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. Author manuscript; available in PMC: 2024 Jun 24.
Published in final edited form as: Am J Perinatol. 2023 Feb 13;41(Suppl 1):e1404–e1420. doi: 10.1055/a-2033-5610

Perinatal Outcomes during versus Prior to the COVID-19 Pandemic and the Role of Maternal Depression and Perceived Stress: A Report from the ECHO Program

Kimberly S McKee 1, Xiaodan Tang 2, Irene Tung 3, Guojing Wu 4, Akram N Alshawabkeh 5, Jessica A Arizaga 6, Theresa M Bastain 7, Patricia A Brennan 8, Carrie V Breton 7, Carlos A Camargo Jr 9, Camille C Cioffi 10, Jose F Cordero 11, Dana Dabelea 12, Arielle R Deutsch 13, Cristiane S Duarte 14, Anne L Dunlop 15, Amy J Elliott 13, Assiamira Ferrara 16, Margaret R Karagas 17, Barry Lester 18, Cindy T McEvoy 19, John Meeker 20, Jenae M Neiderhiser 21, Julie Herbstman 22, Leonardo Trasande 23,24, Thomas G O’Connor 25, Alison E Hipwell 26, Sarah S Comstock 27; on behalf of program collaborators for Environmental influences on Child Health Outcomes*
PMCID: PMC11195909  NIHMSID: NIHMS1998365  PMID: 36781160

Abstract

Objective

We sought to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on perinatal outcomes while accounting for maternal depression or perceived stress and to describe COVID-specific stressors, including changes in prenatal care, across specific time periods of the pandemic.

Study Design

Data of dyads from 41 cohorts from the National Institutes of Health Environmental influences on Child Health Outcomes Program (N = 2,983) were used to compare birth outcomes before and during the pandemic (n = 2,355), and a partially overlapping sample (n = 1,490) responded to a COVID-19 questionnaire. Psychosocial stress was defined using prenatal screening for depression and perceived stress. Propensity-score matching and general estimating equations with robust variance estimation were used to estimate the pandemic’s effect on birth outcomes.

Results

Symptoms of depression and perceived stress during pregnancy were similar prior to and during the pandemic, with nearly 40% of participants reporting mild to severe stress, and 24% reporting mild depression to severe depression. Gestations were shorter during the pandemic (B = −0.33 weeks, p = 0.025), and depression was significantly associated with shortened gestation (B = 0.02 weeks, p = 0.015) after adjustment. Birth weights were similar (B = 28.14 g, p = 0.568), but infants born during the pandemic had slightly larger birth weights for gestational age at delivery than those born before the pandemic (B = 0.15 z-score units, p = 0.041). More women who gave birth early in the pandemic reported being moderately or extremely distressed about changes to their prenatal care and delivery (45%) compared with those who delivered later in the pandemic. A majority (72%) reported somewhat to extremely negative views of the impact of COVID-19 on their life.

Conclusion

In this national cohort, we detected no effect of COVID-19 on prenatal depression or perceived stress. However, experiencing the COVID-19 pandemic in pregnancy was associated with decreases in gestational age at birth, as well as distress about changes in prenatal care early in the pandemic.

Keywords: stress, pregnancy, COVID-19, perinatal, birth weight, gestational age

The association between psychosocial stress and adverse birth outcomes, such as preterm birth, has been well documented.1,2 Evidence from clinical and epidemiologic studies, including natural experiments during times of disasters, demonstrates the adverse effects of both chronic and acute stress.3 As demonstrated by the Dutch Hunger Winter study and other studies,4,5 adverse exposures in utero, especially during critical periods of development, have lasting effects on offspring health outcomes.6 Furthermore, adverse intrauterine exposures negatively impact birth outcomes, resulting in shortened gestation and low birth weight,7 both of which are linked to a wide range of health outcomes across the lifespan, such as cardiovascular disease, type 2 diabetes, and certain cancers.7–9

During the coronavirus disease 2019 (COVID-19) pandemic, many individuals experienced increased stress caused by economic difficulties, social isolation due to stay-at-home orders, fear of illness, fear of infecting vulnerable family members or friends, and disruptions to prenatal care and delivery. The extent of these negative consequences varied according to individual situations and across time as cases surged10 and as hospital systems experienced oscillating strain on their staff and infrastructure.11 This stress of the pandemic may have directly impacted pregnancy health and birth outcomes. In addition, indirect stressors, such as disruptions to daily living and health care, experienced as a result of the pandemic and the timing of pregnancy during different stages of the pandemic may have differential effects on birth outcomes. Further, the direct effects of increased stress during critical periods of fetal and infant development have long-lasting impacts for women and children.11,12 Data from historical natural experiments and several frameworks have demonstrated the biological effects of in utero exposure to maternal psychosocial stress on adverse perinatal outcomes,13–15 suggesting that the COVID-19 pandemic could have similar effects. Studies investigating the impact of the COVID-19 pandemic on maternal and child health have focused on the effects of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection during pregnancy on perinatal outcomes.16–18 However, we hypothesized that the pandemic would also indirectly affect birth and neonatal outcomes due to the increased maternal psychosocial stress caused by pandemic conditions. While some studies have examined the pandemic’s effect on birth outcomes,19 few have included measures of maternal distress, the specific types of stressors that most affect pregnant women during the pandemic, or changes in women’s experiences over the course of the COVID pandemic.

In the current study, we tested the effects of exposure to the COVID-19 pandemic on perinatal outcomes, without accounting for SARS-CoV-2 infection. We used data from cohorts in the National Institutes of Health (NIH) Environmental influences on Child Health Outcomes (ECHO) Program to describe maternal experiences of depressive symptoms and perceived stress prior to and during the pandemic, sources of maternal stress across pandemic time periods, and the association of these exposures with the following perinatal outcomes: gestational age at delivery, unadjusted birth weight, and birth weight adjusted for gestational age at delivery.

Materials and Methods

Overview

The ECHO Program is a diverse consortium of cohorts across the United States that has particular leverage for studying the impact of the pandemic on the health of the population. ECHO includes cohorts of caregivers and children enrolled from multiple existing longitudinal studies. It was designed to evaluate the impact of early-life exposures on child health outcomes and includes survey, medical record, and biospecimen collections; the design and purpose of the ECHO Program has been described.20,21 ECHO cohorts have recruited pregnant women using a common protocol prepandemic and during the pandemic, and thus the ECHO Program allows for direct comparisons of birth outcomes prior to and during the first 15 months of the COVID-19 pandemic.

