Review
article
Optimism
during
pregnancy
and
obstetrical
outcomes:
A
systematic
review
Ilaria
Giangiordano
a,
Harshini
Sahani
b,
Daniele
Di
Mascio
c,d,
Gabriele
Saccone
e,
Federica
Bellussi
f,
Andrea
Berghella
g,
Andrea
Braverman
d,
Vincenzo
Berghella
d,*
a
DepartmentofChildandAdolescentNeuropsychiatry,LocalHealthUnitofAvezzano-Sulmona-L’Aquila,Sulmona,Italy
b
RowanSchoolofOsteopathicMedicineinStratford,NJ,USA
c
DepartmentofMaternalandChildHealthandUrologicalSciences,SapienzaUniversityofRome,Italy
dDivisionofMaternal-FetalMedicine,DepartmentofObstetricsandGynecology,SidneyKimmelMedicalCollegeofThomasJeffersonUniversity,Philadelphia,
PA,USA
e
DepartmentofNeuroscience,ReproductiveSciencesandDentistry,SchoolofMedicine,UniversityofNaplesFedericoII,Naples,Italy
f
DepartmentofObstetricsandGynecology,Sant’OrsolaMalpighiUniversityHospital,UniversityofBologna,Italy
g
BrownUniversity,Providence,RI,USA
ARTICLE INFO Articlehistory:
Received13December2019
Receivedinrevisedform6March2020 Accepted16March2020 Availableonlinexxx Keywords: Happiness Optimism Pretermdelivery Preeclampsia Obstetrics ABSTRACT
Objective:Toascertainthestrengthofassociationbetweendispositionaloptimism,assessedwiththe
Revised Life Orientation Test (LOT-R), and obstetrical outcomes, and to evaluate women’s social
characteristicsthatmayleadtolowdispositionaloptimismduringpregnancy.
Studydesign:TheresearchwasconductedusingMEDLINE,EMBASE,Scopus,WebofSciences,Cochrane
Database,andClinicalTrial.govaselectronicdatabases.Thearticleswereidentifiedwiththeuseofa
combination of the relevant heading term, key words, and word variants for: “optimism” or
“happiness”and“pregnancy”or“obstetricaloutcomes”,fromtheinceptionofeachdatabasetoJune
2019. Review of articles also included the abstracts of allreferences retrievedfrom the search.
Randomized, cohort, case-control, or case series were all accepted study designs. Only studies
reportingobstetricaloutcomesinwomenundergoneLOT-Rtoassessdispositionaloptimismduring
pregnancywereincluded.Obstetricaloutcomesincludedpretermbirth,pre-eclampsiaandsmallfor
gestationalagefetuses.Allanalyseswerecarriedoutusingtherandomeffectsmodel.Dichotomous
variableswere analyzed usingthe oddsratio (OR) witha95 %confidenceinterval (95% CI).No
continuous variables were compared in the analysis. Significance level was set at P < 0.05.
HeterogeneitywasmeasuredusingI-squared(HigginsI2).
Results:Twoprospectivecohortstudies,including3,570pregnanciesundergoneLOT-R-mostlyduring
thesecondtrimester-wereincludedinthesystematicreview.Outofthe3,570pregnanciesincluded,411
wereinthelowestquartileofoptimism,accordingtoLOT-Rscore.Dispositionaloptimismshoweda
trendtowardslowerincidenceofpretermbirth(7.6%vs9.7%;OR0.76,CI0.53–1.09);nodifference
between women at higher levels and women in the lowest quartile of optimismwas found in
preeclampsiaandsmallforgestationalage.
Womenathigherlevelsofdispositionaloptimismweresignificantlyassociatedwith:age30years;
marriageor“marriage-likestatus”;lowerratesofpublicassistanceandsmoking;whiteethnicity;higher
ratesofhighereducation.
Conclusion:Therearelimiteddataonoptimismandobstetricoutcomes.Higherlevelsofoptimism,
evaluated bytheLOT-R toolintwostudies, areassociatedwith anon-significantdecreasein
pretermbirth.
©2020PublishedbyElsevierB.V.
* Correspondingauthorat:DepartmentofObstetricsandGynecology,DivisionofMaternal-FetalMedicine,ThomasJeffersonUniversity,833Chestnut,Philadelphia,PA, 19107,USA.
