Arch Womens Ment Health
DOI 10.1007/s00737-017-0724-y
LETTER TO THE EDITOR
Anxiety, depression, and quality of life in mothers of newborns
with microcephaly and presumed congenital Zika virus infection:
a follow-up study during the first year after birth
Sheila Jaqueline Gomes dos Santos Oliveira 1,2 & Caroline Lima dos Reis 2 &
Rosana Cipolotti 1,3 & Ricardo Queiroz Gurgel 1,3 & Victor Santana Santos 1,2 &
Paulo Ricardo Saquete Martins-Filho 1,4,5
Received: 13 January 2017 / Accepted: 10 April 2017
# Springer-Verlag Wien 2017
Dear Editor
Zika virus (ZIKV) infection is a significant public health prob-
lem worldwide. Currently, Brazil is the country with the
highest number of ZIKV-positive cases in Latin America with
circulation of the virus in almost the entire national territory
(Slavov et al. 2016). A recent case-control study in an epidem-
ic area in the northeast Brazil found a strong association be-
tween microcephaly and in utero ZIKV infection (de Araujo
et al. 2016).
Brazilian newborns with microcephaly have demonstrated
severe abnormalities in the central nervous system including
brain dysgenesis and intracranial calcifications consistent with
an intrauterine infection (Microcephaly Epidemic Research
Group 2016). Ocular lesions (de Paula Freitas et al. 2016)
and sensorineural hearing loss (Leal et al. 2016) in infants with
ZIKV-associated microcephaly have also been described even
in oligosymptomatic or asymptomatic pregnant mothers. In
addition, there are some evidences that the neurological dam-
* Paulo Ricardo Saquete Martins-Filho
martins-filho@ufs.br
1
Postgraduate Program in Health Sciences, Federal University of
Sergipe, Aracaju, Brazil
2
Tiradentes University, Aracaju, Brazil
3
Department of Medicine, Federal University of Sergipe,
Aracaju, Brazil
4
Investigative Pathology Laboratory, Federal University of Sergipe,
Aracaju, Brazil
5
Universidade Federal de Sergipe, Hospital Universitário, Laboratório
de Patologia Investigativa, Rua Cláudio Batista, s/n. Bairro
Sanatório, Aracaju, Sergipe 49060-100, Brazil
ages may even increase during the extrauterine early period of
life (Oliveira et al. 2016). Therefore, the expectancy of micro-
cephaly diagnosis may lead to higher levels of parental dis-
tress because of the uncertainty regarding the developmental
outcome of their children.
Recently, we evaluated nine consecutive mothers of infants
with microcephaly and presumed congenital ZIKV infection
born in a public maternity in Sergipe state, Brazil. We found
that ZIKV-related microcephaly in the newborns may be a
factor significantly associated with high levels of anxiety
and low scores in psychological well-being domain of their
mothers during the first 24 h after birth (dos Santos Oliveira
et al. 2016). Since the previous report was limited to in-
hospital outcomes, we evaluated anxiety, depression, and
quality of life in a long-term follow-up.
Psychometric evaluation of anxiety and depression was
performed using the State-Trait Anxiety Inventory and the
Beck Depression Inventory, respectively. Anxiety levels in-
cluded both trait anxiety as a general aspect of personality
(STAI-T) and state anxiety as a response to a specific situation
(STAI-S). Quality of life was assessed using the World Health
Organization Questionnaire—short version (WHOQOL-
BREF).
In-hospital evaluation was conducted from November
2015 to June 2016. Follow-up examination was performed
in November 2016. A research assistant trained in data collec-
tion systematically interviewed mothers face-to-face.
Research organizers were blinded from results until the end
of follow-up period to avoid social responsibility bias and
reporting bias associated with confidentiality.
We used the Wilcoxon rank-sum test for the mean change in
anxiety, depression, and quality of life scores with a significance
level of 5%. All participants signed the informed consent.

The median of follow-up after home discharge was
10 months, ranging 5 to 12 months. The mothers’ age of
newborns with microcephaly ranged from 18 to 39 years.
Three mothers were married and all of them had low income.
Five of the 9 children with microcephaly have been treated
with phenobarbital and one with sodium valproate. Three chil-
dren have not been treated with any medication. Eight mothers
reported support from a multidisciplinary team comprising a
paediatrician, paediatric neurologist, physiotherapist, speech
therapist, and ophthalmologist.
There were no changes in STAI-T and depression scores,
but there was an increase in state anxiety levels during the
follow-up period (Fig. 1a). Physical, psychological, social,
and environment scores of quality of life remained low over
time (Fig. 1b). Such findings showed that mothers of children
with ZIKV-related microcephaly continued to have high
levels of anxiety and low quality of life during the first year
of their children’s lives. Activities of daily living, quality of
sleep, work capacity, self-esteem, personal beliefs, personal
relationships, sexual activity, financial recourses, sense of
freedom, home environment, and recreation activity participa-
tion may be seriously compromised for these mothers.
Fig. 1 Changes in anxiety, depression (a), and quality of life (b) over
time in mothers of infants with microcephaly
dos Santos Oliveira S.J.G. et al.
High levels of psychological distress have also been ob-
served in mothers of children with other sensory-motor mental
and chronic physical problems (Feizi et al. 2014). Parents of
children with severe mental health problems have shown ele-
vated levels of physical symptoms and low social participa-
tion, which may be related to the uncertainty of how their
children react in everyday situation (Seltzer et al. 2001). In
addition, the chronic stress observed in parents of children
with intellectual disabilities is associated to stigmatized social
interactions and an alienation from unaffected families
(Topper et al. 2011).
Symptoms of ZIKV-associated microcephaly include de-
velopmental delay, seizure disorders, intellectual disability,
cerebral palsy, hearing loss, and ophthalmologic alterations
(Malone et al. 2016), which may lead to increased levels of
anxiety and poor quality of life of the mothers over the life
course. Moreover, it is possible that the smaller head circum-
ference in children having microcephaly may negatively affect
the parent’s emotional and social functioning. Health educa-
tion and community mobilization are needed to avoid social
prejudice and fear of isolation of mothers with children with
ZIKV-related microcephaly.
Evidence has showed that anxiety compromises maternal
sensitivity during mother-infant interaction in the postnatal
year and is associated with poor child outcomes (Nicol-
Harper et al. 2007). In the present report, we did not observe
psychosocial support and counselling for mothers of infants
with microcephaly during the first year of follow-up, although
the children have been followed by a multidisciplinary team.
Our findings should be interpreted cautiously due to the
small sample of mothers of newborns with microcephaly
and presumed congenital ZIKV infection. Nevertheless, we
highlight the need of psychological support and counselling
for mothers of infants with ZIKV-associated microcephaly
into multidisciplinary teams. Psychoeducational strategies
can lead to an improvement in the mental health and quality
of life for these mothers. Further studies with larger sample
sizes are needed to test the generalizability of the findings, to
assess the perceived social support and the capacity of resil-
ience of these mothers, and to establish the impact of maternal
psychological distress on child development outcomes.
Compliance with ethical standards
Funding No funding to declare.
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval The study was approved by the Human Research
Ethics Committee at the Federal University of Sergipe (CAAE:
50165815.6.0000.5546). Informed written consent was obtained from
all participants.
Anxiety, depression, and quality of life in mothers
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