This analysis included a total of 2,983 participants who were pregnant before and/or during the COVID-19 pandemic and recruited from 41 ECHO cohorts across the United States, including Puerto Rico (►Fig. 1). Among these participants, 2,355 (drawn from 14 cohorts) had data available for the first analysis that compared birth outcomes prior to and during the COVID-19 pandemic. This first analysis will be referred to as “aim 1” throughout. In addition, 1,490 participants had data available for the second analysis that compared self-reported maternal stressors across four pandemic time periods. The second analysis drew from 37 cohorts and will be referred to as “aim 2” throughout. A total of 862 participants were included in both the aim 1 and aim 2 samples. These 862 participants are accounted for in each of the within-aim totals above.

Fig. 1.

Fig. 1

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(A) Flow chart of study samples. (B) Map of the locations of ECHO sites that contributed data to aim 1, aim 2, or both. ECHO, Environmental influences on Child Health Outcomes.

For aim 1, women who delivered between January 1, 2016, and March 11, 2020, were classified into the prepandemic group, and those who delivered after March 11, 2020, but before or on May 31, 2021, were classified into the pandemic group. For aim 2, birth outcomes, distress about prenatal care changes, and support from care providers were assessed in four pandemic time frames—February 28, 2020, to June 19, 2020; June 20, 2020, to September 27, 2020; September 28, 2020, to January 10, 2021; January 11, 2021, to May 31, 2021—based on surges in cases using U.S. data (https://ourworldindata.org/coronavirus/country/united-states).10

Data Collection

The primary outcomes of interest were birth weight, gestational age at delivery, and birth weight percentiles adjusted for gestational age at delivery. Birth weight percentile for gestational age using infant biological sex assigned at birth was derived based on 2017 U.S. reference data.22 Gestational age at birth in weeks was categorized as preterm (<37 weeks), early term (37–38 weeks), full term (39–40 weeks), or late term (≥41 weeks).23 Birth weight in grams was categorized as low birth weight (<2,500 g), normal birth weight (≥2,500–3,999 g), or macrosomic (≥4,000 g).24,25 Birth weight and gestational age were primarily abstracted from the maternal or neonatal medical records, or if unavailable, were gathered from maternal self-report.

Maternal psychosocial stress was defined using: (1) maternal self-reports of depressive symptoms or (2) perceived stress within 8 months before the delivery date. Multiple scales for depression and perceived stress have been administered within ECHO cohorts and have been harmonized onto a common metric26 using the scales of the Patient-Reported Outcomes Measurement Information System (PROMIS)27,28 and NIH Toolbox29 for maternal depression and perceived stress, respectively. A description of the specific scales that were administered by the cohorts in this analysis is provided in ►Supplementary Table S1 (available in the online version), e.g., the Edinburgh Postnatal Depression Scale (EPDS) was most commonly used to screen for maternal depression, and the Perceived Stress Scale (PSS) 10-item scale was the most common measure administered for perceived stress in the analytic sample (aim 1). Additionally, a set of cohorts administered a survey to determine sources of maternal stress specific to daily living and coping behaviors and overall maternal stress during the pandemic (aim 2). Due to the rapid deployment of the questionnaire in the midst of the pandemic, mothers completed the questionnaire either prospectively (62.4%) during their pregnancy or retrospectively (37.6%) after they gave birth but were asked about the prenatal period of exposure in both cases. As part of this survey, mothers were also asked to rate the impact of the COVID-19 pandemic on their lives using a 7-point scale: “Please indicate the extent to which you view the COVID-19 pandemic as having either a positive or negative impact on your life.” In analyses, the 7-point scale was collapsed into a binary variable (negative impact, no/positive impact) and used to compare birth outcomes by maternal perception of acute stress. Descriptive statistics were summarized for the impact of the pandemic on the following factors: health care, in-person contact, childcare, behavior change, stress sources, and coping behaviors during the pandemic. On this questionnaire, respondents also indicated if they (1) had tested positive for a SARS-CoV-2 infection or (2) had been told by a health care provider that they had, or likely had, COVID-19.

Relevant covariates and sociodemographic data were collected using methods approved for use in the ECHO Program. These methods include self-report, medical record abstraction, and interview-assisted survey completion.30,31 Maternal race was categorized as white, black, Asian, Native Hawaiian or other Pacific Islander, American Indian or Alaska Native, Multiple races, and other race. Maternal ethnicity was categorized as Hispanic or non-Hispanic. Maternal age at the birth of their child was calculated as the child year of birth (from the Participant Registration Form) minus the maternal year of birth. Maternal education level included the following categories: less than high school; high school degree, General Education Development (GED), or equivalent; and some college, no degree, and higher. Income was classified as follows: <$30,000, 30,000–49,999, 50,000–74,999, 75,000–99,999, and 100,000 or more. Marital status included the categories of married or living with a partner or not married (widowed; separated; divorced; single, never married; partnered, not living together). Child biological sex assigned at birth was drawn from the Participant Registration Form, the Demographics of Child Form, or childbirth/neonatal medical record.

Statistical Analysis

Propensity score matching was applied to account for systematic differences in the demographic characteristics between the prepandemic and pandemic groups when estimating the effect of the pandemic on birth outcomes.32 The two groups were propensity score–matched on maternal race, ethnicity, age, education, income, and marital status, as well as child sex. Only participants with complete data for these variables were included in the aim 1 analyses.

We applied generalized estimating equation (GEE) models with robust variance estimation to examine the pandemic effect on birth outcomes after accounting for maternal perceived stress and depression, respectively. We first identified six subsamples (►Table 1) from the matched sample, each with complete data for the exposure and outcome variables: (1) sample “a” with depression and birth weight (n = 1,073); (2) sample “b” with perceived stress and birth weight (n = 655); (3) sample “c” with depression and gestational age at delivery (n = 1,468); (4) sample “d” with perceived stress and gestational age at delivery (n = 1,063); (5) sample “e” with depression and birth weight adjusted for gestational age at delivery (n = 1,073); and (6) sample “f” with complete data in the perceived stress and birth weight adjusted for gestational age at delivery (n = 655). For each sub-sample, we conducted nested GEE models: a main effect analysis of the pandemic effect on the corresponding birth outcome and models regressing the pandemic effect on the birth outcome after accounting for either depression (a, c, e) or perceived stress (b, d, f). All analyses were conducted using R33 and R packages of MatchIt34 and geepack.35

Table 1.

