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Maternal and child health

Are longitudinal trajectories of maternal stress and resilience during pregnancy associated with infant cognitive and emotional development at 12 months, and do these trajectories account for the association between socioeconomic disadvantage and these developmental outcomes?

The gap

While the retrieved literature confirms associations between socioeconomic disadvantage, maternal stress, and infant neurodevelopment, it does not resolve the specific question of how longitudinal trajectories of maternal stress and resilience mediate these associations, as the studies focus on broad correlations or static measures rather than dynamic mediation pathways.

Study design

Prospective longitudinal cohort study with four prenatal assessments and latent growth curve mediation analysis

High-level approach

Latent Growth Curve Modeling estimates individual intercept and slope parameters for maternal stress and resilience trajectories; these parameters then enter a longitudinal mediation framework (path a: disadvantage index → trajectory parameters; path b: trajectory parameters → infant outcomes), with the indirect effect estimated via bias-corrected bootstrap. Continuous ASQ-3 cognitive scores are analyzed with linear regression; potentially right-skewed ASQ:SE-2 emotional scores use gamma regression or log-transformed linear regression.

Methodology

Design justification

A prospective longitudinal cohort with repeated prenatal assessments is essential for capturing individual change trajectories in stress and resilience, which cross-sectional designs cannot estimate [[4],[8]]. Latent growth curve modeling extracts each woman's baseline level and rate of change, enabling a temporally ordered mediation framework—socioeconomic disadvantage precedes prenatal trajectory parameters, which precede infant developmental outcomes at 12 months. This design directly tests whether maternal stress and resilience trajectories statistically account for the association between socioeconomic disadvantage and infant cognitive and emotional development.

Population

Pregnant women aged 18–45 years in their first trimester (≤14 weeks gestation) attending antenatal services, with singleton pregnancies, who plan to deliver and remain in the catchment area for 12 months postpartum. Women with severe pre-existing psychiatric illness requiring acute care, known fetal anomalies, or plans to relocate will be excluded to reduce attrition-related bias.

Setting

Two to three antenatal clinics at a regional or tertiary hospital serving a socioeconomically mixed population, enabling adequate variation in socioeconomic status — a prerequisite for examining the social-determinants-to-outcome pathway [[2],[9]].

Sampling

Convenience sampling of eligible women sequentially approached at their first antenatal booking visit, supplemented by stratified purposive recruitment to ensure adequate representation across socioeconomic strata (low, middle, high household wealth tertiles based on a household asset index) so that the mediation pathway has sufficient exposure variation.

Sample-size approach

Sample size is driven by the mediation analysis. Using the approach of Fritz and MacKinnon (2007) for bias-corrected bootstrap mediation with 80% power at alpha=0.05, detecting a medium effect path (a: SDOH → stress trajectory; b: stress trajectory → infant outcome) requires approximately 462 participants with complete data. Assuming 30% attrition across pregnancy and 12 months postpartum (consistent with prospective perinatal cohorts), a minimum of 660 women should be enrolled. Additionally, this n provides >90% power to detect a medium correlation (r=0.30) between socioeconomic disadvantage and infant developmental outcomes and >80% power for a medium effect in latent growth curve model parameters.

Variables

Exposure: Socioeconomic disadvantage index (composite of household wealth tertile, education, employment status, food insecurity, and neighborhood deprivation) measured at baseline [[2],[9]]. Mediator (longitudinal): Maternal perceived stress (Perceived Stress Scale, PSS-10 or PSS-14) and resilience (Connor-Davidson Resilience Scale, CD-RISC-10 or similar validated measure) assessed at four time points: T1 (≤14 weeks), T2 (20–24 weeks), T3 (28–32 weeks), T4 (36–40 weeks) [[4],[8],[9]]. Outcome: Infant cognitive and emotional development at 12 months corrected age, assessed using the Ages and Stages Questionnaire, 3rd Edition (ASQ-3) for cognitive/communication domains and the Ages and Stages Questionnaire: Social-Emotional, 2nd Edition (ASQ:SE-2) for emotional/behavioral outcomes [[3],[9]]. Covariates/confounders: maternal age, parity, BMI, prenatal nutrition (including DHA intake as a marker of nutritional status [[6],[10]]), gestational age at delivery, birth weight, postpartum depression (Edinburgh Postnatal Depression Scale at 6 and 12 months) [1], infant sex, breastfeeding duration, and caregiver education/stimulation (HOME inventory short form) [5].

