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Maternal mental health and its
influence on infant growth and
development: A systematic review of
observational studies in South and
East Asia
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10.4103/kleuhsj.kleuhsj_9_19 Shubhashree Venkatesh, J. Vindhya, Anita Nath

Abstract:
Maternal mental stress during pregnancy is an important public health concern. There is strong
evidence from the Western world to support the presence of a significant association between
maternal stress in pregnancy and adverse outcomes in the offspring. There are fewer studies from
the South and East regions of Asia. The search was conducted according to the PRISMA criteria.
Databases which included NCBI PubMed, Scopus, and Embase were used to search for relevant
studies according to the eligibility criteria. Most of the studies have shown a significant relation
between stress, depression, and anxiety during various stages of pregnancy with delayed mental,
motor, and behavioral development of the child. Although studies from the region show a significant
relation between various stress factors during pregnancy and child development, more such studies
are needed, especially those using potential biomarkers as indicators of pregnancy‑related stress.
Keywords:
Child development, maternal depression, maternal mental stress, Southeast Asia

Introduction during pregnancy which include depression,

anxiety, and self‑perceived stress could

T here is supporting evidence that many

physical and mental health conditions
in an individual arise due to adverse early
life experiences, particularly in relation to
prenatal and childhood environment.[1] There
exists a strong background to investigate the
relationship between early life adversities
Public Health Foundation such as exposure to maternal mental stress
of India, Indian Institute during pregnancy and neurodevelopmental
of Public Health, and health outcomes in later life, including
Hyderabad‑Bangalore
Campus, Bengaluru,
behavioral, emotional, and cognitive
Karnataka, India psychopathology and chronic metabolic
diseases.[2] While a lot of importance has
Address for been historically directed toward postnatal
correspondence:
Dr. Anita Nath,
depression, there is now an increasing
Public Health Foundation recognition that common mental disorders
of India, Indian Institute
of Public Health, This is an open access journal, and articles are distributed
Hyderabad‑Bangalore under the terms of the Creative Commons Attribution-
Campus, 1st Cross NonCommercial-ShareAlike 4.0 License, which allows others
Magadi Road, to remix, tweak, and build upon the work non-commercially,
Bengaluru ‑ 560 023, as long as appropriate credit is given and the new creations
Karnataka, India. are licensed under the identical terms.
E‑mail: anitanath@iiphh.
org For reprints contact: reprints@medknow.com
impose an effect on pregnancy outcomes
and offspring development. Animal studies
also demonstrate the presence of this kind
of an association.[3,4]
Etiology and Prevalence of
Maternal Depression
A few physiological pathways are proposed
to mediate this relationship type such as
altered placental function, epigenetic changes,
and stress reactivity.[5] Anxious mothers
may exhibit physiological changes such
as altered uterine flow and consequently
neurotransmitters such as norepinephrine that
may influence the development of the fetus.[6,7]
There also exists a wide belief that increased
How to cite this article: Venkatesh S, Vindhya J,
Nath A. Maternal mental health and its influence on
infant growth and development: A systematic review
of observational studies in South and East Asia. Indian
J Health Sci Biomed Res 2019;12:103-11.

© 2019 Indian Journal of Health Sciences and Biomedical Research KLEU | Published by Wolters Kluwer - Medknow 103
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Venkatesh, et al.: Maternal mental health and infant development

