Journal of Affective Disorders 268 (2020) 158–172

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Review article

Maternal perinatal mental health and infant and toddler neurodevelopment T

- Evidence from low and middle-income countries. A systematic review
Marlette Burgera, , Munira Hoosainb, Christa Einspielerc, Marianne Ungerd, Dana Niehause
⁎

a
Physiotherapy Division, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
b
Occupational Therapy Division, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
c
Research Unit iDN - interdisciplinary Developmental Neuroscience, Division of Phoniatrics, Medical University of Graz, Auenbruggerplatz 26, 8036 Graz, Österreich
d
Physiotherapy Division, Department of Health and Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
e
Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa

ARTICLE INFO ABSTRACT

Keywords: Background: There is extensive lack of awareness of maternal mental health and its impact on child development
Perinatal in low- and middle-income countries (LAMICs). The aim of this systematic review was to analyze evidence for
Maternal mental health various maternal perinatal mental health disorders and their association with different domains of infant and
Infant toddler neurodevelopment during the first two postnatal years in LAMICs.
Toddler
Methods: A comprehensive literature search was conducted within six databases from Jan 1990–April 2019. All
Neurodevelopment
Low and middle-income countries (LAMICs)
included studies were narratively synthesized.
Results: Twenty-four studies, nine cross sectional and 15 longitudinal cohort studies, were included. Three
studies were conducted in low-income, 11 in lower-middle-income and ten in upper-middle-income countries.
The majority of studies assessed maternal mental health postnatally and 14 of these 22 studies found a sig-
nificant association with infant and toddler neurodevelopment. Five of the ten studies reporting on exposure to
prenatal mental health found a significant association. The most common maternal mental health disorder
studied was depression, while the main neurodevelopmental outcomes assessed were motor, cognitive and
language development.
Limitations: Meta-analysis could not be conducted due to the variability in the reported maternal mental health
disorders and the different times of assessment of exposures and outcomes.
Conclusions: Maternal perinatal mental health disorders and their association with different domains of neu-
rodevelopment in LAMICs is still inconclusive due to a limited number of papers. Mother-infant dyads in LAMICs
are exposed to multiple and cumulative risk factors and causal pathways between maternal mental health and
infant neurodevelopment are still poorly understood.

1. Introduction regulation skills (Richter et al., 2017). Biological, environmental and

The first 1000 days of life, the period from conception and the first
two postnatal years, is a time of rapid and complex neurodevelopment
of the human brain (Cusick and Georgieff, 2016). Although neurode-
velopment continues throughout life, the first 1000 days is seen as a
time of unique opportunity, but also of great vulnerability, since this is
the time when the foundations of optimal growth, health and neuro-
development across the lifespan are established (Schwarzenberg and
Georgieff, 2018; Turner and Honikman, 2016). Healthy neurodeve-
lopment is a maturational process, resulting in a systematic acquisition
of motor, perceptual, cognitive, language, psychosocial, and self-
contextual risk factors may have a detrimental effect on fetal and child
development, resulting in reduced or stunted growth and poor long-
term cognitive, psychosocial and health outcomes (Richter et al., 2017;
Grantham-McGregor et al., 2007). Biological factors affecting child
development include intrauterine and birth complications, suboptimal
childhood nutrition and infections (Daelmans et al., 2015). Contextual
factors encompass parental psychosocial risk factors such as poor
mental health, low education, insensitive caregiving, poverty, intimate
partner violence, alcohol and substance abuse and lack or poor quality
of healthcare and social services (Daelmans et al., 2015). Not reaching
full developmental potential may lead to poor academic achievements,

Corresponding author.
⁎

E-mail addresses: mbu@sun.ac.za (M. Burger), munira@sun.ac.za (M. Hoosain), christa.einspieler@medunigraz.at (C. Einspieler), munger@sun.ac.za (M. Unger),
djhn@sun.ac.za (D. Niehaus).