The six subsamples used in the general estimating equation (GEE) analyses

Subsample Variables Sample size
a Depression, birth weight 1,073
b Perceived stress, birth weight 655
c Depression, gestational age at delivery 1,468
d Perceived stress, gestational age at delivery 1,063
e Depression, birth weight adjusted for gestational age at delivery 1,073
f Perceived stress, birth weight adjusted for gestational age at delivery 655
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Results

Participant Characteristics

This study included data from women enrolled in the ECHO Program who had a live birth between January 1, 2016 and May 31, 2021 and complete data on the matched covariates for propensity score matching. The aim 1 analysis included 2,355 women in the prepandemic (n = 1,570) and pandemic (n = 785) cohorts. The aim 2 analysis included a subsequent, partially overlapping subset of pregnant women with COVID-19 survey data (N = 1,490) who described stress in daily living and coping behaviors from March 11, 2020 to May 31, 2021. The demographic characteristics of both subsets of participants are shown in ►Table 2. Nearly two-thirds of participants were white, and about 80% were non-Hispanic. Most participants (approximately 80%) had some college education. Overall, 20 to 30% of participants had an annual income lower than $30,000, and about one-third had incomes higher than $100,000/year. Nearly 40% were either overweight or obese prior to pregnancy. The average maternal age was about 30 years. The mean gestational age at delivery was 38.5 weeks overall. Approximately 24% of pregnant women reported mild to severe depression, and approximately 45% reported mild to severe perceived stress. Using the propensity score–matched sample and continuous outcome data, birth weight, birth weight adjusted for gestational age at delivery, and gestational age at birth were similar before and during the pandemic.

Table 2.

Participant characteristics of matched sample

Aim 1 sample Aim 2 sample
Variable Prepandemic (N = 1,570) Pandemic (N = 785) Overall (N = 2,355) p-Value Overall (N = 1,490)
Racea, N (%)
 White 1,169 (74.5%) 567 (72.2%) 1,736 (73.7%) 0.827 910 (72.4%)
 Black 131 (8.34%) 67 (8.54%) 198 (8.41%) 166 (13.2%)
 Asian 69 (4.39%) 33 (4.20%) 102 (4.33%) 33 (2.63%)
 Native Hawaiian or other Pacific Islander 17 (1.08%) 10 (1.27%) 27 (1.15%) <5 (0.5%)
 American Indian or Alaska Native 45 (2.87%) 30 (3.82%) 75 (3.18%) 59 (4.69%)
 Multiple race 47 (2.99%) 28 (3.57%) 75 (3.18%) 66 (5.25%)
 Other race 92 (5.86%) 50 (6.37%) 142 (6.03%) <30 (<2.5%)
 Missing 233 (15.6%)
Ethnicitya, N (%)
 Non-Hispanic 1,308 (83.3%) 649 (82.7%) 1,957 (83.1%) 0.741 1,074 (78.1%)
 Hispanic 262 (16.7%) 136 (17.3%) 398 (16.9%) 301 (21.9%)
 Missing 115 (7.7%)
Educationa, N (%)
 Less than high school 61 (3.89%) 32 (4.08%) 93 (3.95%) 0.424 79 (7.05%)
 High school degree, GED, or equivalent 174 (11.1%) 101 (12.9%) 275 (11.7%) 166 (14.8%)
 Some college or higher 1,335 (85.0%) 652 (83.1%) 1,987 (84.4%) 875 (78.1%)
 Missing 370 (24.8%)
Incomea, N (%)
 < $30,000 326 (20.8%) 177 (22.5%) 503 (21.4%) 0.902 301 (29.6%)
 $30,000–49,999 172 (11.0%) 84 (10.7%) 256 (10.9%) 115 (11.3%)
 $50,000–74,999 177 (11.3%) 89 (11.3%) 266 (11.3%) 142 (14.0%)
 $75,000–99,999 246 (15.7%) 120 (15.3%) 366 (15.5%) 169 (16.6%)
 $100,000 or more 649 (41.3%) 315 (40.1%) 964 (40.9%) 289 (28.4%)
 Missing 474 (31.8%)
Marital statusa, N (%)
 Married or living with a partner 1,392 (88.7%) 686 (87.4%) 2,078 (88.2%) 0.403 959 (82.7%)
 Not married (widowed; separated; divorced; single, never married; partnered [boyfriend or girlfriend], not living together) 178 (11.3%) 99.0 (12.6%) 277 (11.8%) 201 (17.3%)
 Missing 330 (22.1%)
Child sexa, N (%)
 Female 813 (51.8%) 392 (49.9%) 1,205 (51.2%) 0.423 625 (51.8%)
 Male 757 (48.2%) 393 (50.1%) 1,150 (48.8%) 581 (48.2%)
 Missing 284 (19.1%)
Parity, N (%)
 0 283 (46.9%) 39 (17.3%) 322 (38.8%) <0.001 121 (25.1%)
 1 192 (31.8%) 120 (53.3%) 312 (37.6%) 222 (46.0%)
 2 87 (14.4%) 34 (15.1%) 121 (14.6%) 81 (16.8%)
 ≥3 42 (6.95%) 32 (14.2%) 74 (8.92%) 59 (12.2%)
 Missing 966 (61.5%) 560 (71.3%) 1,526 (64.8%) 1,007 (67.6%)
Birth weight category, N (%)
 Low birth weight (<2,500 g) 104 (7.77%) 32.0 (7.26%) 136 (7.64%) 0.574 42 (5.56%)
 Normal birth weight (≥2,500 g and <4,000 g) 1,124 (84.0%) 379 (85.9%) 1,503 (84.5%) 649 (86.0%)
 Macrosomia (≥4,000 g) 110 (8.22%) 30 (6.80%) 140 (7.87%) 64 (8.48%)
 Missing 232 (14.8%) 344 (43.8%) 576 (24.5%) 735 (49.3%)
Gestational age category, N (%)
 Preterm (≤36 weeks) 166 (10.6%) 80.0 (10.3%) 246 (10.5%) 0.204 100 (8.31%)
 Early term (37–38 weeks) 408 (26.1%) 221 (28.3%) 629 (26.8%) 326 (27.1%)
 Full term (39–40 weeks) 860 (54.9%) 431 (55.3%) 1,291 (55.0%) 682 (56.7%)
 Late term (≥41 weeks) <150 (<10%) <50 (<4.0%) 180 (7.67%) 95 (7.90%)
 Missing <5 (<0.3%) <10 (0.6%) 9.00 (0.4%) 287 (19.3%)
Prepregnancy BMI category, N (%)
 Underweight 23 (1.72%) 12 (2.25%) 35 (1.87%) 0.0642 13 (1.54%)
 Normal weight 660 (49.3%) 238 (44.6%) 898 (47.9%) 345 (40.9%)
 Overweight 349 (26.0%) 132 (24.7%) 481 (25.7%) 204 (24.2%)
 Obese 308 (23.0%) 152 (28.5%) 460 (24.5%) 282 (33.4%)
 Missing 230 (14.6%) 251 (32.0%) 481 (20.4%) 646 (43.4%)
Maternal agea
 Mean (SD) 31.4 (5.25) 31.3 (5.03) 31.4 (5.17) 0.668 29.7 (5.17)
 Median [min, max] 32.0 [17.0, 49.0] 31.0 [19.0, 44.0] 32.0 [17.0, 49.0] 30.0 [17.0, 43.0]
 Missing 262 (17.6%)
Adjusted birth weight
 Mean (SD) 0.0631 (1.08) 0.0941 (0.988) 0.0708 (1.06) 0.578 0.130 (1.04)
 Median [min, max] 0.0176 [−3.99, 4.99] 0.127 [−3.21,3.35] 0.0530 [−3.99, 4.99] 0.138 [−3.21,4.32]
 Missing 235 (15.0%) 346 (44.1%) 581 (24.7%) 735 (49.3%)
Birth weight
 Mean (SD) 3,290 (601) 3,290 (578) 3,290 (595) 0.992 3,350 (550)
 Median [min, max] 3,350 [665, 5,440] 3,360 [539, 4,590] 3,350 [539, 5,440] 3,400 [490, 5,370]
 Missing 232 (14.8%) 344 (43.8%) 576 (24.5%) 735 (49.3%)
Gestational age at birth
 Mean (SD) 38.5 (2.14) 38.5 (1.94) 38.5 (2.08) 0.611 38.6 (1.90)
 Median [min, max] 39.0 [24.0, 42.0] 39.0 [23.0, 43.0] 39.0 [23.0, 43.0] 39.0 [23.0, 42.0]
 Missing <5 (<0.3%) <10 (0.6%) 9.00 (0.4%) 287 (19.3%)
Depression category
 Normal 639 (75.4%) 486 (78.0%) 1,125 (76.5%) 0.672 519 (78.6%)
 Mild 130 (15.3%) 83 (13.3%) 213 (14.5%) 84.0 (12.7%)
 Moderate 72 (8.50%) 49 (7.87%) 121 (8.23%) <60 (9.0%)
 Severe 6 (0.708%) 5 (0.803%) 11 (0.748%) <5 (<0.7%)
 Missing 723 (46.1%) 162 (20.6%) 885 (37.6%) 830 (55.7%)
PSS category
 Low 322 (56.2%) 290 (59.1%) 612 (57.5%) 0.8 423 (60.9%)
 Mild 178 (31.1%) 140 (28.5%) 318 (29.9%) 199 (28.6%)
 Moderate 56 (9.77%) 46 (9.37%) 102 (9.59%) 58 (8.35%)
 Severe 17 (2.97%) 15 (3.05%) 32 (3.01%) 15 (2.16%)
 Missing 997 (63.5%) 294 (37.5%) 1,291 (54.8%) 795 (53.4%)
COVID-19-positive (including likely)
 No 1,342 (90.1%)
 Yes <150 (10%)
 Missing <5 (0.3%)
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Abbreviations: BMI, body mass index; COVID-19, coronavirus disease 2019; GED, General Educational Development; PSS, Perceived Stress Scale; SD, standard deviation.