levels of stress during pregnancy accelerate the secretion Results

of cortisol to the extent to which it becomes neurotoxic to
the developing fetal brain, which likely results in adverse A total of 463 abstracts of studies that had been conducted
development during infancy and childhood.[8] between 2002 and 2017 were retrieved. The steps toward
the final inclusion of the 13 studies (11 published and
The prevalence of antenatal depression ranges from 19% 2 ongoing published protocols) are shown in Figure 1.
to 25% in low‑  and middle‑income countries[9] unlike Table 2 gives a brief presentation of the selected studies
the range of prevalence from 7% to 15% in high‑income while the abbreviations that are used throughout the text
countries.[10,11] There are ample studies which have are explained in Table 3.
been conducted in the Western world to understand
the association between maternal stress in pregnancy Mental distress and infant development
and adverse outcomes in the offspring. These studies While Otake et  al. [26] did not find any significant
range from understanding the mediating pathway in association between antenatal depression and Bayley
animals and humans to epidemiological studies on Scales of Infant Development (BSID) scores in terms of
the burden and associated risk factors of mental stress Mental Development Index  (MDI) and Psychomotor
in pregnancy and its outcome on maternal and child Development Index, they did observe a significant
health.[1] However, there are limited data from Southeast
Asia, given the major difference in social, economic, and Table 1: Key and alternate terms
cultural environment in contrast to the developed world, Key terms Alternate terms
and hence, the findings could vary.[12,13] While there is Maternal Pregnancy, antenatal, prenatal
well‑documented research on postpartum depression, Mental health Common mental disorder, stress,
studies related to mental health issues during pregnancy depression, anxiety
are in its early stage.[13] Therefore, this review was Infant Offspring, baby, child
conducted with the aim to understand if maternal mental Development Growth, motor, cognitive
stress in the form of common mental disorders and South/East/Southeast Afghanistan, Pakistan, India, Maldives, Sri
Asia Lanka, Nepal, Bhutan, Bangladesh, China,
maternal cortisol levels, serving as a potential biomarker Hong Kong, Japan, Macau, Mongolia,
for stress, influence infant growth and development by North Korea, South Korea, Taiwan,
means of a review of studies conducted in countries that Indonesia, Vietnam, Thailand, Singapore,
comprise South and East Asia. Malaysia, Philippines, Cambodia, Myanmar,
Laos

Materials and Methods

463 abstracts of studies published between
The PRISMA criteria, a widely used search strategy 2002 and 2017 retrieved from PubMed,
Embase and Scopus
for systematic review of observational studies, were
employed to include relevant literature.[14] The online 16 duplicate studies removed
databases that were used to extract literature included
NCBI PubMed, Embase, and Scopus.
447 titles screened 269 excluded:
- Not relevant to the study
Eligibility criteria for inclusion of studies were as follows: objectives (176)
- Studies not done in
• Publications over the past 15 years before November South East Asia (52)
- Study types: Cross-
1, 2017 sectional and Randomized
• English language controlled trials (41),
(systematic reviews and
• Full‑text articles meta-analysis
• Observational studies in human participants 178 abstracts screened - No abstract available

• Ongoing study protocols

• Studies done in South and East Asia. 164 abstracts excluded:
-Not relevant to the study
objectives (104)
Search terms used are shown in Table 1. -Studies not done in
South East Asia (32)
-Study types: Cross-sectional and
The exposure variable comprised maternal mental health Randomized controlled trials,
systematic reviews and meta-
in the form of depression, anxiety, and self‑perceived analysis (13)
-Studies done among special
stress,[15] and the outcome variable included infant group of mothers e.g. HIV
growth and development. While “growth” denotes a net 13 articles included for systematic review infected groups (5)
(11 published studies and 2 published -Article not in English (7)
increase in the size or mass of tissues, “development” study protocol) -Full text not available (4)
specifies maturation of functions in the form of skill
acquisition for optimal functioning.[16] Figure 1: Flow diagram depicting selection of studies

104 Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 12, Issue 2, May-August 2019
 Table 2: The details of studies included in the review
References Study Type of Sample size and Exposure variable
Time of Potential confounders Outcome Strength of association
setting study study participants and study measurement variable and
(mother-infant pairs) instrument for of exposure study instrument
measurement variable for measurement
Otake et al., Hokkaido, Prospective 154 Depression 23-35 weeks Maternal age, education, Infant EPDS and MDI: Adjusted:
2014[26] Japan cohort assessed by EPDS occupation, household income, development at β=−0.05, 95% CI (−0.00-
study smoking and alcohol habit, 6 months using 0.00), P=0.585
caffeine intake, presence of BSID‑II EPDS and PDI: Adjusted:
stressful events, self‑reported β=−0.04, 95% CI (−0.00-
depression, paternal age and 0.00), P=0.659)
education, parity, GA, infant sex,
Apgar, IUGR, birth weight, head
and chest circumference, age at
6 months assessment, child care
environment
Nasreen Bangladesh Prospective 652 Depression using Third trimester Maternal age, education, SES, Infant underweight Stunting at 6-8 months
et al., 2013[18] cohort EPDS occupation, anthropometry and stunting using P=0.048)
study (height, weight, MUAC), social WHO growth
support, partner violence, lives standards ‑ 2-3
in joint family, relationship with months and 6-8
husband and mother‑in‑law, months
mother-infant bonding, infant
anthropometry (height, weight,
head circumference), prematurity,
LBW, exclusive breastfeeding till
6-8 months, infant temperament,
infant illness
Tran et al., Vietnam Prospective 418 Depression First: 12- Maternal age, marital status, Infant Early pregnancy:
2014[19] cohort assessed by EPDS 20 weeks educational level, and development at Regression coefficient
study Second: occupational, household 6 months using of−0.60, 95% CI: −1.07-
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28 weeks economic status, maternal BSID‑M −0.13

