REVIEW

Review of Prenatal Maternal Mental

Health and the Development of Infant
Temperament
Nora L. Erickson, Maria A. Gartstein, and Jo Ann Walsh Dotson

Correspondence
Nora L. Erickson, MS,
Department of Psychology,
Washington State
University, P.O. Box
644820, Pullman, WA
99164-4820.
nora.erickson@wsu.edu
Keywords
anxiety
depression
infant development
infant temperament
pregnancy-specific anxiety
prenatal
ABSTRACT
Objective: To present a systematic review of literature and evaluate effects of prenatal maternal depression and
anxiety on the development of infant temperament.
Data Sources: A literature search for studies published between January 1981 and January 2017 was undertaken
using the electronic databases PsycINFO and PubMed, as well as reference lists from select resources. Search terms
included variations on infant temperament, prenatal/pregnancy, depression, mood, and anxiety.
Study Selection: Studies were included if researchers measured psychological distress during pregnancy as
indicated by maternal depression, anxiety, pregnancy-specific anxiety, or a combination of these factors in relation to
the development of infant temperament (i.e., parent report or laboratory observations of temperament from 1 to
12 months). In total, 34 articles met inclusion criteria.
Data Extraction: Authors, year of publication, country of origin, sample information, methods, timing, and applicable
results were summarized and compared across studies.
Data Synthesis: No standardized data analysis was conducted because of methodologic differences across the
identified studies. Of the 34 identified studies, 22 included an indicator of depression (11 with significant results), 26
included an indicator of anxiety (14 with significant results), and 9 included an indicator of pregnancy-specific anxiety
(7 with significant results).
Conclusion: Overall research outcomes were equivocal. Across studies on symptoms of depression and anxiety,
findings related to the potential effect on infant temperament were mixed. Nonetheless, support for the role of prenatal
psychological factors in the development of infant temperament emerged in a subset of population-based studies,
including research to target the effects of pregnancy-specific anxiety. Future research is needed with greater
consistency across studies with respect to methods (e.g., timing and assessment tools). Specific recommendations for
nurses and providers include more routine screening and psychoeducation for expectant mothers about prenatal
symptoms of depression and anxiety and about pregnancy-specific anxiety in particular.
JOGNN, 46, 588–600; 2017. http://dx.doi.org/10.1016/j.jogn.2017.03.008
Accepted March 2017

Nora L. Erickson, MS, is a
doctoral candidate at
Washington State
University, Pullman, WA.
Maria A. Gartstein, PhD, is a
professor in the Department
of Psychology, Washington
State University, Pullman,
WA.
(Continued)
The authors report no con-
flict of interest or relevant
financial relationships.
C onsistent with the concept of fetal pro-
gramming, authors who conduct human
and animal research report that the prenatal
environment profoundly influences the devel-
oping fetus. For example, prenatal maternal
stress increases offspring vulnerability to adverse
health outcomes from birth to adulthood (Barker,
1995; van den Bergh et al., 2005). Introduced
within the context of metabolic and cardiovascu-
lar risks associated with low birth weight (Barker,
2007), fetal programming has more recently been
implicated in behavioral and psychological
development (Rutter and O’Connor, 2004).
We formulated this review in response to this
growing interest and focused on relationships
among prenatal depression, anxiety, and infant
temperament.
In the psychobiological model of temperament
(Rothbart and Derryberry, 1981), reciprocal
relationships between temperament and the
environment are highlighted, and temperament is
defined as constitutionally based individual
differences in reactivity and self-regulation. Within
this conceptualization, constitutional refers to the
relatively enduring biological basis of tempera-
ment, influenced and modified over time via
maturation and experience. Constitutional bases

588 ª 2017 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. http://jognn.org
Published by Elsevier Inc. All rights reserved.
Erickson, N. L., Gartstein, M. A., and Dotson, J. A. W.
also include genetic influences (Posner et al.,
2007) and epigenetic mechanisms linked with
fetal programming effects (Monk et al., 2012;
Werner et al., 2007). Reactivity encompasses
responses to internal and external changes, such
as arousability of affect, motor activity, and
attention, whereas self-regulation is specific to
neural and behavioral processes that serve to
modulate reactivity (Rothbart and Bates, 2006;
Rothbart and Derryberry, 1981).
Temperament difficulty during infancy (e.g., high
reactivity and activity level) significantly increases
child vulnerability for later disorders, including
depression, anxiety, and attention deficit/
hyperactivity disorder (De Pauw and Mervielde,
2010; Muris and Ollendick, 2005; Shaw et al.,
2001). Infant temperament contributes to
maternal postpartum depression, and greater
negative emotionality exacerbates maternal
symptoms (Beck, 2001; Dudley et al., 2001).
Early temperament difficulties also affect mother–
child interactions and maternal well-being.
