Skip to main content Accessibility help

Maternal bereavement and the risk of preterm delivery: the importance of gestational age and of the precursor of preterm birth

  • K. D. László (a1), J. Li (a2), J. Olsen (a2) (a3), M. Vestergaard (a4) (a5), C. Obel (a4) (a5) (a6) and S. Cnattingius (a1)...



Maternal stress during pregnancy may increase the risk of preterm delivery (PD), but the associations between stress and subtypes of PD are not clear. We investigated maternal loss of a close relative and risks of very and moderately PD (<32 and 32–36 weeks, respectively) and spontaneous and medically indicated PD.


We studied 4 940 764 live singleton births in Denmark (1978–2008) and Sweden (1973–2006). We retrieved information on death of women's family members (children, partner, siblings, parents), birth outcomes and maternal characteristics from nationwide registries.


Overall, the death of a close family member the year before pregnancy or in the first 36 weeks of pregnancy was associated with a 7% increased risk of PD [95% confidence interval (CI) 1.04–1.10]. The highest hazard ratios (HR) for PD were found for death of an older child [HR (95% CI) 1.20 (1.10–1.31)] and for death of a partner [HR (95% CI) 1.31 (1.03–1.66)]. These losses were associated with higher risks of very preterm [HR (95% CI) 1.61 (1.29–2.01) and 2.07 (1.15–3.74), respectively] than of moderately preterm [HR (95% CI) 1.14 (1.03–1.26) and 1.22 (0.94–1.58), respectively] delivery. There were no substantial differences in the association between death of a child or partner and the risk of spontaneous v. medically indicated PD.


Death of a close family member the year before or during pregnancy was associated with an increased risk of PD, especially very PD. Possible mechanisms include both spontaneous and medically indicated preterm birth.


Corresponding author

*Address for correspondence: Dr K. D. László, Clinical Epidemiology Unit, Department of Medicine, Karolinska University Hospital and Karolinska Institute, Eugeniahemmet T2, 17176 Stockholm, Sweden. (Email:


