Psychological trauma associated with the World Trade Center attacks and its effect on pregnancy outcome

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DOI: 10.1111/j.1365-3016.2005.00676.x · Source: PubMed
Abstract
The destruction of the World Trade Center (WTC) on 11 September 2001 was a source of enormous psychological trauma that may have consequences for the health of pregnant women and their fetuses. In this report, we describe the impact of extreme trauma on the birth outcomes of women highly exposed to the WTC. We enrolled 187 women who were pregnant and living or working within close proximity to the WTC on 11 September. Among women with singleton pregnancies, 52 completed at least one psychological assessment prior to delivery. In adjusted multivariable models, both post-traumatic stress symptomatology (PTSS) and moderate depression were associated with longer gestational durations, although only PTSS was associated with decrements in infant head circumference at birth (beta=-0.07, SE=0.03, P=0.01). The impact of stress resulting from extreme trauma may be different from that which results from ordinary life experiences, particularly with respect to cortisol production. As prenatal PTSS was associated with decrements in head circumference, this may influence subsequent neurocognitive development. Long-term follow-up of infants exposed to extreme trauma in utero is needed to evaluate the persistence of these effects.
334
©
2005 Blackwell Publishing Ltd.
Paediatric and Perinatal Epidemiology,
19,
334– 341
Blackwell Science, LtdOxford, UKPPEPaediatric and Perinatal Epidemiology0269-5022Blackwell Publishing Ltd, 200519
334341
Original Article
Psychological trauma and pregnancy outcomeS. M. Engel
et al.
Correspondence:
Dr Stephanie Engel,
Department of Community
and Preventive Medicine,
Mount Sinai School of
Medicine. One Gustave L.
Levy Place, Box 1043, New
York, NY 10029, USA.
E-mail:
Stephanie.Engel@mssm.edu
Psychological trauma associated with the World Trade Center
attacks and its effect on pregnancy outcome
Stephanie Mulherin Engel
a
, Gertrud S. Berkowitz
a
, Mary S. Wolff
a
and Rachel Yehuda
b,c
a
Department of Community and Preventive Medicine,
b
Traumatic Stress Studies Program, Department of Psychiatry, Mount Sinai School of
Medicine, and
c
Bronx Veterans Affairs Medical Center, New York, USA
Summary
The destruction of the World Trade Center (WTC) on 11 September 2001 was a source
of enormous psychological trauma that may have consequences for the health of
pregnant women and their fetuses. In this report, we describe the impact of extreme
trauma on the birth outcomes of women highly exposed to the WTC. We enrolled 187
women who were pregnant and living or working within close proximity to the WTC
on 11 September. Among women with singleton pregnancies, 52 completed at least
one psychological assessment prior to delivery. In adjusted multivariable models, both
post-traumatic stress symptomatology (PTSS) and moderate depression were associ-
ated with longer gestational durations, although only PTSS was associated with dec-
rements in infant head circumference at birth (
b
=
-
0.07, SE
=
0.03,
P
=
0.01). The impact
of stress resulting from extreme trauma may be different from that which results from
ordinary life experiences, particularly with respect to cortisol production. As prenatal
PTSS was associated with decrements in head circumference, this may influence
subsequent neurocognitive development. Long-term follow-up of infants exposed to
extreme trauma
in utero
is needed to evaluate the persistence of these effects.
Introduction
The destruction of the World Trade Center (WTC) at
approximately 9 am on 11 September 2001 was a
source of enormous psychological trauma,
1–21
and con-
sequently resulted in a unique opportunity to examine
the effects of extreme trauma on the health of pregnant
women. It has been suggested that psychological stress
experienced during the course of pregnancy could
affect pregnancy outcome, possibly through disrup-
tion of the hypothalamic-pituitary-adrenal (HPA)
axis.