height, use of iron supplements, Late pregnancy: Regression
partner violence, parity, history of coefficient of 0.43, 95% CI:
spontaneous abortions, fetal or −0.06-0.92
neonatal deaths, and whether or
Venkatesh, et al.: Maternal mental health and infant development

not the pregnancy was planned,

life adversity, breastfeeding,
infant weight and length

Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 12, Issue 2, May-August 2019
Bhat et al.[20] India
Prospective 100 Mental distress Third trimester Maternal age, years of school Infant Mental distress not
cohort using GHQ‑28 education, occupation, singleton temperament significant with infant
study pregnancy, no pregnancy‑induced using EITQ temperament, higher
hypertension or gestational Infant salivary cortisol level in infants with
diabetes in the current pregnancy, cortisol higher intensity scores
no maternal use of alcohol/drugs
or smoking, and full‑term infants
with normal birth weight, Apgar
score at 1 min and 5 min, type of
delivery

105
Contd...
 106
Table 2: Contd...
References Study Type of Sample size and Exposure variable Time of Potential confounders Outcome Strength of association
setting study study participants and study measurement variable and
(mother-infant pairs) instrument for of exposure study instrument
measurement variable for measurement
Lin et al., China Prospective 225 Depression using 28-36 weeks Maternal age, education, family Cognition Increase in prenatal GSI
2017[12] cohort GSI‑SCL‑90‑R and monthly income, maternal IQ, using Gesell and SCL was associated
study Life‑Event maternal blood lead levels during Development with decreases in toddler’s
‑Stress Scale pregnancy, gestational weeks, Scale motor, adaptive and social
child’s birth weight, child’s age Temperament behavior development
using Toddler
Temperament
Scale
Bhang et al., South Prospective 641 Depression First trimester Maternal age, residential area, Psychomotor Decreased MDI scores
2016[17] Korea cohort Stress using alcohol exposure during the and mental were observed in the
study PWI‑SF and current pregnancy, indirect development subjects with maternal PWI
CES‑D smoking exposure during the using BSID‑II ≥29 (β=−5.14, P=0.04);
current pregnancy, monthly and K‑ASQ at 6 maternal CES‑D ≥26
income, paternal educational months during early pregnancy was
achievement, GA, week, associated with a decrease
neonate’s sex, birth weight, in MDI scores (P=0.005)
growth retardation, feeding
method
Park et al., South Case- Internalizing problems Maternal Child‑rearing Maternal age, unwanted Internalizing and Antenatal stress
2014[21] Korea control Cases: 44 self‑reporting years pregnancy, no regular prenatal externalizing with internalizing
study Controls: 959 checkups, maternal alcohol behavioral problems (OR=3.36, 95%
intake, severe stress during problems in CI=1.80-6.25). Postpartum
Externalizing
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pregnancy, change in primary childhood (8- stress with externalizing

problems
caretaker, primary caretaker 11 years) using problem (OR=3.19, 95%
Cases: 30 other than mother, postpartum K‑CBCL CI=1.36-7.53)
Controls: 973 depression
Zhu et al., China Nested Cases: 38 Prenatal stress First trimester Infant age, sex, region, family Motor and Prenatal stress in the first
Venkatesh, et al.: Maternal mental health and infant development

