Maternal and Child Health Journal

, Volume 18, Issue 1, pp 52–63 | Cite as

Measuring Stress Before and During Pregnancy: A Review of Population-Based Studies of Obstetric Outcomes

  • Whitney P. Witt
  • Kristin Litzelman
  • Erika R. Cheng
  • Fathima Wakeel
  • Emily S. Barker


Mounting evidence from clinic and convenience samples suggests that stress is an important predictor of adverse obstetric outcomes. Using a proposed theoretical framework, this review identified and synthesized the population-based literature on the measurement of stress prior to and during pregnancy in relation to obstetric outcomes. Population-based, peer-reviewed empirical articles that examined stress prior to or during pregnancy in relation to obstetric outcomes were identified in the PubMed and PsycInfo databases. Articles were evaluated to determine the domain(s) of stress (environmental, psychological, and/or biological), period(s) of stress (preconception and/or pregnancy), and strength of the association between stress and obstetric outcomes. Thirteen studies were evaluated. The identified studies were all conducted in developed countries. The majority of studies examined stress only during pregnancy (n = 10); three examined stress during both the preconception and pregnancy periods (n = 3). Most studies examined the environmental domain (e.g. life events) only (n = 9), two studies examined the psychological domain only, and two studies examined both. No study incorporated a biological measure of stress. Environmental stressors before and during pregnancy were associated with worse obstetric outcomes, although some conflicting findings exist. Few population-based studies have examined stress before or during pregnancy in relation to obstetric outcomes. Although considerable variation exists in the measurement of stress across studies, environmental stress increased the risk for poor obstetric outcomes. Additional work using a lifecourse approach is needed to fill the existing gaps in the literature and to develop a more comprehensive understanding of the mechanisms by which stress impacts obstetric outcomes.


Maternal stress Stress measurement Lifecourse Obstetric outcomes Population-based Review 