22–24
Although the impact of psychological trauma
on the health of pregnant women and their fetuses is
of public health concern, few circumstances allow its
systematic evaluation because traumatic events may
not be of uniform duration and intensity, and may not
be attributable to a single point in time. In many cir-
cumstances, natural or man-made disasters involve
stressful events that share many of these characteris-
tics. However, the existing literature on the impact of
disasters on pregnancy outcome is quite limited. Stress
related to the experience of an earthquake has been
associated with shorter gestational length,
25
an
increase in the frequency of low birthweight neo-
nates,
26
and a decline in the sex ratio at birth.
27
Psychological trauma was a widespread and preva-
lent outcome of the terrorist attacks on the WTC. In a
national probability sample telephone survey 3–5 days
after 11 September, 44% of respondents reported one
or more substantial symptoms of stress, and 35% of
children had one or more stress symptoms.
18
In Man-
hattan, the effects were more pronounced. Between 16
October and 15 November, 7.5% of adults south of
110th Street endorsed symptoms consistent with a
diagnosis of post-traumatic stress disorder (PTSD)
related to the attacks, and 9.7% reported symptoms
consistent with depression. Moreover, among respon-
dents who lived south of Canal Street, closer to the
WTC, the prevalence of probable PTSD was 20%.
7
Psychological trauma and pregnancy outcome 335
©
2005 Blackwell Publishing Ltd.
Paediatric and Perinatal Epidemiology,
19,
334– 341
Compared with Washington DC (2.7%) and other
metropolitan areas (3.6%), New York City residents
experienced a higher burden of probable PTSD in the
1–2 months following 11 September (11.2%).
17
Predic-
tors of PTSD were residence close to the WTC site, low
social support, prior life stressors, panic attack at the
time of the event or soon after, losing possessions in
the attacks, and being involved in the rescue efforts.
8
Women were more likely to report symptoms related
to PTSD than men,
5,8,16,17,19
and only a small proportion
of those with severe responses were seeking
treatment.
5
Among those exposed to the WTC disaster
were an unknown number of pregnant women who
may have lived or worked in close proximity to the
WTC.
We established a prospective epidemiological study
of 187 women, who were pregnant on 11 September or
shortly thereafter, and at or near the WTC on or about
11 September . In this report we describe the relation-
ship between prenatal psychological trauma and preg-
nancy outcome in a cohort of highly exposed women
who completed psychological screening instruments
prior to delivery.
Methods
A total of 187 women were recruited who were within
one of five zones of exposure at 9 am on 11 September
2001, or within the succeeding 3 weeks. Of these
women, 3 miscarried and 2 were lost to follow-up with
unknown birth outcomes. Enrolment began in Febru-
ary 2002 and continued until January 2003. Details of
this cohort have been published.
28,29
Among women
with singleton pregnancies (
n
=
175), 54 (43%) were
interviewed prior to delivery and 52 (96%) of these
women completed at least one prenatal psychological
assessment (Table 1). We abstracted medical records
for birth outcome information, including birthweight,
Table 1.
Characteristics of women enrolled and interviewed prior to delivery (
n
=
52). World Trade Center pregnancy cohort, Mount
Sinai School of Medicine 2002
Covariates
n
%
Maternal age
35 years 26 50.0
Married 51 98.1
Caucasian 38 73.1
College degree or greater 44 84.6
Primiparae 33 63.5
Exposure zone on 11 September at 9 am
Zone 1 19 36.5
Zone 2 17 32.7
Zones 3,4,5 10 19.2
Out of area
a
6 11.5
Trimester on 11 September
Before conception 5 9.6
1st trimester 35 67.3
2nd trimester 12 23.1
3rd trimester 00
Mean SD
Pre-pregnancy body mass index (kg/m
2
) 23.7 5.1
Gestational age at delivery (completed weeks) 39.6 1.3
Birthweight (g) 3391.9 539.8
Head circumference at birth (cm) 34.4 2.0
Birth length (cm) 50.8 3.8
Time between interview and 11 September (weeks) 26.2 3.6
Time between interview and delivery (weeks) 4.1 3.8
Post-traumatic Stress Checklist score 29.2 10.4
Beck Depression Index score 7.9 5.5
a
Out of the area at 9 am on 11 September, but in one of the zones of exposure in the following 3 weeks.