https://doi.org/10.1016/j.jad.2020.03.023
Received 23 December 2019; Received in revised form 4 March 2020; Accepted 5 March 2020
Available online 06 March 2020
0165-0327/ © 2020 Elsevier B.V. All rights reserved.
M. Burger, et al.
economic dependency, violence, crime, substance misuse, and adult-
onset of non-communicable diseases (Schwarzenberg and
Georgieff, 2018; Daelmans et al., 2015). In their study on early child-
hood development, McCoy et al. (2016) found that one-third of 3- and
4-year old children in low and middle-income countries (LAMICs) are
failing to meet their potential with respect to their cognitive, socio-
emotional development, while an additional 16% had delayed physical
growth (McCoy et al., 2016). For infant well-being and optimal neu-
rodevelopment, a sensitive and responsive caregiving environment is
essential. Secure and affectionate relationships with caregivers will not
only meet the physical needs, but also the psychosocial needs of the
infant (Miklush and Connelly, 2013).
One of the most noteworthy aspects of early brain development is
the ability to adapt to the environment. The quality of early caregiving
(i.e. interactions between primary caregivers and the young infant) has
a significant influence on the way in which the brain develops in the
early years (Glaser, 2014). Perinatal mental health disorders can reduce
effective and responsive maternal caregiving behaviors (Miklush and
Connelly, 2013), which can have a profound effect on the infant's en-
vironment and their neurodevelopment (Shonkoff et al., 2012). Peri-
natal mental health refers to a woman's mental well-being during
pregnancy and it also includes the postpartum period up to the first year
after birth. Psychiatric disorders that were present before and persisting
into the pregnancy or that emerge during pregnancy or in the post-
partum period, are all considered perinatal mental health disorders
(Rees et al., 2019. O'Hara and Wisner, 2014).
Mothers and children residing in LAMICs are disproportionately
exposed to multiple and cumulative socioeconomic and environmental
risk factors, which may compromise the mother's health and her child's
development. These risk factors include poverty, high unemployment
levels, low education, war and or armed conflict, displacement, ex-
posure to violence in the community and at home - particularly in-
timate partner violence, alcohol and drug exposure, HIV/AIDS, as well
as inadequate nutrition and lack of healthcare and or social services
(Fisher et al., 2012; Samuels et al., 2012; Black et al., 2017).
Fisher et al. (2012) reported that the socioeconomic circumstances and
environments in which mothers from LAMICs need to cope contribute
significantly to the high prevalence of maternal depression and other
mental health disorders. The bulk of the research on the prevalence of
perinatal mental health disorders has however been generated in high-
income countries (HICs) (Fisher et al., 2012). In their systematic review
on the prevalence of maternal perinatal mental health disorders,
Fisher et al. (2012) found that only nine of 112 studies (8%) on prenatal
prevalence of common mental disorders originated from low and lower-
middle-income countries. Similarly, 17 of 112 studies (15%) on post-
natal prevalence of common mental disorders were generated in low
and lower-middle-income countries.
A substantial body of evidence from HICs has reported associations
between pre- and postnatal exposure to maternal mental health dis-
orders and adverse effects on infant neurodevelopment in the cognitive,
behavioral, socio-emotional and psychomotor domains (Kingston et al.,
2012; Kingston and Tough, 2014; Stein et al., 2014; Kingston et al.,
2015; Rees et al., 2019). Evidence from LAMICs is still extremely scarce,
especially when considering that 89.8% of the world's children live in
LAMICs (World Bank Data, 2018). An expert statement on maternal
mental health and child health and development in resource con-
strained settings by the World Health Organization (WHO) and the
United Nations Population Fund (UNFPA) concluded that there is an
extensive lack of awareness about maternal mental health disorders and
its impact on child development in resource-constrained, low, and
lower-middle-income countries (Fisher et al., 2011). They re-
commended, as a matter of urgency, that it is essential for these
countries to generate local evidence pertaining to the nature, pre-
valence and consequences of maternal mental health disorders
(Fisher et al., 2011).
Since numerous systematic reviews have established links between
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Journal of Affective Disorders 268 (2020) 158–172
pre- and postnatal exposure to maternal mental health disorders and
adverse infant and child neurodevelopment in HICs (Kingston et al.,
2012; Kingston and Tough, 2014; Stein et al., 2014; Kingston et al.,
2015; Cook et al., 2018; Rees et al., 2019), this review focused on re-
search conducted in low-income, lower-middle-income and upper-
middle-income economies as classified by the World Bank (World Bank
Country and lending groups, 2019). The objective of this systematic
review was to analyze the evidence for maternal perinatal mental
health disorders and their association with infant and toddler neuro-
development (namely gross and fine motor, language and cognitive
development as well as behavior and socio-emotional development)
during the first two postnatal years. The focus of this paper will be on
the neurodevelopmental outcomes of the infant and toddler with pre-
and postnatal exposure to maternal mental health disorders.
2. Methods
The Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines were strictly adhered to in this sys-
tematic review (Liberati et al., 2009).
2.1. Eligibility criteria
We included studies that met the following criteria:
■ Studies evaluating the association between maternal perinatal
mental health disorders (including but not confined to the following
psychiatric disorders: depression, stress, anxiety, psychosis, and
posttraumatic stress disorder) and infant or toddler neurodevelop-
ment (namely gross and fine motor, language and cognitive devel-
opment as well as behavior and socio-emotional development).
■ Full-length peer reviewed observational studies including cohort,
case-control and cross-sectional designs, published in English.
■ Only research conducted in low-income, lower-middle-income and
upper-middle-income economies classified by the World Bank was
considered for this review (World Bank Country and lending
groups, 2019).
■ Studies reporting on the neurodevelopmental outcomes of infants
and toddlers up to 24 months.
The following exclusion criteria applied:
■ Studies conducted among a specific subset of infants not re-
presentative of the general population and with a potentially higher
risk of developmental delay [e.g. studies including large cohorts of
infants born preterm; infants with low birth weight; stunted infants
or infants infected with HIV].
■ Studies reporting on the neurodevelopmental outcome of toddlers
with a mean or median age of more than 24 months.
■ Studies reporting on mental disorders during the perinatal period of
primary caregivers alternate to the mother, e.g. father, grandmother
or aunt.
■ Studies that did not directly and separately compare maternal
mental health disorders with infant and toddler neurodevelopment
(e.g. reported on the combined effect of maternal and paternal
perinatal mental health).
2.2. Information sources, search strategy, and study selection
The following six databases, accessed through the Stellenbosch
University Medical Library services, were searched: PubMed – Medline,
CINAHL-EBSCOhost, SCOPUS, PsycARTICLES - American Psychological
Association (APA), ScienceDirect and Web of Science. The search cov-
ered the period from January 1, 1990, to April 30, 2019. Pearling was
conducted to source relevant publications not indexed in the searched
databases. Combinations of the following key search terms were used:
M. Burger, et al.
neonate or infant or toddler or child development; neurodevelopment; motor,
language, cognitive, behavior, emotional, social-emotional; maternal, mental
health, mental disorders, mental illnesses, depression, bipolar, adjustment
disorders, affective disorders, mood disorders, stress, anxiety, distress, psy-
chotic, schizophrenia and psychosis. Two researchers (MH & MB) in-
dependently searched the allocated databases. The six databases re-
ceived an individual search strategy according to its function (e.g. using
MeSH terms in PubMed, Boolean operators such as AND, OR and NOT,
and/or truncation symbols to capture alternative endings and spellings
of search terms as well as applying filters namely language, publication
dates, ages of infant and toddler: birth-24 months). Each part of the
search process was recorded, documented and cross-checked.
Combinations of search terms and filters used for each database are
presented in Supplement A. The detailed search strategy is available
from the authors. Based on the inclusion and exclusion criteria, two
researchers (MH & MB) independently reviewed the titles, abstracts and
full-text articles retrieved in the initial search. The researchers com-
pared the eligible studies, and disagreements regarding the inclusion of
full-text studies were discussed until consensus was reached.
2.3. Quality appraisal, data extraction, and analysis
The Joanna Briggs Institute (JBI) Critical Appraisal tools for Cross
Sectional Studies and Cohort Studies were used to assess the metho-
dological quality of the included studies (Joanna Briggs Institute,
2019). The tools were adapted and from each subcategory's individual
rating, an overall score was derived, scoring each study as ‘high’
(meeting >85% of criteria), ‘medium’ (meeting 50–85% of criteria) or
‘low’ (meeting <50% of criteria) quality. The study quality was as-
sessed by two independent researchers (MH & MB) with experience in
the critical appraisal of different research designs. Data were extracted
independently and cross-checked by two researchers (MH & MB) and
captured on a standardized data extraction form.
Data were analyzed qualitatively (descriptively) and studies were
reviewed for suitability for a meta-analysis. The lack of uniformity
between studies and outcomes measured as well as the timing of as-
sessment of exposures and outcomes rendered a meta-analysis non-
plausible. Data analysis was therefore restricted to a narrative synthesis
(Supplement B).
2.4. Ethical considerations
This study consists of secondary research, thus ethical approval was
not required for this systematic review.
3. Results
3.1. Search results and overview
The PRISMA flow diagram (see Fig. 1) displays the search strategy
and study selection process. A total number of 3771 initial hits were
found in the six databases; of these, 122 studies were conducted in
LAMICs. After removing 59 duplicate studies and adding five studies
identified through pearling, the remaining 68 full-text studies were
assessed according to the eligibility criteria. Twenty-four studies were
retained for the systematic review of which nine were cross sectional
studies (Table 1) and 15 were longitudinal cohort studies (Table 2).
Two of the included longitudinal studies used the same study sample
but reported on the outcomes of different neurodevelopmental domains
and will thus be described separately (Tran et al., 2014a; Tran et al.,
2014b).
Three studies were conducted in low-income countries [Benin
(Koura et al., 2013) and Ethiopia (Hadley et al., 2008; Servili et al.,
2010)]. The eleven studies from lower-middle-income countries were
conducted in Bangladesh (Black et al., 2007; Hamadani et al., 2012;
Nasreen et al., 2013), India (Bhopal et al., 2019; Patel et al., 2003),
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Journal of Affective Disorders 268 (2020) 158–172
Gaza (Punämaki et al., 2018), Kenya (Watts et al., 2018), Mongolia
(Dagvadorj et al., 2018), Pakistan (Ali et al., 2013) and Vietnam
(Tran et al., 2014a, 2014b). Ten studies originated from upper-middle-
income countries: Brazil (Brentani and Fink, 2016; Pinheiro et al., 2014;
Quevedo et al., 2012), China (Peng et al., 2013; Zhu et al., 2014), Iran
(Vameghi et al., 2016a, 2016b), Mexico (Ortiz et al., 2017), Turkey
(Oztop and Uslu, 2007) and South Africa (Choi et al., 2017).
3.2. Quality of included papers
Of the nine cross-sectional studies included in this review, three
were high quality (Hadley et al., 2008; Oztop and Uslu, 2007;
Vameghi et al., 2016b) and the remaining six studies were medium
quality (Black et al., 2007; Brentani and Fink, 2016; Dagvadorj et al.,
2018; Koura et al., 2013; Vameghi et al., 2016a; Watts et al., 2018). The
most common sources of bias were lack of reliability in the measures of
maternal mental health disorders and infant or toddler development,
and limited detail about the study setting and participants. The majority
of the studies clearly described inclusion criteria, identified con-
founding factors as well as strategies to deal with these, and conducted
appropriate statistical analyses (Table 1).
Fifteen longitudinal cohort studies were included, of which eight
were high quality (Bhopal et al., 2019; Nasreen et al., 2013; Ortiz et al.,
2017; Pinheiro et al., 2014; Punämaki et al., 2018; Servili et al., 2010;
Tran et al., 2014a, 2014b), six were medium quality (Ali et al., 2013;
Choi et al., 2017; Patel et al., 2003; Peng et al., 2013; Quevedo et al.,
2012; Zhu et al., 2014) and one was low quality (Hamadani et al.,
2012). The low quality study (Hamadani et al., 2012) did not report on
the reliability of measures of exposures and outcomes, failed to use
valid measures of infant motor milestone development, and did not
describe reasons for attrition (Table 2).
3.3. Maternal characteristics
The majority of studies assessed exposure to maternal mental health
disorders postnatally (n = 15). Other studies assessed the exposure to
maternal mental health disorders at various time points prenatally only
(n = 2) or both pre- and postnatally (n = 8). The most common con-
dition studied was maternal depression (n = 17). Some studies focused
on common mental disorders (n = 4); while others included anxiety
(n = 5) or pregnancy related anxiety (n = 1), stress or exposure to
stressful life events (n = 5), schizophrenia (n = 1), distress (n = 2) or
postnatal affective disorder (n = 1). One study based in Gaza studied
exposure to war trauma and posttraumatic stress disorder. Three of the
four studies reporting on common mental disorders did not differentiate
between the different types of common mental disorders (Servili et al.,
2010; Tran et al., 2014a, 2014b), while Hadley et al. (2008) described
common mental disorders as symptoms of anxiety and depression. The
two studies reporting on distress (Watts et al., 2018; Choi et al., 2017)
did not differentiate between stress, anxiety and depression.
Pinheiro et al. (2014) assessed postpartum affective disorders and di-
vided the mothers into three categories namely, unipolar depression,
mania and mix episodes (Tables 1 and 2).
A variety of measures was used to assess maternal mental health –
these were mostly patient-reported measures, with some clinician-re-
ported measures (Tables 1 and 2). All the included studies used psy-
chometrically validated outcome measures to assess maternal mental
health and the most common tool used was the Edinburg Postnatal
Depression Scale (EDPS) (n = 10). Most studies, expect for
Brentani and Fink (2016), Hadley et al. (2008), Watts et al. (2018),
Bhopal et al. (2019), Ortiz et al. (2017) and Quevedo et al. (2012),
indicated that the outcome measures were validated for their specific
population.
M. Burger, et al.
Fig. 1. PRISMA flowchart of search results.
3.4. Association between maternal perinatal mental health disorders and
infant or toddler neurodevelopment
The main neurodevelopmental outcomes assessed were gross and
fine motor (n = 18), cognitive (n = 13), language (n = 12), behavior
and social-emotional (n = 9) development. Six studies reported on
global neurodevelopment (Table 3). Most of the studies used trained
assessors to evaluate neurodevelopmental outcomes whereas four stu-
dies (Brentani and Fink, 2016; Vameghi et al., 2016a, 2016b;
Punämaki et al., 2018) utilized maternal self-report questionnaires to
assess motor, language and cognitive development (Tables 1 and 2). All
included studies, with the exception of Hamadani et al. (2012),
Ali et al. (2013) and Nasreen et al. (2013) used psychometrically va-
lidated instruments to assess neurodevelopment. Various outcome
measures were used to assess neurodevelopmental outcomes from two
to 24 months. The Bayley Scales of Infant Development (BSID) was the
preferred measure, used by 11 of 24 studies (Tables 1 and 2). Sample
sizes across studies varied greatly, ranging from 31 (Oztop and
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Journal of Affective Disorders 268 (2020) 158–172
Uslu, 2007) to 1237 mother-child dyads (Bhopal et al., 2019). Ten
longitudinal cohort studies reported on the association between pre-
natal exposure to maternal mental health disorders and child devel-
opment. Five of these studies found no significant association (Choi
et al., 2017; Nasreen et al., 2013; Pinheiro et al., 2014; Servili et al.,
2010; Tran et al., 2014a), while the rest reported a significant link
(Ortiz et al., 2017; Peng et al., 2013; Punamäki et al., 2018; Tran et al.,
2014b; Zhu et al., 2014). Most of the papers assessed the association
between postnatal exposure to maternal mental health disorders and
child development. The associations between prenatal and postnatal
exposure to maternal mental health disorders and the different core
domains of child development are describe in the sections below
(Table 3).
3.5. Gross and fine motor development (n = 18)
Ten of the 18 studies evaluated the association between postnatal
depression and motor development (Table 3). Five of these studies
 Table 1
Summary of cross sectional studies.
Citation Sample size Method- Exposure Outcome [infant]; timing of assessment (outcome measure) Results Confounders Significant/not
M. Burger, et al.

