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. Author manuscript; available in PMC: 2024 Oct 1.
Published in final edited form as: Biol Psychol. 2023 Aug 23;183:108664. doi: 10.1016/j.biopsycho.2023.108664

A Perinatal Coparenting Intervention: Effects of a Randomized Trial on Parent Cardiometabolic Risk and Self-Reported Health

Emily J Jones 1, Mark E Feinberg 2, Jennifer E Graham-Engeland 3, Damon E Jones 2, Hannah M C Schreier 3
PMCID: PMC10592003  NIHMSID: NIHMS1929346  PMID: 37625684

Abstract

Background.

The transition to parenthood is a common yet stressful experience faced by many young and midlife adults, and the risk of cardiometabolic conditions also begins to rise at this time. Consequently, parenthood represents an opportune time to intervene with adults to support their psychological and physical health.

Purpose.

We examined whether the benefits of the Family Foundations program, a perinatal preventative intervention promoting positive coparenting, extend beyond documented mental health and family relationship outcomes to better cardiometabolic risk factors among parents.

Methods.

We analyzed data from 183 couples (n = 366 participants) who, eight years prior, were randomly assigned to the 9-session perinatal preventative intervention program or a control condition. We collected dried blood spots to measure C-reactive protein (CRP), interleukin-6 (IL-6), and cholesterol; parents also reported on their self-rated health.

Results.

Randomization to the intervention condition was associated with lower cholesterol (B=−.081, p=.049). Among parents who demonstrated more negative communication styles at pretest (during pregnancy), the intervention was further associated with better self-rated health (B=.181, p=.018). Participation in the intervention program was also marginally associated with lower CRP (B=−.261, p=.077), particularly among mothers (B=−.428, p=.076).

Conclusions.

These findings indicate that coparenting-focused interventions, such as Family Foundations, can lead to benefits beyond psychosocial and behavioral outcomes, and suggest that Family Foundations may improve parents’ longer-term physical health, with potentially more benefits among couples who demonstrated more negative communication styles during pregnancy.

Keywords: coparenting, intervention, cholesterol, self-rated health, inflammation

Cardiovascular disease and type II diabetes are common, preventable health conditions that often co-occur and are among the leading causes of death worldwide. A recent report from the American Heart Association furthermore highlights the substantial economic cost of cardiovascular disease, which is expected to exceed one trillion dollars in combined direct and indirect costs by the year 2035 (American Heart Association, 2017). Although these cardiometabolic conditions are more common in middle and older adulthood, risk factors for these conditions can emerge years earlier, including in young adulthood (Andersson & Vasan, 2018; Toss et al., 2013). Poor self-rated health, elevated cholesterol, and greater systemic inflammation are risk factors for multiple cardiometabolic conditions (D’Agostino et al., 2013; Duncan et al., 2003; Klein et al., 2002; Mavaddat et al., 2014; Noh et al., 2019; Ridker et al., 2000), and exposure to ongoing psychosocial stress may give rise to these risk factors. A robust literature links experiences of chronic psychosocial stress, such as ongoing family stress and work strain, to heightened systemic inflammation (Rohleder, 2014; Wirtz & von Känel, 2017), elevated cholesterol (Troxel et al., 2003; Vitaliano et al., 2002), and lower self-rated health (Farmer & Ferraro, 1997). Importantly, a few randomized controlled trials suggest the potential of brief psychosocial interventions to directly impact these cardiometabolic risk factors even in the absence of an explicit focus on physical health (Miller et al., 2014; Schreier et al., 2013; Villalba et al., 2019).

One commonly encountered psychosocial stressor is the transition to parenthood, which involves adjusting to a new family structure and adapting to evolving social roles and daily routines, all of which could have implications for parents’ physical health and cardiometabolic risk (Saxbe et al., 2018). Indeed, the transition to parenthood has been associated with increased ambivalence and conflict in the couple relationship (Doss et al., 2009; Kluwer, 2010), increased risk for maternal and paternal postpartum depression and anxiety (Paulson et al., 2006; Paulson & Bazemore, 2010), and greater rates of intimate partner aggression (Slep & O’leary, 2005). Nonetheless, couples’ experiences during the transition to parenthood depend on a multitude of factors, including access to resources (Cardenas et al., 2021), children’s temperament, and individual and interpersonal characteristics (Glade et al., 2005; Nelson et al., 2014).

Because the experience of parenthood is so common yet frequently linked to reduced couple relationship quality (Doss et al., 2009), even among relatively well-resourced families, a number of interventions have been developed to support expecting couples. The Family Foundations program is a preventative intervention promoting positive parenting among expecting couples. Over the course of nine sessions during the weeks leading up to and following childbirth, parents learn to work as a coparenting team and develop supportive coparenting skills, incuding affirming one another’s parenting contributions and abilities and minimizing criticism and blame (Feinberg, 2002, 2003). Across a number of randomized-controlled trials, participation in the perinatal preventative intervention promoting positive coparenting has been associated with sustained, multi-year reductions in coparenting conflict and hostility, fewer maternal postpartum depressive symptoms, and greater parental self-efficacy (Ammerman et al., 2021; Feinberg et al., 2010, 2021; Feinberg & Kan, 2015; Giallo et al., 2022). Because psychosocial stress (such as that arising during the transition to parenthood) may confer risk for greater systemic inflammation and worse overall health, it is plausible that a preventative intervention such as Family Foundations may also be associated with reduced cardiometabolic risk factors (including inflammation) and better perceived health following the transition to parenthood. To date, however, this has not been examined.

