in breastfeeding; pregnancy
delay) versus 36.4% normal/low stress group, marijuana; parenting
(delay) 30.5% had delay satisfaction (S)
Single 62.8% (no delay) In extreme/moderate parenting
versus 37.2% (delay) stress group, 36.8% infants
delayed; in low/no parenting
stress group, 28.1% delayed
a
Reported if available or calculable; NS statistically non-significant (p C .05), S statistically significant (p \ .05), PPD postpartum depression
limitation in both studies was the lack of blinding of the outcome assessor (i.e., mother). In
both studies, maternal distress was measured using psychometrically tested self-report
instruments (Spielberger Trait Anxiety, Beck Depression Inventory [19]; Perceived Stress
Scale [20]). Slykerman et al. [20] assessed maternal perceived stress shortly after delivery
for the previous month, a period encompassing largely the prenatal, but also early post-
partum, periods. Both studies controlled for a number of potential confounders, but only
Punamaki et al. [19] adjusted for postpartum and current distress. While Slykerman et al.
[20] used the widely validated Revised Denver Prescreening Developmental Questionnaire
for infant outcomes, Punamaki et al. [19] utilized investigator-developed questions.
Main Findings
The proportions of developmental delay in the Slykerman study [20] were 33.8% in
appropriate for gestational age (AGA) infants and 32.4% in small for gestational age
(SGA) infants (NS difference), and were not reported by Punamaki et al. [19]. Neither
study found a significant direct effect of maternal distress in the whole sample; however, in
a subsample of SGA infants, Slykerman et al. [20] found that those of mothers with high
parenting stress had over twice the odds of developmental delay. Punamaki et al. [19]
found that prenatal anxiety played an indirect role in delayed development (see moderators
and mediators). Neither study found a significant association between the other forms of
distress, including perceived stress, prenatal trait anxiety, or current PPD and global
indices of development.
Moderators and Mediators
Using structural equation modeling, Punamaki et al. [19] found that prenatal anxiety was
mediated by neonatal health (i.e., birthweight, apgar scores, intensive care admission,
maternal report of infant health). In other words, prenatal anxiety during the second tri-
mester was related to poor neonatal health, which then was associated with developmental
problems. In the subsample of women who used assistive reproductive technology (ART)
[19], the relationships were somewhat different. Both prenatal depression and anxiety were
associated with PPD at 2 months, which was related to developmental problems at
12 months. No direct or indirect effect of current PPD was found.
Other Potential Confounders
Although both studies assessed a large number of potential confounders, only prenatal
smoking (n = 1) [20] and parenting satisfaction (n = 1) [20] were significantly related to
child development. Other factors that were not related included socioeconomic status
(education, marital status, occupation), birthweight, pregnancy-related hypertension, par-
ity, social support at 1 year, breastfeeding duration, marijuana use in pregnancy, maternal
medical problems, gestational age [20], birth complications [19, 20], child temperament,
and PPD [19].
Summary of Effect of Maternal Distress on Global Indices of Infant Development
One study reported rates of global developmental delay among SGA infants of 37.6% for
those whose mothers had high perceived stress compared to 30.5% for those of mothers
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with low stress. The authors noted that the high rates of delay observed in this study may
be related to their assessment instrument, which was a screening tool intended to identify
infants requiring further assessment. Of the 2 studies assessing the effect of maternal
distress on global indices of infant development at 12 months, only one showed a small,
indirect effect of prenatal anxiety. Based on this single study with an overall quality rating
of weak, there is insufficient evidence to support an association between maternal prenatal
or postnatal distress and global indices of infant development.
Infant Behavior (Table 2)
One longitudinal [21] and one cross-sectional study [22] explored the relationship between
prenatal maternal distress and infant behavior. These community-based studies involved
participants from the Netherlands [21] and Spain [22] with respective sample sizes of 131
and 163 (Total N = 249). They explored the effect of a variety of forms of prenatal
distress, including third-trimester state-trait anxiety [21, 22], perceived stress, and socio-
emotional stability [22]. Neither study assessed the effect of postpartum distress.
Hernandez-Martinez et al. [22] measured distress during the first few days post-delivery for
the period encompassing the previous month (the third trimester of pregnancy). Some
distinction was made in the definition of state-trait anxiety. In particular, Brouwers et al.
[21] defined high prenatal anxiety as either high state or trait anxiety, whereas Hernandez-
Martinez et al. [22] distinguished between these in the analysis. Infant behavior was
assessed throughout infancy, including the first few days of life [22] and 3 weeks and
12 months of age [21]. In all cases, the developmental assessment was performed by a
researcher or examiner. The early examinations were conducted using the same instrument
(Neonatal Behavioral Assessment Scale).
Quality
These studies achieved overall quality ratings of strong [21] and moderate [22]. The
attrition rate for the longitudinal study was less than 20% [21]. In both studies, self-
reported maternal distress (State-Trait Anxiety Inventory [21, 22]; Perceived Stress Scale
[22]) and infant behavior (Neonatal Behavioral Assessment Scale [21, 22]; Bayley Scales
of Infant Development [21]) were assessed using psychometrically evaluated instruments.
The retrospective measures of prenatal distress used by Hernandez-Martinez et al. [22]
represented a source of limitation in this study. Although confounders were adjusted for in
other outcomes of the Brouwers study [21], statistical adjustment was not used in the
analysis of infant behavior. Neither study adjusted for the potential influence of postpartum
distress on the relationship between prenatal distress and infant behavior.
Main Findings
The proportion of infants with behavior problems was not reported in either study. Both
studies reported significant effects of prenatal anxiety in the third trimester on behavioral
outcomes. Specifically, infants of mothers with high state/trait [21] and trait anxiety [22]
had lower scores on orientation (e.g., infant attention, alertness) in both studies at 23 days
[22], 3 weeks, and 12 months [21]. In addition, moderate levels of prenatal trait anxiety
123
Table 2 Key aspects of studies of infant behavior (n = 2)
Citation/ Study design Measure and timing of exposure Infant outcome (assessor) Results (effect size)a Adjusted for key potential
Quality and sample confounders
rating
Brouwers Longitudinal Prenatal anxiety (State-Trait Infant behavior at 3 weeks S (3 weeks and 12 months) None for this outcome
200121 (Netherlands) Anxiety Inventory) (3rd (Neonatal Behavioral 3 weeks: Infants of anxious
(n = 131) Community trimester) Assessment Scale) and mothers scored S lower on
Quality: Mean age 12 months (Bayley Scales orientation (anxious mothers
strong 30.330.9 of Infant Development) M = 6.0, SD 1.1 (anxious)
years; years (researcher) versus M = 6.5, SD 0.9 (non-
education anxious) 12 months: Infants of
10.211.0 anxious mothers scored S lower