ological [maternal]; timing Clinician rated Questionnaire / Parent report significant

quality of assessment
(outcome measure)

Black et al., 2007 n = 221 Medium Postnatal maternal Mental, motor and behavioral None reported Maternal depression was negatively Significant:
(Bangladesh, Rural) depressive development; 12 months (BSID associated with behavior at 6 months Perceived temperament: infants whose
symptoms; II, MPIT) (p < 0.05) and mental, motor and mothers perceived them as irritable
12 months (CESD) behavioral development at 12 months were more likely to have lower
(p < 0.05) developmental scores.
Brentani and Fink, 2016 n = 798 Medium Postnatal maternal None reported Global development; 12 No associations were found between Not Significant:
(Brazil, Urban) depression; months (BR-ASQ) mothers with “likely depression” Stunting
12 months (EPDS) (EPDS score >13) and developmental Obesity
delay.
Dagvadorj et al., 2018 n = 150 Medium Postnatal maternal Global development (motor, None reported Marginal negative association between Significant:
(Mongolia, Urban) depressive language, cognitive, social- maternal depression and global Higher maternal education was
symptoms (SRQ-20) emotional and adaptive developmental delay (AOR-4.93; protective against developmental
behavior); 13–24 months 95%CI [0.93–26.10]) delay.
(MORBAS) Female gender, higher maternal age,
single mother household associated
with higher risk of developmental
delay.
Hadley et al., 2008 n = 437 High Postnatal CMD, Global development (personal- None reported CMD were negatively associated with Significant:
(Ethiopia, Rural) namely symptoms of social, fine motor, gross motor, personal–social (p < 0.01), fine motor Older children, higher paternal age,
anxiety and language acquisition); 3–24 (p < 0.02), gross motor (p < 0.01), and higher household goods (an
depression (HSCL) months (Denver II) and the global developmental score indicator of SES) were positively
(p < 0.01) but not with language associated with global development.

162
(p < 0.06). Maternal anxiety was Stunted children scored more poorly
negatively associated with with global development.
personal–social development
(p < 0.01), but not with fine & gross
motor, language and global
development.
Maternal depression was negatively
associated with personal–social,
(p < 0.002), fine motor (p < 0.02),
gross motor (p < 0.008) and global
developmental (p < 0.007). No
association was found with language.
Koura et al., 2013 n = 357 Medium Postnatal maternal Global development (gross None reported Maternal depression was not Significant:
(Benin, semi-rural) depression; 12 motor, fine motor, visual associated with gross & fine motor Gender (female infants), home
months (EPDS) reception, language and development, expressive and receptive environment, and maternal education
learning/ cognitive); 12 language & visual reception as well as were positively associated with global
months (MSEL) cognitive development at 1 year. development.
Home environment and family wealth
were positively associated with gross
motor development.
Not Significant:
Marital status (monogamous/
polygamous), Maternal intellect.
Oztop and Uslu, 2007 n = 31 High Postnatal maternal Global development None reported Maternal depression was negatively Significant:
(Turkey, Urban) depression (SCID-I) (communication-cognitive, associated with expressive (p < 0.03), Infant gender was associated with the
motor, social skills, self-care) receptive (p < 0.05) language and total communication and expressive
[ADSI] and (communication, global communication (p < 0.03) and language (VABS).
daily living skills, socializing, coping skills (p < 0.03) (VABS). Infant age was positively associated
No association was found between
(continued on next page)
Journal of Affective Disorders 268 (2020) 158–172
 Table 1 (continued)

Citation Sample size Method- Exposure Outcome [infant]; timing of assessment (outcome measure) Results Confounders Significant/not
ological [maternal]; timing Clinician rated Questionnaire / Parent report significant
M. Burger, et al.