Note: p-Values for chi-squared tests were computed across categories excluding the missing category for all categorical variables between the prepandemic and pandemic groups. COVID-19-positive tests were only collected in the aim two sample.

a

Covariates used in propensity score matching for aim 1. Complete data of these variables were used.

Pregnant women who responded to the COVID-19 survey were similar to the pandemic and prepandemic cohorts (►Table 2). Approximately 10% of the sample responding to the COVID-19 survey (aim 2) self-reported having, or likely having, been infected with SARS-CoV-2.

Aim 1: Pandemic Experience, Psychosocial Stress, and Birth Outcomes

►Table 3 shows the results from models examining the effect of the COVID-19 pandemic on each birth outcome and maternal depression and perceived stress. Depression and perceived stress were highly correlated and thus modeled separately. On average, women who were pregnant during the pandemic had slightly earlier gestational ages at delivery compared with the prepandemic matched sample (B = −0.33 weeks, standard error [SE] = 0.149, p = 0.025). A null association was observed between pandemic experience and birth weight (B = −28.14 g, SE = 49.28, p = 0.568; R-squared = 0.001) and a small association was found between pandemic experience and adjusted birth weight (B = 0.15z-score units, SE = 0.07, p = 0.04; R-squared < 0.001). Screening positive for depression was significantly associated with earlier gestational age at delivery (B = −0.02 weeks, SE = 0.01, p = 0.015) after accounting for the pandemic effect. However, only 1.3% of the variance in gestational age at delivery was explained by the pandemic and depression together.

Table 3.

I impact of COVID-19 pandemic on birth outcomes

Models Predictor Estimate SE Wald p
I Predictors of birth weight
N = 1,073 Intercept 3,254.12 30.65 11,274.37 0.00
 Pandemic group 31.78 24.08 1.74 0.19
 R-squared statistic 0.00
II Predictors of birth weight
N = 1,073 Intercept 3,549.28 177.16 401.37 0.00
 Pandemic group 34.43 19.40 3.15 0.08
 Depression during pregnancy −6.06 3.26 3.45 0.06
 R-squared statistic 0.008
III Predictors of birth weight
N = 655 Intercept 3,356.70 47.50 4,993.23 0.00
 Pandemic group −28.14 49.28 0.33 0.57
 R-squared statistic 0.001
IV Predictors of birth weight
N = 655 Intercept 3,504.64 172.97 410.55 0.00
 Pandemic group −29.19 47.69 0.37 0.54
Perceived stress during pregnancy −3.06 2.72 1.27 0.26
 R-squared statistic 0.004
V Predictors of gestational age at birth
N = 1,468 Intercept 38.61 0.11 116,826.47 0.00
 Pandemic group −0.21 0.16 1.76 0.18
 R-squared statistic 0.00
VI Predictors of gestational age at birth
N = 1,468 Intercept 39.81 0.50 6,297.30 0.000
 Pandemic group −0.22 0.17 1.65 0.199
 Depression during pregnancy −0.02 0.01 5.91 0.015
 R-squared statistic 0.013
VII Predictors of gestational age at birth
N = 1,063 Intercept 38.78 0.14 75,212.94 0.00
 Pandemic group −0.33 0.15 5.01 0.03
 R-squared statistic 0.008
VIII Predictors of gestational age at birth
N = 1,063 Intercept 39.14 0.24 27,041.33 0.00
 Pandemic group −0.33 0.15 5.19 0.02
 Perceived stress during pregnancy −0.01 0.00 3.58 0.06
 R-squared statistic 0.010
IX Predictors of adjusted birth weight
N = 1,073 Intercept −0.05 0.08 0.42 0.516
 Pandemic group 0.15 0.07 4.16 0.041
 R-squared statistic 0.00
X Predictors of adjusted birth weight
N = 1,073 Intercept 0.05 0.17 0.08 0.781
 Pandemic group 0.15 0.07 4.49 0.034
 Depression during pregnancy 0.00 0.00 0.40 0.527
 R-squared statistic 0.005
XI Predictors of adjusted birth weight
N = 655 Intercept 0.09 0.11 0.74 0.39
 Pandemic group 0.10 0.11 0.87 0.35
 R-squared statistic 0.002
XII Predictors of adjusted birth weight
N = 655 Intercept 0.30 0.36 0.71 0.399
 Pandemic group 0.10 0.11 0.86 0.353
 Perceived stress during pregnancy 0.00 0.01 0.64 0.423
 R-squared statistic 0.004
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Abbreviation: COVID-19, coronavirus disease 2019; SE, standard error.

