Feature

Today, it’s well accepted that chronic stress can affect a person’s physical health in all sorts of ways. But more than three decades ago, when psychologist Christine Dunkel Schetter, PhD, joined the faculty at the University of California, Los Angeles (UCLA), the connection between stress processes and physiology was significantly fuzzier. In the intervening years, she has helped bring that picture into focus.

Among her most important findings: The stress and anxiety that women experience while they are pregnant—or even before conceiving—can affect their health and the health of their future children, leading to problems including low birth weight, earlier delivery and postpartum depression.

And although it has taken a while for that message to spread from the psychology lab to the clinic, physicians are finally recognizing the importance of managing stress during pregnancy, Dunkel Schetter says.

“When I started this, there was great skepticism. Now, I am invited to give talks at pediatric and OB-GYN forums,” she says. “It’s so exciting that this has become accepted in medicine.”

A career-changing collaboration

Dunkel Schetter’s career began with a broad interest in the link between social relationships and health, which she studied as a PhD student at Northwestern University and as a postdoctoral fellow at the University of California, Berkeley.

When Dunkel Schetter moved to the psychology department at UCLA in 1983, Susan Scrimshaw, PhD, then a medical anthropologist in UCLA’s School of Public Health, invited her to collaborate on a study exploring stress in pregnancy and its effect on preterm birth. It was the beginning of a body of research that has extended to this day. “That completely transformed my work,” she says.

With Scrimshaw, then-student Marci Lobel, PhD, now at Stony Brook University in Stony Brook, New York, and other colleagues, Dunkel Schetter followed 130 socioeconomically disadvantaged women, mostly Latina- or African-American, from pregnancy through the postpartum period. Through a series of in-depth interviews with each participant, they found that prenatal stress predicted lower birth weight and earlier delivery, after controlling for traditional medical risk factors (Health Psychology, Vol. 11, No. 1, 1992).

Though some previous research had hinted at the connection, Dunkel Schetter says, this was the first prospective study to demonstrate the effect with greater methodological rigor. “Almost immediately, more collaborators and grants started coming to me. There was a deluge of interest,” she says.

Despite that attention, it took a while for the medical community to embrace the findings. So, Dunkel Schetter replicated and extended those results in a series of substantial, long-term studies funded largely by the National Institute of Child Health and Human Development (NICHD). In time, her research helped the medical community come to understand how stress in pregnancy can affect the health of mothers and their babies and has led to assessments of prenatal stress and anxiety in some clinical settings.

Before and after

Dr. Christine Dunkel Schetter (in black “Equality” T-shirt) and her team.Since that first pioneering project, Dunkel Schetter and her colleagues at the UCLA Stress Processes and Pregnancy Lab have conducted numerous studies with expectant mothers, often with large networks of collaborators from fields including public health, medicine, nursing and sociology. In one major undertaking, she participated in the NICHD’s Community Child Health Research Network (CCHN), a multisite project investigating how stress and resilience influence pregnancy outcomes and child health. Beginning in 2008, the researchers followed more than 2,000 families. They conducted interviews with mothers and fathers about their psycho­social experiences and measured health biomarkers such as body mass index, cholesterol levels and levels of cortisol, one hormone involved in regulating stress responses.

In one study from that project, Dunkel Schetter; Darby Saxbe, PhD, at the University of Southern California; and colleagues found that women who reported high levels of physical and emotional aggression from their partners in the first year of their children’s lives had cortisol patterns indicative of chronic stress. Interestingly, those women and their male partners were also more likely to display matching cortisol patterns, suggesting that the men who behaved aggressively were also experiencing chronic stress at levels that could affect their physical and psychological health (Psychoneuroendocrinology, Vol. 62, No. 1, 2015).

After the initial five-year CCHN study concluded, Dunkel Schetter and her colleagues continued following a subset of the women—many of whom went on to have additional children. That’s an exciting development because it allows the researchers to explore how psychosocial factors that were in place before pregnancy might influence birth outcomes. “We have information on the women’s biology, medical background and psychosocial factors from before they even conceived their children,” she says.

