The present study extends previous findings and provides new evidence on how psychosocial environment (i.e. stress/pregnancy planning) affects foetal outcome. We have shown that there was a significant reduction in the intake of alcohol, caffeine-containing and sugary drinks, as well as sugary refreshments during pregnancy. In our cohort 14% of women smoked during pregnancy. This is comparable to a recent study of Australian women that showed that 14.8% of non-indigenous women were smoking during pregnancy (10
). Maternal smoking during pregnancy is a well-established risk factor for perinatal mortality, miscarriage and premature births (11
) and exposure to heavy smoking in utero
increases the risk of nicotine dependence in adulthood (10
). In this study, another notable finding was identified, that parental/passive smoking was not reduced in the household during pregnancy, staying at a high rate of 59%. This could be detrimental, as all types of passive smoking have been associated with a significant increase in the risk of infants developing lower respiratory infections in the first two years of life (12
In this questionnaire seven questions associated with the immune profile of this cohort were incorporated. We have done so, as acute infections in pregnant women are often associated with adverse effects, including miscarriage, preterm labour, preeclampsia (PE) or even stillbirth (13
). Notably, a significant inverse correlation has been identified between difficulty to ‘fight’ an infection and number of colds and number of infections during pregnancy. Similar data have been obtained by a recent study of Australian women, where a cold was the most common infection reported using a similar self-reported method (16
). In the study by Lain et al
), only 21% of the women that reported an infection sought medical attention. We do not have such records for our cohort. However, our data on the immune profile also have certain strengths as it includes the investigation of numerous rather than a single infection and incorporates both chronic and acute infections.
With regard to the effect of caffeine during pregnancy, there is still some controversy in the field, as it has been implicated as a cause of spontaneous abortion, intrauterine growth restriction (IUGR), low birth weight and pre-term delivery (17
). However, other investigators failed to find any association between caffeine intake and poor pregnancy outcomes (18
). Adeney et al
) revealed that moderate caffeine consumption during pregnancy exerts a protective effect towards gestational diabetes mellitus (GDM) (19
). These mixed results may arise due to the problem of accurately assessing the caffeine intake. In addition, the amount of caffeine varies greatly in different coffee chains. In a recent study, caffeine levels varied up to 6-fold (20
). In our cohort, a significant reduction in caffeine intake was noted, although we were not able to quantify the precise amount ingested. Nawrot et al
) suggested that women of reproductive age should consume less than 300 mg of caffeine/day.
In this cohort, a significant decrease in the consumption of sugar-containing drinks during pregnancy was observed. In the USA for example, sugar-sweetened soft drinks are the principal energy contributors in the diet (22
) and they appear to play a role in the obesity epidemic due to their high content of readily absorbed sugars (23
). In a recent study involving 59,334 Danish pregnant women, it has been shown that daily intake of artificially sweetened soft drinks may increase the risk of preterm delivery (24
). Therefore, it appears that the decrease noted in this study may protect from preterm labour. Clearly further epidemiological studies are required to confirm these effects.
Paradoxically, a wide range of responses concerning the consumption of fried/fast-food during pregnancy was noted. As mentioned previously, poor nutrition may lead to a range of health problems for mothers, including metabolic syndrome and cancer. Pregnancy results in a state of increased energy demand of approximately 300 kcals/day. In addition, maternal energy metabolism is altered during pregnancy and varies greatly among women. The same women who had increased consumption of fast food had also increased the intake of iron-rich foods and dairy products. However, there is no evidence to suggest that this beneficial intake of calcium and iron counteract poor eating habits. Our findings are comparable to an Australian study of 409 women where a high proportion of pregnant women consumed 2 meals of snacks (fast food/take away) per week (25
). This finding may also reflect that new generations appear to give up the traditional Mediterranean dietary pattern, adopting new dietary trends (26
). In addition, dietary patterns are influenced by various socio-demographic characteristics. Taking these into consideration it is imperative to develop dietary interventions to prevent undesirable health consequences during pregnancy.
Another factor that affects pregnancy is exercise. Regular physical activity is associated with improved physiological, metabolic and psychological parameters, and with a reduced risk of morbidity and mortality (27
). In our study [based on the measure of Paffenbarger et al
)] there was a clear shift towards a sedentary lifestyle during pregnancy. For example, there was an increase in overall inactivity of approximately 15% and an equal decrease in moderate exercise. Regular physical activity during pregnancy has been proved to be beneficial for the mother as well as the foetus. Maternal benefits include improved cardiovascular function, minimal weight gain during pregnancy, decreased musculoskeletal discomfort and mood stability, reduction of GDM and gestational hypertension that may lead to preeclampsia (PE). Benefits for the foetus include reduction of fat mass, reduced effects of maternal stress and advanced neurobehavioural maturation (27
Pregnancy planning and maternal attitudes towards pregnancy also appear to affect foetal weight. Approximately 87 million unplanned pregnancies occur every year worldwide and there is a link between negative experiences of women with unplanned pregnancies before and after labour. For example, two studies have linked unplanned pregnancies with poor relationships with their spouses, experienced financial and educational difficulties and problems with their professional careers (28
). Data from our study suggest that there is no mother-foetal coherence in the group of unplanned pregnancies, pregnancies since maternal stress did not predict infant weight in that group. Noteworthy findings included the effects of maternal attitude to pregnancy and pregnancy planning on infant birth weight. A potential interpretation would be that possessing a positive or neutral (accepting) attitude towards the pregnancy buffers or protects against any potential negative effect of planning/not planning the pregnancy on foetal weight. However, women may demonstrate negative attitudes even towards a planned pregnancy, and therefore chronic stress may adversely affect foetal development and weight to a greater extent when compared with subjects with a negative attitude but in an unplanned pregnancy.
Consequently, the future directions for healthcare based on these data should be investigated. With regards to the nutritional status and in view of the global epidemic of sedentary life-style and obesity, we propose that pregnant women should increase their physical activity as a preventative measure against adverse pathologies for the mother as well as the foetus. Further studies with larger sample sizes are required to provide solid evidence of associations between increased physical activity and positive outcomes of labour and delivery. The use of a self-reported method for infections may be of clinical significance, as it is likely to allow obstetricians/midwifes to classify patients in a high or low-risk group for predisposition towards pregnancy complications.
Finally, we have also provided evidence that there is no mother-foetal coherence in the group of unplanned pregnancies. Therefore, raising awareness of the impact of unplanned or unintended pregnancy is key. This may be done by educating the public about social and health issues associated with unintended pregnancy. Unintended pregnancy affects individuals, families and communities. Only by communicating this problem to the public, increasing community and individual understanding about prevention and improving access to necessary services, ensures more positive outcomes for both the mother and the foetus.