2014[22] case- Controls: 114 using 19‑item income, paternal education, psychomotor trimester on the MDI η2 of
control prenatal Life maternal education, maternal development 0.11; F=17.63, P<0.001
study Events Checklist alcohol consumption, paternal using BSID Prenatal stress in the first
smoking up to 6 months before Toddler trimester on temperament
pregnancy, paternal alcohol temperament traits Regularity: η2 of 0.04;
consumption up to 6 months using Toddler F=3.01, P=0.085
before pregnancy, pregnancy and Temperament Persistence and attention
birth outcomes (GA, birth weight), Scale span, with a partial η2of
information about breastfeeding 0.04, F=5.88, P=0.016

Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 12, Issue 2, May-August 2019
Contd...
 Table 2: Contd...
References Study Type of Sample size and Exposure variable Time of Potential confounders Outcome Strength of association
setting study study participants and study measurement variable and
(mother-infant pairs) instrument for of exposure study instrument
measurement variable for measurement
Su et al., China Case- 71: Cases Life stressful 26 weeks of Maternal age, GA, residence, Birth weight Exposed group
2015[23] control 71: Controls events using Life pregnancy education, middle school, and head Reduced neurobehavioral
study Events Scale for family income, infant birth, head circumference development=P < 0.001
pregnant women circumference Neurobehavioral LBW and head
development, circumference (P<0.001)
using Neonatal Significant increase in
Behavioral ACTH, norepinephrine,
Assessment Scale and epinephrine
Umbilical levels (P<0.001) and
cord plasma decrease in cortisol
stress‑related levels (P<0.001)
hormones,
including
ACTH, cortisol,
norepinephrine,
and epinephrine
Soe et al., Singapore Prospective 258 Maternal 26 weeks GA, birth weight, Apgar Frontal EEG Internalizing problems: R2:
2016[24] cohort depression using score, gender, birth order, activity 0.239 (P<0.01)
study EPDS postconceptual age on the EEG Child behavior Externalizing problems: R2:
day (week), sleep condition at (internalizing 0.332 (P<0.01)
EEG recording time, maternal and externalizing
age, prenatal smoking exposure, problems) using
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prenatal alcohol exposure, CBCL at 6 months

maternal education, ethnicity, and 18 months
monthly household income
Rahman Pakistan Nested 160: Cases Maternal mental Third trimester Maternal age, maternal BMI, Underweight Underweight: RR=4.0 at
Venkatesh, et al.: Maternal mental health and infant development

et al., 2004[25] case- 160: Controls stress using SCAN education, number of living weight‑for‑age z 6 months and 2.5 at 12
control children, SES, infant nutritional score of < −2 months
study and physical health status, infant Stunting: Stunting: RR=4.4 at 6

Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 12, Issue 2, May-August 2019
sex, LBW, nuclear or joint family Length‑for‑age z months and 2.5 at 12
score of < −2 months
EPDS: Edinburgh Postnatal Depression Scale, IUGR: Intrauterine growth restriction, BSID‑II: Bayley Scales of Infant Development‑II, MDI: Mental Development Index, PDI: Psychomotor Development Index,
CI: Confidence interval, SES: Socioeconomic status, LBW: Low birth weight, BSID‑M: Bayley Scale of Infant and Toddler Development-Motor, GHQ‑28: General Health Questionnaire‑28, EITQ: Early Infancy
Temperament Questionnaire, SCL: Symptom Checklist, GSI‑SCL‑90‑R: Global Severity Index‑Symptom Checklist‑90‑Revised, PWI‑SF: Psychosocial Well‑Being Index‑Short Form, CES‑D: Center for Epidemiologic
Studies‑Depression, K‑ASQ: Korean‑Ages and Stages Questionnaires, CES‑D: Center for Epidemiologic Studies‑Depression, K‑CBCL: Korean‑Child Behavior Checklist, OR: Odds ratio, SCAN: Schedules for Clinical
Assessment in Neuropsychiatry, BMI: Body mass index, GA: Gestational age, IQ: Intelligence quotient, RR: Relative risk, MUAC: Mid upper arm circumference, ACTH: Adrenal cortico tropic hormone, EEG: Electro
encephalogram

