Cortisol levels versus self-report stress measures during pregnancy as predictors of adverse infant outcomes: a systematic review

Figures & data

Figure 1. Flow diagram for selection of studies.

A flow diagram indicating the process of identification, screening, and selection of studies in this review and the final number of included studies.

Table 1. Summary of included studies (n = 28).

Author (year) setting	Study sample	Stress measures		Timing of measures**		Infant outcomes	Results	Quality of study*
		Self-report	Cortisol	Self-report	Cortisol
Observational longitudinal studies
Aatsinki et al. (2020) Turku, Finland	398 pregnant women and their 398 infants	PRAQ-R2, Daily Hassles	Hair cortisol	T1(15 weeks), T2(24 weeks), T3 (34 weeks)	T2 (24 weeks)	Infant gut microbiota	Self-report/Cortisol Not reported Self-report/Outcomes Higher PRAQ-R2 associated with higher levels of Proteobacteria (potentially pathogenic) (p < 0.05) Cortisol/Outcomes Higher cortisol associated with lower Lactobacillus (potentially protective)	Good
Baibazarova et al. (2013) Utrecht, the Netherlands	158 pregnant women and their infants (N = 316 dyads)	Perceived Stress Scale (PSS), Pregnancy related anxieties questionnaire-revised (PRAQ-R), State-Trait Anxiety Inventory-State (STAI-S)	Amniotic fluid and blood serum	T2 (18 weeks)	T2 (18 weeks)	Gestational age at birth; infant birth weight; Infant Behavior: Infant Behavior Questionnaire-Revised (IBQ-R) at T4 (3 months postpartum)	Self-report/Cortisol No significant association Self-report/Outcomes No significant association Cortisol/Outcomes High prenatal cortisol related to low birth weight and high infant temperament at T4 (x^2 = 72, p = 0.95, RMSEA = 0.00, CFI = 1.00, GFI = 1.00, AGFI = 0.99) High amniotic cortisol predicted a lower birth weight (r = −0.25; p < 0.01) High amniotic cortisol related to high infant fear and distress (t = 1.78, p < 0.05; t = 1.94, p < 0.10)	Good
Bergman et al. (2010) London, UK	125 mothers and their 125 babies (N =dyads)	STAI, Stressful Life Events Questionnaire (SLEQ)	Maternal blood cortisol and amniotic fluid cortisol	T2 (18 weeks)	T2 (18 weeks)	Infant development: Bayley Scale of Infant Development (BSID) Mental Development Index (MDI); Infant-mother attachment: Ainsworth’s Strange Situation (ASS) at T4 (17 months)	Self-report/Cortisol No significant associations Self-report/Outcomes Lower maternal postnatal STAI-S scores related to securely attached children (F = 4.20, p < 0.05) Higher postnatal STAI-S scores significantly associated with low MDI scores (r = −0.23, p < 0.05) Cortisol/Outcomes Significant inverse association between amniotic fluid cortisol (ln transformed values) and BSID r = −0.25, p < 0.01) Prenatal amniotic cortisol strongly predicted MDI in children with an insecure attachment history (r = −0.47, p < 0.001) Marginal association between amniotic fluid cortisol and MDI was more negative earlier in gestation (B = 1.08, SE = 0.57, p = 0.06)	Good
Bolten et al. (2011) Trier, Germany	75 pregnant women and their new borns (N = 150 dyads)	PSS, Prenatal Distress Questionnaire (PDQ)	Salivary cortisol on awakening	T2 (18 weeks) and T3 (37 weeks)	T2 (18 weeks) and T3 (37 weeks)	Gestational age at birth; infant birth weight; APGAR score; head circumference (HC) at birth	Self-report/Cortisol No significant associations Self-report/Outcomes No significant associations Cortisol/Outcomes Higher maternal cortisol on awakening at T2 predicted lower birth weight (β= −0.29, p < 0.05) Higher maternal cortisol on awakening at T3 predicted lower birth weight (β= −0.30, p < 0.01) and body length (β= −0.28, p < 0.05) Higher maternal cortisol on awakening (both at T1 and T3) predicted lower birth weight (F = 6.91, p < 0.001), smaller body length (F = 3.29, p < 0.01) and smaller head circumference (F = 2.99, p < 0.05)	Good
