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Health Psychology2000,Vol. 19, No. 6,5*1-553

Copyright2000by the American Psychological Association, Inc.0278-6133/00/J5.00 DO]: 10.103W0278-6I33.19.6.544

The Impact of Prenatal Maternal Stress and Optimistic DispositiononBirth Outcomes inMedically High-RiskWomen

Marci obel andCarlaJ. DeVincentState Univereity of New York at Stony Brook

Anita KaminerQueens-Long Island Medical Grou p

Bruce A. MeyerState University of New York at Stony Brook

Asizable body of evidence indicates that prenatal maternal stress PNMS)has an adverse impact on birthoutcomes, including birth weight and gestational age at delivery. The authors hypothesized that effectsof PNMS are attributable in part to dispositions such as pessimism thatlead women to view their livesasstressful andthateffects ofPNMSanddisposition on birth outcome aremediated by prenatal healthbehaviors.Using structural equations modeling procedures, the authors examined prospective impact ofPNMS anddispositionaloptimism on birth weight andgestational age in a medically high-risk sample = 129),controlling foreffects of risk and ethnicity.Afterits strong inverse associationwithoptimismwas accounted for, PNMS had no impact on birth outcomes. Women who were least optimistic deliveredinfants who weighed significantlyless,controlling for gestationalage.Optimists were more likely toexercise,andexercisew as associatedwith lower risk ofpretermdelivery. Results suggest that chronicstress in pregnancy may be a reflection of underlying dispositions that contribute to adverse birthoutcomes.

Key words pregnancy,stress,disposition, optimism, birth weight, health behavior

Infants weighing between 1 500and2,499 g at birth are fivetimes more likelyto die in the firstyearoflife than normal-weight(2,500+ g)infants; those weighinglessthan 1,500g are 65timesmore likely to die (National Centerfor Health Statistics [NC HS],1997). Surv iving children h ave higher rates of subnorm al grow thand illness, and the majority exhibit mild deficits in cognition,attention, and neuromotorfunction (Hack, Klein, &Taylor,1995;Newnham, 1998; Thompson et al., 1997).For example, childrenaged6 to 15yearswhowerelowbirth weightarenearly50 morelikelyto be in aspecial education program (Chaikind &Gorman,1991).Infantsw eigh too little at birth because of imp aired grow thin utero, because they were born too soon, or both. Preterm

Marci Lobel and Carla J. DeVincent, Department of Psychology, StateUniversity of New York at Stony Brook; Anita Kaminer, Queens-LongIslandMedicalGroup, Jamaica, New York; Bruce A. Meyer, Departmentof Obstetrics, Gynecology and Reproduc tive Medicine, State University ofNew YorkatStony Brook.

This research was supported in part by National Institutes of HealthMM) Biomedical ResearchSupport GrantS07RRO767-25. Marci Lobeland Carla DeVincent received support from N1H Grant 5R29NR03443during preparation of this article.We aregrateful to ValerieParisi,RobertBarbieri,Judith A.Stein,Martin Stone, Joan Quigley, M arianne Tinkla, thestaff of the Stony Brook Pregnancy Project, and all of the women whoparticipated in this study.

Correspondence concerning this article should be addressed to MarciLobel, Department of Psychology, State U niversity of New Y ork at StonyBrook, Stony Brook, New York11794-2500.Electronic mail may be sentto marci.lobel@sunysb.edu.

delivery (before 37 weeks of pregnancy) is itself associatedwith a range of severe health and developm ental consequences(e.g., Ee , Hagan, Evans, & French, 1998). Rates of low birthweight, which range from 6.6 for non-Hispan ic Whites in theUnited Statesto 13.2 for non-Hispanic Blacks (NCHS,2000),have increased steadilysince 1984; rates ofpreterm delivery intheUnitedStates arealsoon theincrease(Paneth, 1995; NCHS,2000).