Hide All
Abeysena, C, Jayawardana, P, de A Seneviratne, R (2010). Effect of psychosocial stress and physical activity on preterm birth: a cohort study. Journal of Obstetrics and Gynaecology Research 36, 260267.
Ananth, CV, Vintzileos, AM (2006). Epidemiology of preterm birth and its clinical subtypes. Journal of Maternal-Fetal and Neonatal Medicine 19, 773782.
Andersen, TF, Madsen, M, Jorgensen, J, Mellemkjoer, L, Olsen, JH (1994). The Danish National Hospital Register. A valuable source of data for modern health sciences. Danish Medical Bulletin 46, 263268.
Andersson, L, Sundström-Poromaa, I, Wulff, M, Aström, M, Bixo, M (2004). Neonatal outcome following maternal antenatal depression and anxiety: a population-based study. American Journal of Epidemiology 159, 872881.
Barrios, YV, Sanchez, SE, Qiu, C, Gelaye, B, Williams, MA (2014). Risk of spontaneous preterm birth in relation to maternal experience of serious life events during pregnancy. International Journal of Women’s Health 6, 249257.
Berkowitz, GS, Blackmore-Prince, C, Lapinski, RH, Savitz, DA (1998). Risk factors for preterm birth subtypes. Epidemiology 9, 279285.
Berkowitz, GS, Kasl, SV (1983). The role of psychosocial factors in spontaneous preterm delivery. Journal of Psychosomatic Research 27, 283290.
Borzychowski, AM, Sargent, IL, Redman, CW (2006). Inflammation and pre-eclampsia. Seminars in Fetal and Neonatal Medicine 11, 309316.
Buzaglo, N, Sheiner, E, Harlev, S, Weintraub, AY, Novack, L (2012). Was the military operation ‘Cast Lead’ a risk factor for preterm deliveries? Journal of Maternal-Fetal and Neonatal Medicine 25, 18741878.
Class, QA, Lichtenstein, P, Långström, N, D'Onofrio, BM (2011). Timing of prenatal maternal exposure to severe life events and adverse pregnancy outcomes: a population study of 2.6 million pregnancies. Psychosomatic Medicine 73, 234241.
Copper, RL, Goldenberg, RL, Das, A, Elder, N, Swain, M, Norman, G, Ramsey, R, Cotroneo, P, Collins, BA, Johnson, F, Jones, P, Meier, AM (1996). The preterm prediction study: maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks’ gestation. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. American Journal of Obstetrics and Gynecology 175, 12861292.
Coussons-Read, ME, Okun, ML, Nettles, CD (2007). Psychosocial stress increases inflammatory markers and alters cytokine production across pregnancy. Brain, Behavior and Immunity 21, 343350.
Coussons-Read, ME, Okun, ML, Schmitt, MP, Giese, S (2005). Prenatal stress alters cytokine levels in a manner that may endanger human pregnancy. Psychosomatic Medicine 67, 625631.
Crump, C, Sundquist, K, Sundquist, J, Winkleby, MA (2011). Gestational age at birth and mortality in young adulthood. Journal of the American Medical Association 306, 12331240.
Crump, C, Sundquist, K, Winkleby, MA, Sundquist, J (2013). Early-term birth (37–38 weeks) and mortality in young adulthood. Epidemiology 24, 270276.
Culhane, JF, Rauh, V, McCollum, KF, Hogan, VK, Agnew, K, Wadhwa, PD (2001). Maternal stress is associated with bacterial vaginosis in human pregnancy. Maternal and Child Health Journal 5, 127134.
Danish Health and Medicine Authority (2013). Recommendations for prenatal care ( Accessed 22 April 2015.
Dayan, J, Creveuil, C, Herlicoviez, M, Herbel, C, Baranger, E, Savoye, C, Thouin, A (2002). Role of anxiety and depression in the onset of spontaneous preterm labor. American Journal of Epidemiology 155, 293301.
Dayan, J, Creveuil, C, Marks, MN, Conroy, S, Herlicoviez, M, Dreyfus, M, Tordjman, S (2006). Prenatal depression, prenatal anxiety, and spontaneous preterm birth: a prospective cohort study among women with early and regular care. Psychosomatic Medicine 68, 938946.
Dole, N, Savitz, DA, Hertz-Picciotto, I, Siega-Riz, AM, McMahon, MJ, Buekens, P (2003). Maternal stress and preterm birth. American Journal of Epidemiology 157, 1424.
Dole, N, Savitz, DA, Siega-Riz, AM, Hertz-Picciotto, I, McMahon, MJ, Buekens, P (2004). Psychosocial factors and preterm birth among African American and White women in central North Carolina. American Journal of Public Health 94, 13581365.
Eskenazi, B, Marks, AR, Catalano, R, Bruckner, T, Toniolo, PG (2007). Low birthweight in New York City and upstate New York following the events of September 11th. Human Reproduction 22, 30133020.