quality of assessment
(outcome measure)

motor development), maternal depression and gross & fine with global development on the ADSI
[VABS]; 14–38 months motor scores, communication- and VABS.
cognitive and social skills scores
(ADSI).
Vameghi et al., 2016a n = 1053 Medium Postnatal maternal None reported Global development Maternal depression was negatively Significant:
(Iran, Urban) depression (BDI) (communication, motor, associated with gross-motor Infant age
problem-solving, personal- (p = 0.001) and problem-solving skills Not Significant:
social skills); 6–18 months (p = 0.015). Unwanted pregnancy, infant gender,
(ASQ) No association was found with type of delivery and socioeconomic
communication (p = 0.368), fine- status.
motor (p = 0.379) and personal-social
skills.
Vameghi et al., 2016b n = 750 High Postnatal maternal None reported Global development Maternal perceived stress (β=−0.09) Not Significant: Maternal and paternal
(Iran, Urban) anxiety, depression (communication, motor, and depression (β=−0.17) were age and education, family income.
and stress (BDI, PSS, problem-solving, personal- directly associated with child
SAI) social skills); 6–18 months development. Maternal anxiety
(ASQ) (β=−0.0357) was indirectly
associated with development.
Watts et al., 2018 n = 81 Medium Postnatal maternal Global development (motor, None reported Maternal distress was negatively Significant:
(Kenya, Unclear) distress (K-10), language, cognitive, social- associated with social-emotional Negative perception of parenting role
emotional and adaptive development (p = 0.01). was associated with further reduced
behavior); 23 days to 25.5 No correlation between maternal social-emotional development.
months (BSID III) distress and cognitive development

163
(p = 0.58), fine motor (p = 0.09) &
gross motor skills (p = 0.27) and
adaptive behavior (p = 0.26).

ADSI = Ankara Developmental Screening Inventory; AIMS = Alberta Infant Motor Scale; AOR = adjusted odds ratios; ASQ = Ages and Stages Questionnaire; ASQ: SE = Ages and Stages Questionnaire: Social-Emotional;
ASQ-C = Ages and Stages Questionnaire – Chinese Version; BDI = Beck Depression Inventory; BR-ASQ = Brazilian version of Ages and Stages Questionnaire; BSID = Bayley Scales of Infant Development; CESD = 20-
item center for Epidemiological Studies Depression Scale; CI = Confidence Interval; CMD = common mental disorders; EPDS = Edinburgh Postnatal Depression Scale; HSCL = Hopkins Symptom Checklist; K-
10 = Kessler 10-item Psychological Distress Scale; MINI = Mini International Neuropsychiatric Interview; MORBAS = Mongolian Rapid Baby Scale; MPIT = Maternal Perception of Infant Temperament; MSEL = Mullen
Scales of Early Learning; PSS = Perceived Stress Scale; SAI = Spielberger Anxiety Inventory; SCID-I = Structured Clinical Interview for DSM-IV; SRQ-20 = 20-item Self-Report Questionnaire; VABS = Vineland Adaptive
Behavior Scales.
Journal of Affective Disorders 268 (2020) 158–172
 Table 2
Summary of Longitudinal Cohort Studies.
Citation Sample size Method- Exposure [maternal]; timing of Outcome [infant]; timing of assessment (outcome Results Confounders Significant/not significant
M. Burger, et al.

ological assessment (outcome measure) measure)

quality Clinician rated Questionnaire /
Parent report

Ali et al., 2013 n = 385 Medium Postnatal maternal anxiety & Global development (motor, None reported Maternal depression were negatively Significant:
(Pakistan, Urban) depression; 1, 2, 6, 12, 18 and 24 language, cognitive, socio- associated with emotional (95% CI: 3.0, Emotional: Higher maternal age, maternal
months (AKUADS) emotional); 1, 2, 6, 12, 18 and 11.9), cognitive (95% CI: 3.0, 15.7), illiteracy, maternal history of physical
24 months (ECD) language (95% CI: 2.3, 12.4), gross motor abuse, lower parity, family income were
(95% CI: 1.2, 6.6) and fine motor (95% negatively associated.
CI: 1.4, 11.3) development. Cognitive: Stunting, lower maternal age,
higher parity, low husband income were
associated with delayed development.
Language: Lower husband income, stunting,
male gender, maternal illiteracy, mothers
who did not work, higher parity were
negatively associated.
Gross and fine motor: Stunting, difficulty
breastfeeding, maternal illiteracy and
physical abuse, lower parity were negatively
associated.
Bhopal et al., 2019 n = 1273 High Postnatal maternal stress; 12 months Motor, cognitive and language None reported Maternal stress was negatively associated Significant: Socioeconomic adversities
(India, Rural) (PHQ9, Stress questionnaire) development; 12 and 18 with motor (p < 0.001), cognitive carer-child relationship, child-related
months (BSID III) (p = 0.001) and language (p < 0.001) factors (e.g. prematurity, hospitalization,
development at 18 months. separation from mother, inadequate care)
associated with delayed development.
Choi et al., 2017 n = 150 Medium Prenatal maternal distress second Emotional and Behavioral None reported Maternal depression and distress were not Significant:

164
(South Africa, trimester (K-10) and postnatal Development; 12 months directly associated with infant Lower maternal education and mother-
Urban) depression at 3–5 days, 6 weeks, and 6 (ITSCL) development (p = 0.061), but predicted infant bonding predicted developmental
months (EPDS) bonding difficulties (p = 0.014), which in delay
turn predicted developmental delay
(p = 0.046).
Hamadani et al., 2012 n = 488 Low Postnatal maternal depression; 6 weeks Motor milestones, None reported Maternal depression at 6 weeks and 6 Significant:
(Bangladesh, and 6 months (EPDS) questionnaire: 6 months. months was not significantly associated Postnatal maternal anemia, child's age at
Rural) Global development with development at 6 or 12 months. test, maternal education were negatively
(mental, psychomotor) BSID II, associated with language development.
and language development Child's age at test, nutritional status, SES,
questionnaire: 12 months gestational age were negatively associated
with motor milestone development.
Nasreen et al., 2013 n = 652 High Prenatal maternal depression; Postnatal Motor development; 6–8 None reported Postnatal maternal depression Significant:
(Bangladesh, maternal depression: 2–3 and 6–8 months (achievement of 9 (p = 0.041) and anxiety about infant care Maternal age and infant weight for age at
Rural) months (EPDS) milestones) (p = 0.04) at 2–3 months were negatively 6–8 months were directly associated with
associated with motor development at motor development. Infant birth-length,
6–8 months. difficult infant temperament, impaired
Maternal depression prenatally and 6–8 bonding, and infant history of acute
months postnatal were not significantly respiratory infection were negatively
associated with motor development. associated with motor development.
Ortiz et al., 2017 n = 537 High Prenatal maternal psychosocial stress; Global development (motor, None reported Prenatal maternal stress was negatively Significant:
(Mexico, Urban) 3rd trimester (CRISYS-R) language, cognitive) at 24 associated with cognitive development, Prenatal lead exposure was negatively
months (BSID III) as well as language development in girls. associated with development.
Patel et al., 2003 n = 89 Medium Postnatal maternal depression; 6–8 Mental and motor None reported Postnatal maternal depression was None assessed.
(India, Urban & weeks (EPDS) development; 6 months negatively associated with mental
Rural) (DASII) development (p = 0.02), but not with
motor development (p = 0.07).
Peng et al., 2013 n = 152 Medium Maternal schizophrenia; prenatal Global development (motor, None reported Maternal use of atypical antipsychotics Significant:
(China, Urban) (SCID-I) language, cognitive, social- was negatively associated with cognitive Not breastfeeding was associated with
(continued on next page)
Journal of Affective Disorders 268 (2020) 158–172
 Table 2 (continued)

Citation Sample size Method- Exposure [maternal]; timing of Outcome [infant]; timing of assessment (outcome Results Confounders Significant/not significant
ological assessment (outcome measure) measure)
M. Burger, et al.

quality Clinician rated Questionnaire /

Parent report

emotional and adaptive (p < 0.001), motor (p < 0.001), delayed development.
behavior) at 2, 6 and 12 social–emotional development Not significant:
months (BSID III) (p < 0.001) and adaptive behavior Unplanned pregnancy, maternal type of
(p < 0.001) at 2 months, but not work, vitamin use, maternal BMI
language development (p = 0.157). At 6
months, the association was only
significant for social–emotional
development (p < 0.007) and adaptive
behavior (p < 0.01)
At 12 months, there were no significant
associations.
Pinheiro et al., 2014 n = 152 High Postnatal affective disorders: namely Motor development; 4 months None reported Postnatal affective disorders (p = 0.049), Significant: Infant stress (cortisol) was
(Brazil, Urban) unipolar depression, mania or (AIMS) maternal anxiety disorder (p = 0.043) negatively associated with motor
hypomania, mix episode. Postnatal were negatively associated with infant development.
anxiety (MINI Portuguese, gross motor development. Stressful life Not Significant: Maternal age, smoking,
questionnaire). Stressful life events in events in pregnancy were not associated alcohol use, social class, cohabitation with
pregnancy (SLEs); 2–3 months postnatal with infant gross motor development father, type of delivery, prematurity, birth
(p = 0.254). weight, breastfeeding and stressful life
events.
Punämaki et al., 2018 n = 454 High Prenatal maternal PTSD, depression, None reported Sensorimotor and Prenatal and postnatal mental health was Significant:
(Gaza, Urban) pregnancy related anxiety. Postnatal language negatively associated with sensorimotor Number of children in the family was
maternal PTSD, depressive and development; 12 and language development (p < 0.0001). negatively associated with infant
dissociative symptoms (HTQ, EDS, PAS, months (IDQ) development.