Perceived stress among mothers was not significantly associated with birth weight (B = −3.06 g, SE = 2.72, p = 0.260), gestational age (B = −0.01 weeks, SE = 0; p = 0.059), or birth weight adjusted for gestational age at delivery (B = 0, SE = 0.01, p = 0.423) after accounting for the pandemic effect.

No evidence suggested that the pandemic was significantly associated with either depression or perceived stress (►Table 1). We performed a sensitivity analysis using data from two cohorts, which contributed around 30 and 40% of the total data in the pandemic sample, and a sensitivity analysis among women who reported having moderate to high depression or perceived stress levels during pregnancy. The results were quantitatively similar to those from the entire sample in that no significant pathways were found between the pandemic and either depression or perceived stress.

Aim 2: Specific Stressors, Coping Behaviors, and Disruptions to Prenatal Care during the Pandemic

Findings from the COVID-19–specific questionnaire highlight the many ways in which the lives of pregnant women were affected by the pandemic. In this sample (n = 1,490), 73.7% of pregnant women reported that the COVID-19 pandemic had a somewhat to extremely negative impact on their lives, whereas 13.6% reported no impact. The prevalence of stressors and coping behaviors in pregnant women during the COVID-19 pandemic is shown in ►Fig. 2. Specifically, with regard to the impact of the pandemic on health care (►Fig. 2A), 42% of perinatal women reported their health care provider changed to phone or online visits; 12% reported that they did not go to health care appointments due to concerns about entering their health care provider’s office; and 16% reported their health care providers canceled appointments. In terms of social isolation (►Fig 2B), 67% reported that they had less in-person contact with family outside the home, and 73% reported less contact with friends during the pandemic.

Fig. 2.

Fig. 2

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Stressors and coping behaviors during the COVID-19 pandemic. COVID-19, coronavirus disease 2019.

Among participants who reported that they had a child in childcare (►Fig. 2C), 37% reported they and their spouse had to change their work schedule to care for their children, and 35% reported they had difficulties arranging for childcare. Some women (8%) reported they had to pay more for childcare since the pandemic began.

In terms of the pandemic impact on pregnant women’s diet and exercise (►Fig. 2D), 60% reported that they ate more home-cooked meals. While 33% reported they performed less physical exercise, 17% reported exercising more compared with before the pandemic. Slightly more women reported they spent more time outdoors in nature (36%) compared with women who reported they spent less time in nature as a result of the pandemic (25%).

Participants reported that the greatest sources of psychosocial stress during the COVID-19 pandemic (►Fig. 2E) included health concerns (46%), the impact on their child and family members (46 and 47%, respectively), and social distancing or being quarantined (51%). Compared to these primary stress sources, participants were moderately stressed about financial concerns (34%) and were concerned about the pandemic’s impact on work (30%) and their community (26%). A smaller number of participants were worried about access to food (13%), baby supplies (15%), personal care products or home supplies (18%), and medical care (14%).

Most participants reported positive adaptive behaviors to cope with the pandemic experience (►Fig. 2F). Specifically, they chose to talk with friends and family by phone, text, or video (69%); engage in more family activities (30%); and spend more time inside reading books or doing puzzles and crosswords (25%) than prior to the pandemic. A small number of participants reported meditation and/or mindfulness practices (19%) and even fewer reported talking to health care or mental health providers more frequently (9%) as a result of the pandemic. Some participants (41%) spent more time on screens, such as TV, video games, and social media, and 25% ate more often, including snacking. Substance use in pregnancy was only reported by a small number of women as a coping behavior: alcohol in 5%, tobacco in 2%, and marijuana in 3%. Nearly 20% of respondents stated that they had not adopted any of the listed coping mechanisms.

Aim 2: Pandemic Experience, Prenatal Care, and Birth Outcomes

We further examined the prenatal care that women received across different pandemic time periods, and the association between distress related to their prenatal care during the pandemic and birth outcomes (►Table 4). Of the women who gave birth during the first wave of the pandemic (i.e., February 28, 2020–June 19, 2020), 45% were moderately or extremely distressed about changes to their prenatal care and birth experiences, and 25% reported that the support they received from their prenatal care provider(s) became somewhat or significantly worse. Women who gave birth during the earliest period of the pandemic were most likely to report feeling sometimes, rarely, or not at all happy and satisfied with life (35%). These rates declined as the pandemic continued to 28% of women who gave birth between September 28, 2020 and January 10, 2021 and to 15% of women who gave birth between January 11, 2021 and May 31, 2021. A similar trend in the prevalence of women reporting moderate to extreme dissatisfaction with their prenatal care was observed as the pandemic continued, starting with 43% and declining to 15% in the spring of 2021. No statistically significant differences were observed in gestational age at delivery, birth weight, or birth weight adjusted for gestational age at delivery across reporting periods (►Table 4).

Table 4.

