Background
Hyperglycemia in pregnancy (HIP), including diabetes before pregnancy, gestational diabetes mellitus (GDM), and overt diabetes in pregnancy, is a common condition, estimated to be complicated with 15.8% of live births in the world [
1]. Since treatment of HIP can reduce several morbidities, such as preeclampsia, macrosomic newborn, and shoulder dystocia, while the cost of treatment was only an increase in the number of prenatal visits [
2], screening of HIP is now essential for the obstetrical practice.
Adverse childhood experiences (ACEs), including physical, psychological, and sexual abuse, neglect, and household dysfunction, have been well reported to influence adult health profoundly [
3]. Several studies showed that ACEs impacted mental health and physical well-being, such as heart disease, stroke, and diabetes [
3‐
5]. As pregnancy is a natural stress test for the future development of chronic disease, groups at high risk of diabetes, that is, women with multiple ACEs, are more likely to develop HIP. [
6,
7]
Poor parent-daughter relationships can be one phenotype of ACEs, as poor parent-child relationships were also associated with youth smoking, unhealthy weight control behavior, obesity, and psychological distress in adulthood [
8‐
10]. Thus, the pregnant women’s relationship with their parents may be associated with HIP risk. Moreover, assessing the parent-daughter relationship is more acceptable than assessing ACEs in a clinical setting and applicable to detecting high-risk groups of HIP [
11].
When analyzing the association between poor parent-daughter relationships and HIP, the presence of psychiatric diseases should be considered because poor parent-child relationships are associated with psychiatric diseases [
10,
12], and psychiatric diseases are known risk factors for diabetes or GDM [
13]. Furthermore, several studies showed that psychiatric diseases increased HIP risk through obesity due to reduced frequency and intensity of exercise and side effects of psychotropic agents [
13,
14]. Besides, a study on 6,317 pregnant women in Australia showed that women with three or more ACEs significantly had an increased risk of GDM only among those with psychiatric diseases [
6]. This study suggested that psychiatric diseases need to be considered as mediators or effect modifiers. Thus, we should carefully consider the involvement of psychiatric diseases in analyzing the relationship between poor parent-daughter relationships and HIP risk. That is, we need further stratified analysis by the existence of psychiatric diseases.
Therefore, using a hospital-based sample, we attempted to clarify whether the parent-daughter relationship influenced the risk of HIP, with carefully considering the impact of the result by the presence of psychiatric diseases.
Results
Maternal backgrounds stratified by satisfaction for relationships with parents were shown in Table
1. 4.4% (274/6264) of women were complicated with HIP. Women who were satisfied with their relationship with patents as “not very satisfied” were 5.5% (343/6,264), and those who were “not satisfied at all” were 1.2% (74/6,264). Women with HIP were more likely to be older, have psychiatric disease histories, and not to be satisfied with their relationships with their parents. Women in Kagawa prefecture were more likely to have HIP than in other prefectures. Other background characteristics were not significantly different between the two groups.
Table 1
Characteristics of the sample by satisfaction for relationship with parents
Gestational age at delivery (weeks) (N = 5124) | 38.8 (2.4) | 38.8 (2.4) | 38.8 (1.5) | 38.1 (4.7) | 0.18 |
Nulliparity (N = 5234) | 2201 (42.1) | 2075 (42.4) | 101 (36.9) | 25 (40.3) | 0.19 |
Maternal age at delivery (year)
| | | | | 0.19 |
15–19 | 61 (1.0) | 58 (1.0) | 2 (0.6) | 1 (1.4) | |
20–24 | 579 (9.2) | 534 (9.1) | 36 (10.5) | 9 (12.2) | |
25–29 | 1713 (27.4) | 1621 (27.7) | 73 (21.3) | 19 (25.7) | |
30–34 | 2206 (35.2) | 2056 (35.2) | 127 (37.0) | 23 (31.1) | |
35–39 | 1375 (22.0) | 1276 (21.8) | 82 (23.9) | 17 (23.0) | |
40–44 | 320 (5.1) | 293 (5.0) | 23 (6.7) | 4 (5.4) | |
45–49 | 9 (0.1) | 8 (0.1) | 0 (0.0) | 1 (1.4) | |
50–54 | 1 (0.02) | 1 (0.02) | 0 (0.0) | 0 (0.0) | |
Prefecture of the institutions
| | | | | 0.06 |
Osaka | 2315 (37.0) | 2182 (37.3) | 111 (32.4) | 22 (29.7) | |
Miyagi | 923 (14.7) | 854 (14.6) | 51 (14.9) | 18 (24.3) | |
Kagawa | 399 (6.4) | 375 (6.4) | 18 (5.3) | 6 (8.1) | |
Oita | 2627 (41.9) | 2436 (41.7) | 163 (47.5) | 28 (37.8) | |
Academic background
| | | | | < 0.01 |
Highschool graduate or more | 5980 (95.4) | 5605 (95.9) | 312 (91.0) | 63 (85.1) | |
High school dropout | 174 (2.8) | 153 (2.6) | 16 (4.7) | 5 (6.8) | |
Junior high school graduate | 110 (1.8) | 89 (1.5) | 15 (4.4) | 6 (8.1) | |
Psychiatric disease history | 350 (5.6) | 276 (4.7) | 54 (15.7) | 20 (27.0) | < 0.01 |
Hyperglycemia in pregnancy | 274 (4.4) | 247 (4.2) | 24 (7.0) | 3 (4.1) | 0.05 |
Fetal birthweight (g) (N = 5207)
| | | | | 0.10 |
<1500 | 29 (0.6) | 25 (0.5) | 4 (1.5) | 0 (0.0) | |
1500〜2500 | 427 (8.2) | 397 (8.2) | 21 (7.7) | 9 (14.3) | |
>2500 | 4751 (91.2) | 4450 (91.3) | 247 (90.8) | 54 (85.7) | |
Associations between HIP and satisfaction for relationships with parents or covariates were shown in Table
2. Those who were not so much satisfied with their relationship with their parents were significantly at high risk of HIP in a crude model of logistic regression analysis (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 1.11–2.63), but when we add a history of maternal psychiatric disease, it became non-significant in multiple logistic regression analysis (OR: 1.53, 95%CI: 0.98–2.39). In contrast, those who were not satisfied with their relationships with their parents at all did not have a high risk of HIP in the crude model (OR: 0.96, 95%CI: 0.30–3.06) and in the adjusted model (OR: 0.78, 95%CI: 0.24–2.55).