165
Quevedo et al., 2012 n = 296
(Brazil, Urban)
Servili et al., 2010 n = 194
(Ethiopia, Rural)
Tran et al., 2014a n = 378
(Vietnam, Rural)
Tran et al., 2014b n = 418
(Vietnam, Rural)
PDSS) Not significant:
Child gender
Medium Postnatal maternal depression; 30–60 Language development; 12 None reported Maternal depression at both time points Significant: Maternal age, parity and
days and 12 months (MINI) months (BSID III) was negatively associated with language alternate caregiver were negatively
development (p = 0.012). associated with language development. Not
significant: Gender, exclusive breastfeeding
until 6 months, history of child illness,
birthweight, type of delivery, socioeconomic
status, living with partner.
High Prenatal and postnatal maternal CMD; 2 Global development (motor, None reported Prenatal and postnatal maternal CMD was Significant: SE status and infant weight-for-
and 12 months postnatal (SRQ-20) language, cognitive), 12 negatively associated with motor age were positively associated with motor
months (BSID III) development (p<0.001), but not and cognitive development. Maternal
significant after adjusting for experience of physical violence was
confounders. associated with impaired cognitive
Prenatal and postnatal maternal CMD was development.
not associated with language and Not significant:
cognitive development. Maternal age, maternal or paternal
education, gender, infant diarrhea
High Prenatal and postnatal CMD; 20 and 28 Socio-emotional development; None reported Maternal postnatal CMD were indirectly Significant:
weeks prenatal, 6 weeks and 6 months 6 months (BSID III; SEQ) associated with lower social-emotional Maternal self-efficacy, warm parenting
postnatal (EPDS) development (95% CI: −1.79, −0.42). practices and household wealth were
There were no direct associations associated with enhanced social-emotional
between pre- or postnatal CMD and development
social-emotional development. Not Significant:
Prenatal anemia, primiparity, gender,
maternal education and age
High Prenatal and postnatal maternal CMD; Motor development; 6 months None reported Maternal CMD in early pregnancy were Significant:
20 and 28 weeks prenatal, 6 weeks and (BSID III FGS) negatively associated with motor Prenatal anemia, primiparity and maternal
6 months postnatal (EPDS) perception of having insufficient breastmilk
Journal of Affective Disorders 268 (2020) 158–172

(continued on next page)

M. Burger, et al. Journal of Affective Disorders 268 (2020) 158–172

AKUADS = Aga Khan University Anxiety and Depression Scale; BDI = Beck Depression Inventory; BSID = Bayley Scales of Infant Development; BSID-CR = Bayley Scales of Infant and Toddler Development – China
Revision; CI = Confidence Interval; CMD = Common Mental Disorders; CRISYS-R = Crisis in Family Systems-Revised; DASII = Developmental Assessment Scale for Indian Infants; ECD = Aga Khan University Early

Dissociative States Scale; PHQ9 = Patient Health Questionnaire 9; PLEC = 19-item Prenatal Life Events Checklist; PTSD = Posttraumatic Stress Disorder; SCID-I = Structured Clinical Interview for DSM-IV; STAI = The
Childhood Development Tool; EPDS = Edinburgh Postnatal Depression Scale; SRQ-20 = 20-item Self-Report Questionnaire; HTQ = Harvard Trauma Questionnaire; IDQ = 15-item Infant Development Questionnaire;
ITSCL = Infant/Toddler Symptom Checklist; K-10 = Kessler 10-item Psychological Distress Scale; MINI = Mini International Neuropsychiatric Interview; PAS = 10-item Pregnancy Anxiety Scale; PDSS = Psychological
reported a significant negative association between postnatal depres-
sion and motor development (Black et al., 2007; Hadley et al., 2008

associated with mental and psychomotor

Duration of breastfeeding was positively
Confounders Significant/not significant

were negatively associated with motor

[gross & fine]; Nasreen et al., 2013 [gross & fine]; Punämaki et al.,
2018; Ali et al., 2013 [gross & fine]. Vameghi et al. (2016a) found a
significant association with gross motor development (p = 0.001), but
not with fine motor development (p = 0.379). In their longitudinal
cohort study, Nasreen et al. (2013) found no association between pre-
natal depression and gross and fine motor development, however
postnatal depression was negatively associated with gross and fine
development.

development
motor outcomes (p = 0.04).
Significant:

Two of the three studies (Pinheiro et al., 2014 [gross]; Ali et al.,
2013 [gross & fine]) reporting on postnatal anxiety found a significant
negative association, while Watts et al. (2018) found that postnatal
distress was not associated with gross or fine motor development.
development at 6 months (95% CI: 3.13,

Maternal stress in the first trimester was

psychomotor development (p = 0.526).

points). There was no association with

Common mental disorders (with the focus on depression and anxiety)

development (95% CI: 3.23, 10.73
negatively associated with mental

found a significant association in early pregnancy (Tran et al., 2014b),

whereas Servili et al. (2010) found that the pre- and postnatal asso-
ciation became non-significant after adjusting for confounders. Post-
partum affective disorders (Pinheiro et al., 2014) as well as posttrau-
matic stress disorder and postnatal dissociative symptoms
(Punämaki et al., 2018) were found to have a significant association
with delayed motor development (Table 3).
11.13).
Results

3.6. Cognitive development (n = 13)

Four of the seven studies reporting on postnatal depression as ex-

posure found a significant negative association with cognitive devel-
Outcome [infant]; timing of assessment (outcome

Questionnaire /

None reported

opment (Table 3). Three longitudinal cohort studies found a significant

Parent report

negative association between prenatal (Ortiz et al., 2017; Zhu et al.,

2014) or postnatal stress (Bhopal et al., 2019) and cognitive develop-
ment. Pre- and postnatal common mental disorders (Servili et al., 2010)
and postnatal distress (Watts et al., 2018) were not associated with
and postnatal depression; (PLEC, EPDS) psychomotor) development; 16

cognitive function (Table 3).

to 18 months (BSID-CR)
Prenatal maternal stress (1st trimester) Cognitive (mental and

3.7. Language development (n = 12)

Clinician rated

Eight studies assessed postnatal depression as exposure (Table 3).

Five of these studies did not find an association with language devel-
measure)

opment (Hadley et al., 2008; Koura et al., 2013; Vameghi et al., 2016a;
Hamadani et al., 2012; Quevedo et al., 2012). A longitudinal cohort
study reported that postnatal anxiety was negatively associated with
language development (Ali et al., 2013) while a cross-sectional study
conducted by Hadley et al. (2008) found no association with postnatal
Exposure [maternal]; timing of
assessment (outcome measure)

anxiety. Two longitudinal studies assessing pre- and postnatal depres-

sion, posttraumatic stress disorder and postnatal dissociative symptoms
(Punämaki et al., 2018) and postnatal stress (Bhopal et al., 2019) found
a significant association with delayed language development. Higher
prenatal stress measured in the 3rd trimester of pregnancy resulted in
lower language scores in girls but not boys (Ortiz et al., 2017). Pre- and
postnatal common mental disorders were not associated with language
development (Servili et al., 2010) (Table 3).