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Venkatesh, et al.: Maternal mental health and infant development
Table 3: Abbreviations
Abbreviation Expansion
BSID‑II Bayley Scales of Infant Development‑II
BSID‑M Bayley of Infant and Toddler Development Motor
Scales
CBCL Child Behavior Checklist
CES‑D Center for Epidemiologic Studies‑Depression
EITQ Early Infancy Temperament Questionnaire
EPDS Edinburgh Postnatal Depression Scale
GHQ‑28 General Health Questionnaire‑28
GSI‑SCL‑90‑R Global Severity Index‑Symptom
Checklist‑90‑Revised
K‑ASQ Korean‑Ages and Stages Questionnaires
K‑CBCL Korean‑Child Behavior Checklist
MDI Mental Development Index
PDI Psychomotor Development Index
PWI‑SF Psychosocial Well‑Being Index‑Short Form
relationship between antenatal depression and shorter
gestational age which in turn was significantly related
to developmental delay in infant cognitive function.
Hence, gestational age was an important confounder in
this association. Tran et al. and Lin et al.,[12,19] however,
in one of their statistical model pathways found a
direct association between high Edinburgh Postnatal
Depression Scale (EPDS) scores in early pregnancy and
low BSID scores for motor development at 6 months and
2–3 years of age. In another model pathway, the presence
of a common mental disorder directly decreased the infant
outcome by 7.13 points  (95% confidence interval  [CI]:
3.13–11.13). Some of the potential confounders that were
identified in this study were parity and breastfeeding.
While infants of primiparous women had lower BSID
scores, infants of mothers who were reported to have
sufficient breast milk scored higher. Bhang et al.[17] also
observed a significant association between presence
maternal stress, depression, and lower scores on the MDI.
However, there was no association with development
of motor, communication, social, and problem‑solving
skills. Likewise, Zhu et  al.[22] also found that the MDI
scores of the infants of mothers with prenatal exposure
to stressful life events averaged seven points  (95%
CI: 3.23–10.73 points) lesser than infants who were
not exposed. The association of prenatal stressful life
events and infant development can be evident early
in neonatal life according to the study by Su et  al.[23]
wherein newborns with maternal life stressors’ exposure
had significantly lower scores on neonatal behavioral
neurological assessment.
Mental distress and undernutrition
Rahman et al.[25] and Nasreen et al.[18] observed that mental
distress in pregnancy was significantly associated with
an increased risk of undernutrition (underweight and
stunting) in infants, even after controlling for all known
confounding factors.
108 Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 12, Issue 2, May-August 2019
Mental distress and infant temperament
Bhat et al.[20] did not observe any significant association
between maternal prenatal psychological distress and
maternal report of difficult temperament in infants
although infant salivary cortisol was significantly higher
in infants with higher intensity scores. A  significant
association between maternal stress reported as Global
Severity Index and decreased toddlers’ adaptive and
social behavior development was observed by Lin et al.[12]
Park et  al.[21] also reported that severe maternal stress
experienced during pregnancy was highly associated
with both internalizing problems and externalizing
problems among school‑aged children. A less optimal
behavioral response among children whose mothers
experience stress in early pregnancy was observed by
Zhu et al.[22]
Ongoing studies
There is an ongoing prospective cohort study that is
being conducted among 2612 eligible pregnant women
who have been registered for antenatal care at selected
public‑sector hospitals in Bengaluru.[27] The study aims
to prospectively assess the association of maternal
psychological distress and cortisol level with motor and
cognitive development of the infant.
Another such study is ongoing among labor migrants and
refugees living on the Thai–Myanmar border in a cohort
of 627 women, to understand the association between
maternal depression and obstetrical and infant outcomes.[28]
Discussion
Most of the studies reported the existence of a significant
relationship between maternal stress, depression, and
lower scores on mental development[17,22,23] which is
evident from literature wherein self‑reported maternal
mental health conditions have been associated with
delayed infant cognitive development.[29,30] Offspring
mental development could also be determined by the
timing of prenatal exposure to maternal stress.[31] Exposure
to mental stress in early pregnancy was significantly
associated with impaired cognitive development in
these studies,[17,22] which has been corroborated by other
studies,[29,30] while in the study by Su et al.,[23] exposure to