Buitelaar et al. (2003) Utrecht, the Netherlands	170 pregnant women and their infants (N = 340 dyads)	Everyday Problem List (EPL), PRAQ-R, PSS.	Salivary cortisol	T2 (17 weeks), T3 (28 weeks and 38 weeks)	T2 (17 weeks), T3 (28 weeks and 38 weeks)	Gestational age at birth; infant birth weight; Infant Development: BSID MDI, BSID Psychomotor Development Index (PDI); Infant Behavior: Infant Behavior Record (IBR), Infant Characteristics Questionnaire (ICQ) at T4 (3 and 8 months)	Self-report/Cortisol Not reported Self-report/Outcomes Higher fear of giving birth at T3 (28 weeks) related to lower 8-month scores of infant development (F = 5.04, p < 0.05) High amount of daily hassles at T2 associated with lower MDI scores at 8 months (F = 3.9, p < 0.05) Strong fear of giving birth at T3 (28 weeks) associated with lower MDI and PDI scores at 8 months (F = 5.58, p < 0.05; F = 7.67, p < 0.01) Fear of giving birth at T3 (28 weeks) and negative correlation with PDI scores at 8 months (F = 5.30, p < 0.05) Daily hassles at T2 an independent risk factor for low MDI scores in 8 months infants (SOR = 1.1, 95% CI 1.02–1.18) High levels of fear of giving birth at T2 increased the risk of having an infant with a low PDI score at 8 months (SOR = 1.3, CI 1.12–1.56) Overall significant effect of fear of giving birth on low exploration, test-affectivity, and goal-directedness scores at 3 and 8 months (BSID sub-scales) (F = 2.74, p < 0.05) Overall significant effect of fear of bearing a handicapped child on low exploration, test-affectivity, and goal-directedness scores at 3 and 8 months (F = 2.87, p < 0.05) Overall significant effect of high PSS scores on low exploration, test-affectivity, and goal-directedness scores at 3 and 8 months (Bayley sub-scales) (F = 2.45, p < 0.05) A strong fear of giving birth at T2 linked to lower test-affectivity at 8 months (F = 1.38, p < 0.001) Strong fear of bearing a handicapped child at T2 associated with lower scores of test-affectivity at 3 months (F = 5.93, p < 0.05) High levels of fear of bearing a handicapped child at T2 related to reduced goal-directedness of 8 months (F = 6.27, p < 0.05) PSS scores at T2 the only significant predictor of mother-reported difficulty and inadaptability at 3 and 8 months (F = 4.44, p < 0.05) Cortisol/Outcomes High cortisol at T3 (28 weeks) related to low MDI and PDI scores at 3 and 8 months (F = 4.61, p < 0.05) High cortisol at T3 (28 weeks) related to lower MDI scores at 3 months (F = 6.38, p < 0.05) High cortisol at T3 (28 weeks) related to lower PDI scores at 3 and 8 months (F = 9.15, p < 0.05; F = 9.38, p < 0.05)	Good
Caparros-Gonzalez et al. (2019) Granada, Spain	91 pregnant women and their 91 infants (N = 91 dyads)	PDQ, PSS	Hair cortisol	T1(10 weeks), T2(23 weeks), T3 (34 weeks)	T1(10 weeks), T2(23 weeks), T3 (34 weeks),	Fetal development (Head circumference)	Self-report/Cortisol Not reported Self-report/Outcomes Higher PDQ scores associated with a higher head circumference (β = 0.54, p < 0.05); Higher PDQ scores associated with a higher neonatal length (β = 0.69, p < 0.05) Cortisol/Outcomes Higher maternal cortisol associated with higher neonatal length (β = 0.49, p < 0.05)	Good