336
S. M. Engel
et al.
©
2005 Blackwell Publishing Ltd.
Paediatric and Perinatal Epidemiology,
19,
334– 341
birth length, head circumference, and date and time
of delivery. Gestational age at delivery was assigned
using the maternal report of last menstrual period
(LMP) date.
Eligibility criteria were pregnancy on 11 September
or shortly thereafter and presence in one of five expo-
sure zones at or near the WTC at 9 am on that day or
within the next 3 weeks. The five exposure zones were
assigned based on increasing distance from the WTC
site, and inversely correlate with particulate matter
(PM) air concentrations.
29
They were: (1) South of Mur-
ray Street; (2) South of Chambers Street and North of
Murray Street; (3) South of Canal Street and North of
Chambers Street; (4) Brooklyn Heights; and (5) the
easternmost part of New Jersey across the Hudson
River from the WTC. Zones 1 and 2 are within 8 blocks
of the WTC.
At their enrolment visit in our research laboratory
at the Mount Sinai School of Medicine, women were
administered a baseline questionnaire that included
socio-demographic information, gynaecological,
reproductive and medical history, occupational his-
tory, physical activity during pregnancy, residential
history, cigarette, alcohol, drug and caffeine use, and
zone location on 11 September and the first 4 weeks
after the attacks. Participants also completed self-
administered psychological instruments at this visit.
These included the Post-traumatic Stress Disorder
Checklist (PCL),
30
Life Events Inventory (LEI),
31
State-
Trait Anxiety Inventory (STAI),
32
and Beck Inventory
of Depression (BDI).
33
Both continuous and categorical versions of psycho-
logical exposure variables were considered in analy-
ses. Categorical cut-points were chosen based on
standard clinical criteria when possible, or percentiles
if no standard clinical criteria exist. A dichotomous
indicator variable for probable PTSD based on clusters
of symptoms reported on the PCL was constructed
using the standard clinical criteria of
1 at least mod-
erately distressing symptom of intrusive thoughts
(PCL items 1–5),
3 at least moderately distressing
symptoms of avoidance or numbing (PCL items 6–12),
and
2 at least moderately distressing symptoms of
hyperarousal (PCL items 13–17).
34
We will hereafter
refer to the continuous version of the total PCL score
as ‘post-traumatic stress symptomatology (PTSS)’, and
the categorical version of the PCL symptom clusters as
‘probable PTSD’. A categorical variable indicating the
severity of depression was constructed using the stan-
dard BDI cut-points: normal (0–9) (
n
=
33); mild
depression (10–18) (
n
=
17); moderate depression (19–
29) (
n
=
2); severe depression (
30) (
n
=
0).
35
Categories
Table 2.
Correlation among symptoms of stress, depression, and anxiety among women who completed their interview prior to delivery
in the World Trade Center pregnancy cohort, 2002
STAI LEI
BDI
Depression
total score
State anxiety
total score
Trait anxiety
total score
Total negative
life events
Total positive
life events
PCL PTSS
r
0.71 0.37 0.64 0.09 0.77
P
<
0.01
<
0.01
<
0.01 0.53
<
0.01
(
n
) (50) (50) (50) (50) (50)
STAI State anxiety
r
0.67 0.39 0.11 0.51
total score P
(
n
)
<
0.01
(52)
<
0.01
(52)
0.46
(52)
<
0.01
(52)
Trait anxiety
r
0.23 0.07 0.17
total score P
(
n
)
0.10
(52)
0.64
(52)
0.24
(52)
LEI Total negative
r
-
0.01 0.72
life events P
(
n
)
0.96
(52)
<
0.01
(52)
Total
r
0.12
positive P 0.41
life events (
n
) (52)
STAI, State-Trait Anxiety Inventory; LEI, Life Events Inventory; BDI, Beck Inventory of Depression; PCL, Post-traumatic Stress Disorder
Checklist.
