Study Results
Our top research findings and publications are put in the spotlight.
Mediating mechanisms for maternal mental health from pre to during the COVID-19 pandemic
Mothers (n = 1,333) from an ongoing longitudinal cohort (All Our Families; AOF) from Calgary, Alberta, Canada, completed online questionnaires prior to (2017–2019) and during the COVID-19 pandemic (May-July 2020).
In unadjusted analyses, maternal depression and anxiety symptoms pre-pandemic were strongly associated with COVID-19 depressive (r = 0.57, p<.01) and anxiety symptoms (r = 0.49, p<.01). Significant indirect effects between maternal depressive symptoms pre- and during COVID-19 were found for coping behavior (abcs=0.014, 95%CI=0.005, 0.022, p=.001), perceived stress (abcs=0.22, 95%CI=0.179, 0.258, p<.001), and strained relationships (abcs=0.013, 95%CI= 0.005, 0.022, p=.003). For maternal anxiety symptoms pre- and during COVID-19, significant indirect effects were observed for perceived stress (abcs=0.012, 95%CI=0.077, 0.154, p=.003) and strained relationships (abcs=0.010, 95%CI=0.001, 0.018, p=.03).
Conclusions: Perceived stress, coping attitudes, and interpersonal relationships are three potential intervention targets for mitigating COVID-19 related mental distress in mothers.
Predictors of preadolescent children's recreational screen time duration during the COVID-19 pandemic
Participants included 846 children (M = 9.85, SD = 0.78) and their mothers from the All Our Families cohort, Calgary, Canada. Mothers reported (May-July 2020) on child screen use and COVID-19 pandemic impacts (e.g., job/income loss and stress), and children self-reported (July-August 2020) on their screen use and daily routines (e.g., sleep, physical activity, and device-free activities).
Screen use during the COVID-19 pandemic was highest among male and minoritized children and families reporting high levels of stress. Children had lower durations of screen time when device limits were set by mothers. Children also had lower durations of screen time when they used screens to connect with others and when they engaged in higher levels of physical activity or device-free recreational activities.
Conclusion: This study sheds light on children's screen use during the COVID-19 pandemic and supports the current screen use guidelines for school-aged children, suggesting that parents monitor use and foster high-quality screen use (e.g., coviewing or used for connection) and device-free recreational activities when possible.
Maternal depressive and anxiety symptoms before and during the COVID-19 pandemic in Canada: a longitudinal analysis
Maternal depression and anxiety symptoms during the COVID-19 pandemic were compared with three previous estimates collected at 3, 5, and 8-year timepoints (between April, 2012, and October, 2019).
Of the 3387 women included in the All Our Families study, 1301 were included in the longitudinal analysis. At the COVID-19 impact survey time point, a higher proportion of mothers had clinically significant depression (35·21%, 95% CI 32·48–38·04) and anxiety symptoms (31·39%, 28·76–34·15) than at all previous data collection timepoints. The mean depression score (8·31, 95% CI 7·97–8·65) and anxiety score (11·90, 11·66–12·13) at the COVID-19 pandemic time point were higher than previous data collection waves at the 3-year time point (mean depression score 5·05, 4·85–5·25; mean anxiety score 9·51, 9·35–9·66), 5-year time point (mean depression score 5·43, 5·20–5·66; mean anxiety score 9·49, 9·33–9·65), and 8-year time point (mean depression score 5·79, 5·55–6·02; mean anxiety score 10·26, 10·10–10·42). For the within-person comparisons, depression scores were a mean of 2·30 points (95% CI 1·95–2·65) higher and anxiety scores were a mean of 1·04 points (0·65–1·43) higher at the COVID-19 pandemic time point, after controlling for time trends.
Conclusion: Larger increases in depression and anxiety symptoms were observed for women who had income disruptions, difficulty balancing home schooling with work responsibilities, and those with difficulty obtaining childcare.
Child and family factors associated with child mental health and well-being during COVID-19
This study included 846 mother–child dyads (child age 9–11) from the All Our Families cohort. Mothers reported on the child’s pre-pandemic mental health at age 8 (2017–2019) and during COVID-19 (May–July 2020), the family’s financial impact due to COVID-19, and maternal depression and anxiety. During COVID-19 (July–August 2020), children reported on their screen time, sleep, physical activity, peer and family relationships, and recreational activities, as well as their happiness, anxiety and depression.
