How the First Years of Motherhood Impact the Cardiac Autonomic Profile of Female Healthcare Professionals

doi:10.21203/rs.3.rs-117217/v1

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How the First Years of Motherhood Impact the Cardiac Autonomic Profile of Female Healthcare Professionals

https://doi.org/10.21203/rs.3.rs-117217/v1

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published 14 Apr, 2021

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Background

The conciliation between career and family is a relevant issue for working women, in particular during the first years of motherhood. Data about the state of the cardiac autonomic regulation in working women with preschoolers are lacking.

Aim

To compare the cardiac autonomic profile of women with and without preschoolers via the analysis of the variability of the time distance between two consecutive R-wave peaks (RR) from standard 24-hour Holter electrocardiogram (ECG).

Methods and Results

Fifty healthy active female healthcare professionals were enrolled: 25 with at least one preschooler (W_KID) and 25 without (W_NOKID). A standard Holter ECG was obtained during a regular working day. Segments of 5000 consecutive RRs were selected during daytime (DAY) and nighttime (NIGHT). Heart rate variability analysis was performed and the following parameters were considered for comparison between the two groups: mean (μ_RR), variance (σ²_RR), and the absolute power in high frequency component (HF) of RR series. HF_RR was considered as a marker of vagal cardiac modulation.

Only µ_RRsignificantly increased from DAY to NIGHT in both groups, W_KID and W_NOKID. Instead, σ²_RRand HF_RR increased from DAY to NIGHT only in W_NOKID. W_KID showed lower σ²_RRand HF_RR during NIGHT, compared to W_NOKID.

Conclusion

The presence of preschoolers lowered nocturnal cardiac vagal modulation of female mothers. This might represent a finalistic adaptation to facilitate reactivity to demanding tasks.

Health Economics & Outcomes Research

Cardiac & Cardiovascular Systems

Maternal & Fetal Medicine

heart rate variability

autonomic nervous system

cardiac control

spectral analysis

gender

health professionals

The conciliation between career and family is a relevant issue. Women are often sandwiched between more and more competitive and demanding working activities and traditional family duties. Debate exists about the impact of the multiple-role engagement, i.e. family and work roles, on psychological stress and quality of life. The “Depletion Hypothesis” considers the multiple-role engagement as a factor contributing to overload and strain, while the “Enrichment Hypothesis” as a factor enhancing individual’s resources, social connections, power, prestige and emotional gratification^{1, 2}. In any case, there might be a potentially stressful condition that, in turn, might influence women’s health status.

Independently from the family engagement, the stress induced by the working load has been associated to an increased risk for cardiovascular diseases development, together with other risk factors, such as physical inactivity, smoking, poor diet habits, overweight, hypertension, dyslipidemia, and diabetes^3–6. This increased risk could be related to an altered cardiac neural regulation due to a reduced vagal and/or an augmented sympathetic modulation to the heart. The sympathovagal imbalance would entail a diminished adaptive capability of the cardiac control to respond to external perturbations⁵.

The cardiac autonomic profile (CAP) can be studied by means of the heart rate variability (HRV), i.e. beat-to-beat variation of the cardiac cycle defined as the time interval between two successive R-wave peaks (RR) from the electrocardiogram (ECG). HRV analysis provides indices of the vagal and sympathetic modulation directed to the sinus node^{7, 8}. These indices vary physiologically in response to a number of daily life challenges, such as orthostatism and physical activity, denoting the transitional finalistic adjustment of the system^9–12.

The same indices assume prognostic significance when modified as the result of pathological conditions. For instance, decreased overall HRV, increased sympathetic and/or decreased vagal activity directed to the heart after a myocardial infarction, in hypertension and heart failure are related to increased mortality and morbidity^13–16. On the other hand, therapeutic interventions that improve the sympathovagal balance may positively affect prognosis^{17, 18}.

In addition, HRV studies^19–23 have demonstrated that also pregnancy and menopause influence the CAP^19–23. During pregnancy, a high sympathetic modulation directed to heart and vessels has been found in women at the late stage of pregnancy compared to the early stage²⁴. After menopause, an overall decreased HRV and a cardiac neural sympathetic predominance have been described²². In these conditions it is still unclear whether the modified CAP is expression of a physiological adaptation or of an increased risk of unfavorable events.

Maternity also represents a delicate and intense period of life, in terms of both physical and mental engagement, in particular in the first years of working women. To our knowledge, there are no data about the state of the CAP in this condition. We hypothesize that the CAP of working women might be influenced by the strain determined by the double burden, i.e. workload and child care.

To test this hypothesis, we compared the CAP of two groups of female healthcare professionals²⁵, one group with at least one preschooler, and a second group without. HRV from a standard 24-hour ECG recording provided the indices of the daily and nocturnal CAP.

