The overarching purpose of this study was to investigate the clustering of multiple prenatal risk factors, as well as mapping differential outcomes on key child, parental and interactional outcomes associated with diverse risk constellations. Our first aim was to investigate if distinct subgroups of pregnant women could be identified based on their exposure to a range of prenatal risk factors. Two elevated risk groups and one low-risk group emerged in the data. The smallest group comprising 7.52% of the participants was characterized as a broad risk group. Additionally, a sizable mental health risk group of 21.62% was identified. Finally, the majority of the sample, 70.86%, was characterized by low-risk- as to be expected in a community sample. This highlights how specific risks cluster, providing information on typical risk patterns during pregnancy. It also aligns with previous studies on prenatal risk patterns reporting patterns of sociodemographic, and psychosocial/ mental health risks (Hendryx et al.,
2020; Molenaar et al.,
2023). In contrast to these studies, we did not find support for additional risk groups in our sample. This may be due to sample and method heterogeneity across studies, or it may reflect that risk patterns clustered around psychosocial stress/ mental health and sociodemographic risk, respectively, constitute more prevalent risk patterns. More studies are needed to confirm these findings.
The
mental health risk profile represents 21.62% of our sample, underscoring that mental health concerns are common in the perinatal period. This group is characterized by higher probabilities for major depressive symptoms, pregnancy related anxiety, previous mental health problems, and adverse childhood experiences. The clustering of these specific risk factors could reflect that mental health issues overlap in symptomatology and prevalence, and that comorbidity is common (Andreassen et al.,
2023; Howard & Khalifeh,
2020). For instance, comorbid depression and anxiety in the perinatal period, may be as high as 20% (Howard & Khalifeh,
2020). This period may also increase risk for a wide range of mental disorders (Howard et al.,
2014; Munk-Olsen et al.,
2006), and a history of previous psychopathology seems to elevate the risk for a new-onset mental illness (Andersson et al.,
2006; Howard et al.,
2014). Although the notion that the perinatal period constitutes a special vulnerable period has been debated, mental health challenges are often referred to as the most common complication of childbearing (Howard et al.,
2014). Research has also documented clear associations between adverse childhood experiences and later mental health problems (Felitti et al.,
1998), in line with the clustering of such experiences into the mental health group in our sample.
The broad risk pattern makes up 7.52% of our sample, and is characterized by risk situated across multiple domains, such as socioeconomic factors (lower education), contextual factors (life stress), substance intake during pregnancy (nicotine, snus, alcohol), and mental health factors (adverse childhood experiences, pregnancy related anxiety and previous psychopathology). Still, levels of risk are low in this sample, hence our use of the term “broad risk” as opposed to “high risk”. This group stands out especially in terms of lower education, daily use of nicotine products during pregnancy, and high alcohol tolerance when compared to the other groups. Note that women in the broad risk group also report mental health issues, albeit to a lesser extent depressive symptoms, compared to the mental health risk group. This corresponds with studies showing that several of the risk factors evidenced in this group are commonly reported to co-occur (Evans,
2004; Evans et al.,
2013).
Risk Constellations and Dyadic, Parental, and Child Outcomes
Our second aim was to investigate how these risk constellations related to interactional quality between mother and infant at 12 months, and to parenting stress, child internalizing and externalizing behaviors at 18 months. Aligning with our hypotheses, the mental health group showed less favorable outcomes relative to the low-risk group on all outcome measures. This group also reported more externalizing behavior and parenting stress than the broad risk group. Although it is as expected that multiple risk is associated with more problems for both parents, children, and the dyads, there seems to be some specificity in terms of risk patterns and outcomes. That is, exposure to a narrower set of risk factors, specifically mental health risks, were associated with more problems than exposure to a wider range of risk factors.