After controlling for pre-pandemic anxiety, connectedness to caregivers (B − 0.16; 95% CI − 0.22 to − 0.09), child sleep (B − 0.11; 95% CI − 0.19 to − 0.04), and child screen time (B 0.11; 95% CI 0.04–0.17) predicted child COVID-19 anxiety symptoms. After controlling for pre-pandemic depression, connectedness to caregivers (B − 0.26; 95% CI − 0.32 to − 0.21) and screen time (B 0.09; 95% CI 0.02–0.16) predicted child COVID-19 depressive symptoms. After controlling for covariates, connectedness to caregivers (B 0.36; 95% CI 0.28–0.39) predicted child COVID-19 happiness.
Conclusion: Fostering parent–child connections and promoting healthy device and sleep habits are critical modifiable factors that warrant attention in post-pandemic mental health recovery planning.
Maternal Health
Differential associations of adverse childhood experience on maternal health
The current study examined whether three distinct antecedent factors related to maternal adverse childhood experiences were differentially associated with maternal health and psychosocial outcomes in the antepartum period.
Path analysis demonstrated that women who had experience with physical/emotional abuse in childhood were significantly more likely to enter pregnancy with a chronic health condition (AOR=1.25, 95% CI=1.02, 1.54) and to have psychosocial difficulties in their pregnancy (AOR=1.60, 95% CI=1.34, 1.89). Women who were exposed to household dysfunction in childhood were also significantly more likely to experience psychosocial difficulties during pregnancy (AOR=2.33, 95% CI=1.49, 3.65).
Conclusions: Adverse childhood experience categories differentially predicted maternal health and psychosocial outcomes prior to and during pregnancy. The overall variance accounted for by adverse childhood experiences was small (3%-19%), suggesting that factors other than childhood adversity likely contribute to maternal health.
The influence of back pain and urinary incontinence on daily tasks of mothers at 12 months postpartum
The present study examined back pain (BP) and/or urinary incontinence (UI) impact on the ability to perform daily tasks at 12 months after childbirth in healthy reproductive women who sought maternity care in community based family practice clinics.
From 1574 women with singleton pregnancies included in the study, 1212 (77%) experienced BP, 773 (49%) UI, and 620 (40%) both BP and UI. From the 821 women reporting impairment of daily tasks due to BP, 199 (24 %) were moderately and 90 (11%) severely affected with the remainder, 532 (64%) being mildly affected. From 267 women with functional impairment due to UI, 52 (19%) reported moderately to severe impairment in their ability to perform daily tasks.
Conclusions: Obesity and parity were risk factors for impairment of daily functioning due to BP, whereas obesity and vaginal delivery increased the risk of moderate to severe impairment due to UI. Maternal performance of daily tasks and women’s health and quality of life are more often impaired due to BP than UI.
Pre-pregnancy Body Mass Index (BMI) and delivery outcomes in a Canadian population
Growing evidence suggests that maternal overweight and obesity is associated with poor maternal and perinatal outcomes. This study evaluated the impact of maternal pre-pregnancy overweight and obesity on pregnancy, labour and delivery outcomes in a cohort of women with term, singleton pregnancies cared for by family physicians in community based practices.
The cohort consisted of 65.8% normal weight, 23.6% overweight and 10.6% obese women. Women with increased pre-pregnancy BMI were more likely to develop pregnancy complications such as preeclampsia (OR 3.5, CI 2.0-4.6 for overweight; OR 5.3, CI 3.3-8.5 for obese) and gestational diabetes (OR 3.0, CI 1.8-5.0 for overweight; OR 6.5, CI 3.7-11.2 for obese) than normal weight women. Spontaneous onset of labour was recorded in 71.2% of women with normal pre-pregnancy BMI, whereas 39.3% of overweight and 49% of obese women had their labour induced. For women with spontaneous labour, pre-pregnancy BMI was not a significant risk factor for mode of delivery, controlling for covariates. Among women with induced labor, obesity was a significant risk factor for delivery by C-section (adjusted OR 2.2; CI 1.2-4.1).
Conclusions: Even among women with term, singleton pregnancies obtaining prenatal care in community-based settings, obese women who undergo labour induction are at increased risk of obstetrical interventions at delivery.
The impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum
Emergency and planned c-sections may adversely affect breastfeeding initiation, milk supply and infant breastfeeding receptivity compared to vaginal deliveries. Our study examined mode of delivery and breastfeeding initiation, duration, and difficulties reported by mothers at 4 months postpartum.