Conradt et al. (2020) Utah, USA	137 pregnant women and their 137 infants (N = 137 dyads)	UCLA Life Stress Interview	Hair cortisol	T3 (33 weeks)	T3 (33 weeks)	Infant behavior (NICU Network Neurobehavioral Scale, NNNS), birth weight, prematurity	Self-report/Cortisol Higher psychological stress indirectly associated with cortisol through maternal body mass index (β = 0.002; 95% CI = 0.0003, 0.0033, p < 0.05) Self-report/Outcomes Not reported Cortisol/Outcomes No significant associations	Good
Davis and Sandman (2010) Southern California, USA	125 pregnant women and their infants (N = 250 dyads)	PSS, STAI-S, Pregnancy Specific Anxiety (PSA)	Salivary cortisol	T1(15 weeks), T2(20 and 26 weeks), T3 (32 and 37 weeks), T4(3, 6 and 12 months postpartum)	T1(15 weeks), T2(20 and 26 weeks), T3 (32 and 37 weeks)	Infant Development: BSID at T4 (3, 6 and 12 months of age)	Self-report/Cortisol No significant associations Self-report/Outcomes High PSA scores at T1 and related to an overall change associated with low MDI (t = 2.4, p < 0.05) High PSA scores at T1 related to low MDI scores (t’s ranged from 2.1 to 2.9, p’s < 0.05) Overall rate of change of PSA was the strongest predictor of MDI (ΔR^2=0.05, p < 0.05) PSA scores independently (from cortisol) predicted MDI (ΔR^2=0.05, p < 0.05) Cortisol/Outcomes Lower maternal cortisol at T1 predicted accelerated MDI scores across the first postnatal year (t = −2.5, p < 0.01) Higher maternal cortisol at T3 (37 weeks) predicted accelerated infant MDI scores over the first postnatal year (t = 1.9, p < 0.05) Lower maternal cortisol before T2 related to infants scoring higher on the 12 month MDI (t’s ranged from −2.1 to −2.7, p’s < 0.05)	Good
Davis and Sandman (2012) Southern California, USA	178 pregnant women and their 178 infants (N = 178 dyads)	PSS, STAI-S, PSA	Salivary cortisol at T2 and T3	T2 (20 and 26 weeks) and T3 (32 weeks)	T2 (20 and 26 weeks) and T3 (32 weeks)	Gestational age at birth, Child anxiety: Achenbach System of Empirically Based Assessment (ASEBA); child behavior: Child Behavior Checklist (CBCL) at 6–9 years of age	Self-report/Cortisol No significant associations Self-report/Outcomes High average PSS and PSA scores associated with higher child anxiety at 6–9 years of age (F = 7.1, p < 0.05; F = 7.3, p < 0.05 respectively) PSS scores at T2 (20 weeks) the strongest predictor of child anxiety (F = 5.8, p < 0.05) PSA scores at T2 (26 weeks) the strongest predictor of child anxiety F = 5.8, p < 0.05) PSA scores associated with child anxiety (Odds ratio = 1.1, 95% confidence interval = 1.0–1.2, p = 0.05) PSA independently predicted child anxiety (F = 6.1, p < 0.05) Cortisol/Outcomes Elevated average maternal cortisol associated with higher child anxiety at 6–9 years of age F = 6.7, p < 0.05) Higher maternal cortisol twice more likely related to children with anxiety ratings within the borderline/clinically significant range ratings (Odds ratio = 2.1, 95% confidence interval = 1.1–3.9, p < 0.05) Maternal cortisol independently predicted child anxiety (F = 6.1, p < 0.05)	Good
De Weerth et al. (2013) Utrecht, the Netherlands	107 pregnant women and their infants (N = 202 dyads)	STAI-S, Daily Hassles Questionnaire (DHQ), PRAQ-R	Salivary cortisol	T3 (37 weeks)	T3 (32 weeks)	Infant salivary cortisol level due to separation at T4 (9 months of age).	Self-report/Cortisol No significant associations, except for a marginally significant positive relation between the STAI-S and maternal cortisol at T3 (r = 0.18, p < 0.10) Self-report/Outcomes Significant positive correlation between STAI-S scores at T3 and cry/fuss at T4 (r = −0.21; p < 0.05) Cortisol/Outcomes Higher maternal cortisol levels predicted higher infant cortisol responses over time (Estimate = 10.03, SE = 4.11, p < 0.05). Higher maternal cortisol levels related to less crying and fussing in general as reaction to maternal separations (Estimate= −0.99, SE = 0.44, p < 0.05).	Good
Doyle et al. (2015) New York, USA	125 pregnant adolescents	Ecological Momentary Assessment (EMA)	Salivary cortisol	T1 (16 weeks), T2 (27 weeks) and T3 (37 weeks)	T1 (16 weeks), T2 (27 weeks) and T3 (37 weeks)	Fetal heart rate (FHR) and fetal movements at T2 and T3; gestational age; birthweight; pregnancy complications at birth	Self-report/Cortisol No significant associations Self-report/Outcomes Negative mood at T1 (F = 4.16, p < 0.05) and T2 (F = 6.77, p < 0.05) significantly associated with lower overall FHR in males Negative mood at T1 more significant in females (F = 9.53, p < 0.01) associated with higher levels of fetal coupling (correlation between FHR and movements) during gestation Cortisol/Outcomes Higher cortisol levels at T2 related to higher FHR at T2 (F = 4.20, p < 0.05) Higher cortisol levels at T1 related to less of an increase in fetal coupling levels during gestation (F = 8.20, p < 0.01), and found an interaction with gender, being more significant in males (F = 5.14, p < 0.05)	Good
Field et al. (2006) Miami, USA	300 pregnant women	STAI-T	Urinary cortisol at T1 (20 weeks)	T2 (20 weeks)	T2 (20 weeks)	Fetal activity; fetal growth measures (femur length, HC, abdominal circumference and biparietal diameter) at T2 (20 weeks). Gestational age; infant birthweight; length; HC; Brazelton Neonatal Behavior Assesment Scale (BNBS) at T4 (birth)	Self-report/Cortisol No significant associations Self-report/Outcomes No significant associations Cortisol/Outocomes High cortisol levels related with more active fetuses, (F = 3.81; p < 0.05), small fetus head circumference (F = 11.66; p < 0.05), small fetus abdominal circumference (F = 11.43; p < 0.05), small fetus biparietal diameter (F = 9.27; p < 0.05) and low fetal weight (F = 5.36; p < 0.05)	Good
Galbally et al. (2019) Perth, Australia	241 pregnant women and their 241 infants (241 dyads)	Adaptation of the Pregnancy Risk Assessment Monitoring System (PRAMS)	Hair cortisol	T2 (20 weeks), T3 (30 weeks)	T3 (30 weeks)	The Brief Infant Toddler Social Emotional Assessment (BITSEA)	Self-report/Cortisol Higher anxiety associated with lower cortisol (r = −.10, p < 0.01) Self-report/Outcomes Higher anxiety associated with lower infant cortisol (r = −0.16; p < 0.01) Cortisol/Outcomes Higher maternal cortisol associated with high neonatal cortisol (r = 0.31; p < 0.05)	Good
Gao et al. (2021) Utah, USA	162 pregnant women and their 162 infants (162 dyads)	UCLA Life Stress Interview, The Everyday Stress Index (ESI)	Hair cortisol	T3 (33 weeks)	T3 (33 weeks)	Neonatal Intensive Care Unit (NICU) Network Neurobehavioral Scale (NICU NNNS)	Self-report/Cortisol Not reported Self-report/Outcomes Higher stress predicted lower NICU NNNS only in females (β = −.30, p < 0.05). Cortisol/Outcomes No significant associations	Good