Population

The study population included 50 healthy women: 25 with at least one preschooler (W_KID) and 25 women without (W_NOKID). They all were active healthcare professionals at IRCCS Istituti Clinici Scientifici Maugeri in Milan, Italy. Sample size calculation was performed over preliminary data collected on a subgroup of W_KID (9) and W_NOKID (8) on the RR variance parameter assuming a power of 0.90 and a level of significance of 0.05. Inclusion criteria were: i) fertile age between 25 and 45 years; ii) normal 12 lead ECG at rest. Exclusion criteria were: i) any history of cardiovascular, respiratory or metabolic disease; ii) any current pharmacological therapy known to influence the CAP; iii) any ongoing acute disease; iv) alcohol consumption > 24 g/day (> 250 ml of wine, > 660 ml of beer, > 80 ml of spirits); v) moderate to heavy smoking (> 8 cigarettes daily).

The protocol adhered to the principles of the Declaration of Helsinki and was approved by the local ethics committee “CE ICS Maugeri-IRCCS, Pavia” (2131CE). Each enrolled subject signed a written informed consent before participating in the experimental protocol.

Experimental protocol

At enrollment, each subject filled out a detailed questionnaire to collect information on demographics, clinical history, working schedules, social, exercise, and sleeping habits. A complete physical examination and a standard 12-lead ECG completed the evaluation. At the beginning of a regular working day, avoiding the 3 days after a night shift and the 7 days after the first day of the menstrual cycle, a 3-lead 24-hour ECG (360° eMotion FAROS, Mega Electronics, Finland; Sylco srl, Monza, Italy) was positioned. The electrodes were adequately positioned to minimize noise and volunteers asked to annotate their daily activities. The sampling rate was 500 Hz. Before starting the recording, each subject rated the perceived stress on a Visual Analogue Scale (VAS), that consisted on an unmarked ruler with endpoints labelled as “no perceived stress” (0)and “very high perceived stress” (10) ^{26, 27}. The scale therefore yielded a subjective score on perceived degree of stress between 0 and 10.

Time series extraction

The modified lead II was chosen to favor R wave identification. From the ECG signal, RR interval time series were derived by an automatic algorithm. RR interval was defined as the temporal distance between two consecutive R-wave peaks. Automatic detection of R-wave peaks was manually checked to avoid missing beats or errors. In presence of premature beats or artifacts, correction by means of cubic spline interpolation was implemented. The fraction of corrections never exceeded 5% of the total considered samples. Segments of 5000 consecutive RR intervals were selected during daytime (DAY, from 1 to 5 p.m.) and during nighttime (NIGHT, from 1 a.m. to 4 a.m.) for further analyses. On these selections, an iterated analysis on windows of 250 consecutive RR intervals, with superposition of 200, was performed. All the time and spectral indices were calculated over each time window and the median of the whole distribution was taken as representative ²⁸. After linear detrending, mean (µ_RR) and variance (σ²_RR) of RR series were calculated, and expressed in ms and ms², respectively.

Power spectral analysis

Parametric power spectral analysis was performed on RR series described by an autoregressive model. The model order was chosen according to Akaike information criterion and power spectral density was decomposed into spectral components characterized by a central frequency. Each frequency component was labeled as high frequency (HF) component if its central frequency dropped in the HF band (0.15–0.5 Hz) band ⁷. The absolute power in HF band of the RR series, HF_RR, defined as the sum of power spectral components classified as HF and expressed in ms², was considered as an index of the vagal modulation directed to the heart ^{8, 29}.

Statistical analysis

Categorical data were reported as absolute number (percentage) and continuous data as mean ± standard deviation. The differences between W_KID and W_NOKID in continuous variables were tested by two-tailed Student t-test in case of normal distribution (tested by means of Kolmogorov-Smirnov test) or Mann-Whitney rank test in case of non-normal distribution, while for categorical variables χ² test was applied. Two-way repeated measures analysis of variance (one factor repetition, Holm-Sidak test for multiple comparisons) was performed to check the differences between the two groups (i.e. W_KID and W_NOKID) within the same experimental conditions (i.e. DAY and NIGHT) and the differences between experimental conditions within the same group. Pearson correlation analysis was carried out to assess the correlation between CAP indices and the perceived degree of stress. Correlation analysis was carried out separately during DAY and NIGHT over the single groups (i.e. W_NOKID and W_KID) and pooling the data together regardless of groups and experimental condition. A p < 0.05 was always considered significant. Statistical analyses were carried out using Sigmaplot, Systat Software, Inc., Chicago, IL, version 11.0.