More women who delivered by planned c-section had no intention to breastfeed or did not initiate breastfeeding (7.4 % and 4.3 % respectively), when compared to women with vaginal births (3.4 % and 1.8 %, respectively) and emergency c-section (2.7 % and 2.5 %, respectively). Women who delivered by emergency c-section were found to have a higher proportion of breastfeeding difficulties (41 %), and used more resources before (67 %) and after (58 %) leaving the hospital, when compared to vaginal delivery (29 %, 40 %, and 52 %, respectively) or planned c-sections (33 %, 49 %, and 41 %, respectively). Women who delivered with a planned c-section were more likely (OR = 1.61; 95 % CI: 1.14, 2.26; p = 0.014) to discontinue breastfeeding before 12 weeks postpartum compared to those who delivered vaginally.
Conclusions: We found that when controlling for socio-demographic and labor and delivery characteristics, planned c-section is associated with early breastfeeding cessation.
Maternal Mental Health
Women's mental health up to eight years after childbirth and associated risk factors
Role and relationship strain factors and anxiety and depression symptoms were measured at repeated time points from four months to eight years after childbirth.
The prevalence of elevated anxiety and/or depression ranged from 18.8% (at four months) to 26.2% (at eight years). The adjusted odds ratio of anxiety and/or depression was 3.5 (95% CI = 2.9, 4.3) for those juggling family responsibilities and 2.4 (95% CI = 2.0, 3.0) for those with stressful partner relationship compared to their counterparts. Similarly, experiencing financial crunch and poor partner relationship were associated with increased mental health difficulties. Women without challenges in roles or relationships had a 23% lower predicted probability of anxiety and/or depression than those with the challenges.
Conclusions: Monitoring mothers for anxiety and depression beyond the postpartum period and strategies that address role and relationship challenges may be valuable to women at risk of anxiety and depression.
The chronicity and timing of prenatal and antenatal maternal depression and anxiety on child outcomes at age 5
Participants were 1,992 mother–child pairs. Mothers reported on anxiety and depression symptoms at six time points between <25 weeks gestation and 3 years postpartum. Child outcomes were assessed at age 5.
Maternal anxiety/depression during pregnancy, infancy, and toddlerhood predicted all child outcomes, even after controlling for depression/anxiety during the other timepoints. However, maternal anxiety and depression during toddlerhood had a stronger association with child internalizing/externalizing symptoms and communication skills than either prenatal or postpartum depression/anxiety.
Conclusions: Increasing number of exposures to clinical-level anxiety and depression is related to poorer child outcomes. Results highlight the need for continued support for maternal mental health across early childhood.
Patterns of change in anxiety and depression during pregnancy predict preterm birth
Anxiety and depression were measured at 17–24 weeks and again at 32–36 weeks’ gestation. Chronic stress was assessed at 17–24 weeks’ gestation as a potential covariate.
Women who experienced an increase in anxiety scores, (time point 32–36 weeks, compared to the earlier time point 17–24 weeks), had 2.70 times higher odds of preterm delivery, compared to those with a reduction in anxiety scores (95% CI 1.28, 5.69). Consistent low or high depression scores did not significantly influence the odds of preterm birth compared to a decrease in depression scores. A co-occurring increase in anxiety and depression scores was not found to increase the risk of preterm birth, and chronic stress did not modify any of these relationships.
Conclusions: Primary prevention could address anxiety during pregnancy to potentially modify preterm birth outcomes.
Social support and maternal mental health at 4 months and 1 year postpartum
Outcomes were depressive or anxiety symptoms at 4 months and 1 year postpartum. Exposures were social support during pregnancy and at 4 months postpartum.
Low total social support during pregnancy was associated with an increased risk of depressive symptoms (RR 1.50, 95% CI 1.24 to 1.82) and anxiety symptoms (RR 1.63, 95% CI 1.38 to 1.93) at 4 months postpartum. Low total social support at 4 months was associated with an increased risk of anxiety symptoms (RR 1.65, 95% CI 1.31 to 2.09) at 1 year. Absolute risk differences were largest among women with previous mental health challenges resulting in a number needed to treat of 5 for some outcomes. Emotional/informational support was the most important type of support for postpartum anxiety.
Conclusion: Group prenatal care, prenatal education and peer support programmes have the potential to improve social support.
Child Development
Risk and protective factors in early child development
Participants completed four questionnaires spanning pregnancy to one year postpartum and provided access to medical records. Risk factors for developmental delay at age one were identified using bivariate methods and multivariable modelling. Protective factors for child development in ‘at risk’ family environments were identified using bivariate analyses.
At one year, 17% of children were developmentally delayed, defined as scoring in the monitoring zone on at least 2 of the 5 developmental domains of the Ages and Stages Questionnaire. Prenatal depression, preterm birth, low community engagement, and non-daily parent-child interaction increased the risk of delay. Protective factors for children in ‘at risk’ environments included relationship happiness, parenting self-efficacy, community engagement, higher social support, and daily parent-child interaction.