3.8. Behavior and social-emotional development (n = 9)

Sample size Method-

Medium
ological
quality

Three of the five studies found a negative association between

postnatal depression and the toddler's behavior and social-emotional
development (Table 3). Oztop and Uslu (2007) reported a negative
n = 152

Stait-Trait Anxiety Inventory.

association between postnatal depression and the toddler's coping skills

(p < 0.03), while they found no association with the child's social skills
(Table 2 and 3). In their longitudinal cohort study, Choi et al. (2017)
Table 2 (continued)

reported that prenatal distress was not associated with the toddler's
(China, Urban)
Zhu et al., 2014

emotional and behavioral development. The cross-sectional study by

Watts et al. (2018) found that postnatal distress was negatively asso-
ciated with social-emotional development while no association was
Citation

found with adaptive behavior. Postnatal anxiety was reported to be

negatively associated with emotional (Ali et al., 2013) and personal-

166
 Table 3
Summary of association of prenatal and postnatal maternal mental health disorders with different core domains of neurodevelopment.
Gross and fine motor Cognitive Language Behavior and social-emotional Global neurodevelopment
M. Burger, et al.

development
Significant Not significant Significant Not significant Significant Not significant Significant Not significant Significant Not significant

Prenatal
Punämaki et al., 2018* Punämaki et al., 2018*
Depression Nasreen et al.,
[H-L] 2013 (gross & fine) [H-L]
[H-L]
Punämaki et al., 2018* Punämaki et al., 2018*
Pregnancy related
anxiety [H-L] [H-L]
Stress Pinheiro et al., Ortiz et al., 2017 Ortiz et al., 2017
2014 (gross) [H-L]; [H-L]; (girls) [H-L]
Zhu et al., 2014*
[M-L] Zhu et al., 2014 [M-
L]
Distress Choi et al., 2017
[M-L]
Tran et al., 2014b* Servili et al., 2010*
CMD [H- [H- Servili et al., 2010 Servili et al., 2010 Tran et al., 2014a
L] L] [H-L] [H-L] [H-L]
Punämaki et al., 2018* Punämaki et al., 2018*
Posttraumatic stress
disorder [H-L] [H-L]
Peng et al., 2013* Peng et al., 2013*
Schizophrenia & (2 (6 & Peng et al., 2013 (2 Peng et al., 2013 (6 Peng et al., 2013 (2, Peng et al., 2013 (2 Peng et al., 2013
Antipsychotic months) [M-L] 12 months) [M-L] months) [M-L] & 12 months) [M-L] 6 & 12 months) [M- & 6 months) [M-L] (12 months) [M-L]
exposure L]
Postnatal
Depression Nasreen et al., Oztop et al., 2007 Black et al., 2007 Oztop et al., 2007 Oztop et al., 2007 Hadley et al., 2008 Hadley et al., 2008 Oztop et al., 2007 Hadley et al., 2008 Brentani and
2013 (gross & (gross & fine) [M-C]; [HeC]; [HeC]; [HeC]; [HeC]; (social skills) [HeC]; Fink, 2016; [M-
fine) [H-L]; [HeC]; Vameghi et al., Koura et al., 2013 Punämaki et al., Koura et al., 2013 Oztop et al., 2007 [HeC]; Vameghi et al., C];
Punämaki et al., 2018*

167
Koura et al., 2013 2016a (problem- [M-C]; 2018;) [H-L]; [M-C]; (coping skills) Vameghi et al., 2016b [HeC]; Koura et al.,
[H-L]; (gross & fine) [M- solving skills) [M- Hamadani et al., Ali et al., 2013 [M- Vameghi et al., [HeC]; 2016a [M-C]; Choi et al., 2017 [M- 2013 [M-C]
Hadley et al., C]; Vameghi et al., C]; 2012 [L-L] L] 2016a [M-C]; Black et al., 2007 Choi et al., 2017 L];
2008 (gross & 2016a Patel et al., 2003 Quevedo et al., [M-C]; [M-L] Dagvadorj et al.,
fine) [HeC]; (fine) [M-C]; [M-L]; Ali et al., 2012 [M-L]; Ali et al., 2013; [M- 2018 [M-C]
Black et al., 2007* Patel et al., 2003*
[M- ; 2013 [M-L] Hamadani et al., L]
C]; [M-L]; Hamadani et al., 2012 [L-L]
2012*
Vameghi et al., [L-L]
2016a (gross) [M-
C];
Ali et al., 2013
(gross & fine) [M-
L]
Anxiety Pinheiro et al., Hadley et al., 2008 Hadley et al., 2008 Hadley et al., 2008 Watts et al., 2018 Vameghi et al., Hadley et al.,
2014 (gross) [H- (gross & fine) [HeC] [HeC]; Ali et al., (adaptive 2016b [HeC] 2008 [HeC]
L] [HeC] 2013 [M-L]; behavior) [M-C]
Watts et al., 2018
(social- emotional)
[M-C]
Distress Watts et al., 2018 Watts et al., 2018 Watts et al., 2018 Watts et al., 2018
(gross & fine) [M- [M-C] (social- emotional) (adaptive
C] [M-C] behavior) [M-C]
Bhopal et al., 2019*
Stress Bhopal et al., 2019 Bhopal et al., 2019 Vameghi et al.,
[HeC] [HeC] [HeC] 2016b [HeC]
Postnatal Affective Pinheiro et al.,
Disorder 2014 (gross) [H-
(Unipolar L]
depression, mania,
mix episode)
(continued on next page)
Journal of Affective Disorders 268 (2020) 158–172
M. Burger, et al. Journal of Affective Disorders 268 (2020) 158–172

social development (Hadley et al., 2008). There were no direct asso-

Not significant
ciations between pre- or postnatal common mental disorders and social-
emotional development (Tran et al., 2014a).

3.9. Global neurodevelopment (n = 6)

Global neurodevelopment

Three (out of six) studies reported significant global developmental

delay in infants and toddlers exposed to postnatal depression
(Dagvadorj et al., 2018; Hadley et al., 2008; Vameghi et al., 2016b).
Significant

Vameghi et al. (2016b) reported that postnatal stress and anxiety were
negatively associated with global neurodevelopment, while
Hadley et al. (2008) found no association with postnatal anxiety
Tran et al., 2014a

(Table 3).
Not significant

Peng et al. (2013) was the only study assessing the effects of fetal
exposure to atypical antipsychotics in mothers with schizophrenia.
Behavior and social-emotional

Their longitudinal case-control study, with repeated BSID III measures,

[H-L]

reported that prenatal exposure to atypical antipsychotics caused sig-

nificant developmental delays in motor, cognitive and social–emotional
and adaptive behavior, but not language development during the first
months after term. However, these associations were not significant at
development
Significant

12 months.

3.10. Confounding variables and mediating or moderating factors

Studies did not report gross and fine motor development separately/ did not differentiate between fine and gross motor development.
Servili et al., 2010

The majority of studies identified and evaluated associations with

Not significant

variables that altered the strength of the association between maternal

mental health and neurodevelopmental outcome. Significant associa-
High quality (meeting >85% of criteria), Medium quality (meeting 50–85% of criteria), Low quality (meeting <50% of criteria).

tions were found with infant factors such as temperament, gender, age,
[H-L]

stunting, weight-for-age, birth length and weight, stress (cortisol le-

vels), preterm birth, hospitalization and history of acute respiratory
Punämaki et al., 2018*

Punämaki et al., 2018*

infection. Significant maternal factors included educational level, age,

literacy, parity, anemia, prenatal lead exposure, experience of physical
Significant

violence and maternal perception of having insufficient breastmilk.

Language

Parenting or social factors included single-parent households, socio-

[H-L]

[H-L]

economic status, income, home environment, perceptions of parenting

role, maternal self-efficacy, parenting practices, separation from mo-
Servili et al., 2010

ther, inadequate care, bonding, breastfeeding, number of children in

Not significant

the family and alternate primary caregiver (see Tables 1 and 2).