Impact of pandemic period on birth outcomes and prenatal care

Delivery dates by four pandemic periods
February 28, 2020-June 19, 2020 June 20, 2020-September 27, 2020 September 28, 2020-January 10, 2021 January 11, 2021-May 31, 2021 Missing Overall p-Value
(N=224) (N=183) (N=183) (N=201) (N=699) (N=1,490)
Adjusted birth weight
 Mean (SD) 0.159 (1.07) 0.270 (0.965) 0.129 (0.842) 0.255 (0.881) 0.0644 (1.12) 0.130 (1.04) 0.93
 Median [min, max] 0.256 [−3.21, 2.49] 0.270 [−1.57, 2.20] 0.0604 [−1.84, 2.13] 0.257 [−1.59, 2.54] 0.0530 [−2.89, 4.32] 0.138 [−3.21,4.32]
 Missing 77 (34.4%) 96 (52.5%) 81 (44.3%) 141 (70.1%) 340 (48.6%) 735 (49.3%)
Birth weight
 Mean (SD) 3,380 (488) 3,370 (577) 3,280 (552) 3,430 (451) 3,350 (582) 3,350 (550) 0.30
 Median [min, max] 3,410 [1,520, 4,480] 3,430 [1,470, 4,340] 3,350 [539, 4,420] 3,430 [2,100, 4,590] 3,380 [490, 5,370] 3,400 [490, 5,370]
 Missing 77 (34.4%) 96 (52.5%) 81 (44.3%) 141 (70.1%) 340 (48.6%) 735 (49.3%)
Gestational age at birth
 Mean (SD) 38.6 (1.59) 38.5 (1.94) 38.5 (1.99) 38.5 (1.70) 38.7 (2.07) 38.6 (1.90) 0.70
 Median [min, max] 39.0 [32.0, 41.0] 39.0 [29.0, 41.0] 39.0 [23.0, 42.0] 39.0 [29.0, 42.0] 39.0 [24.0, 42.0] 39.0 [23.0, 42.0]
 Missing <5 (<3%) 10 (5.5%) <5(<3%) <5 (<3%) 269 (38.5%) 287 (19.3%)
Birth weight category, N (%)
 Low birth weight (<2,500 g) 8 (5.44%) 5 (5.75%) 5 (4.90%) 2 (3.33%) 22 (6.13%) 42 (5.56%) 0.26
 Normal birth weight (≥2,500 g and <4,000 g) 130 (88.4%) 70 (80.5%) 92 (90.2%) 55 (91.7%) 302 (84.1%) 649 (86.0%)
 Macrosomia (≥4,000 g) 9 (6.12%) 12 (13.8%) 5 (4.90%) 3 (5.00%) 35 (9.75%) 64 (8.48%)
 Missing 77 (34.4%) 96 (52.5%) 81 (44.3%) 141 (70.1%) 340 (48.6%) 735 (49.3%)
Gestational age at birth category, N (%)
 Preterm (≤36 weeks) 20 (9.05%) 16 (9.25%) 17 (9.39%) 16 (8.08%) 31 (7.21%) 100 (8.31%) 0.4
 Early term (37–38 weeks) 66 (29.9%) 39 (22.5%) 56 (30.9%) 62 (31.3%) 103 (24.0%) 326 (27.1%)
 Full term (39–40 weeks) 124 (56.1%) 110 (63.6%) 92 (50.8%) 108 (54.5%) 248 (57.7%) 682 (56.7%)
Late term (≥41 weeks) <15 (6.0%) 8 (4.62%) <20 (10.0%) <20 (8.0%) 48 (11.2%) 95 (7.90%)
 Missing <5 (<3%) 10 (5.5%) <5(<3%) <5 (<3%) 269 (38.5%) 287 (19.3%)
In general, how distressed are you about changes to your prenatal care/or your birth and newborn experiences due to the COVID-19 pandemic?
 Not at all 51 (24.3%) 52 (28.4%) 69 (38.3%) 116 (57.7%) 320 (52.4%) 476 (53.7%) <0.001
 Mildly 68 (32.4%) 80 (43.7%) 80 (44.4%) 58 (28.9%) 182 (29.8%) 302 (34.0%)
 Moderately 45 (21.4%) 29 (15.8%) <30 (< 15.0%) <30 (<1 5.0%) 87 (14.2%) 91 (10.3%)
 Extremely 46 (21.9%) 22 (12.0%) <10 (<5.0%) <5 (<2.5%) 22 (3.60%) 18 (2.0%)
 Missing 33 (33.3%) 141 (35.1%) 213 (45.6%) 195 (39.1%) 88 (12.6%) 603 (40.5%)
How has the support you receive from your prenatal care provider(s) changed due to the COVID-19 pandemic?
 Significantly worsened 7 (3.35%) 11 (6.01%) <5(<3%) <5 (<3%) 12 (1.97%) 13 (1.5%) <0.001
 Somewhat worsened 44 (21.1%) 28 (15.3%) 25 (13.7%) 17 (8.50%) 64 (10.5%) 95 (10.7%)
 No change 134 (64.1%) 116 (63.4%) 138 (75.8%) 160 (80.0%) 460 (75.7%) 685 (77.4%)
 Somewhat improved 16 (7.66%) 19 (10.4%) 17 (9.34%) 11 (5.50%) 43 (7.07%) 59 (6.7%)
 Significantly improved 8 (3.83%) 9 (4.92%) <5(<3%) <10 (5%) 29 (4.77%) 33 (3.7%)
 Missing 33 (33.3%) 143 (35.6%) 213 (45.6%) 195 (39.1%) 91 (13.0%) 605 (40.6%)
Since becoming aware of the COVID-19 pandemic, how often have you felt happy and satisfied with your life?
 Not at all <5 (<3%) 6 (3.64%) <5(<3%) <5 (<3%) 29 (4.52%) 40 (2.86%) <0.05
 Rarely 12 (5.56%) 5 (3.03%) 10 (5.52%) 8 (4.06%) 43 (6.71%) 78 (5.57%)
 Sometimes 61 (28.2%) 32 (19.4%) 27 (14.9%) 48 (24.4%) 147 (22.9%) 315 (22.5%)
 Often 82 (38.0%) 77 (46.7%) 93 (51.4%) 84 (42.6%) 276 (43.1%) 612 (43.7%)
 Very often 61 (28.2%) 45 (27.3%) 50 (27.6%) 53 (26.9%) 146 (22.8%) 355 (25.4%)
 Missing <10 (<6%) 18 (9.8%) <5(<3%) <5 (<3%) 58 (8.3%) 90 (6.0%)
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Abbreviations: COVID-19, coronavirus disease 2019; SD, standard deviation.

Note. p-Values for chi-squared tests were computed across categories excluding the missing category for all categorical variables across the pandemic periods.

Overall, when asked how they viewed COVID-19, 74% of pregnant women responded with somewhat, moderately, or extremely negative views. Pregnant women with negative feelings about the pandemic were more likely to be white, married or living with a partner, more highly educated with a higher income level, and older (►Supplementary Table S2, available in the online version). As shown in ►Table 5, birth weight adjusted for gestational age at delivery was higher for children born to mothers with overall positive or neutral feelings toward the pandemic compared with those born to women with negative feelings toward the pandemic (p < 0.05). However, birth weight and gestational age at delivery were similar for infants born to women regardless of the reported impact of COVID-19 on their lives. These results were similar when only those women who had completed the questionnaire while pregnant (i.e., prospectively) were included in the analysis (►Supplementary Table S3, available in the online version).

Table 5.