Table 2
Association between hyperglycemia in pregnancy and satisfaction for relationship with parents or covariates
Satisfaction for relationship with parents
| | | |
Satisfied | reference | reference | reference |
Not very satisfied | 1.71 (1.11–2.63) | 1.53 (0.98–2.39) | 0.06 |
Not satisfied at all | 0.96 (0.30–3.06) | 0.78 (0.24–2.55) | 0.68 |
Psychiatric disease history
| 1.75 (1.14–2.68) | 1.58 (1.02–2.44) | 0.04 |
Maternal age at delivery (year)
| | | |
15–19 | 1.56 (0.55–4.39) | 1.22 (0.42–3.59) | 0.71 |
20–24 | 0.27 (0.13–0.59) | 0.26 (0.12–0.56) | < 0.01 |
25–29 | 0.70 (0.49–0.98) | 0.69 (0.49–0.97) | 0.04 |
30–34 | reference | reference | reference |
35–39 | 1.61 (1.20–2.16) | 1.60 (1.19–2.15) | < 0.01 |
40–44 | 1.64 (1.02–2.65) | 1.61 (1.00-2.61) | 0.05 |
45–49 | 2.78 (0.34–22.43) | 3.09 (0.38–25.04) | 0.29 |
50–54 | - | - | - |
Academic background
| | | |
University or more | reference | reference | reference |
High school graduate | 1.66 (0.91–3.03) | 1.98 (1.06–3.69) | 0.03 |
Junior high school graduate | 1.53 (0.70–3.31) | 1.52 (0.68–3.39) | 0.30 |
Association between HIP and satisfaction for the relationship with parents stratified by psychiatric disease history was shown in Table
3. Among the group without psychiatric disease histories, women who were not very satisfied with their relationship with their parents showed a significant increase in the risk of HIP (OR: 1.77, 95%CI: 1.11–2.84). In contrast, among the group with psychiatric disease histories, satisfaction for the relationship with parents was not associated with HIP (OR: 0.61, 95%CI: 0.16–2.28).
Table 3
Association between hyperglycemia in pregnancy and satisfaction for relationship with mothers stratified by psychiatric disease history
Psychiatric disease history (-)
| | |
Satisfaction for relationship with parents | | |
Satisfied | reference | reference |
Not very satisfied | 1.85 (1.17–2.95) | 1.77 (1.11–2.84) |
Not satisfied at all | 0.91 (0.22–3.76) | 0.85 (0.20–3.56) |
Psychiatric disease history (+)
| | |
Satisfaction for relationship with parents | | |
Satisfied | reference | reference |
Not very satisfied | 0.71 (0.21–2.48) | 0.61 (0.16–2.28) |
Not satisfied at all | 0.64 (0.08–5.01) | 0.60 (0.07–4.93) |
Effect decomposition of the total effect of parent-daughter relationship due to psychiatric disease history on HIP was shown in Table
S1. The association between the relationship with parents and HIP was not mediated by psychiatric disease history (natural indirect effect; OR: 1.00, 95%CI: 0.93–1.07). Multiple imputation analysis showed a similar tendency to the primary analysis (Table
S2,
S3).
Discussion
To the best of our knowledge, this is the first study to show the association between poor relationships with parents and the risk of HIP among pregnant women, using a prospective hospital-based study in Japan. Furthermore, this association differed by the psychiatric disease history and was significant only among the population without a psychiatric disease history, suggesting that the association was modified by psychiatric disease history.
