Prenatal Maternal Psychological Distress and the Risk of Autism Spectrum Disorders in Offspring: Results from a Meta-Analysis of Observational Studies

Abstract

Introduction: Psychological distress, such as stress, depression or anxiety, is a prevalent mental health concern during pregnancy. However, data on the association between prenatal maternal psychological distress and the risk of autism or autism spectrum disorders (ASD) in their offspring have not been synthesized systematically. We performed a meta-analysis to explore this issue and provide evidence regarding maternal mental health screening and ASD prevention. Methods: Six electronic databases were systematically searched up to June 2025. English-language full-text observational studies were included, with no geographic or race restrictions. Studies that quantitatively assessed the association between maternal psychological distress during pregnancy and the risk of ASD in offspring were eligible for inclusion. Pooled odds ratios (ORs) were calculated. Heterogeneity, publication bias, and sensitivity analyses were assessed. Results: Among 484 full-text records screened, 22 studies were eligible. Data analysis demonstrated that offspring of mothers with prenatal psychological distress have a 72% higher likelihood of being diagnosed with ASD or autism after the age of two (OR = 1.72, 95% CI 1.50 to 1.97, P < 0.01) compared to those of mothers without distress. This association was observed across different study designs and ASD diagnostic ascertainment methods, although effect estimates varied. Substantial between-study heterogeneity was observed (I² = 87.90%), largely attributable to differences in study design, ASD ascertainment and distress assessment rather than psychological distress subtype. Conclusion: In this meta-analysis, prenatal maternal psychological distress was associated with an increased likelihood of an ASD diagnosis in offspring. Across the included studies, effect estimates were generally similar for stress, depression, and anxiety, despite substantial heterogeneity in study design and exposure assessment. This consistency suggests that elevated ASD risk is not confined to a single diagnostic category of maternal distress. At the same time, the findings should be interpreted considering the variability in how psychological distress was measured and controlled for across studies. Taken together, the results indicate that maternal psychological distress during pregnancy warrants attention in epidemiological research and routine antenatal care, without implying that specific psychiatric subtypes can be clearly distinguished in terms of offspring ASD risk.