Mothers of highly reactive infants have more
negative views of co-parenting and show greater
noninvolvement and decreased visual and phys-
ical contact with their infants (Burney and
Leerkes, 2010; van den Boom and Hoeksma,
1994). Thus, understanding the influence of pre-
natal depression and anxiety on the development
of infant temperament has implications for multi-
ple health service areas encountered by nursing
professionals, including maternal and infant
mental health and early parent–child interactions.
Objectives
Specific objectives of this review included the
following aims: (a) to examine effects of prenatal
maternal psychological distress on infant
temperament from 1 to 12 months; (b) to describe
similarities and differences across studies of
infant temperament and maternal prenatal
depression symptoms, anxiety symptoms, or
pregnancy-specific anxiety (Huizink et al., 2004);
(c) to evaluate methodologic strengths and
weaknesses among studies; (d) to identify gaps
in the extant literature; and (e) to outline implica-
tions, conclusions, and areas for future research.
Methods
A systematic search for articles published from
January 1981 through January 2017 was con-
ducted in online databases PsycINFO and
PubMed. The initial PsycINFO search included
the terms infant temperament, AND prenatal OR
JOGNN 2017; Vol. 46, Issue 4
REVIEW
A synthesis of the literature on prenatal maternal mental
health and infant temperament has important implications
for future clinical research efforts and perinatal services.
preg, AND depress OR mood. Ninety-six articles
were assessed for relevance based on estab-
lished inclusion/exclusion criteria. Titles and
abstracts were examined, and articles deemed
relevant were subsequently reviewed. From the
initial search, 19 articles were included for review
(i.e., 77 were excluded). A second PsycINFO
search replaced depress OR mood with anxiety
OR anxious and resulted in 67 articles that met
criteria: 37 were redundant, 21 were excluded,
and 9 were included in the final review.
Identical search terms were used in a PubMed
advanced search. The prenatal depression
search yielded 121 results, with four novel articles
meeting inclusion criteria. The search for anxiety-
specific articles yielded 67 articles, all of which
were redundant and/or did not meet inclusion
criteria. A final set of searches replaced the terms
infant temperament with infant cry, infant negative
affect, and infant positive affect. Reference sec-
tions from review papers, meta-analyses, and
notable studies were also examined. In total, 120
abstracts were reviewed, 67 full articles were
assessed, and 34 articles were included in the
final review (see Figure 1).
Inclusion and Exclusion Criteria
Study eligibility was determined based on the
following inclusion criteria: (a) maternal depres-
sion, anxiety, or pregnancy-specific anxiety was
measured in the prenatal period; (b) child
temperament was assessed as an outcome at 1
to 12 months of age; and (c) studies were
published in English in peer-reviewed journals.
Studies were excluded if (a) prenatal stress
(i.e., a focus on stressors or biological indicators
of stress) was the primary independent variable,
(b) effects of prenatal psychotropic medication
use were of primary interest, (c) indications of
psychological distress were specific to sub-
stance use and/or severe psychopathology
(e.g., psychosis, bipolar disorder), and (d) infants
were born preterm or had a NICU stay.
Coding of Studies
Each of the 34 articles in review were examined for Jo Ann Walsh Dotson, PhD,
RN, is an assistant professor
sample size, country of origin, type of sample (e.g.,
in the College of Nursing,
community, clinical, population-based), type of Washington State University
study (prospective vs. retrospective), trimester of College, Spokane, WA.
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REVIEW Prenatal Maternal Mental Health and Infant Temperament

351 7
Citations identified through Citations identified through
electronic database searches reference section hand searches

193
Citations after duplicates removed

53
120 Records excluded:
Abstracts reviewed for Did not meet
eligibility inclusion/exclusion criteria

67 33
Full-text articles assessed Full-text articles excluded:
for eligibility • Outside age criterion
• Stress measurement
• Irrelevant predictor or
outcome variables
34 • Not in English
Studies included in
qualitative synthesis

Figure 1. Selection of review articles based on Preferred Reporting Items of Systematic reviews Meta-Analyses (PRISMA)
guidelines.

prenatal measures (in weeks gestation, if
possible), measure(s) used to assess maternal
psychological distress, timing (in months) of infant
temperament measure, and nature of infant
temperament assessment (e.g., self-report ques-
tionnaire, laboratory observation), along with rele-
vant findings/results. Whenever possible,
indicators of effect size were examined. Conclu-
sions about effect size strength were based on
Cohen (1988) guidelines for trivial (r < 0.10), small
(d ¼ 0.20, r ¼ 0.10–0.30, odds ratio < 1.7), me-
dium (d ¼ 0.50, r ¼ 0.30–0.50, odds ratio ¼ 1.7–
2.5) and large (d ¼ 0.80, r $ 0.50, odds ratio >
2.5). Although coding was completed by the first
author, consultation with coauthors provided a
means to address questions related to literature
inclusion.