E-mailaddress:vincenzo.berghella@jefferson.edu(V.Berghella).
https://doi.org/10.1016/j.ejogrb.2020.03.029
0301-2115/©2020PublishedbyElsevierB.V.
ContentslistsavailableatScienceDirect
European
Journal
of
Obstetrics
&
Gynecology
and
Reproductive
Biology
Contents
Introduction ... 96
Objective ... 96
Methods ... 96
Searchstrategy ... 96
Studyselectionandoutcomes ... 96
RevisedLifeOrientationTest(LOT-R) ... 96
Dataextraction ... 97
Riskofbiasassessment ... 97
Outcomes ... 97
Dataanalysis ... 97
Results ... 97
Studyselectionandstudycharacteristics ... 97
Synthesisofresults ... 97
Comment ... 98
Mainfindings ... 98
Strengthandlimitations ... 98
Comparisonwithexistingliterature ... 99
Implicationsandconclusion ... 99
Financialsupport ... 100
Acknowledgments ... 100
References ... 100
Introduction
Thepursuitofhappinesshasalwaysbeenamainstayinhuman life.DuringtheClassicalperiodin theAncientGreece,Aristotle wrotethat “happinessisthemeaningandthe purposeoflife, the wholeaimandendofhumanexistence”andnowadays,whenpeople areaskedaboutwhatisreallyimportantintheirlives,happinessis oftenconsideredasanessentialgoaltoliveagoodlife[1].High subjectivewellbeinghasbeenshowntobeassociatedwithbetter health outcomes, mood, behavioral, sociability, productivity benefits,andlongerlifeexpectancy2–4.
Thesefindingsseemtobeconfirmedalsowhenevaluatingthe opposite association between depression and poorhealth out-comes. In fact, depression - as defined in the Diagnostic and StatisticalManualofMentalDisorders,5thEdition(DSM-5)[5]–
affectspatients’overallclinicalconditionswithanincreasedriskof cardiovasculardisease, diabetes, Parkinson disease, stroke, and compositemorbidity 6–10and hasalsobeenassociated witha greaterriskofmortality[11].
Although pregnancy is generally considered as a time of emotional wellbeing, minor and major depression affect up to 12.4%ofpregnantwomen,withdetrimentalconsequencesupon pregnancyandtheoffspring[12].
Therefore,severalstudieshavebeenpublishedonthewell-known effectsofdepressionduringpregnancy andthepostpartumperiod[13], whiletherelationshipbetweenobstetricaloutcomesandhappiness evaluatedasdispositionaloptimismisstillasubjectofdebate. Objective
Theaimofthissystematicreviewwastoascertainthestrength ofassociationbetweendispositionaloptimism,assessedwiththe RevisedLifeOrientationTest (LOT-R),and obstetricaloutcomes, andtoevaluate women’s demographic characteristicsthatmay leadtohighdispositionaloptimismduringpregnancy.
Methods Searchstrategy
This study was performed according to a protocol recom-mended for systematic review [14]. The review protocol was
designedaprioridefiningmethodsforcollecting,extractingand analyzing data. The research was conducted using MEDLINE, EMBASE, Scopus, Web of Sciences, Cochrane Database, and ClinicalTrial.govaselectronicdatabases.Thearticleswere identi-fiedwiththeuseofacombinationoftherelevantheadingterm, keywords, andwordvariants,i.e.(((optimism)OR(happiness)) AND(pregnancy))OR(obstetricaloutcomes)fromtheinceptionof eachdatabasetoJune2019.Reviewofarticlesalsoincludedthe abstractsofallreferencesretrievedfromthesearch.
Studyselectionandoutcomes
Onlystudiesreportingobstetricaloutcomesinwomenassessed fordispositionaloptimismduringpregnancywereincluded.We excluded papers whose authors were contacted for further informationwithoutreceivinganyanswer.Onlyfulltextarticles wereconsideredeligible for theinclusion. Randomized,cohort, case-control,orcaseserieswereallacceptedstudydesigns.Studies withfewerthan5caseswereexcludedtoavoidpublicationbias. RevisedLifeOrientationTest(LOT-R)
Weincludedonlystudies thatusedLOT-R toassess disposi-tionaloptimismduringpregnancy.Weexcludedstudiesreporting dataofwomenundergoneotherpsychologicaltests,thosewitha psychologicalassessmentprotocolunspecifiedorunclear.