than non-anxious mothers on
task orientation and motor
coordination (data not shown)
Hernandez- Cross-sectional Prenatal stress (Perceived Stress Neonatal behavior at S (socio-emotional stability on Gestational age; delivery (normal
Martinez (Spain) Scale); anxiety (State-Trait 23 days post-birth infant regulation, B = 0.178, vs. difficult); maternal age;
200822 Community Anxiety Inventory, STAI); socio- (Neonatal Behavioral p = .04; quality of alertness, prenatal nicotine/alcohol use;
(n = 163) Mean age emotional stability (STAI) (23 Assessment Scale, B = 0.196, p = .02; reduced birthweight; gender; infant age
Quality: 31.8 years; days post-delivery for past NBAS) (NBAS irritability, B = 0.184; p = .03) (hours); feeding method
moderate mean weeks month, 3rd trimester) examiners) (small) (significance not reported)
gestation S (trait anxiety on social
39.2 (SD interaction, B = -0.212,
1.38) p = 0.02; quality of alertness,
B = -0.172, p = 0.04) (small)
NS (perceived stress; state anxiety)
Moderator: Gender NS
a
691
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were associated with reduced social interaction scores at 23 days post-delivery [22] and
high state/trait anxiety was related to less motor coordination at 12 months [21]. Socio-
emotional stability (i.e., the absence of mood changes) was associated with improved
infant self-regulation [22]. Of all the measures of prenatal distress assessed, perceived
stress and state anxiety did not have an impact on infant development. The finding that trait
anxiety (and combined trait/state) and socio-emotional stability were related to infant
development may suggest that it is the more enduring forms of prenatal distress that are
implicated in infant behavior. Hernandez-Martinez et al. [22] found these effects to be
small, whereas Brouwers et al. [21] did not report the magnitude of effect or provide data
to derive it.
Hernandez-Martinez et al. [22] found that infant sex did not moderate the relationship
between maternal prenatal distress and behavioral outcomes.
Although Hernandez-Martinez et al. [22] controlled for a wide variety of potential con-
founders, their individual significance was not reported.
Summary of Effect of Maternal Distress on Infant Behavior
No studies reported the prevalence of infant behavior problems. Both studies evaluating the
effect of prenatal distress on infant behavior in infants 48 h to 12 months of age reported
significant findings. Based on these 2 community-based studies of moderate and strong
quality, there is some evidence that third trimester anxiety and socio-emotional stability are
related to behavior problems in infants. No studies assessed postpartum distress.
Infant Cognitive Development (Table 3)
General overview of studies (n = 7)
Seven longitudinal studies evaluated the effects of prenatal (n = 3) and postpartum

(n = 5) distress on infant cognitive development at 312 months. These studies recruited
women from a variety of countries, including the Netherlands (n = 3), Australia (n = 2),
the United Kingdom (UK) (n = 1), and the United States (US) (n = 1). Four represented
community samples [21, 2325], whereas three focused on unique populations including
women attending a residential parentcraft program for infant difficulties [26]; those with
high risk pregnancies complicated by pre-eclampsia, HELLP syndrome (i.e., hemolysis,
elevated liver enzymes, and low platelets), or fetal growth restriction [27]; and chronic
cocaine users [28]. Sample sizes ranged from 71 to 170 for all studies except Reilly et al.
(n = 1,591) [25] (Total N = 2,327).
The studies that assessed prenatal distress measured a variety of types spanning the
second and third trimesters of pregnancy, including state-trait anxiety (32 weeks) [21];
stressful life events, perceived stress, maternal cortisol levels (1517, 2728, and
3738 weeks) [23]; and depression (last trimester) [28]. Of the 5 studies evaluating
postpartum distress, most assessed PPD [24, 26, 28], with 2 assessing non-specific
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Table 3 Key aspects of studies of infant cognitive development (n = 7)
Citation/ Study design and Measure and timing of Infant outcome (assessor) Results (effect size)a Adjusted for key potential confounders
Quality sample exposure
rating
Buitelaar Longitudinal Prenatal stress in 2nd Cognitive development at 3 and S for 2nd trimester stress on 8 month MDI Birthweight; gestational age; prenatal
200323 (Netherlands) trimester (Everyday 8 months (Bayley Scales of scores (AOR = 1.1, 95% CI 1.021.18) smoking/alcohol; biomedical risk factors;
(n = 170) Community Problem List, Infant Development, Mental (small) breastfeeding ? postpartum stress at
Quality: primiparous 1517 weeks) and 3rd Developmental Index, MDI) NS (3rd trimester) 20 days, 3 and
moderate women, low trimester (Pregnancy (researcher) 8 months ? PPD ? postpartum
risk Related Anxieties psychological well-being
pregnancies Questionnaire and
Perceived Stress Scale,
2728 weeks)
Murray Longitudinal PPD at 23 months Cognitive development at S (First onset PPD related to poor performance Gender; education; unplanned pregnancy;
199224 (United (Edinburgh Postnatal 9 months (Piagets Object on object concept task (even significantly obstetric complications; prenatal anxiety;
(n = 111) Kingdom) Depression Scale; concept task) (psychologist) poorer than mothers with history depression marital friction; social support; housing;
Quality: Community Standardized Psychiatric and PPD, p \ .01) employment; social class; paternal
strong Mean age Interview if Severity: infants of mothers with major PPD psychiatric history
28.0 years; EPDS C 13) performed more poorly than those with minor
40% manual PPD
labour/
unemployed
Beckwith Longitudinal Prenatal depression 3rd Cognitive development at S (prenatal ? PPD Mean MDI = 96.0, SD Motherchild interaction; postnatal depression
199928 (United States) trimester (Millon 6 months (Bayley Scales of 14.9; PPD alone) (small)
(n = 71) Chronic cocaine Clinical Multiaxial Infant Development Index, NS (prenatal depression mean MDI = 114.4,
Quality: users Inventory I); MDI) (researcher) SD 10.3 versus never depressed mean
weak Mean age PPD at 6 months (Beck MDI = 110.9, SD 11.2)
28.9 years; Depression Inventory) Moderator: women with severe prenatal
83.3% depression but no depression at 6 months had
minority infants with better MDI scores that women
status; 84.6% depressed pre- and postpartum; chronic
single depression negative impact on caregiving
693
123
Table 3 continued
694
rating
123
Brouwers Longitudinal Prenatal anxiety (State- Cognitive development at NS (In high anxiety group, mean MDI = 97 Apgar 1 and 5 min; home environment;
200121 (Netherlands) Trait Anxiety Inventory) 12 months (Bayley Scales of (SD 14) (high anxiety) vs mean MDI = 103 education; maternal age; prenatal smoking/
(n = 131) Community (3rd trimester) Infant Development, Mental (SD 14) (no anxiety) (p = .07) alcohol; type of delivery; breastfeeding;
Quality: mean age 30.3 Development Index, MDI) gender; birthweight; gestational age; PPD at
strong 30.9; years (researcher) 12 months
education
10.211.0
Cornish Longitudinal PPD (Center for Language development at NS (no depression M = 104.2, SD 11.2; brief Gender; education; maternal age; mother
200526 (Australia) Epidemiological Studies 12 months (Receptive- depression M = 104.9, SD 13.4; chronic bilingual
(n = 112) Clinical Depression Scale; The Expressive Emergent depression M = 102.4, SD 11.3) (NS)
Quality: (recruited from Composite Language Test) (mother) Moderator: gender (NS)
moderate centre for International Diagnostic
infant Interview) (4 and
problems) 12 months)
mean age
31.4 years;
11% B high
school; 93%
Caucasian
Kaspers Longitudinal Postpartum psychological Bayley Scales of Infant NS (Mean MDI = 87 (range 59102), high Maternal disease; SES; education; antenatal
200927 (Netherlands) symptoms (Symptom Development, Mental psychological symptoms versus MDI = 89 corticosteroids; gestational age; birthweight;
(n = 141) Women with Check list-90) (sum of 0, Development Index (MDI) at (range 66124), low psychological apgar scores; gender; neonatal disease
Quality: high risk 3, 12 months) 12 months (psychologist) symptoms)
strong pregnancies
Mean age
30.430.8
years; 3136%
high education;
7881%
Caucasian
Table 3 continued
rating
Reilly Longitudinal Postpartum: psychological Infant communication at 8 and NS (8 months, M = 99.2, SD 14.3; 12 months, Prematurity, sex (S), multiple birth (S), SES
200625 (Australia) distress (Non-specific 12 months (Communication M = 96.4, SD = 13.1) (S), maternal vocabulary and education;
(n = 1591) Community Psychological Distress and Symbolic Behavior non-English speaking background; family
Quality: 9.3% low Scale) (8 months) Scales, CSBS) (mother) history of speech difficulties (S)
moderate education;
3.1% non-
English
speaking
background
a
695
123
psychological distress [25, 27]. In terms of infant outcomes, 5 of these studies assessed
global cognitive infant development, and 2 focused on language development [25, 26].
Quality
Among these 7 studies, most were rated as strong [21, 24, 27] or moderate [23, 25, 26],
with only one study receiving a weak rating [28]. Attrition rates varied from less than
1054%. The main limitation among these studies was the lack of assessment of potential
confounders. All studies used psychometrically evaluated measures of maternal distress
and child cognitive development. Four studies used self-report measures of maternal
distress (State-Trait Anxiety Inventory [21]; Everyday Problem List, Pregnancy Related
Anxieties Questionnaire, Perceived Stress Scale [23]; Non-specific Psychological Distress
Scale [25]; Symptom Check list-90 [27]), and the remaining 3 used a combination of self-
report (Edinburgh Postnatal Depression Scale [24]; Center for Epidemiological Studies
Depression Scale [26]; Beck Depression Inventory [28]) and structured interview by a
psychologist. In most of the studies, assessments of cognitive development were conducted
by a researcher/psychologist [21, 23, 24, 27, 28] with only 2 using maternal report [25, 26].
Global cognitive development was conceptualized quite consistently in these studies, with
4 studies using the Mental Development Index (MDI) of the Bayley Scales of Infant
Development to assess cognitive outcomes [21, 23, 27, 28].
Main Findings
The prevalence of cognitive delay ranged widely from 7% in infants of non-distressed