4. Discussion
[H-L]

To the best of our knowledge, this is the first systematic review to

compile and analyze evidence from LAMICs on the association between
maternal perinatal mental health disorders and infant or toddler neu-
Significant

rodevelopment during the first two postnatal years. The literature

Cognitive

search revealed that the majority of studies (n = 730) on this topic

published during the past 29 years were conducted in HICs (Fig. 1). This
stands in sharp contrast to the sparsity of evidence from LAMICs since
[H-

[H-

only 68 studies were eligible for inclusion after the removal of duplicate
Servili et al., 2010*

Tran et al., 2014b*

Not significant

titles. The evidence from 24 studies included in this review is biased

[M-L] = Medium quality - Longitudinal Cohort Study.

towards middle-income countries, as only three studies were conducted

[H-L] = High quality – Longitudinal Cohort Study.

[L-L] = Low quality – Longitudinal Cohort Study.

[M-C] = Medium quality – Cross Sectional Study.

in low-income countries [Benin (Koura et al., 2013) and Ethiopia

[HeC] = High quality – Cross Sectional Study.

(Hadley et al., 2008; Servili et al., 2010)].

L]

L]
Gross and fine motor

Due to heterogeneity of reported types of maternal health disorders

Punämaki et al., 2018*

Punämaki et al., 2018*

and different domains of developmental outcomes, it was not possible

CMD = Common mental disorders,.

to draw a definitive conclusion about the association between prenatal

Significant

exposure to maternal mental health and child development. The ma-

[H-L]

[H-L]

jority of studies assessed maternal mental health during the postnatal

period. Of these 22 studies, 14 found a significant association with in-
fant and toddler neurodevelopment, while the remaining eight found
Dissociative symptoms
Posttraumatic stress
Table 3 (continued)