LOT-R [15] is a widely used instrument in psychological researchwithgoodpsychometricproperties(theinternal consis-tency-Cronbach'salpha-rangedbetween.74and.78;Cronbach alphaof.71forthetotalscoreandof.64and.77fortheoptimism and pessimism subscale scores) [16]. The LOT-R consists of 10 items: three items are positively worded, three items are negativelyworded,andfouritemsarefilleritems.Therespondents areaskedtoindicatetheiragreementona5-pointLikertscalewith response categories ranging from strongly agree to strongly disagree.Althoughoriginallycomposedasaunidimensionalscale, some studies suggest a bi-dimensionality of two independent factors:optimismandpessimism.Bothsub-scaleshaveascoring rangeof0to12,withhigherscoresindicatingmoreoptimismor morepessimism.NormscoresarenotavailablefortheLOT-R[15]. Womenweredividedintotwogroups:womenathigherlevels (top three quartiles) of dispositional optimism (LOT-R 12)
compared with women in the lowest quartile of optimism (LOT-R<12).
Dataextraction
Twoauthors(IG,DDM)reviewedallabstractsindependently. Agreementregardingpotentialrelevancewasreachedby consen-sus.Fulltextcopiesofthosepaperswereobtainedandthesame reviewersindependentlyextractedrelevantdataregardingstudy characteristics and pregnancy outcome. Inconsistencies were discussedbythereviewersandconsensusreachedorbydiscussion with a third author (VB). Data not presented in the original publications wererequestedfromthe principalinvestigators. If morethanonestudyhadbeenpublishedonthesamecohortwith identicalendpoints,thereportcontainingthemostcomprehensive informationonthepopulationwasincludedtoavoidoverlapping populations. For those articles in which information was not reported but the methodology was suchthat this information wouldhavebeenrecordedinitially,theauthorswerecontacted. Riskofbiasassessment
Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale (NOS) for cohort studies. According to NOS, each study is judged on three broad perspectives:theselectionofthestudygroups,thecomparability ofthegroups,andtheascertainmentoutcomeofinterest[17].
Assessmentoftheselectionofastudyincludestheevaluationof therepresentativenessoftheexposedcohort,selectionofthe non-exposedcohort,ascertainmentofexposureandthedemonstration that outcome of interest was not present at start of study. Assessment of the comparability of the study includes the evaluationof thecomparabilityof cohortsbased onthedesign oranalysis.Finally,theascertainmentoftheoutcomeofinterest includes the evaluation of the type of the assessment of the outcomeofinterest,lengthandadequacyoffollow-up.According toNOSastudycanbeawardedamaximumofonestarforeach numbereditemwithintheSelection andOutcomecategories.A maximumoftwostarscanbegivenforComparability[17]. Outcomes
Theprimaryaimofthissystematicreviewwastoascertainthe strengthofassociationbetweendispositionaloptimism,assessed with LOT-R, and obstetrical outcomes. Obstetrical outcomes included preterm birth (PTB), defined as gestational age < 37 weeks,pre-eclampsia(PE)(asdefinedbyauthors)andsmallfor gestationalage(SGA),definedasbirthweight<10thpercentile.
We also planned sub-group analyses considering patients’ socialhistory,includinginterpersonal,occupational,orfinancial stressorstoidentifywomen’ssocialweaknesspotentiallyleading toalowlevelofoptimism.
Dataanalysis
Thesystematic review was reportedfollowing thePreferred Reporting Item for Systematic Reviews and Meta-analyses (PRISMA)statement[18].
Baselinedemographicdataforeachgroupwithineachstudy wascollectedandmerged. Pregnancyoutcomeswerecollected foreachoftheincludedgroup.Dataanalysiswasperformedwith ReviewManagerVersion5.3(NordicCochraneCentre,Cochrane Collaboration,Denmark).Allanalyseswerecarriedoutusingthe randomeffectsmodel(ofDerSimonianandLaird,assumingthat thedatabeinganalyzedwasdrawnfromahierarchyofdifferent populations). Dichotomous variables were analyzed using the
odds ratio (OR) witha 95% confidence interval(95 % CI). No continuousvariableswerecomparedintheanalysis.Significance level wassetatP<0.05.Heterogeneitywasmeasuredusing I-squared(HigginsI2).