Fransson, E, Ortenstrand, A, Hjelmstedt, A (2011). Antenatal depressive symptoms and preterm birth: a prospective study of a Swedish national sample. Birth 38, 1016.
Gavin, AR, Holzman, C, Siefert, K, Tian, Y (2009). Maternal depressive symptoms, depression, and psychiatric medication use in relation to risk of preterm delivery. Womens Health Issues 19, 325334.
Gennaro, S, Hennessy, MD (2003). Psychological and physiological stress: impact on preterm birth. Journal of Obstetric, Gynecologic, & Neonatal Nursing 32, 668675.
Goldenberg, RL, Culhane, JF, Iams, JD, Romero, R (2008). Epidemiology and causes of preterm birth. Lancet 371, 7584.
Goldenberg, RL, Hauth, JC, Andrews, WW (2000). Intrauterine infection and preterm delivery. New England Journal of Medicine 342, 15001507.
Harville, EW, Hatch, MC, Zhang, J (2005). Perceived life stress and bacterial vaginosis. Journal of Women’s Health 14, 627633.
Harville, EW, Savitz, DA, Dole, N, Thorp, JM Jr., Herring, AH (2007). Psychological and biological markers of stress and bacterial vaginosis in pregnant women. British Journal of Obstetrics and Gynaecology 114, 216223.
Heaman, MI, Blanchard, JF, Gupton, AL, Moffatt, ME, Currie, RF (2005). Risk factors for spontaneous preterm birth among Aboriginal and non-Aboriginal women in Manitoba. Paediatric and Perinatal Epidemiology 19, 181193.
Hedegaard, M, Henriksen, TB, Secher, NJ, Hatch, MC, Sabroe, S (1996). Do stressful life events affect duration of gestation and risk of preterm delivery? Epidemiology 7, 339345.
Høgberg, U, Larsson, N (1997). Early dating by ultrasound and perinatal outcome. A cohort study. Acta Obstetricia et Gynecologica Scandinavica 76, 907912.
Ibanez, G, Charles, MA, Forhan, A, Magnin, G, Thiebaugeorges, O, Kaminski, M, Saurel-Cubizolles, MJ, EDEN Mother–Child Cohort Study Group (2012). Depression and anxiety in women during pregnancy and neonatal outcome: data from the EDEN mother-child cohort. Early Human Development 88, 643649.
Khashan, AS, McNamee, R, Abel, KM, Mortensen, PB, Kenny, LC, Pedersen, MG, Webb, RT, Baker, PN (2009). Rates of preterm birth following antenatal maternal exposure to severe life events: a population-based cohort study. Human Reproduction 24, 429437.
Klebanoff, MA, Keim, SA (2011). Epidemiology: the changing face of preterm birth. Clinics in Perinatology 38, 339350.
Knudsen, LB, Olsen, J (1998). The Danish Medical Birth Registry. Danish Medical Bulletin 45, 320323.
Krabbendam, L, Smits, L, de Bie, R, Bastiaanssen, J, Stelma, F, van Os, J (2005). The impact of maternal stress on pregnancy outcome in a well-educated Caucasian population. Paediatric and Perinatal Epidemiology 19, 421425.
Kramer, MS, Lydon, J, Séguin, L, Goulet, L, Kahn, SR, McNamara, H, Genest, J, Dassa, C, Chen, MF, Sharma, S, Meaney, MJ, Thomson, S, Van Uum, S, Koren, G, Dahhou, M, Lamoureux, J, Platt, RW (2009). Stress pathways to spontaneous preterm birth: the role of stressors, psychological distress, and stress hormones. American Journal of Epidemiology 169, 13191326.
Larsen, AD, Hannerz, H, Juhl, M, Obel, C, Thulstrup, AM, Bonde, JP, Hougaard, KS (2013). Psychosocial job strain and risk of adverse birth outcomes: a study within the Danish national birth cohort. Occupational and Environmental Medicine 70, 845851.
László, KD, Ananth, CV, Wikström, AK, Svensson, T, Li, J, Olsen, J, Vestergaard, M, Obel, C, Cnattingius, S (2014). Loss of a close family member the year before or during pregnancy and the risk of placental abruption: a cohort study from Denmark and Sweden. Psychological Medicine 44, 18551866.
László, KD, Liu, XQ, Svensson, T, Wikström, AK, Li, J, Olsen, J, Obel, C, Vestergaard, M, Cnattingius, S (2013 a). Psychosocial stress related to the loss of a close relative the year before or during pregnancy and risk of pre-eclampsia. Hypertension 62, 183189.
László, KD, Olsen, J, Li, J, Persson, M, Vestergaard, M, Svensson, T, Obel, C, Cnattingius, S (2015). The risk of gestational diabetes mellitus following bereavement: a cohort study from Denmark and Sweden. Paediatric and Perinatal Epidemiology 29, 271280.
László, KD, Svensson, T, Li, J, Obel, C, Vestergaard, M, Olsen, J, Cnattingius, S (2013 b). Maternal bereavement during pregnancy and the risk of stillbirth: a nationwide cohort study in Sweden. American Journal of Epidemiology 177, 219227.
Li, J, Vestergaard, M, Obel, C, Cnattingus, S, Gissler, M, Olsen, J (2011). Cohort profile: the nordic perinatal bereavement cohort. International Journal of Epidemiology 40, 11611167.