women to 25% in those of distressed women in a community sample [21]. Among growth-
restricted infants whose mothers experienced high risk pregnancies, the rates of cognitive
delay were 34% (distressed women) and 38% (non-distressed women) [27]. Three of the 7
studies reported small, significant influences of maternal distress experienced in the pre-
natal (n = 1) [23] or postnatal (n = 2) [24, 28] periods. None of the studies of cognitive
outcomes at 12 months were significant, and neither study focusing on language devel-
opment reported significant associations.
The overall quality ratings of the 3 studies with significant findings varied from weak to
strong. Each of these significant studies controlled for postpartum distress and a variety of
additional potential confounders. By form of distress, first trimester prenatal stress and high
cortisol in the third trimester were associated with small reductions in cognitive scores at
3 months [23]. First onset PPD (at 23 months) was also associated with poor functioning
on a cognitive object task test in 9-month old infants, even compared to mothers who had
experienced both a history of depression and a previous PPD [24]. Adjusting for very few
confounders, a significant association was also found between clinically diagnosed post-
partum dysthymia in cocaine-abusing women and low cognitive scores in 6-month old
infants, as well as with a combination of prenatal and postpartum dysthymia [28]. In this
study, no relationship was found between prenatal dysthymia alone and cognitive devel-
opment. Finally, although Kaspers et al. [27] found no difference in MDI scores of infants
of women with high (MDI M = 87; Range 59102) and low levels of psychological
symptoms (MDI M = 89; Range 66124), all infants in this study were born to mothers
with severe complications (e.g., pre-eclampsia, HELLP syndrome) and the mean MDI
scores were below the population mean of 100. Neither study that assessed cognitive
outcomes by maternal report was significant [25, 26].
123
Beckwith et al.s [28] study of substance-abusing mothers with high levels of dysthymia
found that maternal-child interaction was not a significant mediator of the relationship
between prenatal dysthymia and cognitive development. In this study, chronicity of dys-
thymia was a significant moderator where infants of women who were severely depressed
during pregnancy and postpartum had poorer cognitive outcomes than those of women who
were depressed during pregnancy but experienced recovery [28]. Murray et al. [24] found
that severity of depression was also an important factor in that infants of mothers with
major PPD scored more poorly on cognitive assessments than those with mothers who had
a minor PPD. However, Cornish et al. [26] did not find that severity or chronicity of PPD
had an effect on language development. Finally, one study found a non-significant gender
interaction [26], indicating that the relationship between maternal distress and cognitive
outcomes did not differ between boys and girls.
Numerous potential confounders were assessed in this group of studies, including child
factors (gestational age, birthweight, Apgar scores), maternal demographics (age, income,
education, social class), maternal behavior (prenatal smoking, prenatal alcohol, breast-
feeding), obstetrical characteristics (parity, mode of delivery, complications, unplanned
pregnancy), and social factors (social support, marital conflict, home environment).
Overall, very few additional variables were significant predictors of cognitive develop-
ment. In particular, global cognitive functioning was impacted by low maternal education
in one study [24], whereas language development was predicted by low SES, multiple
births (e.g., twins had poorer scores) gender (e.g., girls better cognitive scores than boys),
and family history of language difficulties [25]. Three of the 7 studies did not report
significance levels for the potential confounders.
Summary of Effect of Maternal Distress on Infant Cognitive Development
The prevalence of infant cognitive delay ranged from 7 to 38%. Given that both studies of
moderate quality (including one community-based study, n = 1,591) did not find an
association between postpartum distress and language outcomes, there is no evidence at
present to support this relationship. No studies evaluated prenatal influences on language
development.
Three of 5 studies found small, significant effects of prenatal stress (n = 1) and PPD
(n = 2) at 23 months on general cognitive development. Based on these studies of weak,
moderate, and strong quality, some evidence exists for a small effect of prenatal and
postpartum distress on infant cognitive development. Because the number of studies was
limited and a variety of forms of maternal distress was studied, clear trends related to the
timing and specificity of the form of prenatal maternal distress were not evident. However,
some preliminary observations can be made. Specifically, of the 3 studies that assessed
prenatal distress, one examined and found a significant second trimester effect on cognitive
outcomes, whereas the 3 that explored a third trimester effect did not. Among the 3 studies
that evaluated postpartum distress, those that explored PPD (n = 2) demonstrated a sig-
nificant relationship with infant cognitive development, whereas the study of psychological
symptoms did not. One study found that infants tended to have poorer cognitive devel-
opment if their mothers experienced chronic depression across pregnancy and postpartum
123
(versus brief), or severe PPD. Importantly, among the wide array of risk factors for cog-
nitive delay assessed by this group of studies, maternal psychological distress was most
consistently related to infant cognitive delay.
Infant Socio-Emotional Development (Table 4)
Four studies evaluated the influence of postpartum distress on infant socio-emotional