A convergence of evidence indicates that prenatal maternalstress (PNMS) is an im portan t contributor to adverse birthout-comes. Both animalandhuma n studiesfindthat mothersexposedto stress prenatally deliver infants significantly earlier and infantswho weigh less at birth (e.g., Copper et al., 1996;Hedegaard,Henriksen, Secher, Hatch, & Sabroe, 1996;Lobel, Dunkel-Schetter, & Scrimshaw, 1992; Molfese et al., 1987; Wadhwa,Sandman, Porto,Dunkel-Schetter,& Garite,1993;see reviews byHoffman &Hatch, 1996; Lederm an, 1995; Lobe l, 1994;Paarlberg,Vingerhoets,Passchier, Dekker, & Van Geijn, 1995). Animpor-tant theme emerging from this literature isthat episodic or acutestressmay not be asdeleterious aschronicstress(Dunkel-Schetter& Lobel,1998; Dunkel-Schetter, Gurung, Lobel, & W adhwa, inpress; Lobel, 1998).Thisthemehasbeen m ost apparentin studiesusing multivariate approaches to conceptualize and operationalizePNMS.Inthese, stressisassessed byindicatorsofstress stimuliorstressors(suchasmajor life events) overthecourse ofpregnancy,repeated measures of stress perception or appraisal, and repeatedmeasures of stress responses, particu larly emotions su ch as anxi-ety. Suchapproaches provide strong tests of PNMSeffects because

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SPECIALSECTION: STRESS, OPTIMISM,ANDBIRTH OUTCOMES 545they are based onwell-elaborated theories of stress and reliablemeasurement (Lobel, J994;Lobel &D unkel-Schetter, 1990).

Twopossibilitiesmight account for the chronicity of stress inthesestudies. Thefirs isthat environmental conditionsthat pro-duce stressmay not change during the 9-month period of a wom -an's pregnancy. A second possibility is that chronic stress may bea reflection of a woman's stable disposition or her tendency toexperience her life as stressful. Disposition is likely to affect apregnant woman's appraisals of stressful life conditions and heremotional experience of stress.We were interested in separatingtheimpact ofindividual disposition fromPNMS todeterminetheunique effect of "environmental" and person factors on birthoutcome. In most previous research, these factors have not beenseparable.Oneexceptionis a recent study of pregnant womenthatdemonstrated the independence of a latent construct composed ofthree dispositional variables and a second latent construct repre-senting stress (Rini, Dunkel-Schetter, Sandman, Wadhwa,1999). After controlling for the strong negative association be-tween these two latent factors, the dispositional construct predictedbirth weight, and the stress construct predicted earlier delive ry.However, stress in this study was operationally defined solely byglobalandpregnancy-specific stateanxiety, neglecting other indi-cators of stress, including stressful stimuli or stress appraisal.Furthermore, the 2-week time frame in which anxiety was mea-sured(28-30weeksofpregnancy) providesavery limitedassess-ment of the 40-week gestational period. For these reasons, addi-tional evidence isneeded to test the notion thatenvironmentallyproduced stress and disposition exert unique effects on birthoutcome.

Little research has been conducted on the impact ofdisposi-tional factors in pregnant women. Some studies examined traitanxiety, astablepredisposition to respond to situations anxiously,but produced equivocal results (Lobel, 1994).We examined dis-positionaloptimism in the present study. Optimists have positiveexpectations for the future.They expect to do well and anticipatefavorable outcomes. Pessimists1 hold negative expectations andexpect things to go poorly (Carver &Scheier, 1991; Scheier &Carver, 1985).Inmefaceof threatening events, optimists experi-ence less distress (Carver & Gaines, 1987; Carver et al., 1993;Scheier & Carver, 1992; Scheier, Weintraub, & Carver, 1986;Stanton &Snider, 1993),and they tend to appraise life conditionsmore favorably (cf. Cantor &Norem, 1989). Optimistic and pes-simisticindividuals also attend to, process, and retain informationabout health threats differently (Aspinwall & Brunhart, 1996).Women in the present s tudy were at high risk for an adverse birthoutcome because of chronic or previous medical conditions orbecause they were experiencing complications with the presentpregnancy (for explanation of medical risk, see Hobel, 1982;Molfese, 1989; Wall, 1988).