The result of our study was consistent with previous studies about ACEs and HIP. Although we did not directly ask whether participants had a history of child abuse and neglect due to social barriers in a clinical setting in Japan, their poor relationships with parents may indicate a history of childhood maltreatment (abuse and neglect), as shown in a previous meta-analysis [
22]. Thus, we used the question of whether women are satisfied with their parents as a proxy of the history of child maltreatment in our study, which was feasible in clinical practice. It is crucial that parent-daughter relationship was identified as a factor in identifying patients at high risk for HIP, one of the important pregnancy complications, because asking about childhood maltreatment history is often burdensome for pregnant women and can be a triggered trauma, which may hamper the patient-physician relationship. In contrast, the other two previous studies on 2,319 Hispanic or Latino women and on 1,274 women in the United States reported that ACE scores were not associated with GDM. This discrepancy could partly be explained by the difference in race or ethnicity, the distribution of ACEs among the population in each study, or the reliability of the ACE questionnaire in these previous studies, i.e., patients may reluctant to report their ACE if asked directly. Further studies are warranted to clarify the relationship between parent-daughter relationship and ACEs, and to investigate their association with HIP.
The possible mechanism by which the parent-daughter relationship may increase the risk of HIP is through an increase in youth smoking [
8] and unhealthy weight control behaviors [
9]. A previous study by telephone interview on 428 youth-parent pairs in the United States showed that among youth whose parents did not smoke, those who reported poor parent-child connectedness were twice as likely to have ever smoked as those who reported high connectedness [
8]. Another study on 4,746 students in public schools in the United States showed that students who reported poor relationships with their mothers had a higher prevalence of unhealthy weight management behaviors than those who reported that they felt their mothers cared about them [
9]. In addition, a poor parent-daughter relationship can increase the frequency of obesity, which is an essential risk for HIP. Previous studies have suggested that poor parent-child relationships caused obesity in children through their effects on stress-induced hypothalamic-pituitary-adrenal (HPA) axis signaling neuroendocrine changes [
23] and impairment of children’s capacity for self-regulation [
24].
This study showed that the groups with lower satisfaction for parent-daughter relationships were associated with HIP, whereas the group with no satisfaction for parent-daughter relationships was not. The possible reason for this result may be due to the child welfare system in Japan. Those who were not satisfied with parent-daughter relationship at all were at higher risk for multiple ACEs, including child maltreatment, and thus they may have been supported by the child welfare system from childhood, paradoxically attenuating the effect of ACEs on HIP [
25].
In the current study, the pregnant women’s relationship with parents was significantly associated with HIP risk in women without psychiatric diseases but not in women with psychiatric diseases. Interestingly, this was inconsistent with the previous study. The study on 6,317 women in Australia suggested that three or more ACEs and individual subcategories of physical abuse significantly increased the risk of GDM among women with preconception depressive symptoms but not among women without preconception depressive symptoms [
6]. This study explained that preconception depressive symptoms were a mediating factor in the relationships between ACEs and GDM. However, it was possible that preconception depressive symptoms were an effect modifier, as shown in the current study. This effect can partly be explained by public health services during pregnancy in Japan. Pregnant women with psychiatric diseases are identified as parents with difficulties raising their children to prevent child abuse by public health nurses in each municipality [
26]. However, pregnant women with poor parent-daughter relationships, one of the phenotypes of ACEs, and without psychiatric diseases are not routinely supported by public health nurses in Japan. Thus, women without psychiatric diseases are less likely to receive public health services and appropriate treatment to reduce the effects of poor parent-daughter relationships. As a result, women without psychiatric diseases may develop HIP due to the accumulated effects of the poor parent-daughter relationship after they suffer from the burden of pregnancy. Further studies to clarify the effect of psychiatric disease on the association between poor parent-daughter relationships and HIP are warranted.
The present study had several limitations. First, the samples used in this study were extracted from four prefectures, and Japan has 47 prefectures, which posed a problem in terms of generalizability for application to the whole population in Japan. Second, since HIP, the primary interest of outcome in this study, was collected as one category, we could not differentiate diabetes before pregnancy, GDM, and overt diabetes in pregnancy. However, since the underlying mechanism of the effect of parent-daughter relationships on HIP were mainly common regardless of the subcategories of HIP, we considered all the subcategories of HIP as one category. Third, we did not consider some potential covariates, such as body mass index, smoking status, diet, blood pressure, and gestational weight gain, which could affect the risk of HIP. However, parent-daughter relationships were upstream of the pathway, that is, chronologically before maternal weight, blood pressure, and diet, and thus might be mediating factors of the association between parent-daughter relationships and HIP, as previous studies suggested. Therefore, we did not include those covariates in the analysi[
20]. Fourth, since the questionnaire in this study was self-administered, there may be response bias.
Conclusions
In conclusion, poor relationships with their parents assessed at the first pregnancy visit were significantly associated with the risk of HIP among pregnant women with no psychiatric disease history. The results suggested that this simple question could be used to estimate the risk of HIP in clinical settings where it was challenging to inquire directly about childhood maltreatment history. Further studies, including various confounding factors, such as BMI, GWG, and smoking status, were warranted.
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