The present study leverages both pre-intervention and 8-year follow-up data from the Family Foundations intervention to examine effects of the Family Foundations intervention on indicators of parents’ physical health. We collected dried blood spot (DBS) samples and reports of self-rated health from parents eight years after completing the intervention to examine whether participation in the perinatal preventative intervention was associated with lower cardiometabolic risk factors years later. DBS samples were collected because the study protocol utilized in-home visits and DBS collection is less invasive, lower cost, and resulting samples are easier to transport (McDade et al., 2007). Additionally, DBS samples have better analyte stability relative to venipuncture because DBS samples do not require immediate processing or freezing (Sharma et al., 2014). We further examined whether participation in the intervention conferred differential benefits for health depending on parents’ gender. Some research suggests that becoming a parent has a stronger effect on mothers’ but not fathers’ psychological well-being (Nomaguchi & Milkie, 2003), whereas some qualitative research suggests that the transition to parenthood affects both mothers and fathers, but does so in different ways (Deave et al., 2008; Lévesque et al., 2020). For example, mothers may feel pressured to meet social expectations of idealized motherhood and take on more childcare and household duties, even in dual-income households, whereas fathers may feel pressured to meet traditionally masculine expectations of being the financial provider (Lévesque et al., 2020). Similarly, mothers report greater psychological distress to interpersonal stressors, including those associated with pregnancy and parenthood (McLeod et al., 2016). Taken together with generally greater systemic inflammation among women compared to men (Darnall & Suarez, 2009), it is possible that intervention effects on systemic inflammation may be stronger for (or only observed among) mothers compared to fathers. However, it is less clear whether these differential effects of the perinatal intervention would extend to differences in mothers’ and fathers’ cholesterol levels and ratings of health.

We also considered whether intervention effects on cardiometabolic risk factors differed by couples’ pre-intervention communication quality, specifically the level of observed negative communication between expectant couples during a relationship discussion task in which couples were asked to discuss characteristics they wanted to change in one another. Observed and self-reported measures of interpersonal conflict in general (Kiecolt-Glaser et al., 2010) and marital strain in particular have been associated with indications of poorer immunological functioning (Kiecolt-Glaser et al., 1997; Wilson et al., 2017), including higher levels of C-reactive protein (CRP) among adults in midlife (Bajaj et al., 2016) and higher levels of interleukin-6 (IL-6) among young women (Whisman & Sbarra, 2012). Similarly, lower marital satisfaction and greater household strain have been cross-sectionally associated with lower self-rated health among women (Staland-Nyman et al., 2008). In contrast, higher marital quality in daily life has been associated with less intima-media thickness, a subclinical marker of atherosclerosis (Joseph et al., 2014) for which total cholesterol is a key predictor (Herder et al., 2012). Because the Family Foundations intervention focuses on fostering positive communication and problem-solving while minimizing criticism and blame, it is possible that intervention effects may be strongest among parents who entered the intervention with more negative communication styles. This is in line with Jones and colleagues (Jones et al., 2018), who found stronger Family Foundations intervention effects at a two-year follow up on negative coparenting relations and the quality of the parent-child triadic relationship among couples who had more negative communication styles during pregnancy.

Given the near-universal experience of becoming a parent and its frequent psychosocial costs, this period in adults’ lives represents a key opportunity for preventive interventions. Moreover, prevalence rates of cardiometabolic diseases rise in early and middle adulthood and can coincide with the transition to parenthood (Andersson & Vasan, 2018). Thus, to the extent that the transition to parenthood is a common and potentially powerful stressor, a coparenting-focused transition to parenthood intervention may have the potential to not only reduce some of the psychosocial stress associated with this transition but also benefit parents’ physical health (Saxbe et al., 2018). Beyond the physiological well-being of individual parents, such findings could have implications for family practitioners and policy makers interested in fostering positive family relationships and reducing chronic disease rates.

In the following set of analyses, we examined whether participation in the Family Foundations intervention was associated with parents’ cardiometabolic health eight years later. We further investigated whether there were differential effects of the intervention on cardiometabolic health indicators depending on parents’ gender and couples’ baseline communication styles. We hypothesized that parents who participated in the co-parenting intervention eight years prior would have better self-rated health, lower systemic inflammation, and lower total cholesterol compared to parents who participated in the control arm of the trial. We further expected stronger effects of the perinatal preventative intervention on mothers’ but not fathers’ systemic inflammation, exploring whether potential differential effects of the intervention for mothers versus fathers extended to cholesterol and self-rated health. We also expected stronger effects of the intervention on cardiometabolic health indicators among couples who demonstrated more negative communication at pretest.

Methods

Participants.

We analyzed data from an 8-year follow-up visit with families who participated in the second randomized controlled trial for Family Foundations (ClinicalTrials.gov identifier: NCT01907412). Couples were recruited for the trial in 2008 via childbirth education programs, OBGYN clinics, media advertisements and fliers distributed near partner health care systems in Maryland, Pennsylvania, Delaware, and Texas. Eligible couples were required to be at least 18 years of age and to be expecting their first child. See Table 1 for details regarding sample characteristics.

Table 1.

Sample descriptive information on model variables, by parent and Family Foundations intervention conditions

