Maternal stressors impact maternal wellbeing and cortisol, and infant growth in rural Guatemala: insights from qualitative and quantitative approaches

Background: Guatemala has one of the highest rates of child stunting in the world, with the indigenous populations being disproportionately affected. Impaired linear growth may result from maternal stresses associated with malnutrition and infection but also with psychosocial (PS) factors, which may be mediated by cortisol. Objective: In 8 rural Mam-Mayan communities in the Western Highlands of Guatemala, our objectives were to (1) characterize women's exposure to nutrition, infection and PS stressors, (2) describe the maternal diurnal salivary cortisol rhythm in pregnancy and postpartum (PP) and explore its association with PS variables, (3) assess the cumulative impact of maternal-level factors (nutritional, infectious, PS), social factors (autonomy, social support, domestic violence), and household factors (SES, food security) on early infant growth, and (4) evaluate whether maternal cortisol may be a mediator in the vertical transmission of stress. Methods: Grounded in participatory action research and a socio-ecological framework, this mixed-methods, observational study enrolled a longitudinal cohort of 155 women, seen in pregnancy (6-9 mo), early (0-6 wk) and later (4-6 mo) PP, and two cross-sectional cohorts (60 early, 56 later PP). Maternal and infant anthropometry was recorded, maternal fecal, urine and saliva samples were collected, and questionnaires were used to explore household, social and maternal-level factors. Photovoice activities involved giving a camera to 23 community women, who documented sources of vulnerability vs. resilience, and shared photo-elicited narratives through 6 group sessions. Results: Diet diversity (3.4±1.3) was low and only 38% of women were food secure. Urinary and gastrointestinal infections were rare (<5%). Participants reported low maternal autonomy (81%), high paternal support (70%), small social support networks (2.7±1.3 individuals) and common domestic violence (22%). Many women (20-50%) had local idioms of distress (enojo, susto, nervios). Infant stunting was common (36% early PP, 43% later PP). Waking and evening salivary cortisol concentrations were 13.1±5.2 and 5.0±3.0 nmol/l in pregnancy and 6.1±3.1 and 2.2±2.3 nmol/l PP. Lower household wealth, food insecurity, shorter maternal stature, high maternal autonomy, high paternal support, low/moderate social support and domestic violence were associated with a more "stressed" cortisol rhythm. Domestic violence increased the odds of feeling overwhelmed (OR=27.3) and of experiencing local idioms of distress (OR=2.3-5.4). Dirt floor, no prior day meat consumption, insufficient breast milk, and short maternal stature were associated with lower early PP height-for-age Z score (HAZ) and increased odds of stunting. Early PP, infants of mothers with greater paternal support, autonomy and emotional distress were more likely to be stunted. Higher levels of early PP evening cortisol increased the odds of stunting. Change in HAZ between early and later PP visits (ΔHAZ) was positively associated with maternal height, BMI and female gender, and negatively with maternal autonomy, problems with partner and difficulty breastfeeding. Later PP waking cortisol was positively associated with ΔHAZ. PhotoVoice narratives highlighted 2 scenarios of particular vulnerability: (1) experiencing domestic violence, low autonomy and socioeconomic dependence, and (2) being a single mother with few employment options and limited rights. Additional sources of stress were poverty and having no social support or access to social services. Sources of resilience were family, nature, livestock, agriculture, traditional practices and spirituality. Implications: This transdisciplinary research highlights the importance of integrating PS interventions into research and intervention programs targeting early infant growth, and sheds light on important strategies to increase resilience and empower women and communities to break the cycle of poor growth and compromised health.

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