Results
Prenatal Depression
In four studies published between 2008 and
2015, researchers exclusively examined effects
of prenatal depression symptoms on infant
temperament (see Supplemental Table S1). One
study was completed in Canada (Babineau et al.,
2015), and the others were conducted in the
United States and Europe. Prospective longitu-
dinal designs were used in all studies, one of
which included a clinical sample (Field et al.,
2009). Timing of prenatal depression measures
varied across trimesters. Indicators of infant
temperament ranged from 2 months to 6 months,
with most assessments conducted at 3 months
and 6 months. Although laboratory measures
were used in two studies, parent-reported
temperament indicators were most common
(Field et al., 2009; Rothenberger et al., 2011).
Cumulative results were generally consistent
among this small subset of studies, and in three
of four studies researchers reported findings to
support a relationship between prenatal depres-
sion symptoms and infant temperament. McGrath
et al. (2008) showed that mothers with prenatal
depression (N ¼ 139) who remained depressed
in the postpartum period rated their 2- and
6-month-old infants as more difficult compared
with those not depressed during pregnancy.
According to Field et al. (2009), infants of mothers
(N ¼ 63) with prenatal dysthymia exhibited more
distress and spent less time smiling compared

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Erickson, N. L., Gartstein, M. A., and Dotson, J. A. W.
with babies of mothers with prenatal major
depression; no significant differences in infant
vocalization, motor behavior, gaze aversion, or
crying emerged. Thus, less severe but persistent
depression symptoms (i.e., dysthymia) during
pregnancy may confer greater risk of having a
distressed infant compared with depression
symptoms of a shorter duration (Field et al.,
2009). In addition to this emphasis on the dura-
tion of depression symptoms, Babineau et al.
(2015) explored the moderating role of infant
genotype among a sample of 213 Canadian
participants. Differential susceptibility was sup-
ported in their results, wherein infants whose
mothers had high levels of prenatal depression
experienced greater dysregulation if they were
S/LG carriers of the serotonin transporter gene
(i.e., those with S or LG alleles of 5-HTTLPR). On
the contrary, if mothers reported low levels of
depression, being an S/LG carrier had a protec-
tive effect for dysregulation (Babineau et al.,
2015). Along with these significant findings,
Rothenberger and colleagues (2011) reported
null results. In their examination of a community
sample of 104 mother–infant dyads in Germany,
prenatal depression across trimesters was not
predictive of infant affective reactivity
(Rothenberger et al., 2011).
Prenatal Anxiety and Pregnancy-Specific
Anxiety
In 12 studies published between 2002 and 2016,
researchers examined the influence of prenatal
anxiety on infant temperament (see Supplemental
Table S2). Nine studies were conducted in
Europe (five in The Netherlands), two in Australia
(Grant et al., 2010; McMahon et al., 2013), and
one in Canada (Coplan et al., 2005). Community
samples were typical, with two population-based
studies (Braithwaite et al., 2013; Henrichs et al.,
2009) and one clinical sample (Grant et al.,
2010). All studies relied on longitudinal prospec-
tive designs, and there was a wide range of
timing for prenatal assessments. Timing of
temperament assessments ranged from 3 to
10 months. Observational methods were used in
three studies to measure temperament (Buitelaar
et al., 2003; Grant et al., 2010; Huizink et al.,
2002), and the remainder used parent-reported
temperament indicators.
Results of 9 of 12 relevant studies showed links
between maternal prenatal anxiety and infant
temperament. In their population-based study in
The Netherlands (N ¼ 2,997), Henrichs et al.
(2009) found small but significant effects of
JOGNN 2017; Vol. 46, Issue 4
REVIEW
general prenatal anxiety on infant activity level,
distress to limitations, and sadness at 6 months
postpartum. Effects of state versus trait anxiety
were examined in two studies. Coplan et al.
(2005) reported that trait anxiety was associated
with greater infant distress to limitations and lower
soothability (N ¼ 60); however, prenatal state
anxiety continued to predict lower infant positive
affect and attention span after controlling for the
effects of maternal trait anxiety. McMahon and
colleagues (2013) also examined unique effects
of state, trait, and pregnancy-specific anxiety
among 512 mother–infant dyads. Contrary to
Coplan and colleagues (2005), McMahon et al.
(2013) found that state anxiety was related to
difficult infant temperament but not when trait and
pregnancy-specific anxiety were examined
simultaneously. Trait anxiety was the only signifi-
cant predictor of difficult temperament when
controlling for demographics, postpartum mood,
and prenatal health status (McMahon et al.,
2013). In a test of the differential susceptibility
model, Peltola and colleagues (2016) examined
the role of infant vagal tone (N ¼ 173), as indexed
by respiratory sinus arrhythmia. They found that
prenatal anxiety predicted negative affectivity but
only for infants with greater respiratory sinus
arrhythmia (Peltola et al., 2016).