Psychological trauma and pregnancy outcome 337
©
2005 Blackwell Publishing Ltd.
Paediatric and Perinatal Epidemiology,
19,
334– 341
of the STAI and LEI were created comparing subjects
having total scores greater than the 75th percentile
with those at or below the 75th percentile. We were
underpowered to examine the effects of individual life
events, such as death of a family member, on preg-
nancy outcome.
Across psychological instruments, symptom report-
ing tended to be highly correlated (Table 2). In partic-
ular, PTSS (based on the PCL) was highly correlated
with state and trait anxiety (based on the STAI), nega-
tive life events (based on the LEI), and depression
(based on the BDI). Because of these correlations, psy-
chological domains were evaluated in separate statis-
tical models to avoid problems of collinearity;
however, state and trait anxiety, and positive and neg-
ative life events, were analysed together as they are
elements of the same instruments. Covariates that
were considered possible confounders of the relation-
ship between psychological trauma and pregnancy
outcome were maternal race (White vs. non-White and
Hispanic); exposure zone on 11 September at 9 am
(zone 1 vs. 3, 4, 5, and out of area; zone 2 vs. 3, 4, 5,
and out of area); trimester on 11 September (precon-
ception and first trimester combined vs. second trimes-
ter); maternal age (
35 vs. younger); maternal
education (college degree vs. less than college degree);
pre-pregnancy body mass index (BMI) (kg/m
2
) (con-
tinuous); and parity (primiparae vs. multiparae). All
birthweight and head circumference models were
adjusted for length of gestation.
Multivariable linear regression was implemented
using PROC GLM in SAS vs. 8.02. Confounding was
assessed in bivariate analyses using either chi-square
or
t-
tests of association. A confounder was defined as
a covariate that was associated with the main psycho-
logical exposure at a
P
<
0.10 level and that changed
the main effect by 10%. Covariates not associated with
the main exposures in bivariate analyses were not
evaluated in regression models owing to our limited
sample size. Model fit was examined by inspecting
residuals. Observations with residual values that were
>
2 standard deviations from the mean were eliminated
and the models were re-run (hereafter called ‘reduced
model’). Parameter estimates were compared between
the original model and the reduced model. If the
parameter estimates of the reduced model were within
10% of the original model, the final model included
these observations.
Results
The majority of the women enrolled while still preg-
nant (
n
=
52) were married (98.1%), primiparae
(63.5%), and in zones 1 or 2 at 9 am on 11 September
(69.2%). They were also predominantly Caucasian
(73.1%), highly educated (84.6%), and in their first tri-
mester on 11 September (67.3%). Women were inter-
viewed on average 26.2 weeks after September 11, and
an average of 1 month prior to delivery (Table 1). Three
women had a preterm delivery (
<
37 completed weeks),
and two women delivered low birthweight infants
(
<
2500 g).
Post-traumatic stress symptomatology was margin-
ally associated with maternal age, in that women aged
35 years and older had a slightly higher mean PCL
score (i.e. they endorsed more symptoms of post-trau-
Table 3.
Adjusted regression estimates for gestational age at delivery, birthweight, and birth head circumference by post-traumatic stress
symptomatology (PTSS) or probable post-traumatic stress disorder (PTSD) in the World Trade Center pregnancy cohort, 2002
PTSS (range 17–69)
(
n
=
50)
a
, b (SD)
P
-value
No PTSD
b
(
n
=
47)
a
adjusted mean
Probable PTSD
b
(
n
=
4)
a
adjusted mean
P
-value
Gestational age at delivery
(completed weeks)
0.04 (0.02) 0.03 39.6
c
40.6
c
0.17
Birthweight (g)
-
2.62 (6.43) 0.69 3387.4
d
3469.9
d
0.73
Birth head circumference (cm)
-
0.07 (0.03) 0.01 34.4
d
34.1
d
0.71
a
Two subjects did not complete an entire PCL questionnaire. One of these subjects answered 16 of 17 items that allowed us to assign a
‘probable PTSD’ diagnosis based on reported symptoms; however, we were unable to compute a summary ‘PTSS’ score for either subject
without complete data.
b
Probable PTSD classified using the cluster diagnosis method:
1 at least moderately distressing symptom of
Intrusive Thoughts
,
3 at
least moderately distressing symptoms of
Avoidance or Numbing
, and
2 at least moderately distressing symptoms of
Hyperarousal
.
c
Mean adjusted for maternal age
35.
d
Mean adjusted for maternal age
35 and gestational age at delivery.