Gilles et al (2018) Mannheim, Germany	405 pregnant women and their 405 infants (405 dyads)	Early Life Stress (ELS)	Salivary cortisol	T3 (31 weeks)	T3 (31 weeks)	Birth weight, birth length, head circumference, length of gestation	Self-report/Cortisol Higher ELS associated with higher cortisol (r = 0.123; p < 0.05) Self-report/Outcomes Prenatal ELS negatively associated with all neonatal anthropometric measures (r = −0.133 to r = −0.183; all p < 0.05). Cortisol/Outcomes Higher cortisol associated with lower anthropometric measures at birth (r = −0.109; p < .05. Cortisol decline during the day associated with length of gestation (r = 0.18, p < 0.01)	Good
Goedhart et al. (2010) Amsterdam, the Netherlands	2810 pregnant women and their infants (N = 2810 dyads)	STAI-S, PRAQ-R, Parenting Daily Hassles (PDH)	Blood cortisol	T1 (13 weeks)	T1 (13 weeks)	Gestational age at birth; infant birth weight; fetal growth	Self-report/Cortisol No significant association Self-report/Outcomes No significant association Cortisol/Outcomes Maternal cortisol levels negatively related to infant birthweight, (B = 0.35; p < 0.001) Maternal cortisol levels positively related to Small for Gestational Age (SGA) (OR = 1.00; p < 0.05) Higher maternal cortisol levels independently related to lower birthweights (B = 0.94; p < 0.05) Higher maternal cortisol levels were independently related to a higher SGA risk (OR = 1.01; p < 0.05)	Good
Hoffman et al. (2016) Colorado, USA	90 pregnant women	PSS, STAI-S	Hair cortisol concentrations (HCC)	T1 (16 weeks), T2 (22 weeks), T3 (28, 34 and 40 weeks)	T1 (16 weeks), T2 (22 weeks), T3 (28 and 40 weeks)	Gestational age at birth	Self-report/Cortisol PSS scores at T1 positively correlated with HCC at T2 (r = 0.28, p < 0.05) Self-report/Outcomes PSS scores at T1 positively correlated with earlier gestational age at delivery (r = 0.30, p < 0.05) Cortisol/Outcomes HCC at T2 was negatively correlated with gestational age at birth (r = 0.25, p < 0.05)	Good
Hompes et al. (2012) Leuven, Belgium	91 pregnant women	Hospital Anxiety Depression Scale (HADS), PRAQ	Salivary cortisol	T1 (11 weeks), T2 (24 weeks) and T3 (35 weeks)	T1 (11 weeks), T2 (24 weeks) and T3 (35 weeks)	Intrauterine growth at 12, 20 and 30 weeks (through ultrasound); infants’ anthropometric measures: length, weight, Body Mass Index (BMI), Ponderal Index (PI), HC at T4 (birth):	Self-report/Cortisol Not reported Self-report/Outcomes No significant associations Cortisol/Outcomes Basal cortisol levels at T2 significantly predicted the variance of weight (proportion of variance in growth variable explained (PVE) = 11.6%) and body mass index (BMI) at birth (PVE = 6.8%)	Good
Huizink et al. (2003) Utrecht, the Netherlands	170 mothers and their 170 newborns (N = 340 dyads)	EPL, PRAQ-R, General Health Questionnaire (GHQ), PSS	Salivary cortisol	T1 (17 weeks), T2 (28 weeks) and T3 (38 weeks)	T1 (17 weeks), T2 (28 weeks) and T3 (38 weeks)	Gestational age at birth; infant birth weight; infant development: BSID (MDI and PDI) at T4 (3 and 8 months of age)	Self-report/Cortisol Not reported Self-report/Outcomes Fear of giving birth at T2 significantly associated with low scores of infant development at T5, (F = 5.04, p < 0.05) High scores in EPL at T1 significantly associated with lower MDI scores at T5 (F = 3.9, p < 0.05) Strong fear of giving birth (PRAQ-R) at T2 significantly associated with lower MDI and PDI scores at T4 (8 months of age ) (F = 5.58, p < 0.05; F = 7.67, p < 0.01) Strong fear of giving birth (PRAQ-R) at T3 significantly associated with lower MDI scores at T4 (8 months of age ) (F = 5.34, p < 0.05) Daily hassles at T1 were an independent risk factor for low MDI scores of infants at T4 (8 months of age ) (SOR = 1.1, CI = 1.02–1.189 Fear of giving birth (PRAQ-R) at T2 increased the risk of having an infant with low PDI scores at T4 (8 months of age ) (SOR= 1.3, CI = 1.12–1.56) Cortisol/Outcomes High cortisol at T3 related to the MDI and PDI scores at T4 (3 and 8 months of age) (F = 4.61, p < 0.05) High cortisol at T3 related to lower MDI scores at T4 (3 months of age) (F = 6.38, p < 0.05) High cortisol at T3 related to lower PDI scores at T4 (3 and 8 months of age) (F = 9.15, p < 0.05; F = 9.38, p < 0.05) Cortisol at T1 or T2 not related with infant development (p > 0.05)	Good
Jahnke et al. (2021) Galapagos, Ecuador	25 pregnant women and their 25 infants (25 dyads)	PSS	Salivary cortisol	T3 (36 weeks)	T3 (36 weeks)	Infant stool	Self-report/Cortisol Not reported Self-report/Outcomes High PSS at T3 (36 weeks) related to higher presence of Clostridiaceae Clostridium (p < 0.05) Cortisol/Outcomes High cortisol at T3 related to higher Enterobacteriaceae, Streptococcaceae, and Veillonella (potentially pathogenic) and lower Bifidobacterium and Lachnospiraceae (potentially protective) (p < 0.05)	Good
Jahnke et al. (2021b) Galapagos, Ecuador	24 pregnant women and their 24 infants (24 dyads)	PSS	Salivary cortisol	T3 (36 weeks)	T3 (36 weeks)	Cortisol reactivity	Self-report/Cortisol Not reported Self-report/Outcomes No significant associations Cortisol/Outcomes No significant associations	Good
Kivlighan et al. (2008) Baltimore, USA	98 pregnant women and their 95 newborns (98 dyads)	Pregnancy Experience Scale (PES) and PSS	Salivary cortisol	T3 (36 weeks)	T3 (36 weeks)	Infant birth weight; gestational age at birth; Apgar scores at 1 and 5 minutes	Self-report/Cortisol Higher scores on STAI-T associated with flatter cortisol decline at T3 (1.74% per +1 SD increase; 95% CI:0–3.3%) Self-report/Outcomes No significant associations Cortisol/Outcomes Low maternal cortisol at T3 associated with higher infant birth weight in primiparous compared with multiparous (t = 1.74, p < 0.09)	Good
Kramer et al. (2009) Montreal, Canada	5092 pregnant women (Prospective study) 207 cases and 444 controls (case and control study)	PSS, PRAQ-R, Daily Hassles Scale (DHS), Marital Strain Scale (MSS), Job-related Stress Scale (JSS), Prenatal Life Event Scale (PLES),	Hair cortisol	T2 (26 weeks)	T4 (at delivery)	Spontaneous preterm birth; placental histopathological features	Self-report/Cortisol No significant associations Self-report/Outcomes Only high PRAQ-R, perception of high pregnancy risk, was significantly associated with the risk of spontaneous preterm birth (OR = 1.7, 95% CI = 1.2–2.3) Cortisol/Outcomes Positive correlation between hair cortisol and gestational age (p < 0.05)	Good
Ponirakis et al. (1998) Pennsylvania, USA	27 adolescent pregnant women and their 27 babies (N = 54 dyads).	NEO-AC Personality Inventory (Anxiety sub-scale), STAI	Salivary cortisol	T1 (16 weeks), T3 (34 weeks) and T4 (24 h–4 weeks after delivery)	T1 (16 weeks), T3 (34 weeks) and T4 (24 h–4 weeks after delivery)	Infant birth weight; APGAR score at birth; abnormalities on newborn profile exam; resuscitation measures used at birth, infant electrocardio-gram (EKG) at T3.	