development, including 3 longitudinal [2931] and one cross-sectional study [32]. No
studies explored the effect of prenatal exposure on infant outcomes. Four different
countries were represented by these studies (Sweden, Israel, Australia, UK), and sample
sizes ranged from 44 to 223 (total N = 481). Two of the 4 studies involved clinical
samples [29, 30], one was community-based [31], and one blended community and clinical
[32]. As such, these studies examined the effect of postpartum psychiatric illness [2932],
generalized anxiety disorder and social phobias [30, 31], major PPD [30], and postpartum
mood [32] on infant socio-emotional development. Infant outcomes were assessed
throughout the first year of life at 10 weeks [31], 9 and 10 months [29, 30] and between 13
and 52 weeks (mean 30.1 weeks) [32]. All studies focused on social behavior as the
indicator of infant socio-emotional development. Three studies assessed sociability using a
variety of laboratory-based tests [2931] and one was based on a primary clinicians rating
of the infant-clinician interaction during a routine child care visit [32]. As such, all studies
used researchers or clinicians to assess infant socio-emotional development.
Quality
Among these studies, most received weak ratings [29, 30, 32], with the remaining study
rated as strong [31]. The main limitations were having high potential for selection bias,
lack of assessment of potential confounders, and lack of blinding of the outcome assessor.
Attrition rates were less than 25% for the longitudinal studies. None of the studies con-
trolled for prenatal mood in their analyses. One study measured maternal distress with a
self-report measure (Edinburgh Postnatal Depression Scale [32]), two used structured
psychiatric interviews [29, 31], and one used both approaches (Beck Depression Inventory,
Structured Clinical Interview, State-Trait Anxiety Inventory, Parenting Stress Index [30]).
Main Findings
The inclusion criteria for each of the 4 studies ensured that rates of clinical maternal
distress were high in these studies. The rates of poor sociability in 2 studies reporting these
data ranged from 6 to 14.8% in non-distressed women and 27.3 to 55% in those experi-
encing distress [31, 32]. Three studies found a significant effect of postpartum distress
involving generalized anxiety/social phobia [30], depression [30], postpartum mood [32]
and psychiatric illness [29] on infant social development. Among the significant studies, all
had an overall quality rating of weak (the single study rated as strong reported a non-
significant association). Overall, these studies found moderate effects of PPD on reduced
social engagement and increased fear in infants; however, the magnitude of this effect may
be inflated by the lack of control for potential confounders.
123
Table 4 Key aspects of studies of infant socio-emotional development (n = 4)
Citation/ Study design and Measure and timing of exposure Infant outcome (assessor) Results (effect size)a Adjusted for key
Quality sample potential
rating confounders
Albertsson- Longitudinal (Sweden) Postpartum psychiatric illness by Sociability and fear of S (Infants in psychiatric sample had Controls matched on
Karlgren Clinical 6 months (diagnostic interview) stranger; approach- more negative sociability (M = 3.9, infant sex; parity;
200029 women admitted to withdrawal at SD = 2.3) vs non-depressed maternal
(n = 114) psychiatric unit; 10 months mothers (M = 5.4, SD = 2.0; education;
Quality: 47.2% post-secondary (stranger-wariness p \ .05); these infants also had paternal education
weak education; 83.3% situation; Stevenson and lower approach-withdrawal scores
married Lamb sociability (depressed M = 2.9, SD = 0.8 vs
situation) (mother/ non-depressed M = 3.4, SD = 0.6),
researcher) p \ .05) (moderate)
Feldman Longitudinal PPD (Beck Depression Inv); Social engagement at S (Social engagement in mothers with Maternal sensitivity
200930 (Israel) generalized anxiety disorder/social 9 months (lab tests maternal depression M = 2.14, (S)
(n = 100) Clinical subsample of phobias (Structured Clinical involving play) SD = 0.94 versus maternal anxiety
Quality: community sample Interview; State-Trait Anxiety (researchers; mothers) M = 2.86, SD = 0.87 versus
weak -mean age 30.7 years; Inventory) (2 days, 6 month, control M = 3.44, SD = 0.92).
completed mean 9 month); parenting stress at (moderate-anxiety; large-depression)
15.7 years education 6 months (Parenting Stress Index) Moderator: In depressed mothers,
maternal sensitivity moderated
effects on child social engagement;
NS for anxiety
Matthey Cross-sectional (pilot) PPD since birth, assessed when infant Social behavior at S (55% women with PPD had infants None
200532 (Australia) 1352 weeks old (Edinburgh 1352 weeks (Mean with low scores (M = 1.6) versus
(n = 44) Community ? Clinical Postnatal Depression Scale) 30.1 weeks, SD 12.1) 6% mothers no PPD (M = 5.6),
Quality: (parentcraft unit) (Alarme Distress de p \ .001)
weak mean age 28.5 years; Bebe Scale)
all mothers partnered; (clinicians)
31.8% post-secondary
education
699
123
Table 4 continued
700
Citation/ Study design and Measure and timing of exposure Infant outcome (assessor) Results (effect size)a Adjusted for key
Quality sample potential
123
rating confounders
Murray Longitudinal Postpartum social phobia; anxiety Social responsiveness at NS (AOR 1.9, 95% CI 0.84.1; Neonatal irritability;
200731 Community (subsample disorder at 10 weeks (Structured 10 weeks (laboratory mothers with social phobia not less sex; degree to
(n = 223) screened for GAD and Clinical Interview for DSM-IV Axis face-to-face interactions sensitive or more controlling than which mother
Quality: social phobia) 1 and social stranger even though they were more anxious encourage infant
moderate -7.416.7% low SES; disorders) challenge) (researcher) and withdrawn) to interact with
5.57.3% single; stranger
85.7100% Caucasian
a
In addition to having an independent, direct effect, Feldman et al. [30] found that maternal
sensitivity moderated the relationship between maternal PPD and infant social engage-
ment. In other words, in mothers with high levels of sensitivity to their infants, maternal
depression had no effect on infant social development; however, infants of depressed
mothers with low sensitivity were more likely to experience suboptimal social develop-
ment. This moderating effect was not found for maternal anxiety.
Few potential confounders were assessed in this group of studies. Among these, infant sex,
neonatal irritability, and the degree to which mother encouraged her infant to interact were
not significant predictors of infant sociability. Only maternal sensitivity demonstrated a
moderate effect on social engagement in infants [30].
Summary of Effect of Maternal Distress on Infant Socio-Emotional Development
Among the studies of infant outcomes, socio-emotional development was defined in terms
of infant social competence with prevalence rates reported as 6.014.8% in infants of non-
distressed women, and 27.355.0% in those of distressed women. There is limited evidence
for an effect of postpartum distress on social development from 2 to 10 months based on
the findings of 3 small, weak studies. Although the effect sizes reported were moderate to
large, this is likely a reflection of the lack of control of potential confounders in these
studies. The study with non-significant findings was a larger, community-based sample of
moderate quality. No studies assessed the effect of prenatal distress. Maternal sensitivity
was a moderator; in other words, there was no effect of maternal depression on infant
sociability in mothers with high levels of maternal sensitivity.
Infant Psychomotor Development (Table 5)
Seven longitudinal studies examined the effect of prenatal [21, 23, 3336] and postpartum
[27, 36] distress on infant psychomotor development. These 7 studies recruited women
from the Netherlands (n = 4) and the US (n = 3). Sample sizes ranged from 131 to 200
with the exception of van Batenburg et al. (n = 2,724) [36] (total N = 3,690). Six of these
studies were community-based, with the remaining study recruiting women for a larger
study of women with pre-eclampsia, HELLP Syndrome, or severe fetal growth restriction
[27]. Two of the community-based studies involved low-to-middle income women [34,
35], one-third of whom were African-American and single.
A wide variety of prenatal influences were assessed, including state-trait anxiety [21],
stressful life events [23], perceived stress [23], salivary cortisol [23], plasma cortisol and
placental corticoptropin releasing hormone [33], anger [34], dysthymia and major
depression [35], anxiety [36], and depression [36]. One study evaluated prenatal distress in
the first trimester [23], 5 in the second [23, 3336], and 2 in the third [21, 33]. Postpartum
distress included exposure to psychological symptoms [27], anxiety, and depression [36],
and was assessed within the first 3 months postpartum [27, 36] and at 12 months [27].
123
702
Table 5 Key aspects of studies of infant psychomotor development (n = 7)
123
Citation/ Study design and Measure and timing of Infant outcome (assessor) Results (effect size)a Adjusted for key potential
Quality sample exposure confounders
rating
Buitelaar Longitudinal Prenatal stress in 2nd Psychomotor development at 3 S (3rd trimester: Postpartum stress at 20 days, 3
200323 (Netherlands) trimester (Everyday and 8 months (Bayley Scales pregnancySpecific stress S risk and 8 months; PPD (same
(n = 170) Community Problem List; hassles) of Infant Development, factor for low PDI at 8 months times); SES; age; birthweight;
Quality: Primiparous women, and 3rd trimester Psychomotor Developmental (AOR 1.3, 95% CI 1.121.56) gestational age; pregnancy
moderate low risk pregnancies (Pregnancy Index, PDI) (researcher) (small) risks; perinatal complications
Related Anxieties; NS (for 2nd trimester)
Perceived Stress
Scale)
Ellman Longitudinal Prenatal stress at 2nd Neuromuscular/physical S (2nd trimester increased Gestational age; infant sex; infant
200833 Community and 3rd trimester maturation within 48 h post- cortisol associated with age at examination; parity;
(n = 158) (plasma cortisol; birth (New Ballard Maturation decreased maturation (std mode of delivery; maternal age;
Quality: corticotrophin Score) B = -0.44) and 19 weeks ethnicity
strong releasing hormone, (physician) pregnancy (std B = -0.185);
CRH) 3rd trimester increased CRH
associated with decreased
physical and neuromuscular
maturation (std B -0.381)
(small)
Field 200234 Longitudinal Prenatal anger (Profile Neurobehavioral development S (Infants of mothers with high None
(n = 166) Community of Mood States) (2nd within 48 h post-birth anger had higher score for
Quality: -35% African- trimester) (Brazelton Neonatal Behavior neonatal depression (high anger
weak American, 25% Assessment Scale) M = 4.20, SD = 3.01; low
Hispanic, 37% (researcher) anger M = 2.03, SD 1.56,
single p = .001) (moderate)
Table 5 continued
rating
Field 200835 Longitudinal Prenatal dysthymia and Neurobehavioral development S (Compared to infants of None
(n = 200) -Community major depression in within 48 h post-birth mothers with major depression
Quality: -mean age 28.4 years; 2nd trimester (Brazelton Neonatal Behavior (MDD), infants of mothers with
weak mean years (Structured Clinical Assessment Scale) dysthymia had lower
education 11.8; 51% Interview for (researcher) orientation scores (dysthymia
Hispanic, 28% Depression) M = 4.2, SD 2.1; MDD
African-American, M = 5.6, SD 1.7; p = .02) and
21% non-Hispanic neonatal depression (dysthymia
white M = 3.8, SD 2.8; MDD 2.4,
SD 1.9; p = .04)) (moderate)
Van Longitudinal Prenatal anxiety and Neuromotor development at S (Prenatal anxiety AOR 1.49 (CI Prenatal and postnatal anxiety;
Batenburg (Netherlands) depression 2nd 915 weeks (Touwens 1.102.03) (small) prenatal and postnatal
200936 Community trimester and 2 month Neurodevelopmental NS (Postnatal anxiety alone; depression; education; age of
(n = 2,724) Mean age 31 years; (Brief Symptom Examination) (researcher) prenatal ? postnatal anxiety; mother; age of child; ethnicity;
Quality: 20% low education Inventory; Edinburgh prenatal depression alone; PPD; prenatal smoking/alcohol;
moderate Postnatal Depression prenatal depression ? PPD) family function; stress previous
Scale) year; obstetric complications;
apgar 1 and 5 min; gestational
age; birthweight; infant gender
Brouwers Longitudinal Prenatal anxiety (State- Psychomotor development at NS (Mean PDI in anxious group Apgar 1 and 5 min; home
200121 (Netherlands) Trait Anxiety 3 weeks (Neonatal Behavioral M = 89, SD = 14 versus non- environment; education;
(n = 131) Community Inventory) (3rd Assessment Scale) and 1 year anxious group M = 97, maternal age; prenatal
Quality: Mean age 30.330.9 trimester) (Bayley Scales of Infant SD = 16; p = .02) smoking/alcohol; type of
strong years; education Development, Psychomotor delivery; breastfeeding; gender;
10.211.0 Development Index birthweight; gestational age;
(researcher) PPD at 12 months
703
123
Table 5 continued
704
123
rating
Kaspers Longitudinal Postpartum Psychomotor development at NS (Mean PDI in mothers with Maternal disease; SES;
200927 (Netherlands) psychological 12 months (Bayley Scales of low symptoms was 80 (range education; antenatal
(n = 141) Women with high risk symptoms (Symptom Infant Development, 50109) and 79 (range 53-118) corticosteroids; gestational age;
Quality: pregnancies Check list-90) (sum of Psychomotor Developmental in highest 25%) birthweight; apgar scores;
strong Mean age 30.430.8 0, 3, 12 months) Index, PDI) gender; neonatal disease
years; 3136% high (psychologist)
education; 78-81%
Caucasian
a
Infant outcomes were assessed throughout the first year of life, ranging from a few days
post-delivery to 12 months of age.
Quality
The overall quality rating was strong for 3 studies [21, 27, 33], moderate for 2 [23, 36], and
weak for 2 [34, 35]. Attrition rates ranged from less than 20% to 35% (not reported in 2
studies), and were a limitation in these studies. The other main contributor to reduced
quality scores was the lack of inclusion of potential confounders. Three of 7 studies
evaluating the influence of prenatal distress controlled for postpartum distress in their
analysis [21, 23, 36] and one of the 2 studies examining postpartum effects controlled for
prenatal distress [36]. All studies utilized psychometrically tested measures for maternal
distress (State-Trait Anxiety Inventory [21]; Symptom Check list-90 [27]; Everyday
Problem List, Pregnancy Related Anxieties Questionnaire, Perceived Stress [23]; Profile of
Mood States [34]; Structured Clinical Interview for Depression [35]; Brief Symptom
Inventory; Edinburgh Postnatal Depression Scale [36]) and child outcomes. Infant psy-
chomotor development was conceptualized quite consistently across these studies and was
measured by a variety of widely used instruments including the Neonatal Behavioral
Assessment Scale [21, 34, 35], the New Ballard Maturation Assessment Scale [33], the
Bayley Scales of Infant Development (Psychomotor Development Index) [21, 23, 27], and
the Touwens Neurodevelopmental Examination [36].
Main Findings
Prevalence rates of psychomotor delay were reported in one community-based study as

