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  • PS62CH20-DunkelSchetter ARI 2 November 2010 14:58

    Psychological Science on Pregnancy: Stress Processes, Biopsychosocial Models, and Emerging Research Issues Christine Dunkel Schetter Department of Psychology, University of California, Los Angeles, California 90095; email: dunkel@psych.ucla.edu

    Annu. Rev. Psychol. 2011. 62:531–58

    The Annual Review of Psychology is online at psych.annualreviews.org

    This article’s doi: 10.1146/annurev.psych.031809.130727

    Copyright c© 2011 by Annual Reviews. All rights reserved

    0066-4308/11/0110-0531$20.00

    Key Words

    preterm birth, low birth weight, pregnancy anxiety, prenatal stress, social support, coping and resilience

    Abstract

    Psychological science on pregnancy is advancing rapidly. A major focus concerns stress processes in pregnancy and effects on preterm birth and low birth weight. The current evidence points to pregnancy anxiety as a key risk factor in the etiology of preterm birth, and chronic stress and depression in the etiology of low birth weight. Key mediating processes to which these effects are attributed, that is neuroendocrine, inflam- matory, and behavioral mechanisms, are examined briefly and research on coping with stress in pregnancy is examined. Evidence regarding social support and birth weight is also reviewed with attention to re- search gaps regarding mechanisms, partner relationships, and cultural influences. The neurodevelopmental consequences of prenatal stress are highlighted, and resilience resources among pregnant women are conceptualized. Finally, a multilevel theoretical approach for the study of pregnancy anxiety and preterm birth is presented to stimulate future research.

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  • PS62CH20-DunkelSchetter ARI 2 November 2010 14:58

    Contents

    BACKGROUND. . . . . . . . . . . . . . . . . . . . . 532 PSYCHOSOCIAL PROCESSES

    IN PREGNANCY AND BIRTH: OVERVIEW . . . . . . . . . . . . . . . . . . . . . . 533

    STRESS PROCESSES IN PREGNANCY AND BIRTH . . . . . . 533 Stress and Preterm Birth . . . . . . . . . . . 534 Stress and Low Birth Weight . . . . . . . 535 Mediating Processes: X-Y-Z . . . . . . . . 536 Differentiating Predictive Models

    of PTB and LBW . . . . . . . . . . . . . . . 538 Coping Processes in Pregnancy . . . . . 539

    SOCIOCULTURAL PROCESSES IN PREGNANCY. . . . . . . . . . . . . . . . . 540 Prospective Observational Research

    on Social Support in Pregnancy . . . . . . . . . . . . . . . . . . . . . . 541

    Partner Relationship Research in Pregnancy . . . . . . . . . . . . . . . . . . . 542

    Social Support as a Moderator of Stress and Birth Outcome Effects . . . . . . . . . . . . . . . . . . . . . . . . . . 542

    Intervention Research on Social Support in Pregnancy . . . . . . . . . . . 543

    Cultural Factors and Relationships Processes in Pregnancy . . . . . . . . . . 544

    FRONTIERS IN PSYCHOLOGICAL SCIENCE ON PREGNANCY . . . . 544 Fetal Programming and

    Developmental Effects . . . . . . . . . . 544 Resilience Resources in

    Pregnancy . . . . . . . . . . . . . . . . . . . . . . 545 Multilevel Models of Birth

    Outcomes . . . . . . . . . . . . . . . . . . . . . . 547 A Theoretical Formulation

    of Pregnancy Anxiety and PTB . . 547 CONCLUSION . . . . . . . . . . . . . . . . . . . . . 549

    BACKGROUND

    The stereotypical image of the experience of pregnancy is as a happy and joyful time in life when a mother and her partner are expect- ing a child they planned to have and that they