338
S. M. Engel
et al.
©
2005 Blackwell Publishing Ltd.
Paediatric and Perinatal Epidemiology,
19,
334– 341
matic stress) (32.1 vs. 26.6, P = 0.07). Adjusted for
maternal age, PTSS was positively associated with ges-
tational duration, such that a 1-unit increase in PCL
score increased gestational duration by 0.04 weeks
(P = 0.03). Further, PTSS was inversely associated with
infant head circumference at birth, such that a 1-unit
increase in PCL score was associated with a 0.07 cm
decrement in head circumference (P = 0.01), adjusted
for maternal age and gestational age at delivery
(Table 3). In the subset of women included in this anal-
ysis, few met the standardised criteria for probable
PTSD (n = 4). We did not detect a relationship between
probable PTSD and gestational duration, birthweight,
or head circumference (Table 3).
Depressive symptomatology (BDI score) was also
marginally associated with maternal age, in that older
women endorsed slightly more depressive symptoms
(P = 0.10). There was no association between increas-
ing number of symptoms for depression and gesta-
tional duration, birthweight, or head circumference.
Few women met the standardised criteria for moderate
depression based on the BDI (n = 2), and none did for
severe depression. Moderate depression was margin-
ally associated with an increased duration of gestation,
adjusted for maternal age (P = 0.05) (Table 4). How-
ever, there was no significant association between
categories of depression and birthweight or head
circumference.
Presence in zone 1 at 9 am on 11 September was
associated with having a state anxiety above the 75th
percentile at interview. However, there was no rela-
tionship between state or trait anxiety, and gestational
age at delivery, birthweight, or birth head circumfer-
ence, adjusted for zone of exposure. Likewise, no cova-
riates were significantly associated with having
positive or negative life events above the 75th percen-
tile, and there was no association between positive or
negative life events and gestational age at delivery,
birthweight, or head circumference.
Discussion
The destruction of the World Trade Center (WTC) on
11 September 2001 created the largest acute environ-
mental disaster that has ever befallen New York
City.36,37 It was also a source of enormous psychological
trauma.1–21 Exposure to the WTC disaster has been
associated with increased risk of small-for-gestational
age births in our cohort,28 as well as decrements in
birthweight, birth length, gestational duration, and
head circumference in a contemporaneous cohort of
pregnant women with term births exposed to the
WTC.38
We restricted our analysis to those women who were
interviewed before delivery. Although this resulted
in a substantially reduced sample size, residual con-
founding owing to post-partum depression or changes
in lifestyle factors related to the birth of an infant
makes prenatal and postnatal psychological assess-
ments not comparable. The entire study population
(n = 187) was evenly distributed across trimesters on
11 September; however, because we restricted our
analysis to only those women who enrolled and were
interviewed prior to delivery and our study did not
begin recruitment until February 2002, the majority of
our analysis population was comprised of women who
Table 4. Adjusted regression estimates for gestational age at delivery, birthweight, and birth head circumference by depression symp-
toms in the World Trade Center pregnancy cohort, 2002
Depression
symptoms
(range 0–28)
(n = 52), (SD) P-value
Normal (no)
depressiona
(n = 33)
Adjusted mean
Mild
depressiona
(n = 17)
Adjusted mean P-valueb
Moderate
depressiona
(n = 2)
Adjusted mean P-valueb
Gestational age at delivery
(completed weeks)
0.04 (0.04) 0.23 39.5c40.4c0.70 41.5c0.05
Birthweight (g) 10.01 (11.59) 0.39 3419.1d3338.4d0.43 3156.1d0.43
Birth head circumference (cm) -0.05 (0.05) 0.31 34.5d33.3d0.66 32.3d0.11
aSeverity of depression cut-points derived using standardised criteria: normal (0–9); mild (10–18); moderate (19–29); severe (30).
bReference category is normal (no) depression.
cMean adjusted for maternal age 35.
dMean adjusted for maternal age 35 and gestational age at delivery.