30% in infants of anxious women and 14% of those in non-anxious women [21]. Rates of
psychomotor delay among growth-restricted infants of women with high risk pregnancies
were similar among those who reported high (58%) and low (50%) levels of psychological
distress [27]. Overall, 5 of the 7 studies reported significant associations between maternal
distress and child psychomotor outcomes. These studies demonstrated an effect of maternal
distress on psychomotor outcomes that spanned across the first year of life from 48 h of
birth to 8 months. However, neither study that evaluated 12-month psychomotor devel-
opment was significant [21, 27]. Significant associations were found in one of the 3 strong
studies [33], both moderate studies [23, 36], and both weak studies [34, 35].
No association was found between any measure of postpartum distress and psychomotor
development. Specific aspects of distress that were associated with poor psychomotor
performance largely clustered in the second trimester of pregnancy, and included second
trimester pregnancy-specific stress, anxiety, anger, dysthymia, cortisol levels, and corti-
cotrophin releasing hormone; and third trimester cortisol. Of importance, both studies that
controlled for postnatal distress found that prenatal distress (but not postnatal distress) had
an independent effect on psychomotor development [23, 36]. In their large, community-
based sample, VandenBurg et al. [36] also observed that infants of women with both
prenatal and postnatal distress were not more likely to experience psychomotor delay,
suggesting a critical role for prenatal distress.
The effect sizes of self-reported maternal distress on psychomotor delay were small in
studies that controlled for postpartum distress and additional potential confounders [23,
36]. However, the two studies that found moderate effects did not control for potential
confounders [34, 35]. Effect sizes for the physiological measures were small to moderate
for cortisol measured in both the first and third trimesters [33].
123
Ellman et al. [33] did not find that child sex was a moderator of the relationship between
prenatal cortisol and CRH and neuromuscular maturation in 2-day old infants.
A large variety of potential confounders was assessed in 5 of the 7 studies, however 4 of