In two studies of maternal prenatal anxiety and
infant temperament, authors examined the effect
of 5-HTTLPR as a moderator. Pluess et al. (2010)
reported that prenatal anxiety among a
population-based sample of 1,513 Dutch women
predicted greater infant negative affect at
6 months after controlling for covariates (e.g.,
postpartum mental health). This relationship was
strongest for infants with two short alleles (i.e.,
s/s) and weakest for those with two long alleles
(i.e., l/l). Although Braithwaite et al. (2013) did not
find 5-HTTLPR moderation within their UK sample
(N ¼ 3,946), mothers with greater prenatal anxiety
had more reactive 6-month-old infants than
mothers reporting average anxiety. Methodologic
differences likely contributed to discrepant
findings, yet both studies had large population-
based designs, measured maternal symptoms
during the second trimester using validated tools,
and used parent reports of infant temperament at
6 months. Discrepant candidate gene findings
suggest a need for a genome-wide strategy and
consideration of epigenetic effects influencing
gene expression.
Authors of four studies reported significant
effects of pregnancy-related anxiety, a construct
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consisting of fear of giving birth, fear of bearing a
physically or mentally handicapped child, and
concern about one’s appearance (Huizink et al.,
2004). In a study of 170 pregnant women in The
Netherlands, pregnancy-specific anxiety at 15 to
17 weeks accounted for 3.3% of the variance in
observed infant attention regulation; however,
there was no significant association between
pregnancy anxiety and mother-reported infant
difficulty (Huizink et al., 2002). Henrichs et al.
(2009) also reported a significant relationship
between participants’ early pregnancy-related
anxiety and infant fearfulness, activity level, and
sadness at 6 months in a population-based
sample (N ¼ 2,997). Examining factors within
pregnancy-related anxiety among a smaller
sample of 170 women, Buitelaar and colleagues
(2003) found that observed infant affect/
behavior was significantly associated with pre-
natal fears of bearing a handicapped child and
fear of giving birth, after controlling for birth out-
comes, socioeconomic status, maternal age, and
postpartum symptoms. However, Kantonen et al.
(2015) reported that only fear of bearing a
handicapped child was predictive of lower infant
activity level among 102 mother–infant dyads,
with no other significant relationships between
pregnancy-related anxiety factors and infant
temperament.
In the 12 studies in which indicators of anxiety
were examined, general prenatal anxiety
markers did not emerge as independent pre-
dictors of infant reactivity or difficulty among
participants in three studies conducted in
Australia (N ¼ 149; Grant et al., 2010), Portugal
(N ¼ 386; Macedo et al., 2011), and The
Netherlands (N ¼ 158; Baibazarova et al., 2013).
Baibazarova et al. (2013) also found no signifi-
cant relationships between infant distress to
limitations or fear and maternal pregnancy-
specific anxiety. Null findings for effects of
pregnancy-specific anxiety on infant difficulty
were also reported by McMahon et al. (2013),
despite the aforementioned significant effects of
trait anxiety.
Comorbid Prenatal Depression and
Anxiety
Depression and anxiety symptoms were jointly
examined in 18 studies published between 1991
and 2016 (see Supplemental Table S3). Nine of
these were conducted in the United States, six in
Europe, one in Australia (Austin et al., 2005), one
in India (Bhat et al., 2015), and one in Singapore
(Chong et al., 2016). Three sets of researchers
592 JOGNN, 46, 588–600; 2017. http://dx.doi.org/10.1016/j.jogn.2017.03.008
Prenatal Maternal Mental Health and Infant Temperament
included clinical populations in their studies: two
used clinical interviews to establish maternal
psychiatric diagnoses (Rouse and Goodman,
2014; Werner et al., 2007), and the third
recruited infants in a “fussy babies” program
(Papousek and von Hofacker, 1998). With the
exception of two population-based investigations
(Alvik et al., 2011; van der Wal et al., 2007), authors
of all studies included community samples. Lon-
gitudinal prospective designs were used, with one
exception (Papousek and von Hofacker, 1998).
Although third-trimester measurement was the
mode, timing of prenatal assessments varied.
Temperament was measured via parent-reported
indicators in 11 studies, observational methods in
1 study (Davis et al., 2004), and a combination of
parent-reported and observation methods in the
remaining 5 investigations.
Of the 18 studies, five groups of researchers
showed significant associations between infant
temperament and prenatal anxiety and depres-
sion, three showed an association for prenatal
depression but not prenatal anxiety, five
showed significant results for anxiety but not
depression, and five showed overall null find-
ings. In the earliest relevant study, Mebert
(1991) reported a significant association
between prenatal anxiety/depression (i.e., a
composite of the Beck Depression Inventory
and State Trait Anxiety Inventory) and infant
fussiness/difficulty (N ¼ 131). Davis et al.
(2004) showed that depression and anxiety
symptoms during pregnancy independently
predicted infant reactivity for their sample
(N ¼ 22), with anxiety accounting for 21% of
the variance in negative behavioral reactivity
and depression accounting for 30%.