She and her collaborators are just starting to work with that rich data set, but they’ve already made important findings. In a study led by Dunkel Schetter’s former graduate student Christine Guardino, PhD, now at Dickinson College in Carlisle, Pennsylvania, the researchers found women who had cortisol patterns associated with greater stress before they became pregnant went on to have children with lower birth weights (Health Psychology, Vol. 35, No. 6, 2016).

In another study of the women who went on to have second pregnancies, Dunkel Schetter and colleagues examined various stressors as well as the women’s perception of their own stress. They found that women who reported more depressive symptoms after the birth of one child were at risk for greater stress in the months and years that followed, and those stressors, in turn, increased the likelihood of depressive symptoms in the next postpartum period (Clinical Psychological Science, Vol. 4, No. 5, 2016).

Together, such findings indicate that the stress women experience even before conceiving a child is associated with poorer health for the women in pregnancy and beyond, and for their future children. “To help mothers, we have to start even before pregnancy,” Dunkel Schetter says.

This year, she launched a randomized controlled pilot study with collaborators at UCLA and the University of California, San Francisco. The researchers are working with doulas in Oakland, California, to provide web-based cognitive-behavioral therapy to pregnant women who are high in anxiety or depression. Initially, they’ll compare 50 women who receive the treatment with 50 who receive care as usual. Eventually, they plan to expand the trial to a second site. “It’s complicated work to get into the right settings to screen women and find a way to make it convenient for a busy pregnant woman,” she says. “It’s a big project, but it’s an exciting one.”

Embracing diversity

While much of Dunkel Schetter’s previous work focused on women’s lives leading up to their pregnancies and giving birth, a new project examines how stress, depression and relationship factors during pregnancy affect the health of the children after they’re born. In 2013, she and Mary Coussons-Read, PhD, at the University of Colorado, Colorado Springs, launched the Healthy Babies Before Birth (HB3) study, also funded by NICHD. They are wrapping up data collection this year. The project follows women in Los Angeles and Denver beginning in the first trimester of pregnancy. Researchers continue to interview the mothers and collect biosamples to measure stress markers and inflammatory activity in both mothers and their babies up to 12 months after birth.

“What’s new with this studyis that now we’re able to look at how these various factors during pregnancy are predictive of inflammation, infant health and developmental outcomes,” says Isabel Ramos, a graduate student who is helping to interview mothers and collect blood and saliva samples.

Ramos hopes to use the data to better understand how psychological symptoms in pregnancy affect health outcomes. In one analysis, she’s exploring the link between pregnancy anxiety and preterm birth, and how corticotropin-releasing hormone (CRH), the levels of which increase during pregnancy, is involved in that pathway. In another study, she’s investigating whether CRH levels during pregnancy predict postpartum depression.

Ramos has a particular interest in Latina mothers and plans to do some analyses by ethnic group to look for ethnic- and culture-specific patterns. “Often in health psychology, ethnicity is something that’s controlled for in the analyses,” she says. “I feel lucky to have these large data sets where we have a big enough sample size to really look at these ethnic effects.”

Indeed, much of Dunkel Schetter’s work embraces diverse populations, often from disadvantaged backgrounds. That was one of the factors that drew postdoctoral researcher Kharah Ross, PhD, to the lab. In a line of research she’s started since joining the lab three years ago, Ross is exploring the interactive effects of race/ethnicity and socioeconomic status on pregnancy physiology and risk factors for preterm birth. “A lot of people look at race/ethnicity and socioeconomic status as separate predictors, with the assumption that gains in socioeconomic status are equally beneficial across populations and contexts. But that might not always be the case,” Ross says. “There’s some evidence that gains in education and income might not always benefit black individuals to the same extent as white individuals. I want to understand whether the same effect appears in pregnancy physiology, and how that affects the way we think about health disparities during pregnancy.”