these did not report significance of the association with infant development [23, 27, 33,
36]. The single study that did report on the associations did not find any significant
predictors, including the 1- and 5-min Apgar scores, home environment, education, age,
parity, prenatal smoking, prenatal alcohol, mode of delivery, breastfeeding, child sex,
gestational age, and birthweight [21].
Summary of Effect of Maternal Distress on Infant Psychomotor Development
The prevalence rates of delayed psychomotor development were 14% in infants of non-
anxious women and 30% in those of anxious women. There is some evidence for a small
effect of prenatal distress on psychomotor development in infants aged 48 h to 8 months
based on 5 studies of strong (n = 1), moderate (n = 2), and weak (n = 2) quality. Indeed,
one large study reported an increase in the odds of psychomotor delay of almost 50% in
infants of mothers with high prenatal anxiety. The association between prenatal distress
and psychomotor delay was consistently found for distress occurring during the second (4
of 5 studies) and third (2 of 3 studies) trimesters across diverse forms of distress, including
stress, anxiety, anger, dysthymia, and physiological measures of cortisol and corticotrophin
releasing hormone. The findings of this limited body of evidence suggest that there is a
lack of specificity with respect to the form of prenatal distress. Although a few studies
reported moderately sized effects (n = 2), potential confounders were not addressed.
Given that both studies that assessed the effect of postpartum distress were non-significant,
there is no evidence to suggest that it has an effect on this outcome. Neither study of
psychomotor development at 12 months of age was significant.
Conclusion and Discussion
Relationship Between Maternal Distress and Infant Development
To our knowledge, this review is the first to systematically compile evidence relating
prenatal and postpartum maternal psychological distress to infant global, behavioral,
cognitive, socio-emotional, and psychomotor development. Based on this review, some
evidence exists for an effect of prenatal psychological distress on behavioral, cognitive,
and psychomotor development, and for an association between postpartum psychological
distress and cognitive development. Limited evidence exists for an effect of postpartum
distress on socio-emotional development (e.g., social competence). In each of the studies
demonstrating associations with maternal distress, the effect size was small. No evidence
was found for an association between maternal prenatal or postpartum distress and global
indices of development, or for postpartum distress and language and psychomotor devel-
opment. No studies assessed the influence of prenatal distress on socio-emotional and
language development, or postpartum distress on behavioral development.
123
Some key observations about these findings as a whole further substantiate the evidence
for an association between maternal distress and infant development. Firstly, although
these 18 studies controlled for a wide variety of potential confounders, relatively few
additional factors were significantly associated with infant development. As such, maternal
distress was one of the most consistent factors related to infant development. Secondly, the
associations between maternal distress and infant development were observed across
several developed countries, including New Zealand, Finland, Netherlands, US, Australia,
Sweden, and Israel. Thirdly, most of these studies were conducted using community-based
samples, with few focusing on clinical populations. Therefore, the findings of this review
largely reflect the risks for developmental delay that occur within the context of the
average, married, middle-income, childbearing woman.
Timing and Specificity of Maternal Distress
The small number of studies that evaluated global indices, behavioral, and socio-emotional
development precluded the ability to define a trend related to the timing or specificity of
maternal distress. However, based on 7 studies, these findings suggest that cognitive
development was associated with both prenatal and postpartum distress. Within the pre-
natal period, studies demonstrated an effect of second trimester distress on cognitive
development, but not third trimester distress. Psychomotor development was influenced by
prenatal distress occurring in either the second or third trimester, but not postpartum
distress. No studies assessed the effect of first trimester prenatal distress on any outcome.
No clear pattern emerged regarding the specificity of certain forms of maternal distress
and their effects on specific infant developmental outcomes. Overall, several forms of
maternal distress were related to infant developmental delay, including stress (perceived;
stressful life events), anxiety (anxiety; state-trait; trait), depression (dysthymia; depression;
major depressive disorder), and psychiatric diagnoses.
Implications
The finding that maternal distress was associated with four of five aspects of infant
development (i.e., cognitive, psychomotor, behavioral, socio-emotional) provides com-
pelling evidence for an upstream, preventative approach to infant developmental problems.
Historically, much of the attention related to the issue of maternal mental health has been
directed toward PPD. This focus has supported an approach to prevention and intervention
that begins during the postpartum period (although not routinely done). While this review
provides evidence of an effect of postpartum psychological distress on infant development
(e.g., socio-emotional and cognitive), it also demonstrates that prenatal distress can have
detrimental effects on cognitive, psychomotor, and behavioral development. The impli-
cations of these results are that our current approach to the postpartum management of
maternal mental health begins far too late.
That these results were found largely in community-based samples suggests that psy-
chosocial care and assessment are important components of routine perinatal care. How-
ever, despite recommendations [37, 38], universal psychosocial assessment has not been
widely implemented as a part of routine prenatal care. As a result, mental health issues
frequently go undetected in the course of routine prenatal care [39]. This is particularly
problematic because during the perinatal period many women do not discuss their mental
health problems with others or seek professional assistance [40], and mental health
123
problems during pregnancy frequently continue into the postpartum period [8, 41]. The
implementation of routine psychosocial assessment and referral processes requires
addressing system-wide barriers, including the lack of established referral processes [42],
lack of community resources to provide mental health care for women in distress [42],
provider time constraints [43], and lack of suitable instruments for clinical assessment [6,
44]. However, studies have demonstrated the effectiveness of psychosocial risk assessment
in promoting the early identification of womens psychosocial risk, facilitating individu-
alized care planning, defining needs for referral, and guiding referral pathways involving
clinical and community-based services with links to nursing, social work, or psychiatry [6].
Preventing the occurrence of infant developmental problems by addressing maternal
psychological distress represents a key strategy. In 2002, McLennan and Offord evaluated
whether PPD was an appropriate target for large-scale prevention efforts that aimed to prevent
the occurrence of child developmental problems [45]. Using 7 criteria to analyze the char-
acteristics of the risk factor (PPD) and interventions to reduce PPD, they assessed whether:
(a) PPD was a causal factor for the negative outcome; (b) PPD had a high attributable risk for
the negative outcome; (c) PPD was alterable; (d) PPD was easily and accurately identified
through screening; (e) interventions to reduce PPD could be easily disseminated; (f) PPD
interventions would have a low risk for impact; and (g) PPD interventions would be
acceptable to stakeholders. At that time, they concluded that targeting PPD with the aim of
reducing child developmental problems had mixed potential as a prevention strategy. They
felt that the criteria were largely met except that the risks of PPD interventions were unknown,
and the strength of the link between PPD and poor child outcomes is undetermined (p.28)
[45]. We propose that the remaining 2 criteria have been met for a preventative strategy
involving both the prenatal and the postpartum period. Specifically, recent studies have found
that women find screening and treatment of PPD acceptable [46, 47]. The final criterion,
evaluating the strength of the relationship between maternal distress and child developmental
delay, has been addressed through this systematic review.
In addition to the criteria established by McLennan and Offord [45], there are other
considerations that substantiate addressing womens mental health in order to reduce the
risk of infant developmental problems. First, there is some evidence to suggest that
treatment of maternal distress results in an improvement in infant outcomes, although to
date most research in this area has focused solely on PPD. For example, a recent review of
8 studies summarizing the effectiveness of treatment for PPD on infant outcomes found an
improvement in the quality of maternal-infant interactions and infant cognitive develop-
ment [16]. Second, this preventative approach is further supported by the challenges that
exist in detecting and treating child developmental problems. Service utilization rates of
children with developmental [48] and mental health issues are typically low (\50%),
particularly among children under 7 years of age [49]. Depending on the nature of the
developmental problem, preventative and treatment services are frequently not available or
easily accessible, or designed and implemented to meet the needs of parents and families
with young children [50]. As Waddell et al. [50] note with respect to child mental health:
It is increasingly evident that treatment services alone cannot reduce the burden of illness.
As well, the understanding that many mental disorders arise during childhood has
encouraged a shift toward considering prevention (p. 174).
Finally, addressing maternal psychological distress may represent one of the most
modifiable and feasible strategies for reducing risk factors for infant developmental delay.
Hertzman and Boyce [51] conceptualized developmental risk factors as those that are most
proximal to the child (e.g., family-based factors), those in the meso-environment (e.g.,
neighbourhood; school), and those belonging to the macro-environment (social/economic/
123
political). It is plausible that addressing maternal psychological distress may, in turn, affect
a mothers relationship with her child and the overall family functioning with benefits that
extend to the meso-environment. This is not to underestimate the impact of risk factors
external to the family; rather, these discussion points are intended to highlight the
importance of addressing maternal psychological distress as one of the most upstream
factors in a childs life. Future research should address these questions through longitudinal
designs, and should also consider family-based and external factors that protect children
from developmental problems even though exposed to prenatal or postnatal distress.
Strengths and Limitations
The findings of this review are the result of a rigorous, systematic process of review of a
large number of articles. Despite the strengths of this review, some limitations exist. We
did not include articles that were published in languages other than English, or prior to
1990. We limited our review to developed countries, because we considered that the
influences on child development may be quite different in developing countries. As such,
the findings of this review cannot be generalized to developing countries. Similarly, only a
few studies were conducted amongst disadvantaged families. Although sociodemographic
factors were inconsistently related to child development in these studies, other aspects
within the context of disadvantage that have been shown to influence child development
were not evaluated in these studies [52]. Because many articles did not report details
regarding maternal distress, it was not possible to comment on the relationship between
severity of maternal distress and infant development. In addition, several of the studies did
not report rates of infant developmental outcomes, and therefore the prevalence rates that
we present reflect those reported in a few studies. Finally, because the infant outcomes
were presented in a variety of ways (e.g., continuous; dichotomous based on clinical cut-
off points), it was not possible to conduct a meta-analysis.
Recommendations
Several recommendations relating to research, clinical practice, and policy development