Psychological trauma and pregnancy outcome 339
©2005 Blackwell Publishing Ltd. Paediatric and Perinatal Epidemiology, 19, 334 –341
were in their first trimester on 11 September. Therefore,
we were underpowered to evaluate the interaction
between trimester, traumatic stress, and pregnancy
outcome.
We report in this paper a significant association
between PTSS and longer gestational duration; a sim-
ilar relationship was observed for moderate depres-
sion. Given the substantial overlap between symptoms
of depression and traumatic stress, these findings were
expected to be highly correlated. Although the litera-
ture is somewhat mixed,39,40 it is commonly believed
that prenatal stress increases risk of preterm delivery
through alterations in the HPA axis;22–24 specifically,
stress may increase the production of cortisol and cor-
ticotrophin-releasing hormone which promote the bio-
logical cascade leading to delivery.23 However, not all
types of stress have the same effect on cortisol produc-
tion. PTSD in particular is associated with depressed
cortisol production in some studies,41 whereas other
types of stress and major depression tend to be associ-
ated with increased cortisol production.41 These
observations suggest that our findings are in agree-
ment with the HPA hypothesis of preterm birth. For
both probable PTSD and moderate depression, the
mean gestational duration was within the normal
range (37–42 completed weeks), which is unlikely to
result in clinically significant adverse health effects. In
addition, the small sample size warrants caution in
interpretation.
We also found an inverse relationship between PTSS
and infant head circumference at birth. Head circum-
ference and depression were not significantly associ-
ated, which, in combination with the absence of any
association between either life events or state and trait
anxiety, suggests specificity in the relationship
between head circumference and traumatic stress.
Consequently, the aetiological impact of stress result-
ing from daily hassles or ordinary life experiences may
be substantially different from that which results from
natural or man-made disasters.
The relationship between PTSS in the prenatal
period and decrements in head circumference may
have clinical significance. Head circumference at birth
correlates directly with brain weight;42 and, both brain
size and head circumference are predictive of IQ and
cognitive ability.43–45 Previous studies have found rela-
tionships between head circumference and maternal
stress,46,47 although only our study and Lou et al.46 mea-
sured stress prior to delivery, and our study alone cap-
tures the effect of extreme trauma. It is unclear whether
modest reductions in head circumference associated
with traumatic stress exposure in utero will have any
impact on subsequent cognitive development. The
only prospective investigation of the effects of mater-
nal prenatal stress resulting from a natural disaster (an
ice storm in Canada) on childhood neuro-development
followed 58 children to age 2.48 There, prenatal stress
explained a significant proportion of the variance in
the Bayley Mental Development Index, as well as in
productive and receptive language abilities, and the
effects were stronger for women who were in their first
trimester when the ice storm occurred.
Because we collected detailed assessments across
multiple psychological domains prior to delivery, this
study was uniquely able to directly evaluate the degree
to which psychological trauma resulting from the
WTC disaster affected pregnancy outcome in a subset
of women enrolled in a longitudinal pregnancy cohort.
Moreover, the uniform and discrete nature of the trau-
matic event allowed us to evaluate the impact of a
stressor that was common to all participants and that
occurred at a known time during pregnancy. We
detected no significant confounding in the pregnancy
outcome analysis by exposure zone with any psycho-
logical symptom except state-trait anxiety, but the pos-
sibility exists that psychopathology and unmeasured
environmental exposures were highly correlated both
with each other and with pregnancy outcome.
However, we believe that zone is a good surrogate
for the environmental exposures experienced on 11
September.
In a recent report, reconstructed particulate expo-
sures among the women in our study based on zone
of exposure were directly related to PM concentrations
in air in late September and early October, with highest
levels in zone 1.29 On 11 September and immediately
thereafter, PM levels in zone 1 were estimated to
be above 100 mg/m3. Therefore, in our confounding
assessments, we incorporated zone (location at 9 am
on 11 September) to estimate exposures on 11 Septem-
ber. We are currently evaluating the long-term effects
of prenatal stress on the neuro-developmental out-
comes of the WTC children, which may further eluci-
date the relationship between PTSS, birth outcome and
child development.