Birth outcomes related to maternal answers to the question, “Please indicate the extent to which you view the COVID-19 pandemic as having either a positive or negative impact on your life”

Negative impact (N = 1,098) Positive or no impact (N = 383)
Extremely negative (N=163) Moderately negative (N=308) Somewhat negative (N=627) No impact (N=202) Slightly positive (N=120) Moderately positive (N=47) Extremely positive (N=14) Overall (N=1,490) p-Value
Gestational age at birth
 Mean (SD) 38.6 (1.82) 38.5 (2.10) 38.6 (1.90) 0.18
 Median [min, max] 39.0 [23.0, 42.0] 39.0 [27.0, 42.0] 39.0 [23.0, 42.0]
 Missing 215 (19.7%) 69 (17.8%) 287 (19.3%)
Birth weight
 Mean (SD) 3,340 (551) 3,390 (552) 3,350 (550) 0.27
 Median [min, max] 3,370 [490, 5,270] 3,430 [900, 5,370] 3,400 [490, 5,370]
 Missing 540 (49.4%) 190 (49.1%) 735 (49.3%)
Adjusted birth weight
 Mean (SD) 0.0800 (1.03) 0.268 (1.06) 0.130 (1.04) <0.05
 Median [min, max] 0.0744 [−3.21,4.11] 0.272 [−2.24, 4.32] 0.138 [−3.21, 4.32]
 Missing 540 (49.4%) 190 (49.1%) 735 (49.3%)
n = 9 participants skipped or missed this question
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Abbreviations: COVID-19, coronavirus disease 2019; max, maximum; min, minimum; SD, standard deviation.

Discussion

Given the known association between psychosocial stress and adverse birth outcomes,1,2 we sought to examine if the pandemic—widely regarded as a source of major stress—was associated with maternal stress and depression as well as birth weight and gestational age. In addition, we aimed to describe COVID-19–specific stressors, including changes in prenatal care, experienced by pregnant individuals among dyads in a large national birth cohort program (ECHO) during specific time periods in the pandemic. This study is the first, to our knowledge, to include measures of maternal depression and perceived stress and assess their impact on birth outcomes prior to and during the COVID-19 pandemic across multiple U.S. cohorts and the first to provide a description of specific types and sources of stress reported by pregnant women across time during the first 15 months of the pandemic. Using a propensity score matching approach, we found that pandemic experience was associated with small effects on birth outcomes, including decreased gestational age at delivery and increased birth weight adjusted for gestational age at delivery. When using data from the COVID-19–specific questionnaire, we found that women who reported a positive impact or no impact of the pandemic on their lives had infants with slightly higher birth weight adjusted for gestational age at delivery.

Contrary to other studies that reported reductions in births prior to 37 weeks during the pandemic,36–40 we did not detect a strong effect of the pandemic on birth outcomes. In fact, our results from the ECHO cohorts demonstrate small negative effects of the pandemic on gestational age at delivery (a decrease of 2.3 days) in the United States. However, such small effects may be meaningful at a population level and may have consequences across the life course.41–43 Explanations for the difference may be that our study was large and composed of many sites throughout the United States. rather than a single site or clinical system. Additionally, pandemic impacts outside the United States may be distinct, and/or the data in this study were not limited to administrative data as prior studies have been.36

Levels of depression and perceived stress were similar prior to the pandemic and during the pandemic (aim 1). While reports from China44 and Canada45 indicate increased levels of depression and anxiety among pregnant individuals during the COVID-19 pandemic compared with before the pandemic, we did not observe similar trends in this large U.S. cohort. Several possible explanations may account for the essentially unchanged maternal depression and perceived stress during the study period. First, our results may reflect the experiences of segments of the population with resources or the resiliency to weather the impact of the pandemic. In addition, these results could highlight the fact that a large and increasing proportion of U.S. pregnant women—approximately 15% (which is slightly higher than the general population)46,47—experienced depressive symptoms and distress even prior to the pandemic.48 Furthermore, the lack of an overall impact of the pandemic on stress and depression could suggest that some sub-populations of individuals may have experienced some benefits from other impacts of the pandemic.49 For example, pandemic-induced changes in remote work could lead to reduced commuting, more positive coping and family time, or other changes.

We detected small negative effects of maternal depression, but not perceived stress, on birth outcomes during the pandemic. In this analysis, depression was associated with decreased gestational age at delivery and tended to be associated with decreased unadjusted birth weight. Depression has been linked to adverse birth outcomes, particularly gestational age at birth, in many previous studies.15,50 It is possible that these effects operated through other factors than the pandemic, and this observation suggests a need for future research to identify the potential mechanisms of pandemic-linked effects on birth outcomes.

The degree to which pregnant individuals perceived the impact of the pandemic on their lives varied widely, and temporal and geographic differences may have played a differential role in the impact of pandemic stressors across the study sites. COVID-19 stressors, such as childcare and finances, were only reported in a small number of pregnant individuals. Most, however, reported social isolation outside of their household and some impact on prenatal care, particularly early in the pandemic when there were many changes to policies, including restrictions on visitors or not allowing the partner to be present during labor and delivery, which are consistent with those in a small mixed-methods study.51

Limitations and Strengths

While our study had a generous sample size assembled from a large number of pregnancy and birth cohorts across the United States, it was not without limitations. First, the findings are limited to the cohorts that comprised the analytic sample, which may not be representative of the U.S. population although assembled from broad geographical locations (►Fig. 1B). The results are also bound to the timing of the assessments during a pandemic with oscillating rates of infection and dramatic changes in immunizations and therapeutics. Additionally, experiences and outcomes may vary by geography and sub-population as pandemic surges varied across place and time and were not equally or randomly distributed in the population. Second, complete data on the gestational age at COVID-19 survey completion were not available, which precluded us from accounting for the timing of psychosocial stress and specific stressors across the prenatal period. Third, women who were included in the analysis and had complete data available on depression and perceived stress may have been less impacted by the pandemic, both individually and geographically, or had more resources to mitigate its impact on their lives than those who did not respond.

Despite these weaknesses, our study is among the largest of its kind and included data from multiple sites across the United States. and across multiple time points during the first 15 months of the COVID-19 pandemic. It is unique for including the effect of maternal depression and perceived stress on birth outcomes using propensity score–matched samples in the period prior to and during the pandemic and for reporting specific stressors and a comprehensive assessment of the many ways the pandemic affected pregnant women. The results provide insight into the design of future research and modalities to best support mothers and their families during critical periods of human development.

Conclusion

In this national cohort, we detected no effect of the COVID-19 pandemic on prenatal depression or perceived stress. However, experiencing the COVID-19 pandemic in pregnancy was associated with decreases in gestational age at birth as well as distress about changes in prenatal care early in the pandemic.

Supplementary Material

Supplementary Material

Key Points.

  • COVID-19 was associated with shortened gestations.

  • Depression was associated with shortened gestations.

  • However, stress during the pandemic remained unchanged.

  • Most women reported negative impacts of the pandemic.