Intervention Control Group difference t-test/χ2 p-value (if <.05)
Mothers n Mean SD n Mean SD
BMI 87 29.4 8.03 61 28.07 6.9
Depressive symptoms (CES-D) 105 24.9 7.84 75 25.35 8.03
Observed negative communication 103 −0.1 0.86 74 −0.07 0.58
IL-6 (raw; pg/mL) 81 1.11 3.55 54 0.8 0.59
CRP (raw; mg/L) 84 1.76 2.06 60 2.54 3.66
Total cholesterol (mg/dL) 72 123.99 44.73 55 128.91 41.94
Self-reported health 105 3.12 0.53 74 3.27 0.6
Medications
 Anti-depressant 100 0.23 0.42 73 0.21 0.41
 NSAID 100 0.22 0.42 73 0.14 0.35
 Anti-inflammatory 100 0.01 0.1 73 0.01 0.12
 Statin 100 NA NA 73 0.01 0.12
Fathers
BMI 81 29.16 4.81 57 29.69 5.82
Depressive symptoms (CES-D) 93 24.25 8.19 70 25.27 8.11
Observed negative communication 103 −0.1 0.84 74 0.07 0.92
IL-6 (raw; pg/mL) 69 0.8 0.93 50 0.8 0.66
CRP (raw; mg/L) 72 1.47 2.56 55 1.4 2.87
Total cholesterol (mg/dL) 68 139.84 36.36 50 152.6 54.59
Self-reported health 95 3.18 0.67 69 3.19 0.52
Medications
 Anti-depressant 91 0.07 0.25 68 0.12 0.32
 NSAID 91 0.24 0.43 69 0.16 0.37
 Anti-inflammatory 91 NA NA 68 0.06 0.24 .02
 Statin 91 0.05 0.23 68 0.07 0.26
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BMI = body mass index, CES-D = Center for Epidemiological Studies Depression Scale, IL-6 = Interleukin-6, CRP = C-reactive protein, NSAID = Non-steroidal anti-inflammatory drugs; NA = not applicable, indicating that no participants were taking the medication. Self-rated health was rated on a 4-point Likert scale from 1 (poor) to 4 (excellent).

Design Overview.

Participating couples completed an in-home pre-intervention assessment midway through pregnancy with their first child and then were randomly assigned to the Family Foundations or control arm of the trial. Participating families completed follow-up home visits when children were 10 months, 24 months, and 8 years of age, with peripheral blood samples collected at the 8-year visit.

Measures

Cardiometabolic markers.

As part of the follow-up home visit, participants had their capillary whole blood drawn through finger-stick. After cleaning the puncture site with alcohol swabs, a trained research assistant pricked the side of participants’ finger (middle or ring finger of non-dominant hand) with a single-use micro-lancet (BD Microtainer). Five free-flowing blood spots were collected onto filter paper cards that were then air-dried for 4 hours. After drying, cards were placed in a biohazard bag with desiccant and shipped using 2-day shipping to Dr. Schreier’s laboratory at The Pennsylvania State University where they were stored at −30°C. DBS collection cards were then shipped in batches to the Laboratory for Human Biology Research at Northwestern University for the measurement of inflammatory markers and then to the Department of Laboratory Medicine at the University of Washington for the measurement of total cholesterol.

CRP.

CRP was measured in DBS using a protocol developed for use with enzyme-linked immunosorbent assay (ELISA) kits for human CRP (McDade et al., 2004). CRP concentrations obtained via this protocol have been compared to plasma CRP concentrations and demonstrated good reliability, precision, and sensitivity (McDade et al., 2004). Samples were run in duplicate and rerun if intra-assay coefficients of variation (CVs) exceeded 10%. Inter-assay CVs for low, medium, and high control samples were 10.23%, 10.33%, and 10.21% respectively.

IL-6.

IL-6 was measured in DBS based on a recent protocol developed for use with MSD v-plex human IL-6 kits (K151QXD-1, Mesoscale Diagnostics; (McDade et al., 2020). This assay involves punching three 5mm disks per participant from the DBS card and placing them in wells on a Millipore MultiScreen HTS filter plate (MSHVN4510) along with IL-6 calibrators and controls. Samples were eluted and submerged in a phosphate-buffered saline solution (0.1% Tween-20; 50 μl per well) and then incubated overnight at 4°C on the covered filter plate. The following day, the MSD v-plex plate was washed three times with a phosphate buffered saline solution (0.05% Tween-20; 150 μl per well per wash). Stacked plates were centrifuged for two minutes at 1900gs (A-2-DWP, Eppendorf) so the 5mm sample disks would separate and the eluate would transfer to the MSD V-plex plate wells that were pre-coated with capture antibodies. The remaining steps in the protocol followed those outlined in the MSD V-plex human plasma IL-6 kit manual. Most samples were run in duplicate (78.9%) with the remainder (21.1%) run in singlicate due to insufficient remaining sample. Samples were repeated if intra-assay CVs exceeded 15% and the inter-assay CVs for low, medium and high control samples were 14.68%, 5.41%, and 3.51% respectively.

Cholesterol.

Total cholesterol in DBS was measured following assay protocols based on the work of Lakshmy and colleagues (Lakshmy et al., 2012) and Corso and colleagues (Corso et al., 2016). Specifically, 3.2 millimeter discs were punched from DBS; these punched samples were then placed in a microtiter plate well with 400 microliters of elution buffer (dd/diH2O with 0.1% Triton X-100; Sigma Aldrich, St. Louis, MO), and then sealed and shaken for one hour to elute. One hundred microliters of cholesterol reagent (IR060-x; Infrared Laboratory Systems, Westfield, IN) supplemented with .1% 15mM Amplex Red (ADHP, Cayman Chemical, Ann Arbor, MI) were then added to each plate well along with 20 microliters of the eluted DBS. The plate was then incubated at 37°C for 30 minutes following a 30-second shaking period. Cholesterol oxidase-catalyzed oxidation of free cholesterol in the wells produced hydrogen peroxide and cholesterol released from esters was coupled with ADHP to produce fluorophore resorufin. Total cholesterol concentrations were based on the level of fluorescence, which was measured at 590nm using a Biotek plate reader (Synergy H1, BioTek, Winooski, VT). Liquichek Lipids Control (Bio-Rad Laboratories Inc., Clinical Systems Division, Hercules, CA; FDA clearance K921286) quality control (QC) samples and laboratory-created DBS QC samples were included on each plate.

Self-rated health.

At the 8-year follow-up home visit, participants rated their overall health on a 4-point Likert scale from ‘excellent’ to ‘poor.’ The majority of participants reported being in good health (66.1%) or excellent health (26.7%), with 7.2% reporting poor or fair self-rated health.

Negative Communication.

