Maternal psychological distress: care trajectories and impact on children

A recent review of initial causes of maternal death based on hospital data in Canada identified suicide as the most frequent specific direct cause of maternal death up to one year postpartum, with a maternal mortality ratio (MMR) of 0.68 per 100,000 live births.

This cause surpasses other specific direct causes such as puerperal sepsis (MMR=0.63) or hypertensive disorders of pregnancy including preeclampsia (MMR=0.47). Maternal psychological distress was also associated with adverse outcomes such as preterm births, stillbirths, low weight for gestational age, preeclampsia, and cesarean or instrumental deliveries. An editorial in the Journal of the Society of Obstetricians and Gynaecologists of Canada also recently underscored the importance and urgency of addressing perinatal mental health disorders.

To be able to respond adequately and effectively to the problem of maternal suicide, we urgently need data to better understand the trajectories of women experiencing psychological distress during pregnancy or postpartum. We also need to better understand the impact of maternal psychological distress on children.

This longitudinal study will be based on data from a large cohort for which recruitment began in January 2023. The cohort includes nulliparous women with a singleton pregnancy, residing in the Greater Quebec City Area, recruited during their 1st trimester of pregnancy (11-14 weeks of amenorrhea). Participants with a negative fetal heartbeat at the initial ultrasound were excluded.

Following a review of the literature on measures of suicidality, this study will use question 10 of the Edinburgh Postnatal Depression Scale (EPDS) to measure suicidality. Maternal psychological distress will be defined according to the recognized thresholds of the assessment tools used. We will also set up a mental health follow-up service for all participants at increased risk of suicide.

Among the potentially associated factors considered, we will measure socioeconomic status, domestic violence, childhood trauma/abuse, social support, history of mental health disorders, history of abortion and sleep patterns.

In addition to calculating the relative frequency of maternal psychological distress and suicidality during pregnancy and at 6 months postpartum, we will conduct an association analysis of these exposures during pregnancy and maternal health outcomes (all-cause mortality, suicide mortality, overdose mortality, hospitalization for mental health diagnosis, severe maternal morbidity and mode of delivery).

Associations between maternal psychological distress, suicidality and child health outcomes will also be assessed. We will consider fetal and neonatal mortality, neonatal intensive care unit admissions, prematurity, low weight for gestational age, congenital anomalies and minor adverse neonatal outcomes. The analyses will take into account the history of mental health diagnoses and pharmacological treatments (initiated before pregnancy, started during pregnancy or stopped during pregnancy; modelled as time-varying variables). We will assess their potential modifying effect on the relationship between distress or suicidality and the outcomes of interest. A draft directed acyclic graph (DAG), which will guide the analyses, is presented in Appendix B. Analyses will be performed with SAS 9.4 (SAS Institute Inc., Cary, NC, USA, 2016). A type II error of 5% will be accepted.

The proposed project aims to :

1. Evaluate the frequency of psychological distress and suicidality during pregnancy and at 6 months postpartum
2. sess the association between psychological distress and suicidality during pregnancy and perinatal maternal health outcomes (maternal mortality and morbidity up to 3 months postnatal)
3. Evaluate the association between maternal psychological distress and suicidality during pregnancy and fetal and neonatal outcomes
4. Identify factors associated with maternal psychological distress and suicidality during pregnancy and at 6 months postpartum, and calculate attributable fractions in order to identify factors with the greatest preventive potential

PROJECT ORIGINALITY

The urgent need to better understand maternal mental health has recently been highlighted, and the number of researchers studying maternal suicidality and its impact on children is still very limited. Thus, the project will aim to develop the principal investigator’s expertise in this field of research. The prospective longitudinal design will provide high-quality, comprehensive data that will enable the assessment of the impact of maternal psychological distress on the health of mothers and newborns.

POTENTIAL IMPACT ON STUDENT TRAINING

We plan to recruit 2 students to work with us on the project. A graduate student will be recruited for objective 2. A post-graduate student will be recruited for objectives 1, 3 and 4.

The project also has great potential for learning about epidemiological concepts and methods, given the longitudinal nature of the data, the possibility of some variables changing over time (e.g., pharmacological treatments) and the complexity of the relationships between the variables studied.

POTENTIAL IMPACT ON CHILDREN’S HEALTH

This study will characterize maternal psychological distress, taking into account the context and the state of health at the time of conception and in early pregnancy, and by developing a longitudinal perspective through prospective follow-up during pregnancy and up to 6 months after delivery/birth. This will provide a portrait of the onset of depressive and anxiety disorders during pregnancy, as well as pharmaceutical treatment patterns, and maternal and child health outcomes associated with these dimensions. The potential impact on children’s health is significant given the paucity of high-quality prospective data measuring the impact of perinatal maternal psychological distress on children. The prospective design will allow us to take into account several potentially confounding factors, and to assess the mediation effects of pharmacological treatments on psychological distress.

POTENTIAL LEVERAGE

The proposed project represents one of the first steps in the study of this cohort, which will be followed by the assessment of maternal psychological distress and suicidality in the postpartum period and the impact on child development at 18 and 30 months. It is part of the principal investigator’s larger research program focusing on psychological distress and suicidality during pregnancy and postpartum, and their impact on maternal and child health, which will be the subject of a Research Scholars Junior 2 funding application with the FRQS. Support from the Foundation of Stars would boost the success of funding applications for subsequent projects.