Results
Studyselectionandstudycharacteristics
Fig.1showstheflowdiagram(PRISMAtemplate)of informa-tion derived from review of potentially relevant articles. Eight articlesusedotherassessmentteststhantheLOT-R,andnoneof themcouldbeincludedinthissystematicreviewaseachuseda different survey tool. Moreover, none of them reported on pregnancy outcomes (Table 1). Two articles [19,20], including 3,570pregnanciesassessedfordispositionaloptimismusingLOT-R – mostly during the second trimester - were included in the systematic review. Both the included studies were prospective cohortstudies(Fig.2).
Theresultsof thequalityassessmentoftheincludedstudies using Newcastle-OttawaScale (NOS)areshown inTable 2.The includedstudiesshowedanoverallmoderatescoreregardingthe selection and comparability of the study groups, and for ascertainment of the outcome of interest. Characteristics and socialhistoryofthewomenincludedareshowninTable3. Synthesisofresults
Outofthe3,570pregnanciesincluded,3,159womenwereat higherlevels(topthreequartiles)ofdispositionaloptimismand 411wereinthelowestquartileofoptimism,accordingtoLOT-R score.Table4showsthepooleddataofobstetricaloutcomesofthe systematicreview.
Dispositional optimism showed a trend towards a lower incidenceofPTB(7.6%vs9.7%;OR0.76,CI0.53–1.09)without reaching statistical significance; instead,nodifference between women at higher levels and women in the lowest quartile of optimismwasfoundintermsofPE(6.5%vs5.5%;OR1.2CI0.75vs 1.91)andSGA(10.8%vs10.7%;OR1.01CI0.72–1.44).
Table5showsresultsfromthesub-groupanalysisonpatients’ social history,includinginterpersonal,occupational, orfinancial
stressors.Womenathigherlevelsofdispositionaloptimismwere significantlyassociatedwith:aged30years(58.1%vs34.7%;OR 2.6, CI 2.09–3.25); married or committed in a “marriage-like status”(88.6%vs68.6%;OR3.57,CI2.8–4.57);lowerratesofpublic assistance (46.4% vs 72.9 %; OR 0.32, CI 0.22 to 0.47); lower incidenceofsmoking (12.5%vs 24.8%;OR0.43,CI 0.34-0.55); whiteethnicity(78.2%vs73.7%;OR1.28,CI1.01–1.62);higher ratesofatleastahighschooleducation(96.2%vs87%;OR3.75,CI 2.66–5.27).Theonlyvariablethatwassimilarinbothgroupswas pre-pregnancyoverweight(35.2%vs39.9%;OR0.82,CI0.66–1.01). Comment
Mainfindings
Thissystematicreview,including3,570pregnantwomenwho underwent LOT-R during pregnancy, showed that dispositional
optimismwasassociatedwithatrendtowardslowerincidenceof PTB,withoutinfluencingPEandSGArates.
Furthermore, there are several social stressors that are significantly associated with dispositional optimism, such as maternalage30 years,married ormarried-likestatus, lower rates of public assistance and smoking, white ethnicity, and educationallevelshighschool.
Strengthandlimitations
Toourknowledge,thereisnopublishedsystematicreviewthat assessed the association between dispositional optimism and obstetricaloutcomes.Moreover,theLOT-Rtoolisoneofthemost acceptedandusedtoolstoassessdispositionaloptimism[21].Both theincludedstudieswereprospective.Themainlimitationisthat while thereareseveral studiesonhappiness/dispositional opti-mism/other measure of emotional wellbeing, and pregnancy outcomes(Fig.1/Table1),thetoolsusedtoassessitwerevaried andmadeasystematicreviewdifficult,intheendrevealingonly two studies, on dispositional optimism, available for analysis. Moreover,thesetwoincludedstudieshadsmallsamplesize.While several factors (Table 5) are associated with dispositional optimism, these could not be controlled for given lack of raw data.Itwasnotpossibletoobtaindatafromthehighestquartileof optimism,andthereforetheanalysisevaluatedwomenathigher levels (top three quartiles) of optimism, and therefore both ‘optimistic’ and ‘neutral’, compared withwomen at the lowest
Table1 Excludedstudies.