As part of the pre-test home visit, expectant couples participated in a videotaped dyadic communication task in which they were asked to discuss qualities or characteristics of each other that they wanted to change. Trained raters viewed the recorded interactions and rated each participant’s level of negative communication based on the extent to which they showed aggression and anger. In the sample, negative communication was positively skewed.

Covariates.

At the pre-test, participants reported their gender (female = 1, male = 0) and family income. No participants identified as non-binary or transgender. At the 8-year follow-up visit, participants reported on their relationship status. Most participants were married or living with the same partner with whom they participated in the trial (87.4%, n = 173). The remaining 12.6% participants (n = 25) were single parents or residing with a new partner. A binary variable was created to compare participants who were living with the same partner they had at baseline to those who were now living without a partner or with a new partner. At the follow-up visit, height and weight were obtained to calculate their body mass index (kg/m2) and participants reported on whether they were regularly taking any prescription or over-the-counter medications. Models adjusted for whether participants were taking anti-depressant medications (n = 52, 15.8%), nonsteroidal anti-inflammatory drugs (n = 65, 19%), statins (n = 11, 3.4%) or respiratory anti-inflammatory medications (n = 6; 1.7%). For analyses, we combined the two anti-inflammatory medications into one indicator (respondent taking either or both) given sparseness of use. Finally, a self-report measure on depressive symptoms at the time of the follow-up visit was included given its relevance to the outcomes included in the study. We used the 20-item Center for Epidemiological Studies Depression Scale (CES-D; (Radloff, 1977)), which assesses the amount of time in which certain feelings are present (e.g., “feel lonely”, “feel that your life had been a failure”). Responses based on a 4-level ordinal scale were summed to derive a total score. Reliabilities were acceptable based on the measure used in the present research (Cronbach’s alphas of .71 and .70 for mothers and fathers, respectively).

Procedure

All participating couples first completed an in-home pre-intervention assessment when expectant mothers were about 22.8 weeks gestation (SD = 5.5 weeks). Subsequently, the research project manager randomly assigned couples to the intervention or wait-list control condition using a random number table. Couples in the intervention arm then attended nine two-hour, in-person sessions (five prenatal, four postnatal) focused on encouraging effective communication, support and problem-solving skills within the coparenting relationship and fostering safety, security and attachment in the parent-child relationship. Sessions included informational presentations, group discussions, video vignettes, written and communication exercises, skill rehearsals, and homework assignments. Couples in the control arm of the trial received written materials in the mail about stages of child development and selecting quality childcare following the in-home pre-test. Participating families then completed follow-up home visits when children were 10 months, 24 months, and 8 years of age (for more details on the development of the Family Foundations intervention and findings from previous waves, please see (Feinberg, 2002, 2003; Feinberg et al., 2010; Jones et al., 2018). See Figure S1 in the online supplement for a consort diagram of participation across study waves. The 8-year in-home visit followed a similar procedure to the earlier visits and included a consenting process, semi-structured interview, and sets of questionnaires to be completed by both parents. Additionally, families had the option to participate in physiological assessments and the collection of DBS to allow for the assessment of systemic inflammation and cholesterol. DBS were collected via fingerstick at the beginning of the visit, immediately following the consenting process and prior to the interview and self-report measures. Participating families were reimbursed for their time and efforts. The Institutional Review Board of The Pennsylvania State University approved this research.

Statistical Analyses

We report all data manipulations and data exclusions in the following section. All data, analysis code, and research materials are available upon request. Data were entered in IBM SPSS (version 26.0, IBM Corp) and cleaned and analyzed using SAS statistical software (SAS Institutes Inc., 2011). Missing data analysis was conducted in Stata (StataCorp, 2019).

Multiple imputation techniques (Graham, 2012) were used to accommodate missing data where home visits could not be completed, based on all families who originally agreed to participate in the follow-up sample.1 Of the 233 couples who completed the follow-up home vists, 198 couples provided blood spots. Of those, 15 couples were excluded (current pregnancy (n = 11); taking disease-modifying antirheumatic drugs, gastrointestinal anti-inflammatory medication for a colitis flair, or opiate antagonists (n = 4)). Because data were imputed at the family level due to the dependent nature of data obtained from mothers and fathers, couples were also excluded at the family level. This enabled a sample of 183 couples providing data. Data were imputed for both parents using some current measures as well as data for many variables collected at baseline before the intervention; data from roughly 45 covariates were used, covering information ranging from demographic (e.g., income, education levels), mental health, parenting characteristics, relationship measures as well as the cardiometabolic risk factors. SAS PROC MI was used to carry out the imputations, using a full predictor covariate matrix as a prior for initial estimates and setting ranges for imputed values post-estimation based on non-missing data variable ranges. Estimates from multilevel regression models presented below were derived through aggregating across 100 imputed data sets using Stata’s xtmixed.

For cholesterol, CRP and IL-6, multilevel (ML) regression models in SAS were used for analyses where a random intercept was specified to acknowledge clustered variance within parent dyads. Based on inspection of outcome distributions, IL-6, CRP and cholesterol were log-transformed before running regressions; these transformations were effective in reducing skew and better approximating a normal distribution. For the self-rated health outcome, clustered variance attributable to the dyad was very low so we used a design-based regression model where standard errors were adjusted based on clustering at the family level. All models adjusted for gender, family income, condition (intervention versus control), relationship status, BMI, depressive symptoms and the aforementioned medications.