Marsál, K, Persson, PH, Larsen, T, Lilja, H, Selbing, A, Sultan, B (1996). Intrauterine growth curves based on ultrasonically estimated foetal weights. Acta Paediatrica 85, 843848.
Mendez, DD, Hogan, VK, Culhane, JF (2014). Institutional racism, neighborhood factors, stress, and preterm birth. Ethnicity & Health 19, 479499.
Moster, D, Lie, RT, Markestad, T (2008). Long-term medical and social consequences of preterm birth. The New England Journal of Medicine 359, 262273.
Munk-Jorgensen, P, Mortensen, PB (1997). The Danish Psychiatric Central Register. Danish Medical Bulletin 44, 8284.
Mustillo, S, Krieger, N, Gunderson, EP, Sidney, S, McCreath, H, Kiefe, CI (2004). Self-reported experiences of racial discrimination and Black-White differences in preterm and low-birthweight deliveries: the CARDIA Study. American Journal of Public Health 94, 21252131.
National Board of Health and Welfare (2003). The Swedish Medical Birth Register-A summary of content and quality ( Accessed 22 April 2015.
National Board of Health and Welfare (2009). Quality and content of the Patient Register. Discharges from inpatient care 1964–2007 and visits to specialized outpatient care (excluding primary care visits) 1997–2007 ( Accessed 22 April 2015.
Neggers, Y, Goldenberg, R, Cliver, S, Hauth, J (2006). The relationship between psychosocial profile, health practices, and pregnancy outcomes. Acta Obstetetricia et Gynecologica Scandinavica 85, 277285.
Niedhammer, I, O'Mahony, D, Daly, S, Morrison, JJ, Kelleher, CC, Lifeways Cross-Generation Cohort Study Steering Group (2009). Occupational predictors of pregnancy outcomes in Irish working women in the Lifeways cohort. British Journal of Obstetrics and Gynaecology 116, 943952.
Nordentoft, M, Lou, HC, Hansen, D, Nim, J, Pryds, O, Rubin, P, Hemmingsen, R (1996). Intrauterine growth retardation and premature delivery: the influence of maternal smoking and psychosocial factors. American Journal of Public Health 86, 347354.
Orr, ST, James, SA, Blackmore Prince, C (2002). Maternal prenatal depressive symptoms and spontaneous preterm births among African-American women in Baltimore, Maryland. American Journal of Epidemiology 156, 797802.
Pedersen, CB, Gotzsche, H, Moller, JO, Mortensen, PB (2006). The Danish Civil Registration System. A cohort of eight million persons. Danish Medical Bulletin 53, 441449.
Precht, DH, Andersen, PK, Olsen, J (2007). Severe life events and impaired fetal growth: a nation-wide study with complete follow-up. Acta Obstetricia et Gynecologica Scandinavica 86, 266275.
Rosenberg, L, Palmer, JR, Wise, LA, Horton, NJ, Corwin, MJ (2002). Perceptions of racial discrimination and the risk of preterm birth. Epidemiology 13, 646652.
Sanchez, SE, Puente, GC, Atencio, G, Qiu, C, Yanez, D, Gelaye, B, Williams, MA (2013). Risk of spontaneous preterm birth in relation to maternal depressive, anxiety, and stress symptoms. Journal of Reproductive Medicine 58, 2533.
Savitz, DA, Dole, N, Herring, AH, Kaczor, D, Murphy, J, Siega-Riz, AM, Thorp, JM Jr., MacDonald, TL (2005). Should spontaneous and medically indicated preterm births be separated for studying aetiology? Paediatric and Perinatal Epidemiology 19, 97105.
Statistics Sweden (2010). Multi-generation register 2009: description of contents and quality ( Accessed 10 December 2014.
Straub, H, Adams, M, Kim, JJ, Silver, RK (2012). Antenatal depressive symptoms increase the likelihood of preterm birth. American Journal of Obstetrics and Gynecology 207, 329. e1e4.
Wadhwa, PD, Entringer, S, Buss, C, Lu, MC (2011). The contribution of maternal stress to preterm birth: issues and considerations. Clinics in Perinatology 38, 351384.
Yonkers, KA, Norwitz, ER, Smith, MV, Lockwood, CJ, Gotman, N, Luchansky, E, Lin, H, Belanger, K (2012). Depression and serotonin reuptake inhibitor treatment as risk factors for preterm birth. Epidemiology 23, 677685.


Type Description Title
Supplementary materials

László supplementary material
Tables S1-S4

 Word (31 KB)
31 KB

Maternal bereavement and the risk of preterm delivery: the importance of gestational age and of the precursor of preterm birth

  • K. D. László (a1), J. Li (a2), J. Olsen (a2) (a3), M. Vestergaard (a4) (a5), C. Obel (a4) (a5) (a6) and S. Cnattingius (a1)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed