title: Maternal bereavement in the antenatal period and oral cleft in the offspring.
abstract: OBJECTIVE
  Is maternal bereavement (emotional stress) due to loss of a close relative in the antenatal period associated with the risk of oral cleft in the offspring?
  
  
  CONCLUSIONS
  Our study suggests prenatal maternal bereavement is associated with an increased risk of oral cleft in the offspring, especially when the bereavement was due to a sudden death or death of a child.
  
  
  BACKGROUND
  The aetiology of oral cleft is unknown but includes both genetic and environmental causes.
  
  
  METHODS
  We performed a population-based cohort study based on several national registers in Denmark from 1978 to 2008.
  
  
  METHODS
  Our final study population consisted of 1 771 663 children. Of these 35 118 (2%) were born to mothers who experienced bereavement in the exposure window from 1 year before pregnancy to the end of the first trimester.
  
  
  RESULTS
  In total, 3043 children were diagnosed with a cleft; 968 with cleft lip, 1206 with cleft lip and palate and 869 with a cleft palate. For overall bereavement the prevalence was 1.7 per 1 000 live born in the unexposed children and 2.2 per 1 000 live born in the exposed children. Overall, maternal bereavement due to the death of a close relative from 1 year before conception to the end of the first trimester was associated with a significantly increased risk of oral cleft [odds ratio (OR): 1.28, 95% confidence interval (CI): 1.01; 1.61). When mothers lost a relative due to a sudden death, the risk of oral cleft in the offspring was higher (OR: 1.76, 95% CI: 1.06; 2.94). Losing a relative in the time period before pregnancy and during the first trimester showed a tendency to an increased risk. The risk increase was 77% when the mother was bereaved due to sudden death and the estimation was robust in different analytical strategies.
  
  
  CONCLUSIONS
  It is a limitation that we only studied live born children, but most children with isolated oral cleft would survive their pregnancy and birth. Since oral cleft are rare and despite the large study population, we still had a relatively small number of cases, which results in limited power to detect small differences. We did not have actual measurements of the maternal cortisol concentration, but we believe that bereavement due to death of a close relative produces a strong stress reaction in most people. Also we did not have the opportunity to adjust for intake of folic acid and use of anti-depressant; however, analysis in a subset of the data showed no difference in these intakes between exposed and unexposed mothers.
  
  
  CONCLUSIONS
  With this study we add a large-scale human cohort study to the body of literature on stress and birth defects. Our study is in agreement with previously published results and can be generalized to similar populations like the native Danish population. Severe stress may be added to the list of potential causes for oral cleft.
authors.affiliation: Section for Epidemiology, Department of Public Health, Aarhus University, Bartholins Allè 2, Aarhus C 8000, Denmark. ki@soci.au.dk
authors.forename: K G
authors.initials: KG
authors.lastname: Ingstrup
authors.forename: H
authors.initials: H
authors.lastname: Liang
authors.forename: J
authors.initials: J
authors.lastname: Olsen
authors.forename: E A
authors.initials: EA
authors.lastname: Nohr
authors.forename: B H
authors.initials: BH
authors.lastname: Bech
authors.forename: C S
authors.initials: CS
authors.lastname: Wu
authors.forename: K
authors.initials: K
authors.lastname: Christensen
authors.forename: J
authors.initials: J
authors.lastname: Li
mesh_terms: D001601:Bereavement; D015331:Cohort Studies; D003718:Denmark; D005260:Female; D006801:Humans; D009056:Mouth Abnormalities / Q000209:etiology*; D011247:Pregnancy; D012307:Risk Factors; D013315:Stress, Psychological