Results

Due to the COVID-19 pandemic, home visits had to be stopped before all families originally enrolled in the trial had aged into the 8-year follow-up. Thus, data presented here were all obtained during pre-pandemic home visits. Family income ranged from $1,250 - $162,500 (mean = $85,230 ± $3,578) at baseline. At the follow-up visit, parents were around 38 years old (fathers: mean age = 39.21 ± 5.11 years, range = 27 – 55 years; mothers: mean age = 37.40 ± 4.11, range = 24 – 50 years) and the majority of parents identified as White (n = 69 fathers, n = 72 mothers), with the remainder identifying as Black or African American (n = 3 fathers, n = 2 mothers), American Indian or Indigenous American (n = 1 father, n = 0 mothers), Asian American or Pacific Islander (n = 2 fathers, n = 1 mother), or with another race (n = 2 fathers, n = 1 mothers). The couples who participated in the 8-year follow-up visit were similar in age (participating fathers’ age at baseline = 30.0±5.1 years, participating mothers’ age at baseline = 28.9±4.1 years; non-participating fathers’ age at baseline = 31.3±5.6 years; non-participating mothers’ age at baseline = 29.3±4.7 years) and socioeconomic status (participating couples’ median income at baseline = $83,750, non-participating couples’ median income at baseline = $87,500), but more likely to be White compared to couples who were lost to follow-up (participating fathers = 90.9% White, participating mothers = 93.8% White; non-participating fathers = 80.3% White, non-participating mothers = 81.2% White). Correlations of main study variables can be found in Table 2.

Table 2.

Correlations across main study variables

1 2 3 4 5 6 7 8 9 10 11
1. BMI 1 −0.05 0.06 0.25** 0.45** −0.11 −0.28** −0.03 0.12 −0.01 0.14
2. Depressive symptoms 0.32** 1 0.05 −0.03 −0.01 0.10 −0.25** 0.36** −0.01 0.09 0.08
3. Observed negative communication 0.01 0.01 1 0.20* −0.03 −0.03 −0.08 0.06 −0.13 0.20* 0.21**
4. IL-6 (raw; pg/mL) 0.31** −0.04 −0.02 1 0.25** −0.09 −0.25** 0.00 0.01 0.22* 0.20*
5. CRP (raw; mg/L) 0.38** 0.13 0.03 0.27** 1 −0.11 −0.13 0.09 0.06 −0.02 −0.01
6. Total cholesterol (mg/dL) −0.06 −0.04 −0.07 −0.15 −0.15 1 −0.05 −0.07 −0.03 0.13 −0.22*
7. Self-reported health −0.39** −0.34** 0.07 −0.06 −0.21* 0.07 1 −0.07 −0.06 −0.12 −0.22**
8. Anti-depressant 0.15 0.12 −0.02 0.14 0.23 −0.05 −0.15 1 −0.10 −0.05 0.10
9. NSAID 0.08 0.08 −0.06 −0.04 0.05 0.13 −0.13 −0.04 1 −0.08 −0.07
10. Anti-inflammatory −0.04 −0.02 −0.03 −0.02 −0.01 0.02 −0.03 −0.06 −0.05 1 0.12
11. Statin 0.02 −0.03 −0.02 0.04 0.07 0.05 −0.03 −0.04 −0.04 −0.01 1
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Correlations among study variables for fathers are depicted in the upper diagonal in grey. Correlations among study variables for mothers are depicted on the lower diagonal. BMI = body mass index; IL-6 = Interleukin-6; CRP = Creactive protein; NSAID = Non-steroidal anti-inflammatory drug

*

= correlation significant at p < .05

**

= correlation significant at p < .01

Please see Tables 3 and 4 for results of regression analyses for main effects of the intervention (Table 3) and moderation effects of parent gender and communication style on measures of parents’ cardiometabolic and self-rated health 8 years later (Table 4). Regression results showed that participation in the Family Foundations intervention was not associated with participants’ self-rated health or peripheral levels of IL-6 eight years later (ps > .30). Participating in Family Foundations was, however, associated with lower cholesterol levels (B = −.081, SE = .041, p = .049, 95% confidence interval (CI) [−.161, −.0005]) and marginally lower levels of CRP (B = −.261, SE = .147, p = .077, 95%CI [−.550, .028]).

Table 3.

Main effects of the Family Foundations intervention and parents’ cardiometabolic risk and self-rated health eight years later

IL-6 CRP Total cholesterol Self-rated health
b SE p b SE p b SE p b SE p
Intervention condition −0.071 0.093 0.445 −0.261 0.147 0.077 −0.081 0.041 0.049 0.064 0.057 0.265
Mother 0.123 0.069 0.074 0.415 0.130 0.001 −0.164 0.036 0.000 0.053 0.058 0.369
Anti-depressant −0.080 0.114 0.484 0.083 0.198 0.673 0.002 0.055 0.973 0.028 0.072 0.694
Anti-inflammatory −0.020 0.095 0.835 0.091 0.170 0.594 0.065 0.048 0.175 0.080 0.075 0.290
Statin 0.286 0.212 0.177 −0.226 0.376 0.548 −0.211 0.103 0.041 0.303 0.153 0.049
Age (follow-up) −0.003 0.010 0.797 0.023 0.017 0.175 −0.001 0.005 0.783 0.016 0.007 0.017
BMI (follow-up) 0.041 0.006 0.000 0.115 0.011 0.000 −0.003 0.003 0.309 0.024 0.005 0.000
Both parents in home −0.253 0.144 0.080 −0.405 0.229 0.077 0.105 0.064 0.100 −0.046 0.110 0.676
Family income (pre-test) 0.009 0.014 0.532 0.026 0.024 0.265 −0.003 0.007 0.630 −0.018 0.009 0.048
Depressive symptoms (follow-up) −0.026 0.147 0.859 −0.299 0.255 0.242 0.009 0.073 0.905 0.510 0.109 0.000
Intercept −1.370 0.650 0.035 −3.469 1.089 0.001 5.038 0.304 0.000 −1.055 0.457 0.022
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BMI = body mass index, b = unstandardized beta coefficient, SE = standard error, IL-6 = Interleukin-6, CRP = Creactive protein; significant intervention effects (p < .05) are bolded

Table 4.