Conclusion: The study results suggest that maternal and infant outcomes would be improved, even for vulnerable women, through identification and intervention to address poor mental health, and through normalizing engagement with low cost, accessible community resources that can support parent-child interaction.
Risk factors for delayed social-emotional development and behavior problems at age two
Mothers completed five comprehensive questionnaires spanning mid-pregnancy to 2 years postpartum. At child age two, behavior and competence outcomes were measured using the Brief Infant‐Toddler Social and Emotional Assessment.
Risk factors for possible delayed social‐emotional development in children included maternal depression at 2 years postpartum (OR 2.46, 95% CI 1.63, 3.72), lower parenting self‐efficacy at 2 years postpartum (OR 2.76, 95% CI 1.51, 5.06), non‐daily play‐based interaction when child was 1 and 2 years old (OR 1.43, 95% CI 1.02, 1.99), child delayed sleep initiation at 2 years of age (OR 1.58, 95% CI 1.05, 2.37), and playgroup non‐attendance between 1 and 2 years postpartum (OR 1.43, 95% CI 1.03, 1.99). Risk factors for possible behavior problems included lower maternal optimism during pregnancy (OR 2.02, 95% CI 1.36, 2.99), maternal depression at 2 years postpartum (OR 2.19, 95% CI 1.46, 3.27), difficulty balancing responsibilities at 2 years postpartum (OR 2.32 95% CI 1.55, 3.47), child second language exposure at 2 years of age (OR 1.88, 95% CI 1.37, 2.58), child delayed sleep initiation at 2 years of age (OR 1.55 95% CI 1.06, 2.26), child frequent night wakings at 2 years of age (OR 2.95 95% CI 2.13, 4.10), and more screen time exposure at 2 years of age (OR 1.85 95% CI 1.34, 2.54).
Conclusions: This study suggests that addressing maternal mental health and promoting parenting strategies that encourage play‐based interaction, limiting screen time, preventing sleep problems, and engagement in informal playgroups would reduce the risk of behavior and social‐emotional problems.
Risk and protective factors for externalizing behavior at 3 years
Externalizing behavior was assessed using a short version of the Child Behavior Checklist. Risk and protective factors included the child's characteristics, maternal mental health and disposition, socioeconomic status, and community engagement and child care.
Poor maternal mental health and high levels of maternal neuroticism were associated with an increased risk for externalizing problems at 3 years (AOR, 1.66; 95% confidence interval [CI], 1.16–2.40 and AOR, 2.28; 95% CI, 1.58–3.30). Care by their mother, relative, or a nanny (compared with being in child care) also conferred an increased risk (AOR, 1.38; 95% CI, 1.01–1.90). Mothers' community engagement modified the risk for boys, such that boys whose mothers did not participate in community activities were 4 times more likely to have externalizing problems than boys whose mothers engaged in community activities.
Conclusion: Identification of mothers with mental health challenges or dispositional traits provides the opportunity to promote engagement with parenting supports to improve outcomes of child and family. Providing opportunities for children to practice their self-regulation skills through participation in child care and community activities promotes development and mitigates the risk of externalizing behavior.
Maternal adverse childhood experiences, mental health, and child behaviour at age 3
Links between adverse childhood experiences (ACEs) and threats to health and well-being later in life are well established. The current study extends those findings into younger populations of pregnant women and their children.
Approximately 62% of participants experienced at least one ACE; 25% experienced 3 or more ACEs. The presence of 3 or more ACEs was associated with postpartum smoking, binge drinking, depressive and anxiety symptoms, lower optimism and higher neuroticism, and lower reported parenting morale. In children, 3 or more maternal ACEs was associated with higher levels of internalizing (e.g., anxiety) and externalizing difficulties (aggression and hyperactivity), as well as temperament (surgency and negative affectivity).
Conclusion: Cumulative maternal ACEs are associated with postpartum mental health and parenting morale, as well as maladaptive coping strategies. The downstream consequences of maternal ACEs for child outcomes suggests that early intervention strategies and community resources to improve life course outcomes for parents and children are critical for breaking intergenerational continuities of risk.
More than 200 peer reviewed papers have been published thus far!
Lead Investigators
Drs. Suzanne Tough and Sheila McDonald are the lead investigators for the All Our Families cohort study. Access to their peer-reviewed publications are available through the PubMed and Research Gate links below. As indicated above, more than 200 papers have been published from the All Our Families study thus far; if you are looking for a particular study and need help, please reach out to us.