Effects of prenatal depression and pregnancy-
specific anxiety were focused on in three
studies (Alvik et al., 2011; Nolvi et al., 2016; van
der Wal et al., 2007). In a population-based
study of 1,330 Norwegian women and their
infants, difficult temperament at 6 months was
associated with prenatal depression and worry
about child abnormality, after controlling for
postpartum symptoms (Alvik et al., 2011). The
strength of these associations was moderate, with
symptoms of depression and worries about child
abnormality resulting in 2.1- and 2-fold increases
in the risk of having a difficult child, respectively
(Alvik et al., 2011). Among 282 mother–infant
dyads, Nolvi and colleagues (2016) found no
effects of prenatal depression or general anxiety
after controlling for postpartum symptoms,
http://jognn.org
Erickson, N. L., Gartstein, M. A., and Dotson, J. A. W.
although pregnancy-related anxiety was associ-
ated with infant fearfulness and falling reactivity.
There were no significant relationships between
prenatal indicators of distress and infant positive
reactivity (Nolvi et al., 2016).
In their population-based Dutch sample (N ¼
4,976), van der Wal et al. (2007) found that
greater pregnancy-related anxiety increased the
risk of an infant crying excessively by 1.69.
Mothers with high levels of prenatal depression
also had a 1.93-fold increased risk of having an
infant who cried excessively, whereas mothers
with moderate depression symptoms increased
their risk by 2.41 (van der Wal et al., 2007).
Werner et al. (2007) also explored maternal
depression and general anxiety in relation to in-
fant crying behavior. The authors reported a large
effect in their U.S. study (N ¼ 50), wherein
mothers with a prenatal diagnosis of depression
or anxiety had almost a fourfold increase in risk of
having an infant with greater cry reactivity. Dif-
ferences in the magnitude of the findings be-
tween Werner et al. and van der Wal et al. could
be attributed to the fact that Werner and col-
leagues examined a clinical sample, which un-
derscores potential implications for maternal
symptom severity.
Depression, but not anxiety, was associated with
significant effects in three studies. Within a sam-
ple of 107 women, Della Vedova (2014) found that
prenatal depression and postpartum state anxi-
ety emerged as the only independent predictors
of difficult temperament, after controlling for so-
cioeconomic and relationship factors (e.g., qual-
ity of partner support). Davis et al. (2007)
reported that average prenatal anxiety and
depression were correlated with infant negative
reactivity in their sample (N ¼ 247), but only
maternal depression emerged as a significant
predictor after controlling for postpartum psy-
chological symptoms. Similarly, Rouse and
Goodman (2014) found a moderate positive as-
sociation between antenatal depression and in-
fant negative affect after they controlled for
postpartum symptoms; however, significant as-
sociations between prenatal anxiety symptoms
and infant distress were not observed in the
sample of 77 mother–infant dyads.
Effects of anxiety and not depression were also
reported by several research groups. In a study
of 970 Australian participants, Austin et al. (2005)
found significant effects of prenatal anxiety but
not depression. Prenatal trait anxiety was
JOGNN 2017; Vol. 46, Issue 4
REVIEW
associated with a 2.56-fold increase in infant
temperament difficulties and remained a signifi-
cant predictor of difficult temperament at 4 and
6 months, after controlling for perinatal depres-
sion scores (odds ratio ¼ 1.96; Austin et al.,
2005). Papousek and von Hofacker (1998)
found that extreme crying (i.e., about 5 hours
per day) was associated with maternal prenatal
anxiety, but not depression, for their sample (N ¼
61). Researchers of two recent studies explored
effects of prenatal depression and anxiety on in-
fant temperament among understudied pop-
ulations: parents of twins (N ¼ 58; Prino et al.,
2016) and Asian mother–infant dyads (N ¼ 609;
Chong et al., 2016). According to Chong et al.
(2016), prenatal state and trait anxiety, but not
depression, predicted infant emotionality and
attention regulation; however, this relationship
was only significant for women in Singapore who
identified as Chinese (i.e., not Malay or Indian
mothers; Chong et al., 2016). Prino et al. (2016)
found that prenatal trait anxiety was associated
with infant sadness in twins, despite unique
findings related to differences in maternal per-
ceptions across the individual twins. Additional
relationships between prenatal state anxiety,
depression, and other infant temperament di-
mensions were not significant (Prino et al., 2016).
Results of five studies in which researchers did
not find a significant effect of prenatal depression
or anxiety scores on infant temperament were
notable. Nonsignificant associations between
these sets of variables were reported in three
studies in the United States with relatively small
sample sizes (N range ¼ 47–70; Diener and
Goldstein, 1995; Kaplan et al., 2008; Werner
et al., 2012). Proposed relationships diminished
to nonsignificance after controlling for postpartum
symptoms in the remaining two studies in India
(N ¼ 100; Bhat et al., 2015) and the United States
(N ¼ 272; Stapleton et al., 2012). These findings
highlight the importance of considering potential
confounding variables (e.g., postnatal psychiatric
status) and examining unique contributions of
maternal predictors of infant temperament not
discernable via simple correlations.
Discussion
The 34 articles in our review did not conclusively
document strong associations between maternal
depression and anxiety and infant temperament.
Of the 22 studies for which the authors included
indicators of depression symptoms, significant
relationships between prenatal depression and
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Despite largely equivocal results, preliminary support
emerged to link infant temperament and prenatal maternal
mental health, with particular risk associated with
pregnancy-specific anxiety.
infant temperament were identified in 11 studies,
and findings of 11 studies did not provide this
support. Among the 26 studies of prenatal anxiety
symptoms, significant effects on infant tempera-
ment indicators were reported in 14. Finally, in
seven out of nine investigations in which
pregnancy-specific anxiety was addressed,
researchers reported significant associations with
infant temperament. The nearly equal number of
studies with divergent findings for anxiety and
depression underscore the seemingly equivocal
nature of findings in this field of research.
Methodologic Differences
Differences in temperament measures may
partially explain inconsistent findings. Validated
measures of infant temperament were frequently
used, yet there was considerable inconsistency
across studies (e.g., Infant Behavior
Questionnaire-Revised, Infant Characteristics
Questionnaire, Early Infant Temperament
Questionnaire). Even with a single measure (e.g.,
Infant Behavior Questionnaire), differences
emerged with respect to whether one factor
(e.g., negative emotionality), particular subscales
(e.g., fear, distress to novelty), or a subset of
dimensions was examined. Negative reactivity
was also measured via maternal report of crying,
with variability in whether crying was assessed
via a single question (van der Wal et al., 2007), a
cry diary, or clinical referrals for excessive crying
(Papousek and von Hofacker, 1998). In 12
studies, researchers used an observation or
laboratory indicator of infant temperament, which
is notable because of historically limited conver-
gence with parent reports (Stifter et al., 2008).
Differences between laboratory/observation and
maternal-report measures of infant temperament
were explored by Leerkes and Crockenberg
(2003), who found greater discrepancies across
methods for mothers who were depressed during
pregnancy. As such, it is possible these results
are due to a depression/distortion bias. None-
theless, reports of temperament provided by
mothers are a rich source of information about
infants across settings (Gartstein et al., 2012),
and a mother’s perception represents a critical
aspect of an infant’s social milieu (Bornstein et al.,
2015a,b). Parent-reported items can be
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Prenatal Maternal Mental Health and Infant Temperament
constructed to minimize the need for parents’
global judgments about infant behaviors, wherein
biases are most likely to be introduced (Gartstein
and Rothbart, 2003; Rothbart, 1981).
Additional differences in design/methodology and
implementation represent likely sources of vari-
ability among the findings. First, geographic
location may have played a role, because most
reports were based on samples from the United
States (n ¼ 15), followed by The Netherlands
(n ¼ 7), with only two studies based on non-
Western populations (Bhat et al., 2015; Chong
et al., 2016). There is considerable evidence of
cross-cultural differences in infant temperament
(Chen, Yang, & Fu, 2012); thus, location and cul-
ture may be important to consider in future studies.
In addition, the wide range in sample sizes, from
22 (Davis et al., 2004) to 4,976 (van der Wal et al.,
2007), could affect the statistical power and
generalizability of results, possibly contributing to
differences in findings across studies.
Differences were also noted with respect to the
timing of prenatal and infant measures. Prenatal
symptoms during the second and third trimesters
were assessed most frequently, with symptoms
across all three trimesters addressed in only two
studies (Papousek and von Hofacker, 1998;
Rothenberger et al., 2011). Rothenberger et al.
(2011) found that maternal depression
measured during each trimester was not signifi-
cantly associated with infant affective reactivity,
whereas Papousek and von Hofacker (1998)
used a retrospective indicator of average
emotional distress across all trimesters. The
limited number of studies exploring these effects
speaks to the need for more targeted longitudinal
prospective research into potential differences in
prenatal maternal distress across trimesters and
infant temperament development. Studies also
varied in timing of infant evaluations within the
inclusion criteria (i.e., from 1 to 12 months), with
most assessments occurring between 3 and
6 months. Davis et al. (2007) found a significant
effect of maternal depression on infant fear as
early as 2 months. Nonetheless, because
temperament remains relatively stable, even in
infancy (e.g., Bornstein et al., 2015a; Field et al.,
1987; Peters-Martin and Wachs, 1984), differ-
ences in timing of temperament evaluations may
have less of an effect on discrepant results
compared with prenatal assessments.
Researchers included clinical indicators of
depression and anxiety in only five studies, three
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Erickson, N. L., Gartstein, M. A., and Dotson, J. A. W.
of which used composite indicators of anxiety
and depression disorders. Two research groups
reported no significant effects (Grant et al., 2010;
Kaplan et al., 2008), whereas Werner et al. (2007)
found that having a prenatal psychiatric
diagnosis (e.g., major depression disorder,
generalized anxiety disorder) increased the odds
of having an infant with greater crying reactivity.
In the remaining two studies, researchers
analyzed differences across specific diagnostic
categories. Field et al. (2009) found greater
effects for dysthymia compared with major
depression, and Rouse and Goodman (2014)
reported effects for depression but not anxiety
disorders. Collectively, these results underscore
the need for future research into the effects of
clinically significant symptoms of depression and
anxiety on infant temperament, as well as differ-
ences across specific diagnostic categories.
A final relevant methodologic consideration
concerns postpartum symptoms. Across several
studies, prenatal maternal effects on infant
temperament were no longer significant after
statistically controlling for maternal postpartum
symptoms (e.g., Davis et al., 2007; Rouse and
Goodman, 2014). Although controlling for post-
partum psychological symptoms has become the
norm rather than the exception, van der Wal and
colleagues (2007) expressed concerns about
collinearity between prenatal and postpartum
symptoms. Because of the strong correlation
between prenatal and postpartum indicators of
maternal psychological distress (r ¼ .63), the
authors did not control for postpartum symptoms
and argued that “collinearity poses a real prob-
lem if the purpose of the study.is to estimate the
contribution of individual predictors” (p. 433).
Alternative approaches, such as modeling growth
of maternal symptoms, warrant consideration,
because anxiety and depression can be tracked
across the perinatal period. Shifts in maternal
symptoms across pregnancy and postpartum
likely represent meaningful patterns that, once
identified, could be used to aid diagnosis and
treatment of maternal–child health concerns.
Population-Based Studies
Despite general inconsistencies across studies, it
is notable that authors of the four most represen-
tative (i.e., population-based) studies in the United
Kingdom (Braithwaite et al., 2013), Norway (Alvik
et al., 2011), and The Netherlands (Henrichs
et al., 2009; van der Wal et al., 2007) provided
evidence for reliable relationships between pre-
natal depression and anxiety and infant
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REVIEW
temperament. Specifically, researchers indicated
that psychological distress during pregnancy
increased the risk of having an infant rated as
more difficult, reactive, sad, active, and prone to
excessive crying (Alvik et al., 2011; Braithwaite
et al., 2013; Henrichs et al., 2009; van der Wal
et al., 2007). These consistently significant re-
lationships stand in contrast to the overall equiv-
ocal results. Although the null findings deserve
attention, recommendations based on results from
representative samples are more conclusive,
because population-based studies have greater
external validity and allow more extensive gener-
alization. Further, there is evidence that represen-
tative samples provide more accurate estimates of
risk (Szklo, 1998) and can be expected to do so
when links between prenatal mental health and
infant temperament are examined.
Pregnancy-Specific Anxiety
Researchers examined pregnancy-specific
anxiety in only nine studies, yet available data
indicate a considerable effect on infant tempera-
ment, exacerbating distress and dysregulation.
Overall, associations between pregnancy-specific
anxiety and infant temperament were more
consistently significant across studies, relative to
other forms of prenatal distress (i.e., symptoms of
depression or more general anxiety). Links be-
tween pregnancy-specific anxiety and tempera-
ment were supported by seven studies, three of
which included large, representative, population-
based samples (Alvik et al., 2011; Henrichs
et al., 2009; van der Wal et al., 2007). Thus, to
inform women about pregnancy-specific anxiety,
and to assess and treat its manifestations, ap-
pears important for supporting temperament
development during infancy.
Limitations and Future Directions
Several limitations of our review, resulting from the
inclusion criteria, should be noted. The exclusive
focus on infancy meant that investigations spe-
cific to the neonatal and toddler periods were
excluded. Similarly, studies aimed at addressing
stress reactivity or more chronic psychological
conditions were not reviewed. Biases related to
studies published in Western, developed
countries likely resulted from the exclusion of
articles published in languages other than
English. Given the limited number of population-
based studies, overall results may also have
limited generalizability because of the small
number of representative samples. In terms of
future directions, the relatively understudied
construct of pregnancy-specific anxiety deserves
595
REVIEW
Nurses possess skills to aid in assessment and referral
efforts to lower prenatal psychological distress, which can
also be expected to confer benefits to offspring.
further consideration, given the results of our re-
view. Future research would also benefit from
greater attention to mediating and moderating
variables, which may explain some in-
consistencies. Additionally, increased reporting
of effect sizes is a critical future direction. Re-
ported effect sizes were small to moderate, with
three notable exceptions. Large effect sizes
emerged for prenatal anxiety (Austin et al., 2005),
prenatal depression (Davis et al., 2004), and
prenatal psychiatric status in a clinical sample
(Werner et al., 2007) in association with indicators
of infant difficult temperament, reactivity, and
observed crying, respectively. Future research
should be undertaken to explore whether the
strength of these effects is replicable. Ultimately,
results of our review indicated continued need to
explore the pathways and mechanisms that drive
the links between prenatal symptoms of depres-
sion and anxiety and infant temperament.
Nursing Implications
Conclusions stemming from our review, although
tentative, are informative to nurses and provide
recommendations to hone services and inform
women in a probabilistic manner. Nurses have
multiple opportunities to assess and support
maternal–infant relations. Newborn nurses,
midwives, advanced practice registered nurses,
and family nurse practitioners have the skills and
access to efficiently assess maternal symptoms
of depression and anxiety and to support
maternal and infant mental health efforts in one-
on-one or group formats. Nurses are positioned
to encourage discussions about depression,
general anxiety, and pregnancy-specific anxiety
during the prenatal period, given their critical role
in supporting pregnant women and their partners.
In inpatient and outpatient settings, nurses could
lead the development of policies to guide
perinatal care management; ensure that mental
health screening and referrals (including ques-
tions concerning depression and anxiety) are
carried out; and promote effective and ongoing
training of nurses and other staff involved in
maternal–child health care services.
In light of evidence indicating particular risks
associated with pregnancy-related anxiety (see
also Dunkel Schetter and Tanner, 2012), nurses
596 JOGNN, 46, 588–600; 2017. http://dx.doi.org/10.1016/j.jogn.2017.03.008
Prenatal Maternal Mental Health and Infant Temperament
and other health professionals could incorporate
questions to assess fears about the birth process
and outcomes (e.g., having a handicapped child)
and concerns about pregnant women’s changing
appearance (Huizink et al., 2004). Depression/
anxiety screenings during health care visits
enable expectant mothers to share concerns with
nurses and others. Moreover, psychosocial
assessment during the prenatal period can act as
a form of intervention, because questions often
normalize and validate pregnant women’s expe-
riences (Darwin et al., 2013). Providing regular
opportunities for women to share their thoughts
and concerns related to pregnancy and childbirth
during prenatal visits can also serve as a sensi-
tive means to assess change in anxiety over time
(Saisto et al., 2001).
The limited study of nonpharmacologic in-
terventions for prenatal depression and anxiety
(Beddoe and Lee, 2008; Dimidjian and
Goodman, 2009) makes conclusions about spe-
cific clinical strategies premature. Further,
interventions for pregnancy-specific anxiety
(Saisto et al., 2001) and effects of prenatal
maternal mental health interventions on infant
outcomes have not been adequately evaluated
(Bergner et al., 2008; Chan, 2014). There is no
reason to believe the cognitive-behavioral
therapy for anxiety and depression would not be
well-tolerated by pregnant women, although
randomized controlled trials are ongoing
(Wilkinson et al., 2016). In a recent pilot ran-
domized controlled trial, women with prenatal
depression who received cognitive behavioral
therapy described their infants as less fussy/
difficult compared with a treatment-as-usual
group (Netsi et al., 2015). Therefore, the reduc-
tion of prenatal symptoms of anxiety and
depression holds promise of benefits for the
mother and child, and nurses are ideally
positioned to extend support and educational
resources to pregnant women. Nurses can also
assume key roles in interdisciplinary research in
this field—bridging clinical research and practice
in addressing maternal depression/anxiety and
infant temperament, as well as disseminating
research findings and support services.
Conclusion
The variability in findings should not be inter-
preted as an indication that links between
maternal prenatal mental health and the devel-
opment of infant temperament are negligible.
Researchers of population-based studies and
those aimed at examining pregnancy-specific
http://jognn.org
Erickson, N. L., Gartstein, M. A., and Dotson, J. A. W.
anxiety provide largely consistent evidence to link
prenatal maternal mental health and infant
temperament. Overall, maternal anxiety and
depression during pregnancy serve to increase
the risk of having an infant who is less likely to
express joy (e.g., smiling and positive affect); is
experienced as “difficult” (e.g., crying/fussing
excessively); and is more dysregulated or fearful.
Nonetheless, it is important not to overstate the
implications of these results. There was no
support for relationships between prenatal mental
health indicators and infant temperament in
multiple studies, suggesting that other factors are
important in shaping the individual differences in
reactivity and regulation that emerge. These
equivocal results point to a need for additional
research to further elucidate the links between
maternal well-being in pregnancy and infant
socioemotional outcomes. Nonetheless, our
review serves to inform nurses and other health
care providers about maternal mental health and
the development of infant temperament, which is
important in its own right and because of its
contributions to a variety of long-term health
outcomes (Gartstein et al., 2016).
Supplementary Material
Note: To access the supplementary material that
accompanies this article, visit the online version
of the Journal of Obstetric, Gynecologic, &
Neonatal Nursing at http://jognn.org and at http://
dx.doi.org/10.1016/j.jogn.2017.03.008.
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