Mental health is often reported to constitute a specific kind of risk in the early parent-child interactions, and we expected this to play out in our sample. Across cultures and different SES groups, maternal mental disorders (pre- and postnatally) have repeatedly been found to reduce mothers` ability to sensitively read and respond to infant cues (Anke et al.,
2019; Bernard et al.,
2018; Dix & Yan,
2014; Field,
2010; Hakanen et al.,
2019; Newman et al.,
2007). It should be noted that maternal distress in pregnancy also predicts negative emotionality in their babies (Field,
2017; Kling et al.,
2023), possibly making interactions more difficult to manage. Our findings add to this literature, as dyads in the mental health group showed significantly poorer interactional quality than dyads with little or no prenatal risk. The women in the mental health group further reported higher stress scores than participants in the two other groups. In the literature, mental health issues in pregnancy and adverse childhood experiences have been linked to later parenting stress (Huizink et al.,
2017; Lange et al.,
2019). This may be due to mental health issues hindering proper parenting preparations, reducing maternal self-efficacy (Wernand et al.,
2014) and/ or impacting stress and behavioral responses in the infant (Huizink et al.,
2017). These processes act bi-directionally (Doiron & Stack,
2017), wherein the mother struggles to soothe the child, thereby increasing difficult behavior in the child, further elevating parenting stress. This may be especially relevant in a longitudinal context. The finding of elevated internalizing and externalizing difficulties in the children at 18 months was as expected for a pattern of prenatal mental health risks, as maternal prenatal psychopathology repeatedly has been linked to child social, emotional, and behavioral maladjustment (Clayborne et al.,
2021; Davis et al.,
2007). Various explanations have been suggested to account for this association. One line of argument relates to genetics and/ or neurobiological development in utero. Although our study does not include data suited to uncover genetic or epigenetic mechanisms, it is plausible that such mechanisms are effective. Prenatal distress may alter epigenetic regulation in utero, placing the baby at elevated risk for future maladjustment (Babenko et al.,
2015). Furthermore, the concept of shared genetic vulnerability applies both to same category mental disorders and across categories (Andreassen et al.,
2023). With the mental health risk group in our study encompassing several mental health risk indicators, this may render these dyads especially vulnerable through shared genetics. Another proposed mechanism relates to how mental health issues affect parenting through reduced sensitivity in interactions, with mothers failing to respond adequately and regulate the child properly, or even displaying more overtly negative or intrusive parenting (Choe et al.,
2013; Clayborne et al.,
2021; Dix & Yan,
2014)- all of which may elicit internalizing or externalizing responses in the child, but also elicit parenting stress and affect daily interactions. A recent meta-analytic review found that parental sensitivity was related to both types of behaviors, but with a stronger association for externalizing than for internalizing (Cooke et al.,
2022), which concurs with our findings. It may be that maternal mental health plays a larger part in the development of externalizing behaviors. Aversive child behaviors have been found to elicit negative parenting responses in highly depressed mothers- further increasing maladjustment (Dix & Yan,
2014). Such behaviors might be seen as a reaction to maternal insensitivity or to the lack of responsivity frequently associated with maternal psychopathology, as discussed above. Curiously, there is a dearth of literature explaining how comorbid conditions may affect interactions, parenting stress and child behaviors. This is striking, as various mental health risks tend to cluster together, as shown in our study.
The broad risk group was the only constellation that evinced elevated risk probabilities across multiple domains. Along with the mental health group, this group displayed significantly poorer interactional quality than the low-risk group. Still, we speculate that underlying mechanisms for the two elevated risk groups may differ. Previous findings point to mothers` sensitivity in interactions being reduced when overall stress is elevated (Neuhauser,
2018). Furthermore, high SES parents tend to display more responsive and sensitive parenting behaviors in interactions (Paulussen-Hoogeboom et al.,
2007; Piccinini et al.,
2010). Higher levels of education/ SES have been suggested to reflect educated mothers reading up on child development and having more cognitive resources available to adjust parenting strategies (Bornstein et al.,
2010). Perhaps it is not SES per se, but rather the cumulative effect of the many co-occurring risk factors of low SES, such as more instability, less social support, and lower quality services, that lead to the accumulation of negative outcomes (Evans,
2004). However, the broad risk group also overlaps to some degree with the mental health risk group in terms of risk exposure. For instance, life stress, pregnancy related anxiety, previous psychopathology, and adverse childhood experiences are almost equally distributed in the two elevated risk groups. These factors may all contribute to difficulties that play out for both risk groups in the dyadic interactions. The combination of mental health risks with these other types of risks may particularly affect maternal reactivity and sensitivity (Mertesacker et al.,
2004). Contrary to our hypotheses, we did not find significant differences in parenting stress, internalizing and externalizing behaviors between the broad risk and the low-risk group, although previous research has shown associations between parenting stress and sociodemographic factors, such as ethnicity and socioeconomic status (Cassells & Evans,
2017; Raphael et al.,
2010). Worldwide mental health challenges are heavily associated with social inequality (World Health Organization,
2013). When the social risk factors, do not stand out more in our study, it may reflect that mean scores for each risk indicator are low, even within the broad risk group. It could also reflect access to free health care and perinatal follow-up and generous social policies of paid parental leave in Norway, potentially mitigating some of the burden of sociodemographic risk on child and parental outcomes reported above. Consequently, this may play out differently in countries where health care is less accessible and/ or costly. A recent meta-analytic review found stronger associations between internalizing and parental sensitivity in studies with low SES-samples (Cooke et al.,
2022), rendering it open to speculation whether the low proportion of low-SES participants in our sample may bias results. Because the narrower mental health group had scores higher on parenting stress and problematic child behaviors, one might wonder whether ongoing (rather than previous) psychopathology, or even depression specifically (which is much more common in the mental health group) contributes more to these difficulties. One might further speculate that the mental health challenges that exist without additional stressors, may be less reactive, and perhaps to a greater extent reflect genetic risk- a genetic vulnerability shared with the child. For the broad risk group, mental health issues may to a lesser extent be associated with genetic vulnerabilities, but rather understood in relation to the total burden of contextual stressors. If this is the case, then broad risk exposure will have more detrimental consequences in contexts without established social welfare systems. Still, a strong social safety net may to a lesser extent alleviate consequences of severe, ongoing psychopathology.