stressful life events at any point of time during pregnancy
was considered. The impairing effect of antenatal
mental stress on motor development in infancy was
observed in one study.[19] While all these studies used
self‑reporting measurements to establish the presence
of a mental morbidity, none of these have studied the
mediating effect of cortisol which reflects the activity
of the hypothalamic–pituitary–adrenal (HPA) axis and
is observed to mediate the effects of prenatal maternal
stress on the developing fetus.[3,32] The independent
effect of maternal psychological stress and cortisol on
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Venkatesh, et al.: Maternal mental health and infant development
both cognitive and motor development of the infant will
be analyzed in the ongoing prospective cohort study
that is being conducted in South India.[27] Cortisol is a
stress‑related neurohormone and is important for fetal
maturation and birth process, even a slight variation in
this hormone early during pregnancy can generate a
cascade of events resulting in a change in the fetal stress
response system which eventually impacts growth and
development.[33]
All the studies observed a significant association
between antenatal mental distress and undernutrition
in infancy.[18,25] This could be attributed to various
factors such as poor care‑seeking behavior during the
antenatal period which could also be influenced by other
psychosocial factors such as lack of family support and
interpersonal conflicts.[13]
Social behavior of the offspring can be influenced
by prenatal depression resulting in deviations from
the acceptable level as reported from most of the
studies.[12,21,22] This finding is also supported by studies
done in other countries which also observed the existence
of this kind of a strong association.[34‑36] However, only
Bhat et al.[20] measured the infant salivary cortisol levels
which were higher in infants with high intensity scores;
however, there was no significant association between
maternal psychological distress and infant outcome.
Strengths and limitations
Measures of exposure variables
All the studies used depression and stress as their
exposure variable. Different scales were used to measure
depression across these studies. EPDS was used in four
studies[18,19,24,26] and is a widely used reliable instrument
for screening depression in the postnatal period but has
shown high reliability when used prenatally.[37] The use
of EPDS had been translated into the local language
and validated for measuring prenatal depression in the
countries where these four studies were done. The EPDS
cutoff scores for detecting the probability of depression
varied across the four studies. Tran et  al.[19] used the
EPDS‑Vietnam Validation in which scores  ≥4 detect
clinically significant symptoms with a sensitivity of
70% and specificity of 73%.[38] Soe et al.[24] did not use a
specific cutoff score but analyzed the changes in EPDS
scores throughout pregnancy and postpartum. Otake
et al.[26] used a standardized cutoff score of 8/9 which is
applicable to Japanese women.[39]
The General Health Questionnaire‑28 which is a 28‑item
questionnaire used in the study by Bhat et  al.[20] to
assess prenatal depression has also been validated for
screening with a sensitivity of 82% and a specificity of
85%.[40] Bhang et al.[17] used the Center for Epidemiologic
Studies‑Depression Scale which measures general stress
Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 12, Issue 2, May-August 2019 109
rather than pregnancy‑specific stress; however, it has
been shown to be a reliable and valid tool to measure
prenatal depression. [41] Lin et  al. [12] and Su et  al. [23]
assessed the presence of mental distress by analyzing
exposure to stressful life events using the Symptom
Checklist‑90‑Revised Scale and Life‑Event‑Stress
Scale which have been well validated and used in
China.[42] Park et al.[21] did not use any measuring scale
for psychological distress, instead they inquired for any
personal or social situations that may have caused severe
physiological and psychological stress during pregnancy.
Measures of outcome variables
Five studies used infant development as their outcome
variable. BSID‑II and its other version BSID Motor
Scale was the most commonly used scale in four of the
studies and is the most reliable scale for infant motor
and cognitive development.[17,19,22,26] The use of BSID had
been translated into the local language, pilot tested, and
validated for use in the corresponding study area in all
the studies. Lin et al.[12] used Gesell Development Scale
to measure cognition. The scale, originally designed
by Arnold Gesell in 1925, is now known as Gesell
Developmental Observation‑Revised, has been validated
for use in children residing in the United States,[43] and
was revised again by Chinese scholars in 1994.[44]