Acknowledgements

The authors wish to thank our ECHO colleagues; the medical, nursing, and program staff; and the children and families participating in the ECHO cohorts. We thank Tim Shields of Johns Hopkins Bloomberg School of Public Health for making the map (►Fig. 1B). We also acknowledge the contribution of the following ECHO program collaborators:

ECHO Components—Coordinating Center: Duke Clinical Research Institute, Durham, North Carolina: Smith PB, Newby KL; Data Analysis Center: Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland: Jacobson LP; Research Triangle Institute, Durham, North Carolina: Parker CB; Person-Reported Outcomes Core: Northwestern University, Evanston, Illinois: Gershon R, Cella D.

ECHO Awardees and Cohorts— Albert Einstein College of Medicine, Bronx, New York: Aschner J; Icahn School of Medicine at Mount Sinai, New York, NY: Teitelbaum SL; Stroustrup A; Cohen Children’s Medical Center, Northwell Health: Stroustrup A; Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio: Merhar S; Children’s Hospital and Clinic Minnesota, Minneapolis, MN: Lampland A; University of Buffalo, Buffalo, NY: Reynolds A; University of Florida, College of Medicine, Jacksonville, FL: Hudak M; University of Rochester Medical Center, Rochester, NY: Pryhuber G; Vanderbilt Children’s Hospital, Nashville, TN: Moore P; Wake Forest University School of Medicine, Winston Salem, NC: Washburn L; Boston Children’s Hospital, Boston, MA: Mansbach J; Children’s Hospital of Philadelphia, Philadelphia, PA: Spergel J; Norton Children’s Hospital, Louisville, KY: Stevenson M; Phoenix Children’s Hospital, Phoenix AZ: Bauer C; Memorial Hospital of Rhode Island, Providence RI: Deoni S; University of Puerto Rico, San Jaun, PR: Canino G; Kaiser Permanente Northern California Division of Research, Oakland, CA: Croen L; University of Wisconsin, Madison WI: Gern J; Henry Ford Health System: Detroit, MI: Zoratti E; Marshfield Clinic Research Institute, Marshfield, WI: Seroogy C: Bendixsen C; Boston Medical Center, Boston MA: Bacharier L; O’Connor G; Children’s Hospital of New York: New York, NY: Bacharier L; Kattan M; Johns Hopkins University, School of Medicine, Baltimore, MD: Wood R; Bacharier L; Washington University in St Louis, St Louis, MO: RiveraSpoljaric K; Vanderbilt University, Nashville TN: Hartert T; Henry Ford Health System, Detroit, MI: Johnson C; University of Wisconsin, Madison, WI: Singh A; University of Southern California, Los Angeles, CA: Gilliland F; Farzan S; Bastain T; University of Pittsburgh, Pittsburgh, PA: Hipwell A; University of Washington, Department of Environmental and Occupational Health Sciences, Seattle, WA: Karr C; University of Tennessee Health Science Center, Memphis, TN: Mason A; Seattle Children’s Research Institute, Seattle, WA: Sathyanarayana S; Children’s Mercy, Kansas City, MO: Carter B; Emory University, Atlanta, GA: Marsit C; Helen DeVos Children’s Hospital, Grand Rapids, MI: Pastyrnak S; Kapiolani Medical Center for Women and Children, Providence, RI: Neal C; Los Angeles Biomedical Research Institute at Harbour-UCLA Medical Center, Los Angeles CA: Smith L; Wake Forest University School of Medicine, Winston Salem, NC: Helderman J; Prevention Science Institute, University of Oregon, Eugene, OR: Leve L; George Washington University, Washington, DC: Ganiban J; Pennsylvania State University, University Park, PA: Neiderhiser J; Indiana University, Riley Hospital for Children: Indianapolis, IN, Tepper R; University of Pittsburgh Medical Center, Magee Women’s Hospital, Pittsburgh, PA: Simhan H; Michigan State University, East Lansing, MI: Kerver J; Henry Ford Health System, Detroit, MI: Barone, C; Michigan Department of Health and Human Services, Lansing, MI: McKane, P; Michigan State University, East Lansing, MI: Paneth N; University of Michigan, Ann Arbor, MI: Elliott, M; Columbia University Medical Center, New York, NY: Herbstman J; University of Illinois, Beckman Institute, Urbana, IL: Schantz S; University of California, San Francisco:, San Francisco, CA: Woodruff T; University of Utah, Salt Lake City, UT: Stanford J; Icahn School of Medicine at Mount Sinai, New York, NY: Wright R; Boston Children’s Hospital, Boston MA: Bosquet-Enlow M; George Mason University, Fairfax, VA: Huddleston K; University of California, San Francisco, San Francisco CA: Bush N; University of Minnesota, Minneapolis, MN: Nguyen R; University of Rochester Medical Center: Rochester, NY: Barrett E.

Funding

Research reported in this publication was supported by the Environmental influences on Child Health Outcomes (ECHO) program, Office of the Director, National Institutes of Health, under Award Numbers U2COD023375 (Coordinating Center), U24OD023382 (Data Analysis Center), U24OD023319 (PRO Core), UH3OD023251 (Alshawabkeh), UH3OD023320 (Aschner), UH3OD023253 (Camargo), UH3OD023248 (Dabelea), UH3OD023313 (Deoni), UH3OD023328 (Duarte), UH3OD023318 (Dunlop), UH3OD023279 (Elliott), UH3OD023289 (Ferrara), UH3OD023282 (Gern), UH3OD023287 (Breton), UH3OD023244 (Hipwell), UH3OD023275 (Karagas), UH3OD023271 (Karr), UH3OD023347 (Lester), UH3OD023389 (Leve), UH3OD023288 (McEvoy), UH3OD023349 (O’Connor), UH3OD023285 (Kerver), UH3OD023290 (Herbstman), UH3OD023272 (Schantz), UH3OD023249 (Stanford), UH3OD023305 (Trasande), and UH3OD023337 (Wright).

Footnotes

Conflict of Interest

C.M. served as Chair of the Data Safety Monitoring Board (DSMB) for an Aerogen-supported trial: A Partially-Blind, Randomized, Controlled, Parallel-Group Dose Ranging Study to Determine the Efficacy, Safety and Tolerability of AeroFactTM (SF-RI 1 surfactant for inhalation combined with a dedicated drug delivery system) in Preterm Infants at Risk for Worsening Respiratory Distress Syndrome; Chair of the DSMB for the NIH RCT evaluating Sildenafil in Preterm Infants with Pulmonary Hypertension. J.N. served on the Advisory Board for the Twin Life Study (Germany); received royalties or licenses from Macmillan and consulting fees from the University of Southern California. J.H. served on the New York State Drinking Water Quality Council. The other authors have no conflicts of interest to disclose.

Note

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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