Firstauthor Samplesize Evaluationtool Results
Mooreetal2015 75 Semi-structuredinterviews Higherverbalpositivityandanxietyduringpregnancy independentlypredictedlowermother-infantsynchronywith potentiallydifferentconsequencesforinfantdevelopment. (LinguisticInquiryandWordCountsoftware)
Gariepyetal2017 161 LondonMeasuresofUnplannedPregnancy Womenreportingmixedfeelingsaboutwantingtohavea“baby”, anunplannedpregnancy,thatthepregnancyoccurredatthewrong time,anundesiredpregnancyorreportedfeelingunhappyorvery happyaboutpregnancynewshadincreasedoddsoflowphysical health-relatedqualityoflife,comparedtowomenreportingthat thepregnancywaswanted,planned,occurredattherighttime,was desired,andthattheyfelthappyaboutthepregnancy.
Louetal2017 20 Notvalidatedtool: Themajorityofwomenacknowledgethatpregnancyinvolves simultaneousfeelingsofhappinessandworry.
Ahappy/worriedcontinuumwithacarefreeandhappy pregnantwomanatoneendandaworriedandconcerned pregnantwomanattheotherendofthecontinuum.
Polanskyetal2018 258 Notvalidatedtool: Womenwhofeltthepregnancywastoosoonwerelesshappybeing pregnant.Prenataldepressivesymptomswereinverselyassociated withhappinesswithbeingpregnantandcompletinghighschool. Aquestionnaireassessingpregnancyintendedness
validatedinaninner-citypublicprenatalclinic
Tiemeyeretal2019 5721 Notvalidatedtool: Pregnancylosscanbeahighlydistressingexperience,women’s happinessaboutasubsequentpregnancyisnotreduceddueto priorpregnancyloss.
Anumericscalewhere1meansveryunhappytobe pregnantand10meansveryhappytobepregnant
Kemetetal2018 161 LondonMeasureofUnplannedPregnancy HappinessaboutnewpregnancieswasmorelikelyamongBlack non-HispanicthanWhitenon-Hispanicwomen.
Blakeetal2007 1044 NationalSurveyofFamilyGrowth Pregnancyintentionsandhappinesswerestronglyassociated,but happinesswasthebetterpredictorofrisk.Unhappywomenhad higheroddsthanhappywomenofsmoking,beingdepressed, experiencingintimatepartnerviolence,drinkingandusingillicit drugs.
ShortversionoftheNegativeMoodRegulationScale
Lundsbergetal2017 123 LondonMeasuresofUnplannedPregnancy Unintendedpregnancyisassociatedwithsignificant patient-reporteddisutility,asispregnancyoccurringinotherunfavorable contexts.
Fig.2.Forestplotofpretermbirthoutcome.
Table2
QualityassessmentoftheincludedstudiesaccordingtoNewcastle-OttawaScale (NOS).Astudycanbeawardedamaximumofonestarforeachnumbereditem withintheSelectionandOutcomecategories.Amaximumoftwostarscanbegiven forComparability.
Author Selection Comparability Outcome Catov2010[19] ** * ** McDonald2014[20] ** * **
level of optimism. Comparison of the highest quartile (truly ‘optimistic’)versuslowestquartile(least‘optimistic’)aswellasthe lackofinformationaboutdepression,anxiety,orotherpsychiatric diagnosesmayhaverevealeddifferentresults.
Comparisonwithexistingliterature
To ourknowledge, priorstudies evenperipherallyevaluating happiness/dispositional optimism/other measure of emotional wellbeingduringpregnancy,(Table1)useddifferentpsychometric tools.Someoftoolsusedinthesestudieswerenotevenvalidated,all didnotevaluatedjustpositivepsychologyandhappinessperseasan influenceonoutcomes,andnoneofthesereportedonpregnancy outcomes(Table1).Toourknowledge,noreviewscombiningdata frommorethanonestudyonhappiness/dispositionaloptimism/ other measure of emotional wellbeing during pregnancy, and pregnancyoutcomes,havebeenpreviouslyreported.
Implicationsandconclusion
There is a vast literature on the negative psychology, e.g. depression.Antenataldepressionhasbeenshowntobeassociated
withmultiplepoorobstetricaloutcomes,suchasPTB, lowbirth weight, fetal growth restriction, stillbirth, vaginal bleeding, PE, operative delivery, and lower rates of initiating exclusive breastfeeding [13,22–25]. Depressive symptoms experienced during pregnancyhave alsobeen related withinfantand child development disorders, such as sudden infant death, impaired neurobehavioralfunctioning,disorganized sleeppatterns, exces-siveinfantcryingandbehavioralproblemsaswellasimpairments incognitivefunctioning,mostlyoccurringwithdelaysinacquiring languageskillsandemotionaldysfunction[26–35].Wefoundin ourreviewthat severalrisk factorswereassociatedwithlower levelofdispositionaloptimism(Table5).