All subjects completed the experimental protocol and referred a regular night sleep during the Holter ECG recording. Awakenings were recorded on the personal diary and these periods were not considered for the analysis. The demographic and clinical features of the enrolled population are shown in Table 1. As regards W_KID, an only child was present in 48% of cases, 2 children in 52% of cases. The number of holidays and shifts was similar for W_KID and for W_NOKID. The percentage of subjects performing regular exercise (at least 1 day/week for at least 4 weeks) was also homogenous in the two groups, as well as the amount of sleeping hours per night.

Table 1

Demographic and clinical features of the enrolled population
	W_NOKID (n = 25)	W_KID (n = 25)
Age, years	35.4 ± 7.2	37.7 ± 5.6
BMI, kg/m²	22.7 ± 3.7	23.4 ± 3.1
SAP, mmHg	108 ± 11	109 ± 13
DAP, mmHg	67 ± 10	70 ± 10
Sleep per night, hours	6.6 ± 0.9	6.4 ± 1.3
Smoking, n (%)	7 (28)	5 (20)
Regular physical exercise, n (%)	12 (48)	8 (32)
Physical exercise, hours/week	3.0 ± 1.6	2.7 ± 1.9
Regular social activities, n (%)	23 (92)	17 (68)
Social activities, hours/week	7.4 ± 8.0	3.3 ± 2.3
Employment
Nurse, n (%)	7 (28)	10 (40)
Physician, n (%)	4 (16)	6 (24)
Physiotherapist, n (%)	13 (52)	6 (24)
Nursing assistant, n (%)	1 (4)	3 (12)
Working hours, hours/day	7.9 ± 1.0	7.7 ± 1.4
W_NOKID, women without preschoolers; W_KID, women with at least one preschooler; BMI, body mass index; SAP, systolic arterial pressure; DAP, diastolic arterial pressure. Data are presented as mean ± standard deviation or number (percentage).

The perceived stress according to the VAS was surprisingly similar in the two groups (W_KID had 4.7 ± 2.1 and W_NOKID 5.7 ± 2.1, p = 0.087).

The results of the HRV analysis did differ as shown in Fig. 1. Only µ_RR significantly increased from DAY to NIGHT in both W_KID and W_NOKID (Fig. 1a), that is, as expected, healthy subjects are more bradycardic during the night. Instead, the expected increase of σ²_RR and HF_RR from DAY to NIGHT was observed only in W_NOKID. Thus, compared to W_NOKID, W_KID showed lower σ²_RR and HF_RR during NIGHT (Fig. 1b and Fig. 1c).

Figure 2 shows two representative examples of the power spectrum of the RR series during daytime (DAY, on the left) and during nighttime (NIGHT, on the right) in a 30-year-old female physician with a 2-year-old child (W_KID, top panel) and in a 28-year-old nulliparous physician (W_NOKID, bottom panel). Each 3D graph represents the power spectral density of the RR series (z-axis) for the considered frequency (x-axis), associated to each window of 250 consecutive RR intervals (cycle, y-axis). Of notice, during NIGHT, the relative absence of peaks in the HF band in the W_KID compared to the higher activity in the HF band of the W_NOKID indicates the paradoxical modulation directed to the heart for the W_KID.

Table 2 summarizes the results of the correlation analysis between HRV indices and the level of perceived stress assessed by the VAS. No significant correlations were found nor considering W_KID and W_NOKID separately, nor pooling the data together regardless of groups and experimental conditions. Thus, CAP modifications seemed to be unrelated to the degree of perceived stress.

Table 2

Results of the correlation between cardiac autonomic profile indices and VAS scale on perceived stress
	W_NO KID		W_KID
	r	P	r	p
µ_RR DAY, ms	-0.336	0.101	-0.009	0.965
σ²_RR DAY, ms²	-0.089	0.670	0.001	0.999
HF_RR DAY, ms²	-0.028	0.894	-0.062	0.768
µ_RR NIGHT, ms	-0.139	0.508	0.171	0.413
σ²_RR NIGHT, ms²	-0.053	0.801	-0.154	0.464
HF_RR NIGHT, ms²	-0.014	0.946	-0.166	0.428
W_NO KID, women without preschoolers; W_KID, women with preschoolers; RR, RR interval; µ_RR, mean of RR; σ²_RR, RR variance; HF_RR, absolute power in high frequency band of the RR; DAY, daytime; NIGHT, nighttime; r, Pearson product moment correlation coefficient; p, p value. Data are presented as mean ± standard deviation.

In the present study, we demonstrated that the cardiac autonomic profile of a group of female healthcare professionals with preschoolers is different compared to that of a matched group of working women without children. During nighttime a decreased vagal modulation was demonstrated in the former group. However, such autonomic nervous system changes seemed to be unrelated to stress.