Data sources

Primary prospective data collection via: (1) interviewer-administered structured questionnaires at each antenatal visit (sociodemographics, stress, resilience); (2) maternal self-report questionnaires at 6 and 12 months postpartum (postpartum depression, caregiving environment); (3) infant developmental screening at the 12-month immunization/well-child visit (ASQ-3 and ASQ:SE-2 administered by trained research nurses); (4) medical record extraction for gestational age, birth weight, mode of delivery, pregnancy complications, and neonatal outcomes.

Time

24–30 months: 6 months for ethics approval, instrument validation, and staff training; 12 months for enrollment (overlapping with follow-up of early enrollees); 12 months postpartum for final outcome assessment; 3–6 months for data cleaning and analysis.

Cost

Moderate-to-high. Major costs: 2–3 part-time research nurses/interviewers for recruitment and follow-up; ASQ-3 and ASQ:SE-2 kits and scoring licenses; mobile data collection devices/tablets; participant transport reimbursement for the 12-month visit; data management software; biostatistician consultation for LGCM. Estimated USD 40,000–80,000 depending on setting and staffing.

Ethics

Requires full IRB/ethics committee approval. Informed written consent at enrollment, with separate consent for medical record access. Minimal risk to participants (questionnaire-based), but vulnerable population (pregnant women, infants) necessitates safeguards: distress protocol with referral pathway for women scoring above clinical cutoffs on stress or depression scales; data safety monitoring for any adverse events; compensation for time and transport. IRB will require a data management plan for longitudinal identifiable data.

Grounding references

  1. Maternal Depression During Pregnancy and the Postnatal Period — Pearson RM, Evans J, Kounali D, Lewis G, Heron J, Ramchandani P · JAMA Psychiatry, 2013 · DOI 10.1001/jamapsychiatry.2013.2163
  2. Socioeconomic disadvantage, gestational immune activity, and neurodevelopment in early childhood — Gilman SE, Hornig M, Ghassabian A, Hahn J, Cherkerzian S, Albert PS · Proceedings of the National Academy of Sciences, 2017 · DOI 10.1073/pnas.1617698114
  3. Disrupted beginnings: Neurodevelopmental outcomes of COVID-19 lockdowns in early childhood (Review). — Giannopoulou I, Efstathiou V, Stefanou MI, Korkoliakou P, Tsoporis JN, Spandidos DA · Experimental and therapeutic medicine, 2026 · DOI 10.3892/etm.2026.13132
  4. Pregnancy as a period of risk, adaptation, and resilience for mothers and infants — Elysia Poggi Davis, Angela J. Narayan · Development and Psychopathology, 2020 · DOI 10.1017/s0954579420001121
  5. The influence of attachment and relational quality on developmental outcomes across the lifespan: a systematic review and meta-analytic insights (2014-2024). — Ho J, Rahaman MA · Frontiers in psychology, 2026 · DOI 10.3389/fpsyg.2026.1745013
  6. Nutrition as the Foundation of Human Capital: Pathways to Holistic Development. — Hassen DM · Maternal & child nutrition, 2026 · DOI 10.1111/mcn.70196
  7. Chronic stress may disrupt covariant fluctuations of vitamin D and cortisol plasma levels in pregnant sheep during the last trimester: a preliminary report — Wakefield C, Janoschek B, Frank Y, Karp F, Reyes N, Schulkin J · arXiv preprint, 2019
  8. Resilience and Stress during Pregnancy: A Comprehensive Multidimensional Approach in Maternal and Perinatal Health — Anic C. Alves, José Guilherme Cecatti, Renato T. Souza · The Scientific World JOURNAL, 2021 · DOI 10.1155/2021/9512854
  9. Maternal Stress During Pregnancy and Infant and Child Outcome — Glover V · Oxford Handbooks Online, 2014 · DOI 10.1093/oxfordhb/9780199778072.013.006
  10. Maternal Docosahexaenoic Acid Status During Pregnancy and Its Impact on Infant Neurodevelopment — Basak S, Mallick R, Duttaroy AK · 2020 · DOI 10.20944/preprints202010.0406.v1

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Are longitudinal trajectories of maternal stress and resilience during pregnancy associated with infant cognitive and emotional development at 12 months, and do these trajectories account for the association between socioeconomic disadvantage and these developmental outcomes? · PaceResearcher