no association (Supplement C). Although most of the evidence suggests

that exposure to postnatal maternal mental health disorders is nega-
disorder

tively associated with various domains of infant and toddler develop-

ment, the association becomes less clear when looking at the different
CMD

types of mental health disorders e.g. postnatal depression or anxiety

⁎

and their associations with the various domains of neurodevelopment

168
M. Burger, et al.
namely fine and/or gross motor, cognitive, language, behavior and
global development (see Table 3).
More than half of the studies in the current review reported on the
association between postnatal depression (n = 15) or common mental
disorders (including depression) (n = 2) and developmental outcomes.
In the past, perinatal mental health research has mainly focused on
adverse effects of postnatal depression (Kingston et al., 2015). In fact,
the link between mothers with postnatal depression residing in HICs
and children's cognitive (Beck 1998; Grace et al., 2003; Kingston et al.,
2012, 2015), language (Grace et al., 2003; Kingston and Tough, 2014),
behavior (Kingston and Tough, 2014) and socio-emotional develop-
ment (Kingston et al., 2012; Kingston and Tough, 2014) has been well
established. A recent systematic review, combining studies from HICs
and middle-income countries, found that maternal depressive symp-
toms are related to lower cognitive scores among children younger than
56 months (Liu et al., 2017). These findings are consistent with another
systematic review including studies from HICs and middle-income
countries (Stein et al., 2014) as well as a literature review conducted by
Wachs et al. (2009). Persistent postnatal depression seems to be of
particular importance in relation to early cognitive development in 12
and 24 month old toddlers (Stein et al., 2014). Contrary to research
generated in HICs, no clear association between postnatal depression
and infant cognitive, motor, language, behavior and social-emotional
development was found in this review. There are several possible ex-
planations for this inconsistency. A high variability was noticed among
the studies in timing of exposure to maternal depressive symptoms
(ranging from 1–24 months postpartum), timing of measurement of
developmental outcomes (ranging from 23 days −24 months), mea-
sures of maternal depression and infant or toddler neurodevelopment,
sample size and the choice of potential confounders. The difficulty to
draw conclusions on the associations between the different types of
maternal mental health disorders and various domains of neurodeve-
lopment may partly be explained by the limitations of the included
studies. These limitations and recommendations for future research will
be discussed in more detail below.
5. Strengths and limitations
The findings of this review are based on systematic searches using a
wide variety of keywords in six databases. A large number of titles and
articles were reviewed systematically by two independent reviewers
and each part of the search and data extraction process was recorded,
documented and cross-checked. The review was limited to articles
published in the English language and from 1990 onwards. As this re-
view was limited to LAMICs only, it did not include studies conducted
in low socioeconomic areas within HICs. Furthermore, it was beyond
the scope of this review to assess the association between timing and/or
chronicity of maternal mental health disorders and infant or toddler
neurodevelopmental outcomes. Meta-analysis could not be conducted
due to the variability in the reported maternal mental health disorders
and their association with different domains of neurodevelopment, as
well as the different periods of assessment of exposures and outcomes.
Limitations in individual studies included the following:
■ Most of the studies included a wide variety of confounding variables
and/or mediating and moderating factors in the association between
maternal mental health and child development. These included
parent-related factors such as parenting practices, perceptions of
parenting, bonding, breastfeeding; child-related factors, e.g. gesta-
tion, nutritional status, ill health, gender; and factors relating to the
home environment e.g. socioeconomic status (SES), maternal and/or
paternal employment status and education. However, causal path-
ways were not always adequately explained. While this review
found evidence that poor pre- and postnatal mental health is asso-
ciated with delays in infant and toddler development, the nature of
the relationship between maternal mental health disorders and
169
Journal of Affective Disorders 268 (2020) 158–172
these variables and their cumulative effects on the development of
the fetus and young child is still poorly understood. Understanding
the underlying associations between maternal mental health and the
development of the young child can contribute valuable information
to the development of more effective intervention programs
(Herba et al., 2016). In the Lancet series on maternal and paternal
perinatal mental health, Stein et al., 2014, found that the most
important potential mediator is the quality of parenting. Stein et al.,
2014 argued that in LAMICs, the quality of parenting and maternal
care may play a greater role in the health of the child, since families
are exposed to harsher environmental factors. They also identified
evidence for the effect of moderators whereby the severity and
persistence of the mental health disorder after the postnatal period,
low SES, and absence of social support (including partner support)
increased the child's risk of adverse outcomes (Stein et al., 2014). It
must be acknowledged that failure to account for potential demo-
graphic, socioeconomic, maternal and child variables could have
changed the strength of associations between the exposure and
outcomes in some of the included studies. It was, therefore, difficult
to draw definitive conclusions.
■ A variety of outcome measures were used to describe infant and
toddler development, which made comparison across studies diffi-
cult. Studies used measures to assess neurodevelopmental outcomes
that had not been reported as validated (Hamadani et al., 2012;
Nasreen et al., 2013; Ali et al., 2013) and the majority of studies
included neurodevelopmental measures validated in high-income
settings, but not in the country of the study.
■ Nine of the included studies used cross sectional study designs ra-
ther than longitudinal designs. This may be reflective of the diffi-
culty conducting longitudinal research, with follow-up of mothers
and infants in resource-constrained environments. Prospective
longitudinal cohort studies are considered the gold standard of ob-
servational research (Thiese, 2014), but these are usually more time
consuming and costly than other observational study designs
(Vetter, 2017). In cross-sectional studies, exposure and outcome are
ascertained at the same time. This design may suffer from ante-
cedent-consequent bias since no conclusions can be made about the
temporal or causal relationship between the exposure and outcome
(Vetter, 2017).
Recommendations for future research
■ The use of developmental assessment tools that differentiate be-
tween neurodevelopmental domains e.g. cognitive, language, fine
and gross motor, socio-emotional development, adaptive behavior
and screening for disabilities will be valuable for clarifying domains
of child development that may be more vulnerable, and assist in
identifying focus areas for intervention.
■ The reliability, validity, cross-cultural applicability and feasibility of
developmental individual-level assessment and/or population-level
screening tools should be determined for the specific population.
The development of norm-referenced outcome measures need a
large representative sample of children of the same age and sex and
the rapidly changing nature of society means that normative data
may become outdated very quickly (Sabanathan et al., 2015). Thus
the development of norm-referenced assessment tools in LAMICs is
not always realistic when funding for research is limited. However,
using tools that were developed in high-income western settings and
their norms for child development is not ideal. Therefore, re-
searchers using tools that were validated in HICs need to include
local healthy comparison groups of reference for standardization to
reduce norm-related bias (Sabanathan et al., 2015; Boggs et al.,
2019).
■ Studies on prenatal mental health and the association with infant
and toddler developmental outcomes in LAMICs were scarce. In fact,
only one study reported on the association of prenatal mental health
M. Burger, et al.
disorders and toddler development in a low-income country
(Servili et al., 2010). The association between prenatal mental
health and child development could be a focus area for future
longitudinal research.
■ Well-constructed, sustainable global partnerships between HICs and
LAMICs could aid in the transfer of research skills and resources as
well as research capacity development in the field of maternal
mental health and child development.
■ Longitudinal studies will enable data collection at various time
points, including prenatal and postnatal mental health, as well as
child development at different ages. This can help to identify ma-
ternal mental health and child developmental trends that may occur
over long periods. Changes can be tracked so that cause and effect
relationships can be identified. Researchers should follow the
Strengthening the Reporting of Observational studies in
Epidemiology (STROBE) guidelines (Von Elm et al., 2007) for re-
porting of observational studies.
■ Various types of maternal mental health conditions were sometimes
grouped together, as either “maternal distress or common mental
disorders”. Differentiation of pre- and postnatal mental health con-
ditions and distinguishing between constructs such as stress, dis-
tress, anxiety, and depression will allow for a better understanding
of the dynamic between maternal mental health and child devel-
opment.
■ Pathways between maternal mental health and infant and toddler
development are poorly understood. The environment within which
maternal mental health disorders in LAMICs occurs, including ex-
posure to a multitude of risk factors, differentiates LAMICs from
HICs. Longitudinal research with assessment of potential con-
founders, mediators and/or moderators will aid in explaining the
nature of the association. However, the multifaceted and complex
interacting nature of maternal mental health and other potential risk
factors on child development, means that the same factor may act as
a moderator of the risk of maternal mental health and/or a potential
confounder and/or may act as a mediator on the causal pathway
between maternal mental health and child outcome (Stein et al.,
2014). Knowledge of these pathways will enable identification of
high risk groups and development of appropriate interventions in
resource-constrained countries. Tran et al. (2014a) used path ana-
lyses to assess relationships; these methods might be particularly
important for guiding future research conducted in LAMICs.
■ Future systematic reviews should assess the long term association
between maternal mental health and child neurodevelopment, spe-
cifically in LAMICs, as this review focused on children under the age
of two years.
■ It would also be beneficial to include mothers’ use of psychotropic
medication and/or mental health services to further understand the
impact of treated versus non-treated maternal mental health dis-
orders on child developmental outcomes.
5.1. Implications for clinical practice
There is growing global recognition by policymakers that improving
child survival rates in LAMICs is no longer sufficient; and early child
health and development are high on the political agenda. The launch of
the Nurturing Care Framework (NCF) for early childhood development
at the 2018 World Health Assembly (World Health Organization, 2018)
were in response to substantial evidence and recognition that the first
1000 days of life are critical for human development. The NCF provides
five strategic ‘nurturing care’ directions for supporting the development
of children from pregnancy up to age three. The NCF defines ‘nurturing
care’ as the ability of communities to support caregivers and (i) provide
a safe and secure environment, (ii) ensure children's good health, (iii)
ensure adequate nutrition, (iv) give opportunities for early learning and
(v) promote responsive and supportive caregiving (World Health
Organization, 2018).
170
Journal of Affective Disorders 268 (2020) 158–172
Parents, especially the mother, are the closest to the young child in
the period from pregnancy to age three, and thus in the best position to
provide nurturing care. The mother will however only be able to pro-
vide nurturing care and be a responsive and compassionate caregiver if
she has good physical and mental health (World Health
Organization, 2018). One of the key features of nurturing care is to be
sensitive and responsive to the infant's emotional and physical needs.
Poor mental health may interfere with mothers’ sensitivity and re-
sponsiveness to their infants’ developmental needs. Mothers may miss
cues for interaction, struggle to facilitate the child's early social and
emotional development and not be able to provide early learning op-
portunities through age appropriate stimulation (Liu et al., 2017).
Kingston et al. (2012) proposed that addressing maternal mental health
disorders during the perinatal period, may be one of the most modifi-
able and feasible strategies for reducing risk factors for developmental
delay in HIC. However, in LAMICs, the health sector is not necessarily
able to provide adequate psychiatric health care for mothers during the
perinatal period due to financial constraints and lack of basic services.
Emerging evidence from LAMICs suggests that where there is a scarcity
of mental health specialists, intervention during the perinatal period by
trained healthcare workers in primary care and community settings is
effective at improving maternal mental health as well as child health
and development (Rahman et al., 2013). In their systematic review on
interventions for common perinatal mental health disorders in LAMICs,
Rahman et al., 2013 reported that in all but one of their included stu-
dies the interventions were delivered by supervised, non-specialist
health and community workers. They concluded that for LAMICs the
training of non-specialist health care workers to deliver homebased
mental health interventions involving the entire family is a feasible and
effective strategy to address both perinatal mental health disorders and
infant development. Lasater et al. (2017), argued that detecting peri-
natal mental disorders can however be a challenge in LAMICs because
of stigma and lack of awareness at community level, poverty and in-
adequate investment in the mental health infrastructure. They sug-
gested bridging the diagnosis and treatment gap by integrating ma-
ternal mental health into existing obstetrical health services
particularly at the community level (Lasater et al., 2017). Midwives and
community health workers should be trained by mental health specia-
lists how to use locally adapted and culturally-sensitive screening tools
during routine prenatal and postpartum appointments to identify
women who may need support (Lasater et al., 2017). Government
commitment to adequate healthcare during the first 1000 days of life
will enable mothers and their infants residing in LAMICs not only to
survive but also to thrive, despite challenging circumstances.
Conclusion
More than half of the studies reporting on pre- and postnatal ex-
posure to maternal mental health disorders found a significant asso-
ciation with adverse infant and toddler development. However, when
comparing the different types of pre- and postnatal mental health dis-
orders (e.g. pre- or postnatal depression, anxiety, posttraumatic stress
disorder, distress, schizophrenia, and/or stress) with the different do-
mains of neurodevelopment namely motor, cognitive, language, beha-
vior, social-emotional and global development, these associations be-
come less evident. The majority of studies identified and evaluated
associations with confounding variables and mediating or moderating
factors such as infant, maternal, parenting, social and environmental
factors, which altered the strength of the association between maternal
mental health and neurodevelopmental outcome. A better under-
standing of these causal pathways, especially modifiable factors, is of
upmost importance for identifying and managing mothers with mental
health disorders and the wellbeing of their offspring. Routine maternal
mental health screening as a component of obstetric care and well-baby
clinic visits should be a public health priority in LAMICs.
M. Burger, et al.
Authorship contribution statement
Marlette Burger: responsible for the conception and design of the
study; managed the literature searches and selection process of the
included studies, quality assessment and extracting and capturing data,
data analyses, cross-checking data, writing - original draft.
Munira Hoosain: literature searches and selection of the included
studies, quality assessment and extracting and capturing data, data
analyses, cross-checking data, writing - review & editing.
Dana Niehaus, Marianne Unger, Christa Einspieler: supervising,
reviewing & editing the manuscript critically for important intellectual
content and approving the final version to be published.
All authors contributed to and have approved the final manuscript.
Declaration of Competing Interest
The authors to declare no conflicts of interest.
Acknowledgments
The work reported herein was made possible through funding by the
South African Medical Research Council through its Division of
Research Capacity Development under the Bongani Mayosi National
Health Scholars Program from funding received from the South African
National Treasury. The content here of is the sole responsibility of the
authors and do not necessarily represent the official views of the South
African Medical Research Council or the funders.
The authors want to thank Prof Karen Grimmer, University of South
Australia, Division of Heath Sciences, Adelaide, Australia, for her ad-
vice regarding the data analysis of the included papers.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.jad.2020.03.023.
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