  1. 1.
    Heron, M. (2012). Deaths: Leading causes for 2008. National Vital Statistics Reports. Hyattsville, MD: National Center for Health Statistics.Google Scholar
  2. 2.
    Vohr, B. R., Wright, L. L., Dusick, A. M., et al. (2000). Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993–1994. Pediatrics, 105, 1216–1226.PubMedCrossRefGoogle Scholar
  3. 3.
    Bhutta, A. T., Cleves, M. A., Casey, P. H., et al. (2002). Cognitive and behavioral outcomes of school-aged children who were born preterm: a meta-analysis. JAMA, 288, 728–737.PubMedCrossRefGoogle Scholar
  4. 4.
    Arck, P. C., Rucke, M., Rose, M., et al. (2008). Early risk factors for miscarriage: a prospective cohort study in pregnant women. Reproductive Biomedicine Online, 17, 101–113.PubMedCrossRefGoogle Scholar
  5. 5.
    Dole, N., Savitz, D. A., Hertz-Picciotto, I., et al. (2003). Maternal stress and preterm birth. American Journal of Epidemiology, 157, 14–24.PubMedCrossRefGoogle Scholar
  6. 6.
    Copper, R. L., Goldenberg, R. L., Das, A., et al. (1996). The preterm prediction study: Maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks’ gestation. American Journal of Obstetrics and Gynecology, 175, 1286–1292.PubMedCrossRefGoogle Scholar
  7. 7.
    Gennaro, S., & Hennessy, M. D. (2003). Psychological and physiological stress: Impact on preterm birth. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32, 668–675.PubMedCrossRefGoogle Scholar
  8. 8.
    Nordentoft, M., Lou, H. C., Hansen, D., et al. (1996). Intrauterine growth retardation and premature delivery: The influence of maternal smoking and psychosocial factors. American Journal of Public Health, 86, 347–354.PubMedCrossRefGoogle Scholar
  9. 9.
    Paarlberg, K. M., Vingerhoets, J., Passchier, J., et al. (1999). Psychosocial predictors of low birthweight: A prospective study. BJOG, 106, 834–841.CrossRefGoogle Scholar
  10. 10.
    Pagel, M. D., Smilkstein, G., Regen, H., et al. (1990). Psychosocial influences on new born outcomes: A controlled prospective study. Social Science and Medicine, 30, 597–604.PubMedCrossRefGoogle Scholar
  11. 11.
    Pritchard, C., & Teo Mfphm, P. (1994). Preterm birth, low birthweight and the stressfulness of the household role for pregnant women. Social Science and Medicine, 38, 89–96.PubMedCrossRefGoogle Scholar
  12. 12.
    Rondo, P., Ferreira, R., Nogueira, F., et al. (2003). Maternal psychological stress and distress as predictors of low birth weight, prematurity and intrauterine growth retardation. European Journal of Clinical Nutrition, 57, 266–272.PubMedCrossRefGoogle Scholar
  13. 13.
    Jacobsen, G., Schei, B., & Hoffman, H. (1997). Psychosocial factors and small-for-gestational-age infants among parous Scandinavian women. Acta Obstetricia et Gynecologica Scandinavica. Supplement, 165, 14–18.PubMedGoogle Scholar
  14. 14.
    Cohen, S., Kessler, R. C., & Gordon, L. U. (1995). Strategies for measuring stress in studies of psychiatric and physical disorders. In S. Cohen, R. C. Kessler, & L. U. Gordon (Eds.), Measuring stress: A guide for health and social scientists (p. 3). Oxford: Oxford University Press.Google Scholar
  15. 15.
    Lu, M., & Halfon, N. (2003). Racial and ethnic disparities in birth outcomes: A life-course perspective. Maternal and Child Health Journal, 7, 13–30.PubMedCrossRefGoogle Scholar
  16. 16.
    Dunkel-Schetter, C., & Glynn, L. (2010). Stress in pregnancy: Empirical evidence and theoretical issues to guide interdisciplinary research. In: R. Contrada & A. Baum (Eds.), Handbook of stress science. New York: Springer.Google Scholar
  17. 17.
    Misra, D., Guyer, B., & Allston, A. (2003). Integrated perinatal health framework. A multiple determinants model with a life span approach. American Journal of Preventive Medicine, 25, 65–75.PubMedCrossRefGoogle Scholar
  18. 18.
    Halfon, N., & Hochstein, M. (2002). Life course health development: An integrated framework for developing health, policy, and research. Milbank Quarterly, 80, 433–479.PubMedCrossRefGoogle Scholar
  19. 19.
    Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.Google Scholar
  20. 20.
    House, J. S. (1974). Occupational stress and coronary heart disease: A review and theoretical integration. Journal of Health and Social Behavior, 15, 12–27.PubMedCrossRefGoogle Scholar
  21. 21.
    Evans, R. G., & Stoddart, G. L. (1990). Producing health, consuming health care. Social Science and Medicine, 31, 1347–1363.PubMedCrossRefGoogle Scholar
  22. 22.
    Witt, W. P., Wisk, L. E., Cheng, E. R., et al. (2011). Preconception mental health predicts pregnancy complications and adverse birth outcomes: A national population-based study. Maternal and Child Health Journal, 16, 1525–1541.CrossRefGoogle Scholar
  23. 23.
    Harville, E., Xiong, X., & Buekens, P. (2010). Disasters and perinatal health: A systematic review. Obstetrical & Gynecological Survey, 65, 713–728.CrossRefGoogle Scholar
  24. 24.
    Witt, W. P., Wisk, L. E., Cheng, E. R., et al. (2011). Poor prepregnancy and antepartum mental health predicts postpartum mental health problems among US women: A nationally representative population-based study. Women’s Health Issues, 21, 304–313.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Federenko, I., & Wadhwa, P. (2004). Women’s mental health during pregnancy influences fetal and infant developmental and health outcomes. CNS Spectrums, 9, 198–206.PubMedGoogle Scholar
  26. 26.
    Metcalfe, A., Lail, P., Ghali, W. A., et al. (2011). The association between neighbourhoods and adverse birth outcomes: A systematic review and meta-analysis of multi-level studies. Paediatric and Perinatal Epidemiology, 25, 236–245.PubMedCrossRefGoogle Scholar
