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Study Protocol

Association of maternal mental health on development and growth of children under two years old from Wardha: Protocol for a cross-sectional study

[version 1; peer review: awaiting peer review]
Alisha Handa
https://orcid.org/0000-0003-4764-6442
1, Abhay Gaidhane
https://orcid.org/0000-0002-4814-2695
1, Zahiruddin Quazi1, Sonali Chaudhari1
Alisha Handa
https://orcid.org/0000-0003-4764-6442
1, Abhay Gaidhane
https://orcid.org/0000-0002-4814-2695
1, Zahiruddin Quazi1, Sonali Chaudhari1
PUBLISHED 08 Jan 2024
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS AWAITING PEER REVIEW

This article is included in the Datta Meghe Institute of Higher Education and Research collection.

Abstract

Background

A mother’s mental health is crucial in shaping the early years of her child’s development and growth. Many mental health conditions can have an impact on pregnant and postpartum mothers. Postpartum anxiety, postpartum depression, and postpartum psychosis are a few mental health conditions that can affect the mother and child if not catered to at the right time. A mother’s mental health can lead to childhood delays in milestones, language development and growth. This study intends to examine the way various aspects of mothers’ mental health, like depression and stress, can influence the early developmental trajectories and physical growth of young children.

Protocol

A cross-sectional study with 196 participants will be conducted. Eligibility criteria includes mothers with children under two years old. Data will be collected using a semi-structured questionnaire. Maternal mental health will be assessed using validated measures, including standardised questionnaires. Established developmental assessments and anthropometric measurements will evaluate child development and growth.

Conclusions

The findings of the study shall help in planning appropriate interventions to reduce the association of maternal mental with childhood delay in development and growth.

Keywords

Maternal health, Maternal mental health, Mental health, Childhood developmental delay, Childhood growth delay, Cross-sectional study, Maternal depression, Maternal toxic stress

Corresponding author: Alisha Handa
Competing interests: No competing interests were disclosed.
Grant information: The author(s) declared that no grants were involved in supporting this work.
Copyright:  © 2024 Handa A et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Handa A, Gaidhane A, Quazi Z and Chaudhari S. Association of maternal mental health on development and growth of children under two years old from Wardha: Protocol for a cross-sectional study [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:23 (https://doi.org/10.12688/f1000research.142774.1) First published: 08 Jan 2024, 13:23 (https://doi.org/10.12688/f1000research.142774.1) Latest published: 08 Jan 2024, 13:23 (https://doi.org/10.12688/f1000research.142774.1)

Introduction

The well-being of an individual is highly influenced by their mental health, which in turn impacts the people around them. According to the World Health Organization (WHO), the importance of mental health is shown by the fact that health is a state of complete physical, mental and social well-being and not merely the absence of disease.1 A crucial component of the environment in which a child dwells is responsive parenting, which positively affects a child’s early life development.2 Mental health includes emotional, psychological, and social well-being components.3 In a study conducted out of 280,584 deliveries, the maternal mortality rate was 138 per 100,000 and 11.7% of the women had at least one morbidity.3 WHO claims that mental health is a condition in which people are aware of their potential, can manage daily stress successfully, work efficiently, contribute to their community, and lead fulfilling lives.4 Our mental health profoundly shapes our thoughts, actions, and reactions to life’s challenges. Personal, societal, and structural factors can influence our mental health at any time, leading to shifts along the mental health continuum. Adverse experiences during critical periods, such as early childhood, can have particularly detrimental effects.2 Given these considerations, safeguarding mental health and implementing measures to promote positive mental well-being are crucial for shaping an individual’s life.

Early childhood development (ECD) programmes come in a wide variety and frequently follow a one-size-fits-all format driven by broad, generally unsuccessful aims.5 The interactions between mothers and their children are more pleasant when the mothers have the necessary knowledge and abilities to promote ECD.2 ECD programmes are modified in a way to meet the particular needs of the families and the communities and that’s how they benefit the families.6

Development delay is when the child falls behind their peers in one or more aspects of their emotional, mental, or physical development. Infants and young children may face developmental delays, including language or speech challenges, eyesight, motor skills, social-emotional development, and cognitive skills.7

Cognitive growth is how an individual learns to gather, arrange, and use their knowledge.8 Children of mothers with poor mental health may struggle to learn, remember, pay attention, and solve problems.9 Poor cognitive and behavioural outcomes, aberrant neurodevelopment, and growth failure result from inadequate early postnatal nutrition.10

Language development peaks when the brain develops and matures during the first three years of life. A rich auditory and linguistic environment is crucial for optimal language acquisition. Children of mothers with poor mental health may encounter difficulties acquiring language and exhibit delays in speech and language development.11