Limited evidence exists regarding the effects of dispositionaloptimism onphysical health.Dispositionaloptimists recover morequickly (Scheier et al., 1989) and more successfully (Fitzgerald,Tennen,Affleck, & Pransky, 1993) from coronary artery bypasssurgery.Optimistshavealsobeen shown to exhibit better immuneresponse to short-term stressors(F.Cohen etal., 1999).Further-more, situational (as opposed to dispositional) optimismis asso-ciated with betterimmuneresponse (Segerstrom,Taylor,Kemeny,& Fahey, 1998) and with better symptomatology profiles and

survival in AIDS patients (Reed, Kemeny, Taylor, & Visscher,1999; Reed, Kemeny, Taylor, Wang, & Visscher, 1994).

Several mechanisms may account for the impact of PNMS ordispositional optimism on birth outcome; changes in biochemistry,especially in the neuroendocrine and immune systems (seeDunkel-Schetter et al.,in press; McEwen, 1998), and changes inbehavior.Wefocusedon the latter as an exploratory component ofthepresentstudy. Earlydeliveryand lowbirth weightare affectedbysmoking, alcohol abuse, and illicit druguse(Chomitz,Cheung,& Lieberman, 1995; McCormick et al., 1990), behaviors thatoptimistic pregnant women are likely to avoid but that may beincreased understress(Picone,Allen,Schramm,&Olsen,1982).Optimists tend to engage in positive health practices, such asexercising, and they avoid health-impairing activities (Scheier&Carver, 1992). Similarly, stress has been shown to affect health-relevant behaviors that may mediate its adverse impact on birthoutcomes(Griffin, Friend,Eitel,&Lobel,1993;Krantz, Grunberg, Baum,1985), includ ing smoking and substance use (Bresnahan,Zuckerman, & Cabral, 1992; Conway, Vickers, Ward, & Rahe,1981; Hutchins & DiPietro, 1997), eating and sleeping patterns(Krantz et al., 1985), andcompliance with therapeutic regimens(Caldwelletal.,1983). Thus,weexaminedrelevantprenatal healthpractices to explore whether theywouldhelpexplain the impact ofoptimism orPNMSon birth outcome.

Medical risk is also an important predictor of birth outcome,especially gestational age at delivery. Past research showed thatmedical risk shouldbe accountedfo rwhen investigating the im-pact of psychological factors onbirth outcome, because it can beconfounded withtheireffects (Lobel, 1994). Although as a groupwomen in thepresent study wereathighrisk for anadverse birthoutcome, interindividual variation permitted us to examine theimpact of medical risk in this sample.

Non-White ethnicity is an additional predictorof lower birthweight in the United States (NCHS, 1997, 2000;Rowley et al.,1993; Shiono, Klebanoff, Graubard,Berendes,&Rhoads, 1986),althougheven among White women ratesof lowbirth weight arehigherthanin other industrialized countries (NCHS, 1997). For thecurrent study,ethnicity was examined as adichotomousvariable,consisting of White and non-White ethnicity. Although this is acrudecategorization,it wasnecessitatedby theLimitednumberofnon-White women in thepresent study.

Insummary, using structural equation modelingprocedures,weexamine the impactof optimism andPNMSonbirth weight andgestational age at delivery while accounting for the impact ofmedical risk and ethnicity. We hypothesize that the impact ofPNMS will be relatively lower than in past studiesbecause thepredicted inverseassociation between optimism and stress is con-trolled, and that optimism will exert independent impact on birthoutcomes,especially birth weight(cf.,Rini etal., 1999). In addi-tion, we explore whether prenatal health behaviors will mediateeffectsof optimism or PNMS on birth weight and gestational age.

1We use the term "pessimist" throughout this article to refer to anindividual low in optimism, consistent with the view that optimism andpessimism are poles of a unidimensional construct (Scheier & Carver,1985; for opposing views see Marshall, Wortman, Kusulas, Hervig, &Vickers,1992;Mroczek,Spire,Aldwin,Ozer,& Bosse,1993).