High expectations

While research on stress and pregnancy is the centerpiece of the Dunkel Schetter lab, her interests continue to incorporate her early work on relationships and health. Her research has covered topics such as social relationships and adjustment to cancer; psychological adjustment to other health conditions, such as HIV and infertility; and social support in middle-aged couples.

To help juggle these projects, she typically has two postdocs and two to four graduate students who work primarily with her. And, because the health psychology program at UCLA requires graduate students to have two advisors, she often works with three or four additional graduate students whose primary research is done with another faculty member.

The double-advisor arrangement was first tested by Dunkel Schetter and her UCLA psychology colleague Shelley Taylor, PhD, as part of a National Institues of Health training grant. It was so successful that when UCLA’s health psychology PhD program was founded, it continued the model. “Our students develop a relationship to a second mentor and gain a second set of perspectives,” Dunkel Schetter says.

Thanks to that model, Dunkel Schetter’s lab often welcomes students from a variety of areas, including social, clinical and quantitative psychology. The resulting mix of backgrounds is extremely helpful during regular lab meetings where members share what they’re working on and solicit feedback from one another, she says. “It’s great to have those perspectives when we talk about each other’s work and provide feedback.”

High stress in moms is linked to lower-birth-weight babies.Dunkel Schetter admits that feedback isn’t always easy to swallow. “I think some people might characterize us as sort of ruthless, but our lab meetings are always thought-provoking and lead to better, more rigorous work,” she says. Students say they appreciate the emphasis Dunkel Schetter puts on scientific precision. “She does have high expectations for us, but she is always in the loop and available to guide us every step of the way,” Ramos says.

“There’s a lot of focus on putting out high-quality work, and we’re always challenged to grow and develop,” adds Ross. “There’s no laurel-resting.”

Mentor of mentors

In Dunkel Schetter’s case, there isn’t much resting, period. In addition to her research portfolio, she’s involved with the UCLA Healthy Campus Initiative, an effort to enhance healthy lifestyle choices at the university. With her psychology department colleague Theodore Robles, PhD, Dunkel Schetter is helping to design an “Engage Well” component of the project to improve social relationships on campus, with the goal of improving health and well-being among staff and students.

Dunkel Schetter also holds a part-time position as associate vice chancellor for faculty development for all of UCLA. In that role, she mentors junior faculty and runs programs to help her colleagues succeed.

Whether she’s helping junior faculty or her students, Dunkel Schetter takes pride in helping others learn, grow and identify their passions and talents. “Being a mentor is what I do,” she says. “There’s a lot of camaraderie, a lot of friendship, a lot of collaboration in my lab, but I’m not looking to create little versions of me. Everyone becomes a unique researcher.”

She is also passionate about health psychology and enjoys helping her field of research grow. “Not only do I know most of the psychologists working on maternal and child health, more than half of them were my students,” she says. “I continue to want to see the science get sharper and better, and to be applied in clinical settings and in policy.” 

“Lab Work” illuminates the work psychologists are doing in research labs nationwide. To read previous installments, go to www.apa.org/monitor/digital and search for “Lab Work.”

Research foci

The Stress Processes and Pregnancy Lab at UCLA is exploring:

  1. Stress processes in pregnancy
  2. Social support processes and their influence on health
  3. Socioeconomic and ethnic disparities in maternal and child health

Further reading

Resilience in the Context of Chronic Stress and Health in Adults
Dunkel Schetter, C., & Dolbier, C. Social and Personality Psychology Compass, 2011

Shedding Light on the Mechanisms Underlying Health Disparities Through Community Participatory Methods
Dunkel Schetter, C., et al. Perspectives on Psychological Science, 2013

Explaining Racial and Ethnic Inequalities in Postpartum Allostatic Load: Results From a Multisite Study of Low to Middle Income Women
O’Campo, P., et al. SSM–Population Health, 2016

Moving Research on Health and Close Relationships Forward—A Challenge and an Obligation
Dunkel Schetter, C. American Psychologist, 2017