For two years, the interdisciplinary IGNITE project followed 1,000 pregnant women and their children to learn about the role environmental factors play in preterm birth, poor pregnancy outcomes, and social and emotional development.
April 2020 has been a confusing and uncertain time. Just weeks after the first US cases of COVID-19 emerged, guidance on the new virus was changing daily. “Only grocery stores were open. People were wiping everything. All playgrounds have been closed,” says Penn psychologist Rebecca Waller. “It was pretty scary for everyone, but we imagined, especially for pregnant women.”
Waller and his colleagues at Perelman School of Medicine and Children’s Hospital of Philadelphia (CHOP) had recently begun working together on an interdisciplinary initiative. They called it the Exposome Intergenerational Project – IGNITE for short – and their goal was to unite traditionally siled research fields to better understand risk factors for preterm birth and poor pregnancy outcomes.
“Abundant data from animal and human studies show that the intrauterine environment is important and that a stressful life can have long-term effects on fetal development,” says Raquel Gur, a Penn Medicine psychiatrist who directs the Lifespan Brain Institute (LiBI). “Genes are important, but they are expressed in the context of an environment.”
Although IGNITE had to pivot online at the start of the pandemic, the researchers had already put in place the necessary infrastructure to carry out the project they envisioned. About 1,000 people and their children are now part of this study, which includes data for most stages of pregnancy and the postpartum period, as well as 12 and 24 months postpartum.
The work so far has revealed a lot about the effect of the pandemic on pregnancy in the United States. The team’s first paper, published in Psychiatry Research in November 2020, confirmed that, like many facets of COVID-19, the pandemic has placed a disproportionate burden on black pregnant women. The researchers’ latest study, published in August in the Archives of Women’s Mental Health, showed that people who reported traumatic birth experiences had an increased risk of developing postpartum depression.
There’s still a lot to learn, says Waller. “We are now seeing some of these children for the second time. The future of this research is really exciting.
Weave disparate threads
Although IGNITE itself is nascent, the threads the collaboration weaves together have existed for years. LiBI, for its part, started about six years ago, created by Gur to better understand the risk factors that affect the developing brain. Several National Institutes of Health (NIH) grants to Michal Elovitz of Penn Medicine allowed him to study cohorts of pregnant women to learn more about preterm birth and poor pregnancy outcomes, which affect black populations at significantly higher rates. For his part, Waller has 12 years under his belt studying parenthood and the risk of aggressive and antisocial behavior in children.
The IGNITE project includes other partners from various disciplines, such as Wanjikũ Njoroge, preschool psychiatrist at CHOP, who is medical director of the Early Childhood Clinic; Lauren White, LiBI psychologist; Ran Barzilay, a psychiatrist at CHOP and Penn who studies suicide risk factors in young people; Sara Kornfield, licensed clinical psychologist and director of Penn Medicine’s Maternal Wellness Initiative; Barbara Chaiyachati, a CHOP physician with Safe Place: The Center for Child Protection and Health who studies adversity in early life; and neonatologist Heather Burris.
Although many people knew each other through previous partnerships or overlapping research interests, no previous project matched the intended scope of IGNITE, which aimed to merge maternal-fetal medicine research, obstetrics and gynecology, psychiatry, psychology, neonatology and pediatrics.
“One of the big challenges for Penn and CHOP is that they are massive institutions with so much great research on both campuses, but it can be difficult to connect,” says Njoroge. Elovitz, for example, focuses on pregnant women, and their involvement in research usually ends once the baby is born. Njoroge studies the next phase of development, working with infants and young children, and Waller’s research centers on young elementary-aged children.
The team speculated that getting a more complete picture of these families, starting with pregnancy and extending into the first years of a child’s life, could offer better insight into how early childhood exposures could affect development. “We cannot understand much about these children without knowing more about their families, their parents,” says Njoroge. “We formed this collaboration to better understand the environment in which these children will live and grow.”