  27. 27.
    Blaxter, M. (2010). Health (key concepts). Cambridge: Polity Press.Google Scholar
  28. 28.
    Szklo, M. (1998). Population-based cohort studies. Epidemiologic Reviews, 20, 81–90.PubMedCrossRefGoogle Scholar
  29. 29.
    Khashan, A. S., McNamee, R., Abel, K. M., et al. (2009). Rates of preterm birth following antenatal maternal exposure to severe life events: A population-based cohort study. Human Reproduction, 24, 429–437.PubMedCrossRefGoogle Scholar
  30. 30.
    Khashan, A. S., McNamee, R., Abel, K. M., et al. (2008). Reduced infant birthweight consequent upon maternal exposure to severe life events. Psychosomatic Medicine, 70, 688–694.PubMedCrossRefGoogle Scholar
  31. 31.
    Precht, D. H., Andersen, P. K., & Olsen, J. (2007). Severe life events and impaired fetal growth: A nation-wide study with complete follow-up. Acta Obstetricia et Gynecologica Scandinavica, 86, 266–275.PubMedCrossRefGoogle Scholar
  32. 32.
    Lu, M., & Chen, B. (2004). Racial and ethnic disparities in preterm birth: The role of stressful life events. American Journal of Obstetrics and Gynecology, 191, 691–699.PubMedCrossRefGoogle Scholar
  33. 33.
    Nkansah-Amankra, S., Luchok, K. J., Hussey, J. R., et al. (2010). Effects of maternal stress on low birth weight and preterm birth outcomes across neighborhoods of South Carolina, 2000–2003. Maternal and Child Health Journal, 14, 215–226.PubMedCrossRefGoogle Scholar
  34. 34.
    Whitehead, N., Hill, H., Brogan, D., et al. (2002). Exploration of threshold analysis in the relation between stressful life events and preterm delivery. American Journal of Epidemiology, 155, 117–124.PubMedCrossRefGoogle Scholar
  35. 35.
    Class, Q., Lichtenstein, P., Långström, N., et al. (2011). Timing of prenatal maternal exposure to severe life events and adverse pregnancy outcomes: A population study of 2.6 million pregnancies. Psychosomatic Medicine, 73, 234–241.PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Eskenazi, B., Marks, A., Catalano, R., et al. (2007). Low birthweight in New York City and upstate New York following the events of September 11th. Human Reproduction, 22, 3013–3020.PubMedCrossRefGoogle Scholar
  37. 37.
    Zhu, J. L., Hjollund, N. H., Andersen, A. M., et al. (2004). Shift work, job stress, and late fetal loss: The national birth cohort in Denmark. Journal of Occupational and Environmental Medicine, 46, 1144–1149.PubMedCrossRefGoogle Scholar
  38. 38.
    Pryor, J., Thompson, J., Robinson, E., et al. (2003). Stress and lack of social support as risk factors for small-for-gestational-age birth. Acta Paediatrica, 92, 62–64.PubMedCrossRefGoogle Scholar
  39. 39.
    Ghosh, J. K., Wilhelm, M. H., Dunkel-Schetter, C., et al. (2010). Paternal support and preterm birth, and the moderation of effects of chronic stress: a study in Los Angeles county mothers. Archives of Womens Mental Health, 13, 327–338.CrossRefGoogle Scholar
  40. 40.
    Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385–396.PubMedCrossRefGoogle Scholar
  41. 41.
    Tegethoff, M., Greene, N., Olsen, J., et al. (2010). Maternal psychosocial adversity during pregnancy is associated with length of gestation and offspring size at birth: Evidence from a population-based cohort study. Psychosomatic Medicine, 72, 419–426.PubMedCrossRefGoogle Scholar
  42. 42.
    Sable, M., & Wilkinson, D. (2000). Impact of perceived stress, major life events and pregnancy attitudes on low birth weight. Family Planning Perspectives, 32, 288–294.PubMedCrossRefGoogle Scholar
  43. 43.
    Atrash, H. K., Johnson, K., Adams, M., et al. (2006). Preconception care for improving perinatal outcomes: The time to act. Maternal and Child Health Journal, 10, S3–S11.PubMedCrossRefGoogle Scholar
  44. 44.
    Cohen, S., & Williamson, G. M. (1987). Perceived stress in a probability sample of the United States. In S. Spacapan & S. Oskamp (Eds.), The social psychology of health (pp. 31–49). Newbury Park, CA: Sage Publications.Google Scholar
  45. 45.
    McEwen, B. S. (1998). Stress, adaptation, and disease: Allostasis and allostatic load. Annals of the New York Academy of Sciences, 840, 33–44.PubMedCrossRefGoogle Scholar
  46. 46.
    McDade, T. W., Williams, S., & Snodgrass, J. J. (2007). What a drop can do: dried blood spots as a minimally invasive method for integrating biomarkers into population-based research. Demography, 44, 899–925.PubMedCrossRefGoogle Scholar
  47. 47.
    Affonso, D. D., Liu-Chiang, C. Y., & Mayberry, L. J. (1999). Worry: Conceptual dimensions and relevance to childbearing women. Health Care for Women International, 20, 227–236.PubMedCrossRefGoogle Scholar
  48. 48.
    Lobel, M., Cannella, D. L., Graham, J. E., et al. (2008). Pregnancy-specific stress, prenatal health behaviors, and birth outcomes. Health Psychology, 27, 604–615.PubMedCrossRefGoogle Scholar
  49. 49.
    Misra, D., O’Campo, P., & Strobino, D. (2001). Testing a sociomedical model for preterm delivery. Paediatric and Perinatal Epidemiology, 15, 110–122.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Whitney P. Witt
    • 1
  • Kristin Litzelman
    • 2
  • Erika R. Cheng
    • 2
  • Fathima Wakeel
    • 2
  • Emily S. Barker
    • 2
  1. 1.Department of Population Health Sciences, School of Medicine and Public HealthUniversity of Wisconsin, MadisonMadisonUSA
  2. 2.Department of Population Health Sciences, School of Medicine and Public HealthUniversity of Wisconsin, MadisonMadisonUSA

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