Moderation effects of gender and negative communication on associations between randomization to the Family Foundations intervention and parents’ cardiometabolic risk and self-rated health eight years later

IL-6 CRP Total cholesterol Self-rated health
Moderation by gender b SE p b SE p b SE p B SE p
Intervention condition −0.096 0.113 0.397 −0.047 0.188 0.804 −0.080 0.053 0.131 0.017 0.085 0.846
Mother 0.096 0.097 0.320 0.659 0.186 0.000 −0.163 0.051 0.001 −0.002 0.083 0.983
Anti-depressant −0.082 0.115 0.473 0.105 0.197 0.595 0.002 0.055 0.972 0.025 0.072 0.730
Anti-inflammatory −0.021 0.095 0.822 0.103 0.170 0.545 0.065 0.048 0.175 0.078 0.075 0.305
Statin 0.285 0.212 0.178 −0.222 0.374 0.551 −0.211 0.103 0.041 0.302 0.150 0.046
Age (follow-up) −0.002 0.010 0.819 0.021 0.017 0.208 −0.001 0.005 0.782 0.017 0.007 0.015
BMI (follow-up) 0.041 0.006 0.000 0.117 0.011 0.000 −0.003 0.003 0.311 0.024 0.005 0.000
Both parents in home −0.253 0.144 0.079 −0.401 0.228 0.079 0.105 0.064 0.100 −0.047 0.110 0.672
Family income (pre-test) 0.009 0.015 0.541 0.028 0.024 0.244 −0.003 0.007 0.630 −0.018 0.009 0.046
Depressive symptoms (follow-up) −0.026 0.147 0.860 −0.303 0.255 0.234 0.009 0.073 0.905 0.511 0.109 0.000
Constant −1.360 0.649 0.036 −3.567 1.088 0.001 5.038 0.304 0.000 −1.032 0.460 0.026
Intervention*mother 0.048 0.129 0.710 −0.428 0.241 0.076 −0.002 0.068 0.982 0.095 0.118 0.421
Moderation by negative communication
Intervention condition −0.070 0.093 0.449 −0.261 0.148 0.076 −0.081 0.041 0.047 0.062 0.057 0.279
Negative communication (pre-test) 0.140 0.083 0.091 −0.020 0.141 0.887 −0.006 0.037 0.864 0.094 0.043 0.028
Mother 0.130 0.069 0.059 0.414 0.130 0.001 −0.164 0.036 0.000 0.056 0.058 0.336
Anti-depressant −0.089 0.114 0.436 0.084 0.198 0.670 0.001 0.055 0.980 0.020 0.072 0.788
Anti-inflammatory −0.024 0.095 0.802 0.091 0.171 0.594 0.063 0.048 0.188 0.071 0.075 0.346
Statin 0.194 0.219 0.377 −0.212 0.388 0.584 −0.207 0.106 0.052 0.248 0.156 0.114
Age (follow-up) −0.002 0.010 0.833 0.023 0.017 0.181 −0.001 0.005 0.754 0.016 0.007 0.024
BMI (follow-up) 0.041 0.006 0.000 0.115 0.011 0.000 −0.003 0.003 0.315 0.025 0.005 0.000
Both parents in home −0.259 0.144 0.072 −0.404 0.228 0.077 0.105 0.064 0.101 −0.053 0.110 0.629
Family income (pre-test) 0.010 0.015 0.481 0.026 0.024 0.273 −0.003 0.007 0.602 −0.018 0.009 0.050
Depressive symptoms (follow-up) −0.058 0.149 0.697 −0.295 0.260 0.257 0.007 0.075 0.927 0.468 0.107 0.000
Constant −1.302 0.657 0.048 −3.475 1.116 0.002 5.054 0.312 0.000 −0.901 0.454 0.049
Intervention*Negative communication −0.171 0.108 0.114 0.020 0.182 0.913 −0.003 0.048 0.951 −0.158 0.051 0.002
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BMI = body mass index, b = unstandardized beta coefficient, SE = standard error, IL-6 = Interleukin-6, CRP = Creactive protein; significant moderation effects (p < .05) are bolded

Assessment of moderation based on couples’ negative communication style at baseline revealed a moderated association between participation in the Family Foundations intervention and participants’ self-rated health (B = .158, SE = .051, p = .002, 95%CI [−.258, −.058]) eight years later (Figure 1). Specifically, participation in the intervention at baseline was associated with better self-reported health at follow-up, but only among participants who were observed to have more negative communication styles at baseline. Negative communication style did not moderate the association between the intervention and IL6, CRP, or cholesterol levels eight years later (p > .10).

Figure 1.

Figure 1.

Open in a new tab

The effect of Family Foundations on self-rated health was moderated by expectant couples’ observed negative communication style prior to participating in the trial. Randomization to the Family Foundations intervention was associated with higher self-rated health eight years later, but only among couples who were observed to have more negative communication styles at pre-test. The black line represents parents in the intervention and the gray line represents parents in the control arm of the trial. Conditional effects are graphed at ± 1 standard deviation above and below the mean of observed negative communication style for the sample.

There was also a marginal moderation effect of gender on the association between participation in the Family Foundations intervention and CRP levels at the 8-year follow-up (B = −.428, SE = .241, p = .076, 95%CI [−.902, .045]). Compared to mothers in the control condition, mothers who participated in the intervention had marginally lower levels of CRP eight years later. There were no differences in fathers’ CRP levels regardless of whether they participated in the intervention or control condition. Gender did not moderate associations between the Family Foundations intervention and self-rated health, cholesterol, or IL-6 levels eight years later (all ps > .40).