Motor development refers to the changes in motor behaviour experienced throughout an individual’s lifespan. A combination of biological and environmental variables influences motor development. Gross motor skills are those that require whole-body movement and involve the large (core stabilising) muscles of the body to perform everyday tasks, whereas fine motor skills include making precise motions with the small muscles of the hands and wrists.12 Children of mothers who experience mental illness may struggle with the use of fine motor skills and general motor abilities.13

A child’s social and emotional well-being encompasses developing emotional intelligence and self-regulation capacity, establishing and maintaining relationships, and creating a sense of self and social identity. Delays in social and emotional well-being are observed in children with mothers experiencing poor mental health, which can lead to difficulties in establishing and maintaining relationships, regulating emotions, and engaging in age-appropriate social interactions.14

A significant public health issue worldwide is child malnutrition. Overall, 144 million children under 5 years of age are stunted, and 47 million are wasted. Around 45% of deaths among children under 5 years of age are linked to undernutrition. An essential part of child health surveillance is measuring the growth of infants and children.15 Impaired growth and development that children have from poor nutrition, repeated infection, and inadequate psychosocial stimulation is known as stunting. Height-for-age is less than two standard deviations according to the WHO Child Growth Standards median. In the first 1,000 days from conception until two years of age, impaired growth has adverse consequences on the child.16 The most immediate and visible life threatening form of malnutrition is wasting. Children with weak immune systems and who are too thin for their age succumb to developmental delays, disease and death.17 The most vulnerable age group for malnutrition and micronutrient deficiencies continues to be children under 5 years old. Worldwide, 5.9 million children under the age of five die each year, with hunger being a factor in 45% of those fatalities. Being underweight is a major sign of malnutrition in children and has long-term consequences such as irregularities in physical and mental health, behavioural issues, and poor academic performance. Underweight children are those whose weight for age measurements are below minus two standard deviations (2SD).18

Parents and paediatricians can monitor weight changes in the child by regularly weighing them. They can then advise the mother what steps should be taken to maintain proper weight of the child based on these weight changes.19 The responsibility of providing appropriate care for children is significant; moreover, according to some theories, the caregivers’ poor mental health may compromise the growth and development of their offspring. Recent studies in South Asia have shown a connection between postnatal depression and stunted child development, underscoring the link between care givers mental health and their children.20

Millions of people worldwide are condemned to a life of limitations and physical damage due to childhood stunting, malnutrition, and Water, Sanitation and Hygiene (WASH) practices. The leading causes of diarrhoea and slow growth, which have long-lasting negative impacts on a child’s health, include undernutrition, nutritional deficiencies, and contamination.21

This research aims to examine the cognitive, verbal, physical, social, and emotional development of children and how maternal mental health can affect these domains. The objective is to explore the connection between possible child growth and developmental delay with maternal mental health.

Rationale

Research on the relationship between maternal mental health and childhood delay in growth and development is substantially underexplored. Limited research and knowledge has been found about the connection between mothers’ mental health and the growth and developmental outcomes of their children. Although evidence suggests that a mother’s mental health and infant development are strongly correlated, there is a lack of comprehensive and in-depth studies that thoroughly explore the underlying mechanisms of this relationship and its long-term effects on the child’s growth and development. This research gap emphasizes the need for additional investigation in this area. The objective of our study is to address this gap by examining the effect of maternal mental health on the delay in development and growth of children, thereby bridging the existing knowledge deficit.

Aim

To explore the association of maternal mental health on the development and growth of children under two years old from Wardha.

Objectives

  • 1. To study the association of maternal mental health, i.e., toxic stress and depression, on developmental delays in children under two years old.

  • 2. To study the association of maternal mental health on the physical development (stunting/wasting) of children under two years old.

Protocol

Ethical considerations

The study protocol is approved by the Institutional Ethics Committee of Datta Meghe Institute of Higher Education and Research (letter number DMIMS (DU)/IEC/2023/1036).

Written informed consent will be obtained from the study participants after explaining the study’s purpose, nature, procedure and publication of the article in prescribed pro forma before the data collection.

Study design

The present study will be a cross-sectional study.

Study setting

The study will be carried out at the Datta Meghe Institute of Higher Education and Research in Seloo Block of Wardha, Maharashtra.

Eligibility criteria

Study participants

Mothers with children under two years.

Inclusion criteria

Mothers with children under two years.

Exclusion criteria

  • 1. Pregnant mothers.

  • 2. Mothers with existing mental health problems and are currently on medications and treatment.

Sampling procedure

The list of mothers with children under two years old will be obtained from Anganwadi Centre (AWC) of the village. After obtaining the list from AWC the recruitment will be made from house to house considering the inclusion criteria. The study participants will be explained the process and purpose of the study. Written informed consent will be taken. The participants will be surveyed using semi-structured questionnaires.