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546 LOBEL,DEVINCENT,KAMINER, ANDMEYERMethod

ParticipantsThesample consisted of 129women receiving prenatal carein aprivate,

university-affiliated obstetric practice that caters to medically high-riskpregnancy. Allwere participants in a larger longitudinalstudy ofprenatalstress and coping.To participate, women were required to be atleast 18yearsofage, because theresearchwas not designed to deal withmedicaland psychosocial issuesunique to adolescent pregnancy(Coley &Chase-Lindale, 1998). Participants were also required to be between 10 and 20weeks gestation at first approach, after pretesting revealed that womenexperienced thephysicalandemotional implicationsof being pregnantatapproximately 10weeks into their pregnancies.

Studyparticipants wereathigh risk foradverse birth outcomes becauseof chronic medical conditions (e.g., hypertension or diabetes), previousmedical, gynecological, or obstetric problems (e.g., fetal demise) or be-causethey were experiencing complications (e.g., bleedingorpreeclamp-sia)with their current pregnancy(Hotel, 1982, 1990;Molfese, 1989).Onaverage, womenhad twofactors thatput themat risk SD 1.5).

Participants rangedin agefrom 20 to 43years(A*= 31years,SD =4.6)and most (87%) were White. Virtuallyall(99%) were high school grad-uates; 33% completed college,and approximately 17% obtained graduatedegrees. On average, women were 14.5 weeks pregnant SD 2-7)atstudy entry. Most (97%) of the sample was married or living with theinfant's fatheras if married. Forty-six percentofparticipants reported anannualhousehold income above$50,000 M - $35,000-50,000).Approx-imatelyhalf (49%) maintainedfull-timejobsduringtheir pregnancies,16%were employed part time, and 35% were not employed. Approximately50% of study participants weregiving birth for the first time.

ProcedureEligible women were approached while waiting for their prenatal care

appointment, givenabrief descriptionof the study,and asked toprovidewritten informed consent. Participants completedaquestionnaireat threetime points during the courseof their pregnancies: between 10 and 20weeks gestation (Time 1),between 21 and 30weeks gestation (Time 2),and after 31weeks gestation (Time3).

Of the 327women approached,279(85%) agreed toparticipate.Atotalof 181were administered at least one questionnaire; of these,52womenhadsubstantial missing data (theytypicallycompleted onlyasmall portionofthefirst questionnaire)andwereremoved from thesample.Of the finalsample of 129participants,14womenhad anaverageof 1.6missing itemsof 229 total study items. Mean substitution was used to replace theirmissingitems becauseth eextentofmissing datawasminimal.No differ-ences were found between the 52 excluded participantsand the womenwho comprised the study sample on anyvariables that we were able toexamine,withone exception: Approximately50% of thewomen excludedwerenon-White comparedwith 13% in the study sample p

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SPECIALSECTION: STRESS, OPTIMISM, ANDBIRTH OUTCOMES 547

analyses and internal consistency coefficients were examined to createscales at each tune point. These analyses indicated that a reliable index ofsubstance use could not beconstructedfrom the three items assessing useofalcohol, marijuana,andotherillicitsubstances(as - .26, -.04, and.44,at each time point, respectively). Because diere wasuniformly low en-dorsement of these three items at each time point (means ranged from 1to 1.1 on the 6-point scale), substance use was not included in furtheranalyses.

Two items assessing frequency of stretching and of 15-min periods ofexercise were summed to create an exercise scale with high internalconsistency (as = .78, .80, and .85 ateachtimepoint, respectively). Fiveitemsassessingfrequency of nutritional practices were summed to create anutrition scale: calcium and fluid consumption, minimization of fats,adherence to abalanced diet,andskipping meals (reverse scored). Internalconsistency wasacceptable for a scale ofthis type (as = .64, .62, .61,respectively).