Instead,theliteratureonpositivepsychology,e.g.happiness,is scant.Onewaytoevaluatehappinessisbyassessingdispositional optimism.Moststudiesdonotreallyevaluate happiness/disposi-tionaloptimismeffectonobstetricoutcomes(Table1),revealing onlytwoprospectivestudiesevaluatinghappinesswithavalidated tool,i.e.LOT-R,summarizedinthisreview.
Regardingassociationswithdispositionaloptimism,ourstudy foundthatbeing>30yearsofageandmarriedormarried-like,as wellashavinglowerratesofpublicassistanceandsmoking,white ethnicity,and educationallevelshighschoolwereassociated
Table3
Characteristicsofthewomenincludedinthestudies.
Catov2010[19] McDonald2014[20] Total Age <18 11/490(0.2%)vs2/177(1.1%) 0/2489(0%)vs0/209(0%) 11/2979(0.4%)vs2/386(0.5%) 18to<25 267/490(54.5%)vs141/177(79.7%) 142/2489(5.7%)vs23/209(11%) 409/2979(13.7%)vs164/386(42.5%) 25to<30 118/490(24.1%)vs23/177(13%) 711/2489(28.6%)vs63/209(30.1%) 829/2979(27.8%)vs86/386(22.3%) 30 94/490(19.2%)vs11/177(6.2%) 1636/2489(65.7%)vs123/209(58.9%) 1730/2979(58.1%)vs134/386(34.7%) Marriedormarriage-like 247/490(50.4%)vs49/137(35.8%) 2552/2668(95.7%)vs204/232(87.9%) 2799/3158(88.6%)vs253/369(68.6%) Publicassistance 227/489(46.4%)vs129/177(72.9%) Notreported 227/489(46.4%)vs129/177(72.9%) Cigarettesmoking 106/490(21.6%)vs60/177(33.9%) 291/2683(10.8%)vs42/234(17.9%) 397/3173(12.5%)vs102/411(24.8%) Pre-pregnancyoverweight 211/488(43.2%)vs71/176(40.3%) 885/2623(33.7%)vs89/225(39.6%) 1096/3111(35.2%)vs160/401(39.9%) Ethnicity AfricanAmerican 144/490(29.4%)vs56/177(31.6%) 38/2669(1.4%)vs2/232(0.9%) 182/3159(5.8%)vs58/411(14.1%) White 346/490(70.6%)vs121/177(68.4%) 2125/2669(79.6%)vs182/232(78.4%) 2471/3159(78.2%)vs303/411(73.7%) Education <Highschool 54/490(11%)vs35/176(19.9%) 67/2667(2.5%)vs18/232(7.8%) 121/3157(3.8%)vs53/408(13%) Highschool 132/490(26.9%)vs68/176(38.6%) 180/2667(6.7%)vs27/232(11.6%) 312/3157(9.9%)vs95/408(23.2%) >Highschool 304/490(62%)vs73/176(41.5%) 2420/2667(90.7%)vs187/232(80.6%) 2724/3157(86.2%)vs260/408(63.7%) DataarealwayspresentedaswomenwithLOT-R12versuswomeninthelowquartileofoptimism(LOT-R<12).
Table4
Obstetricaloutcomes.
Catov2010[19] McDonald2014[20] Total OR(95%CI) PTB 46/497(9.3%)vs19/177(10.7%) 182/2,520(7.2%)vs19/214(8.9%) 228/3,017(7.6%)vs38/391(9.7%) 0.76(0.53to1.09) PE 22/496(4.4%)vs6/177(3.4%) 161/2,329(6.9%)vs15/207(7.2%) 183/2,825(6.5%)vs21/384(5.5%) 1.20(0.75to1.91) SGA 59/496(11.9%)vs21/176(11.9%) 251/2,368(10.6%)vs19/198(9.6%) 310/2,864(10.8%)vs40/374(10.7%) 1.01(0.72to1.44) PTB,pretermbirth;SGA,smallforgestationalage;PE,preeclampsia;OR,oddsratio;CI,confidenceinterval.