Discussion

Becoming a parent is a very common and often positive event, but can be a stressful transition for many young and midlife adults that is hallmarked by changes across a number of psychosocial domains. The transition to parenthood also generally coincides with a rise in risk factors for cardiometabolic diseases (Andersson & Vasan, 2018). The transition to parenthood, when parents are eager for education and support, represents an opportune period to intervene with parents to promote not only their mental health and family relationships, but also their physical health (Saxbe et al., 2018). Drawing on data collected as part of an ongoing randomized controlled trial for the Family Foundations intervention, we examined whether randomization to the intervention condition was associated with lower systemic inflammation and total cholesterol and better self-rated health among parents eight years later. We further assessed whether there were differential intervention effects on cardiometabolic risk markers for mothers compared to fathers and depending on expectant couples’ communication styles at pretest.

Compared to parents in the control condition, parents who participated in the Family Foundations intervention had lower levels of total cholesterol and marginally lower levels of CRP eight years later. Findings align with prior studies finding support for the potential secondary benefits of psychosocial-focused interventions on cardiometabolic risk factors (Miller et al., 2014; Schreier et al., 2013). For example, Schreier and colleagues (2013) found that youth randomly assigned to a volunteering intervention had greater reductions in total cholesterol and marginally greater reductions in CRP levels compared to their peers in the control arm. Despite differences in sample characteristics and contexts, our results and those of Schreier and colleagues converge on the notion that psychosocial interventions may be leveraged to support both psychosocial and physical health. The mechanisms underlying effects of the Family Foundations intervention on cholesterol and CRP levels eight years later are yet to be determined and should be explored in future research. It is possible that supportive co-parenting skills and closeness cultivated through participation in Family Foundations may be sustained well beyond the intervention and potentially exert stress-buffering effects on health, either directly through reducing psychological distress and promoting coparenting support (Feinberg & Jones, 2018) or indirectly via fostering adaptive health behaviors and coping skills. Because there were no main effects of the intervention on peripheral levels of IL-6 or self-rated health eight years later, and effects for CRP were only marginal, follow up studies are warranted to replicate results and disentangle how the intervention may relate to lower cholesterol levels years later.

Among parents who were observed to have had a more negative communication style during pregnancy, participating in the Family Foundations intervention was associated with better self-rated health eight years later. Negative communication style has been shown previously to moderate Family Foundations intervention effects; for example, Jones and colleagues (Jones et al., 2018) found that among couples higher in negative communication at pretest, those in the Family Foundations intervention had lower levels of negative coparenting and better parent-child triadic relationship quality two years later. Taken together with research that has linked lower marital satisfaction and greater household strain to poorer self-rated health (Staland-Nyman et al., 2008), it may be that the perinatal preventative intervention promoting positive coparenting changes the way families communicate with one another and reduces the frequency and severity of arguments. Moreover, the Family Foundations intervention has demonstrated reductions in family violence and parental anxiety and depressive symptoms and improvements in child self-regulation and social-emotional functioning, all of which may translate to better self-rated health among parents (Ammerman et al., 2021; Feinberg et al., 2014, 2021; Giallo et al., 2022; Takeishi et al., 2019). However, we did not find this same pattern for objective measures of cardiometabolic risk despite prior research suggesting strong correlations between self-rated health and, for example, CRP and IL-6 (Christian et al., 2011; Shanahan et al., 2014).

We found potentially stronger effects of the intervention on mothers’ than fathers’ CRP levels, with a marginally significant effect among mothers but not fathers eight years later. Although it was not significant in the present research, such a gender difference is in concordance with prior research. The transition to parenthood is generally harder for mothers, as indicated by higher rates of maternal versus paternal post-partum depression and mothers taking on more household and parenting duties compared to fathers (McLeod et al., 2016; Nomaguchi & Milkie, 2003). The Family Foundations intervention cultivates coparenting support, which is critical for satisfaction with the division of household and parenting duties as well as for managing depressive symptoms (Feinberg & Jones, 2018; Feinberg & Kan, 2015). Compared to parents in the control group, it is possible that parents in the Family Foundations intervention were more satisfied with the distribution of parenting and household duties (Feinberg & Kan, 2015), perhaps with fathers in the intervention group being more likely to recognize and show appreciation for mothers’ parenting contributions by providing affirmation and limiting criticism. Future research should therefore examine whether marital satisfaction and reductions in parenting stress and depressive symptoms may explain why mothers randomized to the Family Foundations intervention had marginally lower levels of CRP compared to mothers in the control arm of the trial.

In aggregate, gender differences observed with Family Foundations data may help inform the adaptation of the Family Foundations intervention to mothers in non-traditional family settings, where stress and depression levels among mothers may be higher than in the general population. Future interventions could focus on helping expectant single mothers build a coparenting bond with another close adult, whether that be a romantic partner, extended family member or close friend. Examining the generalizability of the psychological and physiological benefits of the Family Foundations intervention to single mothers is of critical importance as the percentage of single-headed female households with dependent children continues to rise in the U.S. (Livingston, 2018). Fortunately, the Family Foundations intervention has been successfully adapted to serve expectant parents from various sociodemographic backgrounds (Giallo et al., 2022; Lewin et al., 2015; Takeishi et al., 2019), including expectant teenage mothers who had a coparenting team comprised of the expectant father, grandparents, and other extended family members and friends (Lewin et al., 2015). Nonetheless, intervention effects on mothers’ CRP levels eight years later were only marginal and would require replication in future studies before conclusions can be drawn.

Additionally, there were no main or moderation effects of the intervention on IL-6 levels, which is surprising given that IL-6 is involved in stimulating the release of CRP from hepatic cells (Gabay & Kushner, 1999). Null findings may be in part because IL-6 is a pleiotropic cytokine with both pro- and anti-inflammatory attributes that is released by adipose, bone, and other cells in addition to immune cells (Mauer et al., 2015) and because IL-6 levels can be impacted by other factors, such as exercise or acute stress (O’Connor et al., 2009). We did, however, advise parents to abstain from strenuous physical activity prior to the visit and attempted to create a calming environment for the DBS collection. Alternatively, null findings for IL-6 could simply be a reflection of measurement error as several samples with higher inter-assay CVs could not be rerun due to insufficient sample volume.