Two composite factors (CF) reported: CF Trait variables (STAI-trait, STAS-trait, , NEO Anxiety) and CF State variables (STAI-state, STAS-state, and BDI) Self-report/Cortisol Not reported Self-report/Outcomes Maternal trait composite score at T1 positively correlated with infant Apgar at 5 min (r = 0.47, p < 0.05) Maternal state composite score at T2 positively correlated with the number of abnormalities on the newborn profile exam (r = 0.59, p < 0.001) Maternal trait composite score at T1 the only significant predictor of infant cardiac vagal tone (r = 0.49, p < 0.01), accounting for 24% of the variance Cortisol/Outcomes Maternal mean cortisol at T1 a significant predictor of infant Apgar at 1 min, 5 min and number of resuscitation measures on the infant (r = − 0.39, p < 0.05; r = −0.45, p < 0.05; r = 0.45, p < 0.05)	Fair
Ramiro-Cortijo et al. (2021) Madrid, Spain	182 pregnant women and 133 infants (133 dyads)	Pregnancy concerns scale	Blood cortisol	T1 (9–11 weeks), T2 (24–25 weeks), T3 (36 weeks)	T1 (9–11 weeks)	Fetal complications (prematurity, intrauterine growth restriction, physiologic system)	Self-report/Cortisol No significant associations Self-report/Outcomes No significant associations Cortisol/Outcomes No significant associations	Good
Smew et al. (2018) Stockholm, Sweden	92 pregnant women and their 92 babies (92 dyads)	PSS-10	Salivary cortisol	T1 (10–14 weeks), T2 (26–28 weeks), T4 (6, 12, 24 months postpartum)	T1 (10–14 weeks), T2 (26–28 weeks), T4 (6, 12, 24 months postpartum)	Infant birth weight; HC, body length, gestational age at T3 (birth)	Self-report/Cortisol An inverse association between salivary cortisol and the PSS at T2 (r = −0.31, p < 0.05) Self-report/Outcomes No significant associations Cortisol/Outcomes No significant associations	Good
Observational Cross-sectional study
Diego et al. (2006) Miami, USA	41 pregnant women	STAI-T, DHS	Urinary cortisol	T2 (16 and 29 weeks)	T2 (16 and 29 weeks)	Fetal ultrasound biometry measures: femur length, HC, abdominal circumference, biparietal diameter, fetal weight estimation at T2	Self-report/Cortisol Maternal STAI-T and hassles scores positively related to maternal cortisol (r = 0.41, p < 0.001; r = 0.26, p < 0.01; r = 0.28, p < 0.01) Self-report/Outcomes Maternal STAI-T scores negatively related to biparietal diameter, HC, and abdominal circumference (r = −0.28; p < 0.001; r = − 0.23; p < 0.05; r = −0.21; p < 0.05) Maternal hassles scores negatively related to biparietal diameter (r = −0.29; p < 0.01) Cortisol/Outcomes Maternal cortisol negatively related to biparietal diameter, HC, abdominal circumference, and fetal weight (r = −0.47; p < 0.001; r = −0.43; p < 0.001; r = −0.42; p < 0.001; r = −0.33; p < 0.01) Prenatal cortisol was the only significant predictor of fetal weight (X^2 = 42.46, p = 0.28, CFI = 0.99, RMSEA = 0.03) Mothers with elevated maternal cortisol levels at risk for having below average estimated fetal weight (OR = 12.81; CI = 4.81–34.09)	Fair
Romero-Gonzalez et al. (2021) Granada, Spain	108 pregnant women and their 108 infants (108 dyads)	PDQ, PSS, Stress Vulnerability Inventory (SVI)	Hair cortisol	T1 (8–10 weeks)	T1 (8–10 weeks)	Fetal sex ratio	Self-report/Cortisol Not reported Self-report/Outcomes Not reported Cortisol/Outcomes Higher cortisol associated with female neonate (t = −2.04; p < 0.05)	Fair

Note. *The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies (National Institute of Health, 2014) was applied to assess quality of studies included in this systematic review; ** Weeks refers to weeks of gestation; T₁: First trimester; T₂: Second trimester; T₃: Third trimester; T₄: Postpartum.

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