Acknowledgements
This research was supported by grants from the
National Institute of Environmental Health Sciences
340 S. M. Engel et al.
©2005 Blackwell Publishing Ltd. Paediatric and Perinatal Epidemiology, 19, 334 –341
(NIEHS P42 ES07384) and The September 11th Fund
created by The United Way of New York City and The
New York Community Trust, and the National Center
for Environmental Research (NCER) STAR Program,
EPA (RD 83082701). Support for Dr Yehuda was pro-
vided by the National Institute of Mental Health (5
R01 MH64675-03 PI: YEHUDA, RACHEL). The
authors would like to thank the participants of the
WTC Pregnancy Study for their continued coopera-
tion, and the WTC staff for their dedication, especially
Joan Golub, Kelly Nichols, Martha Malagon, and Lee
Spellman.
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    • "Birth Fukushima City, which showed that mothers in areas most affected by the nuclear accident, i.e., those with higher radiation levels, were more likely to have depressive symptoms (Goto et al. 2014; 2015). Regarding pregnancy outcomes, several reports have suggested that the earthquake disaster affected fetal outcomes (Camacho 2008; Chang et al. 2002; Catalano et al. 2006; Engel et al. 2005; Eskenazi et al. 2007; Fukuda et al. 1998; Saadat 2008; Smits et al. 2006), while others found no associations (Berkowitz et al. 2003; Hamilton et al. 2009; Leaderman et al. 2004). The present study excluded cases needing special medical intervention and showed that mental and physical stress caused by the earthquake did not affect newborns' anthropometric measures at birth. "
    [Show abstract] [Hide abstract] ABSTRACT: This study examined the effects of three disasters (the Great East Japan Earthquake of March 11, 2011, followed by a tsunami and the Fukushima Daiichi Nuclear Power Plant accident) on feeding methods and growth in infants born after the disasters. Using results from the Fukushima Health Management Survey, Soso District (the affected area where the damaged nuclear power plant is located) and Aizu District (a less-affected area located farthest from the plant) were compared. In this study, newborn and maternal background characteristics were examined, as well as feeding methods, and other factors for newborn growth at the first postpartum examination for 1706 newborns born after the disaster in the affected (n = 836) and less-affected (n = 870) areas. Postpartum examinations took place 1 month after birth. Feeding method trends were examined, and multivariate regression analyses were used to investigate effects on newborn mass gain. There were no significant differences in background characteristics among newborns in these areas. When birth dates were divided into four periods to assess trends, no significant change in the exclusive breastfeeding rate was found, while the exclusive formula-feeding rate was significantly different across time periods in the affected area (p = 0.02). Multivariate analyses revealed no significant independent associations of maternal depression and change in medical facilities (possible disaster effects) with other newborn growth factors in either area. No area differences in newborn growth at the first postpartum examination or in exclusive breastfeeding rates were found during any period. Exclusive formula-feeding rates varied across time periods in the affected, but not in the less-affected area. It is concluded that effective guidance to promote breast-feeding and prevent exclusive use of formula is important for women in post-disaster circumstances.