Variables

The outcome variables of the study are height for age, weight for age. The exposure variables include depression and toxic stress. The predictors are age in years, occupation, education, socioeconomic status, number of children, approximate family income, religion, weight of child (kg), weight of mother (kg), height of child (cm). The effect modifiers include the child’s age, sex and support system of the mother.

Data collection tools and procedure

Face to face interactions will be conducted with every respondent at their household. The questionnaires that will be used are Edinburg Postnatal Depression Scale (EPDS) and Parent Stress Scale (PSS), these are previously published, widely used questionnaires. We will be taking written informed consents via forms from the participants. We will be going to each participants household and perform face to face interviews using the questionnaire we have provided. Once the sample size is achieved we will know that we have reached the adequate number of interviews. All data will be analysed using SPSS version 26. The quantitative measurement of the EPDS and PSS will be presented by mean, median, standard deviation, minimum, and maximum.

Semi-structured questionnaires containing the following sections will be used to conduct the interviews: i) Section A will include: Questions Related to Demographic Profile Section - demographic variables such as age (years), occupation, education, socioeconomic status, number of children, approximate family income, religion, weight of child (kg), weight of mother (kg), height of child (cm), will be measured; ii) Section B will include: Questions about Maternal Mental Health, the Edinburg Postnatal Depression Scale (EPDS)22 and Parent Stress Scale (PSS) will be used to assess maternal mental health including depression and toxic stress23; and iii) Section C will include: Tools to measure stunting, wasting and underweight in children under two years old using the WHO growth chart.24 Section A has been created by our team and can be found as Extended data.35

The tools that will be used to measure maternal mental health include the EPDS22 and PSS.23 EPDS is a well-known self-report test used to screen and evaluate a mother’s postpartum depression. In our study we will be using the EPDS questionnaire to assess depression in mothers. After giving birth, some women have postpartum depression, also known as postnatal depression. It aims to identify depression and anxiety symptoms that new mothers may experience. The EPDS includes questions about various emotional states, including suicidal thoughts, despair, anxiety, guilt, and sleep issues. Each question receives a score between 0 and 3, with 0 meaning “Never” and 3 meaning “Most of the time”. The likelihood of experiencing postnatal depression will then be calculated from the overall scores, and higher scores imply a higher probability of having it. To gauge how stressed out parents are concerning their role as carers, a measurement tool called the PSS will be used. It aims to highlight the challenges parents have when raising children. Toxic stress in mothers will be assessed using the PSS. The PSS consists of a series of inquiries that centre on several potentially stressful parenting-related subjects. These inquiries are meant to look at different parenting pressures, such as the interpersonal, logistical, and emotional challenges of parenthood. A total of 18 questions make up the PSS. Less stress is indicated by a lower score, which runs from 18 to 90.

Impaired height-for-age is referred to as stunting, which typically indicates chronic malnutrition. Stunting will be determined by taking the child’s height or length measurements when lying down (for height) or standing (for length), respectively. The relevant length-for-age or height-for-age growth chart will be used to compare the measurement. An average definition of stunting is a length/height-for-age Z-score of less than -2. We will use the WHO growth chart,24 reference25 to measure the Z score and percentile for length/height for age. Low weight-for-height or weight-for-length is known as “wasting”, which frequently denotes acute malnutrition. The child’s weight will be determined using a calibrated scale, and their height or length will be measured to determine the degree of wasting. A weight-for-length/height Z-score less than -2 is commonly used to describe wasting.

Sample size

The sample size calculation based on the prevalence of childhood communication delay (13), gross motor delay, fine motor delay (13), problem-solving skills (13) and social skills (13) as 22, 15, 25, 21 and 27%, respectively. Using the sample size calculator with the formula, where α was taken 0.05, the estimated proportion(p) is 0.15, and the estimated error (d) is 0.05. A sample size of 196 was accepted.

Data analysis plan

All the results will be calculated and analysed using SPSS software version 26. Descriptive statistics over the demographic variable such as age (years), occupation, education, socioeconomic status, number of children, approximate family income, religion, weight of child (kg), weight of mother (kg), height of child (cm), locality categorical data will be displayed as frequency and percentage, and for quantitative measurement, mean and standard deviation minimum and maximum.

The quantitative measurement of the EPDS and PSS will be presented by mean, median, standard deviation, minimum, and maximum. Data will be tested for finding the normality over the parameters EPDS and PSS by using the Kolmogorov-Smirnov test. Variables with non-normal distribution will be transformed for normality using mathematical algorithms. If data persists with a non-normal distribution, then the non-parametric test will be used to find the significance at 5% (P≤0.05).