Repeated measures ANOVAs revealed no differences insmoking,ex-ercise, ornutrition scores across the three time points. Therefore, scoreswere averaged over time to create a prenatal smoking, nutrition, andexercisescorefor each study participant.

Ethnicity. A dichotomons variablewascreated with valuesofWhite(n = 112)andnon-White(n = 17).Thenon-White category includedallparticipantswhoidentified themselves as Black, Latino or Hispanic, AsianorPacific Islander, orm ultiple non-White ethnicity.

Medical risk. Trained research assistants abstracted medical charts. A38-item medical risk index was used to assign riskscores.This index wasadapted from the Problem Oriented Perinatal Risk Assessment System(Hobel, Youkeles, & Forsythe, 1979). Items were grouped under thefollowingsixcategories:unusu al featuresofpregnancy (e.g.,R hnegative),gynecological and obstetrical history (e.g., previous preterm delivery),complications of past pregnancies (e.g.,hemorrhage),family history (e.g.,diabetes), patient's medical history (e.g.,hypertension), andcurrent preg-nancycomplaints (e.g.,anemia). Items were scored as present or absentandsummed tocreatea riskscore.2

Birth outcomes. Birth weight(ingrams)andgestationalage at time ofdelivery (inweeks) were obtained from medical charts andused ascon-tinuous variables inanalyses.

Data Analytic StrategyData were first examined for violations of assumptions of univariate

normality. Square root transformationwasperformed on numberof lifeevents, life event distress, state anxiety, pregnancy distress, and bulbweight toreducekurtosis.

Astepwise approach is recommended to test structural equation models(Anderson& Gerbing, 1988; Newcomb,1990).The m easurement model istestedbyconfirmatory factor analysisof latent variables; next,th estruc-tural model ofassociationsamong independent and dependent variables istested. Accordingly, data analyses usingtheEQSprogram (Bentler, 1989)were undertaken as follows. First, we tested the measurement model ofstress using all five hypothesized indicators of the latent stress factor.Second,wetestedthemeasurement modelofoptimism usingfour subsetsof randomly paired LOT items as indicators of this latent factor (seeNewcomb, 1990; Marshall & Lang, 1990).Third, wetested thehypothe-sized structural modelof gestational age andbirthweight Inthis model,stress, optimism, and medical risk were predictors of birth weight andgestational age. To control for its impact as demonstrated by past studies,ethnicity w as included in the m odel as a predictor of birthweightWe alsoincorporated paths representing correlations of stress with medical risk andwith optimism (inversely). Although optimism is a stable trait that isunlikely to be influenced by stress (e.g., Bromberger & Matthews, 1996;Scheier & Carver, 1985), we used a bidirectional path to represent theassociationbetween these variables, because we cannot rule out the pos-sibility that chronic stressaffected optimisminthis study.

Table1Description of Major Study Variables

Variable M S

Prenatal lifeeventsLife eventdistressPrenatal perceived stressPrenatal state anxietyPregnancy-specific distressOptimismSmokingExerciseNutritionMedical risk (no. ofconditions)Birth weight (g)Gestational age(weeks)b

2.4 2.51.9 1.4

15.3 5.535.1 10.514.8 7.620.4 4.7

1.4 1.02.3 1.14.7 0.62.1 1.5

3,260 518.538.5 1.9 8% ofsample

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548 LOBEL, DBVINCENT,KAMINER,ANDMEYER(Cohen &Williamson,1988) women, and that their level of stateanxiety is similar to that of other pregnant (Lobel & Dunkel-Schetter, 1990)and nonpregnant (Spielberger, 1983)women.Rates of low birth weight and preterm delivery were slightlyhigher than national norms (NCHS, 1997) but consistent with theprofileof a high-risk sample.

As showninTable2,age, education, income,andmarital statuswere associated with some study variables. These correlationswere of modest magnitude, and all suggestedsensiblerelationshipsbetween variables. As expected, there were strong correlationsamongthe psychological stress variables.