    Full-text · Article · Feb 2016
    • "Although we did not investigate associations of low infant birthweight in the current analysis, maternal trauma was found to be significantly associated with reduced HCAZ at birth in our final multivariate model. This is in line with one study (Engel, Berkowitz, Wolff, & Yehuda, 2005) which found that women with posttraumatic stress symptomatology resulting from the World Trade Center attacks were more likely to deliver infants with reduced head circumference at birth (beta0(0.07, SE00.03, "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Prenatal and peripartum trauma may be associated with poor maternal-fetal outcomes. However, relatively few data on these associations exist from low-middle income countries, and populations in transition. Objective: We investigated the prevalence and risk factors for maternal trauma and posttraumatic stress disorder (PTSD), and their association with adverse birth outcomes in the Drakenstein Child Health Study, a South African birth cohort study. Methods: Pregnant women were recruited from two clinics in a peri-urban community outside Cape Town. Trauma exposure and PTSD were assessed using diagnostic interviews; validated self-report questionnaires measured other psychosocial characteristics. Gestational age at delivery was calculated and birth outcomes were assessed by trained staff. Multiple logistic regression explored risk factors for trauma and PTSD; associations with birth outcomes were investigated using linear regression. Potential confounders included study site, socioeconomic status (SES), and depression. Results: A total of 544 mother-infant dyads were included. Lifetime trauma was reported in approximately two-thirds of mothers, with about a third exposed to past-year intimate partner violence (IPV). The prevalence of current/lifetime PTSD was 19%. In multiple logistic regression, recent life stressors were significantly associated with lifetime trauma, when controlling for SES, study site, and recent IPV. Childhood trauma and recent stressors were significantly associated with PTSD, controlling for SES and study site. While no association was observed between maternal PTSD and birth outcomes, maternal trauma was significantly associated with a 0.3 unit reduction (95% CI: 0.1; 0.5) in infant head-circumference-for-age z-scores (HCAZ scores) at birth in crude analysis, which remained significant when adjusted for study site and recent stressors in a multivariate regression model. Conclusions: In this exploratory study, maternal trauma and PTSD were found to be highly prevalent, and preliminary evidence suggested that trauma may adversely affect fetal growth, as measured by birth head circumference. However, these findings are limited by a number of methodological weaknesses, and further studies are required to extend findings and delineate causal links and mechanisms of association.
    Full-text · Article · Feb 2016
    • "An important limitation of this study is that by its crosssectional design, we could only measure associations rather than prediction and direction of effects. For example, it could be the case as has been postulated (Engel et al., 2005) that low percentage of methylation NR3C1 epigenetic signature could represent an effect of fetal programming and be a risk factor for the development of PTSD rather than an associated feature or effect of PTSD. Similarly, as noted above, we cannot tease apart whether early and chronic exposure to physical abuse and domestic violence alone might be necessary and sufficient to generate the epigenetic signature if occurring during a sensitive window of development, or if while necessary, it remains insufficient, and the development of PTSD is necessary. "
    [Show abstract] [Hide abstract] ABSTRACT: Prior research has shown that mothers with Interpersonal Violence-related Posttraumatic Stress Disorder (IPV-PTSD) report greater difficulty in parenting their toddlers. Relative to their frequent early exposure to violence and maltreatment, these mothers display dysregulation of their hypothalamic pituitary adrenal axis (HPA-axis), characterized by hypocortisolism. Considering methylation of the promoter region of the glucocorticoid receptor gene NR3C1 as a marker for HPA-axis functioning, with less methylation likely being associated with less circulating cortisol, the present study tested the hypothesis that the degree of methylation of this gene would be negatively correlated with maternal IPV-PTSD severity and parenting stress, and positively correlated with medial prefrontal cortical (mPFC) activity in response to video-stimuli of stressful versus non-stressful mother-child interactions. Following a mental health assessment, 45 mothers and their children (ages 12-42 months) participated in a behavioral protocol involving free-play and laboratory stressors such as mother-child separation. Maternal DNA was extracted from saliva. Interactive behavior was rated on the CARE-Index. During subsequent fMRI scanning, mothers were shown films of free-play and separation drawn from this protocol. Maternal PTSD severity and parenting stress were negatively correlated with the mean percentage of methylation of NR3C1. Maternal mPFC activity in response to video-stimuli of mother-child separation versus play correlated positively to NR3C1 methylation, and negatively to maternal IPV-PTSD and parenting stress. Among interactive behavior variables, child cooperativeness in play was positively correlated with NR3C1 methylation. Thus, the present study is the first published report to our knowledge, suggesting convergence of behavioral, epigenetic, and neuroimaging data that form a psychobiological signature of parenting-risk in the context of early life stress and PTSD.
    Full-text · Article · May 2015
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