    are well prepared to love and nurture. Most early psychological research on pregnancy ac- tually studied samples that conform to this stereotype—married, middle-class, and afflu- ent women recruited in private health-care set- tings. The fact, however, is that pregnancy for many women today is an experience charac- terized by a lack of adequate resources, both socioeconomic and psychosocial, and the pres- ence of many stressors such as work and family responsibilities that make pregnancy a distant reflection of the ideal prototype. Indeed, there is tremendous variability in the experiences of pregnant women as a function of many factors at multiple levels of analysis including an ex- pectant mother’s emotional state, her health and physical condition, where she lives, her socioeconomic status, whether her partner is involved in the pregnancy, and the availabil- ity of social support. Thus, one cannot char- acterize the psychological experiences of preg- nancy in any single way for women as a whole. Many of the progressive physiological changes that take place in pregnancy are universal and may generate emotional effects that can make at least the first trimester of pregnancy try- ing. These changes are well established. Yet the sources of variability in physiology and emo- tions during pregnancy and in pregnancy out- comes are less well known. Thus, it behooves psychological scientists to consider the major biopsychosocial and sociocultural sources of variation among women and their effects on maternal health and well-being. In addition, the effects of differences in maternal experi- ences on the developing fetus and infant are beginning to emerge more clearly. A grow- ing body of research over the past decade has established that maternal experiences in preg- nancy have extensive effects on the fetus and offspring, which may persist throughout the lifespan.

    The purpose of this review is to highlight active areas of research on pregnancy within the domain of psychological science and to point to some emerging themes. In particular, it contains an overview of research on stress processes in pregnancy and the effects on two

    532 Dunkel Schetter

  • PS62CH20-DunkelSchetter ARI 2 November 2010 14:58

    birth outcomes, preterm birth (PTB) and low birth weight (LBW), and on the mediating pro- cesses to which the effects of stress on these outcomes are most often attributed. It also re- views the role of social processes in pregnancy including social support, partner relationships, and cultural factors, and research on maternal coping. Finally, areas of emerging interdisci- plinary science are highlighted wherein psy- chological research is playing a major role. These are the fetal and neurodevelopment effects of prenatal stress and anxiety, resilience resources in pregnancy, and multilevel analy- ses of pregnancy and birth outcomes. Due to space limitations, some topics are touched upon only briefly with sparse referencing, but rele- vant reviews and example research studies are cited that provide some direction for scholarly pursuit.

    PTB and LBW are major health problems. Defined as birth before 37 weeks gestation (PTB) and weight at birth of 2,500 grams or less (LBW), these birth outcomes occur in 8% to 12% of all pregnancies worldwide, with strikingly high rates in the United States compared to other industrialized nations (Goldenberg et al. 2008). Moreover, these rates are disproportionately high among some subgroups in the U.S. population; African Americans have roughly twice the rates of most other groups even after controlling for socioe- conomic status (SES) and other confounding factors. The potential adverse consequences of PTB and LBW are reviewed elsewhere (e.g., Aarnoudse-Moens et al. 2009, Behrman & Butler-Stith 2006); briefly, these critical indi- cators of newborn health pose risks of infant mortality, various infant and early childhood health problems, and a range of developmental abnormalities that increase as gestation and birth weight decline. There are many known and hypothesized psychosocial risk factors, and there are considerable psychological consequences for families, both of which bring psychological scientists to the multidisciplinary arena in which these phenomena are now studied.

    Birth outcomes: refers to medically defined and clinically significant birth endpoints including low birth weight and preterm birth

    Preterm birth (PTB): birth before 37 weeks gestation due to early labor, early rupture of fetal membranes, induced labor, or elective surgical delivery

    Low birth weight (LBW): weight of an infant at birth of less than or equal to 2,500 grams

    SES: socioeconomic status

    PSYCHOSOCIAL PROCESSES IN PREGNANCY AND BIRTH: OVERVIEW

    A multilevel approach to understanding any health outcome includes individual, social rela- tionship, sociocultural, and community levels of analysis (Dunkel Schetter & Lobel 2010). In the context of pregnancy, relevant individual-level factors influencing birth outcomes are medi- cal (e.g., historical and current medical condi- tions); genetic; neuroendocrine profiles; behav- ioral; stress and emotion; and coping behavior, styles, and resources. Relationship-level analy- ses include social network, social support, part- ner relationship, family, and intergenerational influences. Sociocultural-level analyses include race/ethnicity, nativity, acculturation, SES, and cultural norms and values. Community-level factors include the physical environment, char- acteristics of neighborhoods, health-care access and quality, and related geographical factors. Each of these has received attention in past re- search on pregnancy, with a stronger emphasis historically on medical and behavioral risk, and recent emphasis on sociocultural and commu- nity factors. The focus here is on several of these factors at more than one level centering around the key concept of stress. Research on stress and emotions in pregnancy has been growing rapidly for two decades and is a timely topic for consideration.

    STRESS PROCESSES IN PREGNANCY AND BIRTH

    The study of stress in pregnancy became of in- terest because many other approaches to the prediction of adverse birth outcomes did

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