DataarealwayspresentedaswomenwithLOT-R12versuswomeninthelowquartileofoptimism(LOT-R<12).
Table5
Sub-groupanalysisonpatients’socialhistoryandassociationwithhigherorlowerlevelofdispositionaloptimism.
Total OR(95%CI) p-value
Age30 1,730/2,979(58.1%)vs134/386(34.7%) 2.6(2.09to3.25) <0.0001 Marriedormarriage-like 2,799/3,158(88.6%)vs253/369(68.6%) 3.57(2.80to4.57) <0.0001 Publicassistance 227/489(46.4%)vs129/177(72.9%) 0.32(0.22to0.47) <0.0001 Cigarettesmoking 397/3,173(12.5%)vs102/411(24.8%) 0.43(0.34to0.55) <0.0001 Ethnicity:White 2,471/3,159(78.2%)vs303/411(73.7%) 1.28(1.01to1.62) 0.04 Ethnicity:AfricanAmerican 182/3,159(5.8%)vs58/411(14.1%) 0.37(0.27to0.51) <0.0001 Education:Highschool 3,036/3,157(96.2%)vs355/408(87%) 3.75(2.66to5.27) <0.0001 Pre-pregnancyoverweight 1,096/3,111(35.2%)vs160/401(39.9%) 0.82(0.66to1.01) 0.07 OR,oddsratio;CI,confidenceinterval.
withhigherlevelofdispositionaloptimism(Table5).Itisunclearif optimistic people get pregnant later, get married more often, smokelessandstudymore,orifthesecharacteristicscontributeto makea woman optimistic.Assessingdirectionof causalityit is difficultandliteratureonthistopicincontroversial.
A recent review reported that there is a high correlation between happiness and marital status, at least in Western countries, and that there is a trend towards lower level of happinessinpeoplebelongingtosocialminorities,suchasethnic minorities. Moreover, authors showed a correlation between happinessand educationthatwashigher inpoorcountriesand lowerorevennegativeinhighincomenations[36].
The relationshipbetweenhappinessandaging is evenmore challenging. There are two main hypotheses of correlation betweenhappinessthroughoutlife:thesocioemotionalselectivity theorystatesthataspeoplegetolder,theyincreasinglyattendto positive information and memories, leading to a stable or increasedlevelofhappinesswithage;theU-shapedhypothesis suggestsacurvilinearshape,withadipduringmidlife.Anyway, recentresearchesarefocusingalwaysmoreonthesocioeconomic influenceonhappinessamongdifferentagesratherthanonthe singlehappiness-agerelationship[37].
Regardingoutcomes,happinesshasbeenassociatedin non-pregnant adults with better cardiovascular and endocrine health, improvement in immune (i.e. fewer cold signs and symptoms), reduced inflammation, less stress and anxiety, lowersuicideratesandquickrecoveryfromdisease[2].Toour knowledge,therearenostudiesinpregnancyevaluatinganyof theseeffectsfoundoutsidepregnancy.Ourreviewwasthefirst thoughtoevaluatedispositionaloptimismandPTB,PEandSGA inpregnancy.
Insummary,thisstudyfoundatrendtowardslowerincidence ofPTB and nodifferencein terms ofPE andSGA incidences in women at higher levels compared with women in the lowest quartileofdispositionaloptimism.Ahigherlevelofdispositional optimismwasalsoassociatedwithmanysocialvariables,suchas maternalage30years, marriedor married-likestatus,lower rates of public assistance and smoking, white ethnicity, and educationallevelshighschool.
Furtherprospectiveresearchinvestigating happiness/disposi-tionaloptimism during pregnancywithvalidated psychometric tool,suchasLOT-R,areneededtobetterevaluatetheassociation withpregnancyoutcomesandtohighlightdemographic character-isticsrelatedwithhappinessduringpregnancyinordertohelp womenatleastwithmodifiabletraits.
Financialsupport
Nofinancialsupportwasreceivedforthisstudy DeclarationofCompetingInterest
The authors declare that they have no known competing financial interests or personal relationships that could have appearedtoinfluencetheworkreportedinthispaper.
Acknowledgments
We thank Dr Sheila McDonald,Dr Muci Wu and Dr Cheryl Moyerfor having provided furtherinformation toincrease the strengthofthispaper.
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