Some studies explored infant behavior and temperament
as the outcome variable using Toddler Temperament
Scale,[12,22] Korean‑Ages and Stages Questionnaires,[17]
Korean‑Child Behavior Checklist  (K‑CBCL), [21,24]
76‑item Early Infancy Temperament Questionnaire,[20]
Neonatal Behavioral Assessment Scale,[23] and CBCL,[24]
all of which are parent‑reported questionnaires. The
Toddler Temperament Scale measures the following
four categories of temperament  –  mood adaptability,
intensity, approach, and activity wherein the data
generated from this questionnaire have shown a strong
correlation with laboratory‑based videotapes of the
child’s behavior. [45] K‑CBCL derived from CBCL
designed by Achenbach in 1983[46] has shown a high
inter‑rater reliability and concurrent validity when used
in South Korea. Cronbach’s alpha using the CBCL scale
ranged from 0.62 to 0.95 within the sample in the study
which was done by Soe et al.[24]
Two studies used infant undergrowth and stunting as the
outcome variable – Nasreen[18] used the appropriate WHO
growth standard for assessment while Rahman et al.[25]
used weight‑for‑age z score of <−2 for underweight and
length‑for‑age z score of <−2 for stunting. To strengthen
evidence, in addition to self‑reporting measures,
objective measures of exposure outcomes were also
assessed by Bhat et  al.,[20] infant salivary cortisol; Soe
et al.,[24] infant frontal activity; and Su et al.,[23] umbilical
cord plasma stress‑related hormones. Cortisol reactivity
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Venkatesh, et al.: Maternal mental health and infant development
to an acute stressor is commonly used to measure the
functioning of the HPA axis functioning which in turn
influences infant development.[47]
Risk of bias and confounding
The risk of bias due to confounding appears to have
been addressed in all the studies by adjusting for all
the possible known and relevant confounders. Bhang
et al., 2016,[17] however, in their study on the association
between prenatal depression and infant development,
did not measure postpartum mental health of the
mother, which could also be a potential confounder.
However, unlike in other studies, Bhang et al. [17]
measured and adjusted for exposure to heavy metals
and oxidative stress which can adversely influence infant
neurodevelopment. All the studies except for four were
prospective cohort studies which eliminate the risk of
recall bias. Park et al.[21] interviewed mothers of third‑ and
fourth‑grade children, to probe for the presence of
any kind of psychological distress that might have
taken place during pregnancy, which could have been
characterized by gross inadequacies in memory recall.
The measuring scales that were used for the exposure
and outcome variables were valid and reliable which
minimized the risk posed by measurement. However,
the parent reporting scales that were used to report
offspring behavior could be subjected to two potential
sources of bias  –  the first is the mental or emotional
status of the parent and the second is gender‑wise
behavioral expectations from the child.[48] The study by
Otake et al.[26] was based on one regional hospital treating
pregnant women in the Sapporo area of Japan which
could give rise to selection bias. They also reported a
low participation rate (30%) which could have resulted
in many depressed women being excluded from the
study resulting in selection bias. Likewise, in the study
by Bhang et al.[17] on prenatal depression and infant
development, development scores were only available
for 50% of the infants, which could also give rise to
a selection bias. The examiners for measuring infant
development were blinded to other study data which
minimized the chance of observer and reporting bias
by Otake et al. The study by Nasreen et al.[18] and Tran
et al.[19] was also conducted in a rural setting, and thus,
the results may not be applicable for women residing in
urban areas. Bhat et al. (2013), Park et al., Lin et al., and Zhu
et al. did their studies on prenatal psychological distress and
offspring temperament in a small sample which could impact
the external validity of their study findings.
Conclusion
Common mental disorders during pregnancy which could
be in the form of depression, anxiety, and self‑perceived
stress are strongly associated with offspring growth,
development, and behavior in South and East Asia.
110 Indian Journal of Health Sciences and Biomedical Research KLEU - Volume 12, Issue 2, May-August 2019
Although the number of studies done in this area in the
region is rather limited, especially in relation to studies
on the objective measures of maternal stress, there is a
growing interest and recognition of maternal mental
health as an important public health concern.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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