stem from this systematic review.
Research
We did not find any studies that assessed the effect of prenatal distress on language or
socio-emotional development. Given the consistent effect of prenatal distress on cognitive,
psychomotor, and behavioral development, future research should consider evaluating its
influence on language and socio-emotional development. Additionally, there is a gap in our
knowledge related to the association between postpartum distress and behavioral and
psychomotor development.
One of the challenges in conducting this review was the lack of detail regarding the
severity of maternal distress. Providing additional detail on the severity of maternal distress
would further our understanding of its role in child development. Similarly, several studies
conducted multiple assessments of maternal distress, but did not specifically address the
impact of chronic distress. As such, it was difficult to draw conclusions regarding the
impact of chronic distress on aspects of infant development. Understanding the roles that
123
severity and chronicity of psychological distress play is important in the identification and
management of risk.
Only one study [19] explored the mechanisms of maternal distress on infant develop-
ment. A priority of future research should be to describe the pathways between maternal
distress and infant developmental problems in order to inform intervention approaches and
the timing. It should address these questions through longitudinal designs, and should
consider family-based and external factors that protect children from developmental
problems even though exposed to prenatal or postnatal distress.
The most common factor contributing to low quality scores of the studies in the review
was the lack of control for potential confounders. Maternal reports of infant outcomes
should be accompanied by an assessment of current maternal distress to reduce the
potential for reporter bias. It would also be beneficial to include womens use of antide-
pressants or mental health services to further understand the impact of treated versus non-
treated distress on infant outcomes. From a surveillance perspective, it is also important for
future studies to consistently report the prevalence of the infant developmental outcomes.
Clinical
The findings of this review have particular utility for primary care clinicians involved in the
care of women and infants. The results support an early approach to prevention and
intervention of infant developmental problems where maternal psychological health rep-
resents an early, modifiable influence. As such, maternal psychological health should be
routinely assessed beginning in pregnancy and continue throughout the postpartum period.
Routine prenatal care should encompass psychosocial assessment and referral or inter-
vention as required. This process should continue throughout the postpartum period, either
in the care of a perinatal clinician or a paediatrician. The Canadian Paediatric Society has
recommended the implementation of screening questions for PPD in routine visits and
facilitation of referrals to the mothers primary care physician or a psychiatrist
(http://www.cps.ca/english/statements/pp/pp04-03.htm). This recommendation is sup-
ported by numerous studies that have documented the feasibility of assessing women for
mental health issues as part of routine well-baby visits [53]. Given the time constraints that
exist in primary care, alternative approaches to assessment and intervention should also be
considered. For example, a recent study demonstrated the effectiveness of universal home
visits by para-professionals in the prevention of PPD [54]. Others have found internet-based
screening to be a feasible and acceptable approach for the assessment of PPD [55]. These
early studies suggest that the development and evaluation of innovative service delivery
approaches, such as low cost telephone or internet-based interventions, are warranted as
sustainable and resource-sparing approaches to psychosocial assessment and care. Nurses
involved in primary or acute care and midwives are also ideally situated to conduct psy-
chosocial assessments during pregnancy and the postpartum period. Finally, developmental
assessments form a routine part of well-baby visits to 18 months. However, Tough et al.
[48] demonstrated that a substantial proportion of children are not identified as being at risk
by primary care providers, or referred for appropriate follow-up services. There is a need for
further education regarding development delay among primary care practitioners [56].
Policy
Many of the recommendations proposed as a result of this review are dependent upon the
application of the findings to policy at various levels. Given the focus of this review on
123
early, maternal contributions to infant developmental outcomes, discussions regarding