The enrolled subjects in the two groups were similar in respect of demographic and clinical parameters, life and working habits, and they were all healthy. The perceived stress was also similar in the two groups, as witnessed by the VAS scores. This finding was somehow surprising, as based on common experience and literature, women with double burdens (child care and workload) would be expected to define themselves as more stressed ^{30, 31}. This seems to support the enrichment hypothesis^{1, 2}, according to which women who are involved in multiple social roles experience satisfaction rather than stress.

Thus, the presence of a commitment to childcare, rather than stress per se, would influence the CAP of the working women of this study.

In healthy subjects, the sympathovagal balance shifts towards an active mode during daytime, instead the sleep is used as a period of cardiovascular relaxation and autonomic quiescence ³².

In this study, heart rate physiologically decreased during nighttime in both groups, as mirrored by the µ_RR increase. Instead, the expected physiological increase of the vagal cardiac activity during the night, mirrored by higher σ²_RR and higher HF_RR, compared to daytime, was observed only in W_NOKID. Indeed, an altered circadian variation was clearly identified in W_KID³⁰.

While during daily hours the two groups of women were characterized by similar CAP, during the nighttime, W_NOKIDS turned to an autonomic “sleep mode”, while W_KID remained in an “active mode”, i.e. they diverted the circadian CAP pattern^{7, 29, 33}.

This raises the question whether such modifications may jeopardize these women’s health, as it is well known that a decreased vagal modulation in resting conditions is an independent risk factor for all-cause mortality in several pathological situations, including myocardial infarction, hypertension, heart failure and diabetes^13–16. On the other hand, it has to be underlined that W_KID showed a normal sympathovagal modulation during daytime with a paradoxical behavior only during the night.

This CAP modification could be the results of an adaption modality to maintain a high level of alert aimed at maximizing the survival of both herself and the offspring throughout the 24 hours. Based on the fight or flight theory³⁴, the sympathetic branch of the autonomic nervous system is more active, causing a concomitant de-activation of the vagal one, in presence of external challenges of the system or emergency situations, to cope with the acute stress³⁵. As an example, in reaction to the passive orthostatic challenge applied during tilt test the reduction of the vagal activity aims at maintaining the homeostasis¹¹. In the case of a woman with the baby sleeping next door, a low level of vagal activity during the nocturnal hours would facilitate a prompt reaction in case of a child’s cry of hunger or a threat.

This is in keeping with the theory that cardiac vagal control may regulate behavioral, cognitive, and emotional responses by inhibiting the central autonomic network ³⁶.

Nevertheless, some important questions remain open. A prolonged or continuous decreased level of vagal activity could represent for the young mothers an additional risk factor for the development of future cardiovascular events ³⁵. Indeed, a reduced vagal activity directed to the heart during daytime was recently observed in mothers up to two years postpartum with symptoms of anxiety and depression³⁷.

Moreover, stress and lack of sleep are recognized causes of reduced heart rate variability and higher sympathovagal ratio^38–41. Therefore, further longitudinal studies are advocated to verify if the observed vagal hypotonia is only transient, to deepen the relation between the cardiac controls and the mothers’ psychological status, and to eventually include a male population.

The main limitations of the present study are the lack of information about hormonal levels and sleep staging, which should also be evaluated in future studies.

We conclude that the results of this study add important information for understanding the gender-related adaptation of the autonomic nervous system. Female workers engaged in the care of young children seem to have a different cardiac autonomic profile from their peers without such commitment, that is, a reduced vagal activity that can favor a prompt response and greater reactivity in case of any need of the offspring.

Acknowledgements

We thank all the participants who adhered to the experimental protocol. We thank Valeria Mansi, Chiara Andreotti and Lorena Grano de Oro for their precious help in organizing the experimental protocol during the first months.

Author contributions

LAVD devised the research protocol; VDG, LADV, FP enrolled the population; LADV and BDM performed the experiments; BDM, LADV and LC analyzed the data; BDM prepared figures and tables; BDM and LADV drafted the manuscript; BDM, GC, LC, VDG, FP, AP and LADV edited and revised the manuscript; BDM, GC, LC, VDG, FP, AP and LADV approved the final version of the manuscript.

Competing interests

The authors declare no conflicts of interest.

Data availability

Anonymized data are available upon reasonable request to the corresponding author. Potential data exchange will be conducted in accordance with the European legislation about data protection.

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You are reading this latest preprint version

How the First Years of Motherhood Impact the Cardiac Autonomic Profile of Female Healthcare Professionals

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Journal Publication

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Abstract

Figures

Introduction

Methods

Population

Experimental protocol

Time series extraction

Power spectral analysis

Statistical analysis

Results

Discussion

Declarations

References

Status:

Journal Publication

Version 1