Model TestingMeasurement modelof stress. In the first stepof model test-

ing, we examined the hypothesized m easurement model of stress.Themodel was a poor fit, x* 5, N = 129)= 43.66, p

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SPECIALSECTION:STRESS, OPTIMISM, ANDBIRTH OUTCOMES 9

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duringpregnancy, and exercise wasassociatedwith greatergesta-tional age. The exercise variable was not ideal, because it wasbased onself-report and was composed of only two items withuntestedvalidity. However, exercise in pregnancy may be benefi-cial by reducing levels of hypothalamic, pituitary, and placentalhormones, which are thought to trigger labor (Hobel, Dunkel-Schetter, Roesch, 1998;Wadhwa, Porto, Garite, Chicz-DeMet, Sandman, 1998), or by reducing the cardiovascular and otherphysiological reactivity that is associated with adverse birth out-comes (see Dunkel-Schetter etal.,in press). Furthermore,exercisemay be aproxyforsalutary healthpracticesmore generally. Forexample, good nutrition, which is also posited to play a role in thetimingofdelivery (Casanueva,Vadillo-Ortego,Pfeffer, Tejero,1998), was significantly correlated (r = .31) withexercise in thisstudy, although nutrition itself did not mediate the impact ofoptimism on birthoutcome.

Research has highlighted some of the other mechanisms bywhich optimism may confer health benefits. Enhanced immunefunction (F. Cohen et al., 1999; Segerstrom, Taylor, Kemeny,Fahey,1998) is one potentially important mechanism in the con-text of birth outcome (e.g., Garite, 1994; Kelly, 1995;Lockwood,1994; Romero et al., 1994 . Behavioral mechanisms include theadaptive ways that optimists cope with stress during pregnancy(Lobel,Yali, Zhu,1998;Lobel,Yali,Zhu, DeVincent, Meyer,2000 . Although the present study adds to the accumulationofevidencethat optimism yields important health benefits, there issurprisingly little research on the basic physiological and behav-ioral consequences of an optimistic outlook. Such research isespecially vital in pregnant women, because there is some evi-dencethatalterationsof the intrauterineenvironment producedbyprenatal psychosocial conditionsmay have permanenteffects onthecognition,affect, andbehavior ofchildren over their lifetime(see review by Wadhwa, 1998).

The oleof StressThis study suggests th attheobstetric impactofchronic PNMS,

whichhas been demonstrated in a variety of past studies, may beattributable to women's stable tendencies to view their lives asstressful. This finding is consistent with the observation thatchronic stress appears across past studies to be a more potentpredictor of adverse birth outcomes than acute or episodic stress(Dunkel-Schetter Lobel, 1998;Lobel,1994).Chronic stress maybe a manifestation of underlying dispositions or traits. Alterna-tively, chronic stress may contribute to low optimism, althoughthere issome evidence that optimismisrobust evenin thefaceofstressful experiences (Bromberger Matthews, 1996; ScheierCarver,1985). Nevertheless,thecurrent studyresultsindicatethatdisposition, rather than stress per se, may be the contributor toadverse birth outcomes.

The failure to seedirect effects ofPNMSinthis studymay befor other reasons, however. One possibility is that women whocomprised the current samplethose with education and financialresourcesare relatively invulnerable to PNMS compared withthe socioeconomicallydisadvantaged women, who constitute thesamples ofmanyprevious studies illustrating impact of PNMS. Analternative possibility is that the stress measure used in the presentstudywas not sufficientlysensitive. However, several points mil-itate against this possibility. First, the operational definition of

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550 LOBEL DEVINCENT KAMDMER AND MEYER

8

9

Figure 1. Structural model of the impact of stress, optimism, ethnicity, medical risk, and exercise ongestationalage atdelivery andbirth weight, 73,N129) = 79.03,p = .29, comparative fitindex = 0.96;root mean square error ofapproximation = 0.03; allpaths significant atp

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SPECIAL SECTION: STRESS, OPTIMISM,AND BIRTH OUTCOMES 551health that are affected by disposition and related psychosotialfactors and to extend our understanding of the reasons whyopti-misticindividuals experience betterhealth.

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