policy implications must address maternal mental health. Despite recommendations [37],
routine psychosocial care and assessment have not been implemented, and many barriers
exist. The routine assessment of maternal psychological distress and referral mechanisms
require community-level integration of a number of processes that minimally include:
(a) the availability and use of effective, easy-to-use, and rapid assessment instruments that
quantify the level of risk; (b) the education and confidence of practitioners to address
psychological issues that may be resolved at a primary care level; (c) referral processes that
involve mental health professionals when the level of risk exceeds that which can be
addressed in primary care; (d) the availability of accessible, effective mental health ser-
vices and interventions, and (e) a funding model that enables primary care clinicians and
other health care providers to incorporate screening and services in their routine care. This
system-level approach will necessarily involve inter-disciplinary collaboration and advo-
cacy of perinatal psychosocial care providers for changes at the local and provincial levels.
The importance of the involvement of national-level bodies (e.g., Public Health Agency of
Canada) in this process must be acknowledged. For example, the routine psychosocial
assessment and care processes that were initiated in Australia over a decade ago were the
result of a national initiative that mandated psychosocial assessment, referral, and care
during pregnancy and postpartum [57, 58].
The current approach to delivery of early child education and care in Canada has been
criticized on the basis that it is underfunded, inaccessible, and fragmented with little
integration and coordination among health, education, social, and justice sectors [2, 59]. A
number of political steps related to the coordination of federal and provincial bodies have
been recommended, along with the development of a pan-Canadian framework to provide
policies and programs to support children and their families (p. 661) [59]. The findings of
this review imply that this framework needs to extend the breadth of its policies and
programs to support pregnant and postpartum women as a strategy to reduce risk in the
earliest environments of a childs life. As such, expansion of resources and services should
not only be limited to programming involving child education and care, but should also
extend to pregnant and postpartum women.
In addition, reducing the risk of infant developmental delay by addressing maternal
mental health requires that women in childbearing years are aware of the risks. The results
of the recently conducted Canadian Maternity Experiences Survey demonstrated that most
Canadian women had enough information on PPD (http://www.phac-aspc.gc.ca/rhs-ssg/
survey-eng.php). However, it is unclear how knowledgeable women are regarding the
potential effects of PPD on their children. We do know that many women do not seek
needed care for PPD [40] and therefore may be incurring greater risk than necessary. In
addition, far less attention has been directed toward prenatal psychological distress and its
long-term effects on child development. There is a need for a comprehensive public
awareness strategy that increases pregnant and postpartum womens knowledge of their
risks, or the presence of psychological distress, the effects on their children, and where to
obtain support.
Summary
This systematic review demonstrated that four of five developmental domains in infants
from birth to 1 year of age were adversely influenced by maternal psychological distress.
These findings suggest that prenatal distress has a detrimental effect on cognitive,
123
behavioral, and psychomotor development, and that postpartum distress contributes to

cognitive and socio-emotional delay. All forms of maternal psychological distress (e.g.,
stress, anxiety, depression, psychiatric diagnoses) were implicated in poor infant devel-
opment. No clear trends were observed in the specific timing of exposure within the
prenatal or postpartum period and the effect on infant outcomes.
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Child Psychiatry Hum Dev (2012) 43:683714

Prenatal and Postpartum Maternal Psychological

Dawn Kingston Suzanne Tough Heather Whitfield

Published online: 10 March 2012

Keywords Infant development Maternal psychological distress

Inclusion and Exclusion Criteria and Definitions

Results: Infant Development

Global Indices of Infant Development (Table 1)

General Overview of Studies (n = 2)

*Articles retrieved through search

Studies retrieved for more

Studies excluded due to recruitment in developing countries; maternal distress

Studies included in the

Studies involving outcomes of children aged 13 months to 8 years (n=46)

Studies summarized in this paper

Moderators and Mediators

Other Potential Confounders

Summary of Effect of Maternal Distress on Global Indices of Infant Development

Infant Behavior (Table 2)

General Overview of Studies (n = 2)

10.211.0 anxious mothers scored S lower

Moderators and Mediators

Other Potential Confounders

Summary of Effect of Maternal Distress on Infant Behavior

Infant Cognitive Development (Table 3)

General overview of studies (n = 7)

Seven longitudinal studies evaluated the effects of prenatal (n = 3) and postpartum

The prevalence of cognitive delay ranged widely from 7% in infants of non-distressed

Moderators and Mediators

Other Potential Confounders

Summary of Effect of Maternal Distress on Infant Cognitive Development

Infant Socio-Emotional Development (Table 4)

General Overview of Studies (n = 4)

Four studies evaluated the influence of postpartum distress on infant socio-emotional

Moderators and Mediators

Other Potential Confounders

Summary of Effect of Maternal Distress on Infant Socio-Emotional Development

Infant Psychomotor Development (Table 5)

General Overview of Studies (n = 7)

Table 5 Key aspects of studies of infant psychomotor development (n = 7)

Prevalence rates of psychomotor delay were reported in one community-based study as

Moderators and Mediators

Other Potential Confounders

A large variety of potential confounders was assessed in 5 of the 7 studies, however 4 of

Summary of Effect of Maternal Distress on Infant Psychomotor Development

Conclusion and Discussion

Relationship Between Maternal Distress and Infant Development

Timing and Specificity of Maternal Distress

Strengths and Limitations

Several recommendations relating to research, clinical practice, and policy development

early, maternal contributions to infant developmental outcomes, discussions regarding

behavioral, and psychomotor development, and that postpartum distress contributes to

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