Pivoting during a pandemic
IGNITE was just getting started when COVID-19 hit the U.S. Rather than suspending plans or canceling the project entirely, the researchers decided to change course slightly. Naturally, they understood that the stress of a global pandemic would significantly affect pregnant women and their children, but they wanted to understand precisely how.
“People who were already pregnant or became pregnant during the pandemic, they were isolated, they couldn’t have visitors,” says Gur. “It was a terrible time.”
Through her previous research, Elovitz already had a group of people — pregnant or who had just given birth — who had agreed to participate in research studies. Beyond that, several of the IGNITE researchers who are also clinicians were still treating patients. “We were actively seeing families struggling and we started thinking, ‘We should see how the women are doing. It looks like they are not well,” says Njoroge.
The IGNITE team received institutional approval to proceed with a new research protocol, then created a standardized questionnaire to dig into some of the common issues. “We wanted to assess depression, anxiety, health disparities, COVID-related concerns,” says Gur. More than 1,000 people responded to this survey.
Analysis of this data quickly led to the Psychiatry Research article. He revealed that in many ways, black pregnant women felt a greater burden of COVID-19 than their white counterparts: they reported more concerns about economic hardship and negative employment consequences, as well as more concerns at every stage of the birthing experience, from prenatal care to postnatal needs. They were also more likely to meet criteria for clinical depression.
A double shot
“People were surprised by the results of our first study,” says Njoroge. “But I’m a health equity researcher. I was not shocked by the results. They did, however, goad her into pulling the curtain further; she began examining historic Philadelphia redlining maps.
“Colleagues at Drexel were taking those same maps and overlaying the current maps to show the disproportionate impact of the pandemic on Philadelphians. I started thinking about the cohort we were working with. Of the original IGNITE participants, 151 Black people had completed two additional online surveys, which focused on the dual impact of institutionalized racism and the COVID-19 global health crisis on postpartum mental health.
Njoroge learned that many participants lived in districts that were demarcated around 80 years ago, areas that see even less investment and more poverty today. The JAMA Psychiatry article the team published later clearly explains the findings: “Associations between interpersonal racism, structural racism, and negative experiences of the COVID-19 pandemic were associated with increased risk of depression. and postpartum anxiety.”
The data confirmed the researchers’ suspicions. “We are here in 2022 and black people are still affected by decisions made in the 1930s,” says Njoroge. “This is the continuation of this story about the impacts of structural racism on the health and well-being of black people.”
Beyond studying the effect of the pandemic on pregnancy, researchers have also found a way to continue seeing families beyond the initial postpartum period, checking in on both the parent and the child after about a year.
“A parent with a one-year-old who might have other kids during a pandemic — we knew we weren’t going to get that data by bringing people in,” Waller says. Instead, they sent home a package with games and books. “We asked the parent to sit with their child and read the books, play with a rattle, play a game with a bilboquet,” she explains. The IGNITE team recorded and coded behaviors during interactions.
The setting and number of parent-child exchanges, Waller admits, provides a more complete picture than people who visit a lab multiple times. “In a world without a pandemic, we have this rather fancy setup with cameras in every corner. You can zoom in and out,” she says. “But there’s a lot to be said for getting a phone or laptop out at home. This changes the quality, richness and quantity of behavioral data we can collect.
Thanks to recently obtained funding from the NIH, the team can now see these families again when the child turns 2 years old. Recruitment and data collection for this effort, called “Prenatal to Preschool,” is underway. In a parallel LiBI-funded substudy, the team is sending saliva kits home to collect participants’ DNA and RNA in hopes of better understanding how stress integrates biologically.
Despite the difficult topic – or perhaps because of it – there is excitement about the potential of this collaboration. Its operation as a research unit can become a model for further interdisciplinary work across the University. What researchers learn can shape policy with data and, importantly, save lives through relatively simple and timely interventions.
“Yes, IGNITE has shown some grim data so far, but the flip side is that while the data doesn’t look great, it also shows some amazing stories of resilience,” says Njoroge. “Part of our job is to show what families and communities do, weaving them together into a tapestry. People have found amazing ways to support each other. This is also what we hope our work will do.
Screenwriter Michele W. Berger