This study has several strengths. We were able to draw on rich psychosocial and longitudinal data collected from the ongoing randomized controlled trial of the Family Foundations intervention, which has demonstrated beneficial effects on adults’ adjustment to parenthood, psychological well-being, and familial relationships over time. For the 8-year follow-up visit, we were able to add to existing psychosocial assessments to include the collection of both more objective indicators of health, inflammatory markers, and cholesterol measured via DBS, as well as participants’ subjective self-rated health to examine whether favorable intervention effects extended to measures of parents’ physical health. Additionally, this study included data collected from both mothers and fathers within the same household, which is an advantage over much prior research that has often focused only on the assessment of one parent. Finally, we were able to draw on observer-rated perceptions of couples’ communication styles prior to participating in the trial rather than relying on parent self-report of their communication style.

Our findings also need to be considered in light of several limitations, most notably the absence of baseline data on systemic inflammation, total cholesterol, and self-rated health among parents prior to participating in perinatal preventative intervention. We can only speak to between-group differences and not within-person change in cardiometabolic risk markers. Given that couples were randomly assigned to either participate in the intervention or the control arm, however, it is unlikely that group differences with respect to these outcomes existed at baseline. The assessment of physical health indicators was further limited to parents who remained in the clinical trial and who consented to participate in the optional collection of DBS and physiological assessments. Indeed, this was a relatively low-risk sample of primarily white, stably married couples who had the ability to participate in an 18-hour intervention. It is possible we underestimated the effects of the intervention on total cholesterol and systemic inflammation if parents who were higher risk (such as higher in negative communication styles at baseline or with fewer psychosocial resources) were lost to follow-up at higher rates, or less likely to provide DBS. Then again, it is possible that salubrious effects of the intervention on cholesterol and CRP only emerge within socially advantaged samples and may be attenuated or non-existent among parents with more social and health risks. Nonetheless, the long-term follow-up of these couples eight years following the initial intervention represents a considerable strength of this research. Moreover, the Family Foundations intervention has been successfully adapted for higher-risk samples (e.g., teen parents; Lewin et al., 2015) so future work should examine whether the physical health benefits we observed here generalize to parents who may be at greater risk for psychosocial challenges during the transition to parenthood.

Similarly, future work should examine which mechanisms could explain our findings. Along with the reduction of psychosocial stress and increased coparenting support mentioned above, it may also be possible that the Family Foundations intervention improves overall family functioning, decreases parental anxiety, supports better child functioning, or even encourages better health habits among parents (e.g., getting sufficient sleep, maintaining a healthy weight), which in turn may contribute to better long-term health (De Heredia et al., 2012; Irwin et al., 2016; Michopoulos et al., 2017; Prosper et al., 2009). Future data collection efforts should also leverage multiple waves of physiological outcome data in order to speak to within-person changes.

As alluded to above, the generalizability of our study findings remains to be determined. All couples enrolled in the present trial were heterosexual and cohabitating prior to participating in the intervention. Participants were also predominantly white non-Hispanic. Compared to the general U.S. population, participating parents were more likely to be married at the start of the intervention and remain married to one another at the 8-year follow-up visit. Thus, future research is needed to assess whether intervention effects on markers of physical health among certain subsets of participants in the study (i.e., mothers and couples higher in negative communication) generalize to parents who identify as LGBTQI+ or as a racial/ethnic minority, or who are not in a cohabitating relationship.

Excellent interventions and educational programs have been developed to support the common but nonetheless often stressful transition to parenthood. Parallel intervention efforts have focused on reducing rates of cardiometabolic conditions among young and middle-aged adults. Importantly, these intervention efforts have been implemented largely independently of one another. The ability to leverage a preventative intervention promoting positive coparenting, (such as Family Foundations) to support not only parents’ psychological well-being and family relationships but to also benefit their longer-term physical health could have powerful and cost-saving implications for public policy initiatives aimed at supporting the health and well-being of families. Although to date no economic evaluation has been completed for the Family Foundations program, evidence from another universal prevention program, the Positive Parenting Program, suggests a benefit to cost ratio of $7.78 (Washington State Institute for Public Policy, 2020). This does not include a focus on parent health outcomes, however, which might result in a more advantageous benefit to cost ratio and should be explored in future research. Our findings demonstrate that benefits of the Family Foundations intervention, a universal intervention meant to be incorporated into existing childbirth education programs, may extend to parents’ physical health.

Supplementary Material

1

Highlights.

  • Long-term effects of Family Foundations, a coparenting intervention, were examined

  • Outcomes were C-reactive protein, Interleukin-6, cholesterol, self-reported health

  • Parents in the intervention group had better health at follow-up

  • Parents with more negative communication styles at baseline may benefit more

  • Even purely psychosocial interventions can impact physical health

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

The randomized trial from which data are drawn for the presented analyses is registered at ClinicalTrials.gov, Identifier: NCT01907412.

Declaration of Generative AI and AI-assisted technologies in the writing process Statement: No AI-assisted technologies were used in the preparation of this manuscript.

1

Results for analyses without imputation are provided in the Supplement, see Tables S1 and S2. Main differences to the results reported below include the absence of a significant main effect of the intervention on total cholesterol; the presence of a significant intervention*parent gender effect on CRP with mothers in the intervention group having significantly lower levels of CRP than mothers in the control group; and a significant intervention*negative communication effect on IL-6, such that participation in the intervention at baseline was associated with lower IL-6 at follow-up, but only among participants who were observed to have more negative communication styles at baseline.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Dr. Feinberg, who created the Family Foundations program, is the owner of a private company, Family Gold, which disseminates the Family Foundations program. His financial interest has been reviewed by the Institutional Review Board and the Conflict of Interest Committee at The Pennsylvania State University. The remaining authors have no potential conflicts of interest to declare.

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