The EPDS has 10 questions. The maximum score is 30, and a score of 10 and above suggests possible depression. Each question from Q1, Q2 and Q4 has been scored 0, 1, 2, 3 from the top box to the bottom box with a maximum score of 3 and Q3, Q5-Q10 has been scored 3, 2, 1, 0 from the top box to the bottom box, respectively, with a maximum score of 3. A total score of less than 8 indicated depression was not likely, a score of 9-11 indicated depression is possible, a score of 12-13 indicated a fairly high possibility of depression, and a score of 14 and above indicated probable depression.

The PSS has 18 questions. The score ranges from 18 to 90, with lower scores indicating lower stress levels. To compute the parental stress scale, items 1, 2, 5, 6, 7, 8, 17 and 18 should be reversed and scored as follows: (1=5) (2=4) (3=3) (4=2) (5=1); the scores are then summed up.

Factors associated with maternal mental health with the development and growth of the child will be evaluated using the One-Way ANOVA test or the Non-parametric Kruskal Wallis Test. Association with demographic variables will be evaluated using Chi-square analysis. The relative risk for the associated factors will be evaluated with RR values. Confounding factors affecting the results will be evaluated using multivariate analysis.

Dissemination

Articles arising from the study will be published in indexed journals of public health.

Study status

Study yet to be started.

Discussion

Studies on the effects of antenatal distress on birth outcomes and antenatal/postnatal distress on infant temperament and child behaviour (cognitive, emotional, and behavioural) issues have been few, according to a review of the literature in this field.26 This study will look into the relationship between toxic stress and depression in mothers and developmental deficits in young children under the age of two. It will study the causal connection between a mother’s experience of toxic stress and depression and the risk that her young child will have developmental deficits.27 The results of this objective will provide insight into how maternal mental health may affect the development of young children. With an emphasis on stunting and wasting, the objective is to examine any possible links between maternal mental health and the physical growth of children under two years old. Wasting refers to inadequate weight for height, while stunting relates to impeded height growth.28 The goal of the study is to determine whether the physical growth patterns of young children could be influenced by a mother’s mental health, in particular by elements such as toxic stress and depression.29 The findings of this goal would shed light on the more general implications of maternal mental health on the physical health of their infants.

Limitations

The study is cross-sectional and does not intend to establish direct causality, but it does demonstrate a link between risk factors for infant development. The participants in the study provide their own information, which cannot be evaluated or verified, is one of the study’s primary drawbacks.

Interpretation

In conclusion, the study’s findings will contribute to the growing body of research showing that maternal depression raises the risk of stunted growth and delayed development in children.30 Given that mothers are typically the primary carers for their children during the first year of life, a thorough analysis of mental health issues in women during the perinatal period must take into account how these issues affect babies. The infant needs a mother (or primary carer) who is both physically and emotionally capable, as well as a nurturing environment given by the father and extended family, in order to be adequately cared for.31 The prevalence of maternal common mental disorders (CMD) is 38.8% overall. A greater understanding of the variables influencing mothers’ mental health should be considered, given the high prevalence of CMD among mothers.32 Mothers with young children frequently experience mental health difficulties such as depression and anxiety, but these conditions are underreported, making it difficult for mothers to function normally. Children may be at higher risk for behavioural and emotional issues, cognitive delays, and psychiatric morbidity later in life due to their mother’s mental health issues.33 Compared to other developing nations that have been previously researched, maternal CMD prevalence is comparatively higher in low socioeconomic countries. Maternal CMD is shown to be related to maternal undernutrition and household food insecurity.34

Generalisability

The research emphasises the critical role of a mother’s mental health in shaping early childhood development and growth. Providing adequate support and interventions for mothers, particularly those at risk of mental health problems, is essential to promote optimal child development outcomes. This implies that there is a need for healthcare professionals, policymakers, and community stakeholders in Wardha and similar settings to focus on the need for integrated approaches that address both mother’s mental health and child development in early intervention programs.

Data availability

Underlying data

No data are associated with this article.

Extended data

Zenodo: Questionnaires to be used and blank consent forms. https://zenodo.org/doi/10.5281/zenodo.10202500. 35

This project contains the following extended data:

  • - Blank consent form

  • - Section A of questionnaire that will be used

Reporting guidelines

Zenodo: STROBE checklist for ‘Influence of maternal mental health on development and growth of children under two years old from Wardha: Protocol for a cross-sectional study’. https://zenodo.org/doi/10.5281/zenodo.8363139. 36

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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Handa A, Gaidhane A, Quazi Z and Chaudhari S. Association of maternal mental health on development and growth of children under two years old from Wardha: Protocol for a cross-sectional study [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:23 (https://doi.org/10.12688/f1000research.142774.1)
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