Many of the studies reviewed rely primarily on self-reported questionnaires such as the EPDS, STAI, and PSS to assess maternal psychological distress during pregnancy. While these tools are validated and widely used, they are inherently subjective. To what extent can we rely on these self-reported measures as accurate reflections of maternal distress, especially considering potential underreporting due to stigma or overreporting due to situational stress?
Furthermore, how do the authors account for the variability in timing, frequency, and duration of psychological distress assessments? For instance, distress measured at a single timepoint may not capture the full trajectory of maternal mental health throughout pregnancy. Could this temporal limitation skew associations with fetal or neonatal brain development?
In addition, while structural and functional fetal brain alterations are reported in association with maternal distress, many of these studies involve small sample sizes and high inter-individual variability in fetal MRI data. How do the authors evaluate the robustness of these correlations, particularly when controlling for confounding variables such as genetic predisposition, socio-economic status, medication use (e.g., SSRIs), and comorbidities?
Also, considering that the fetal BOLD signal and MRI-based metrics are still being refined and are sensitive to motion and resolution limitations, how confident can we be in interpreting these subtle changes as meaningful indicators of neurodevelopmental disruption rather than normal developmental variability?
Finally, would integrating objective physiological biomarkers, such as maternal cortisol levels, inflammatory cytokines, or placental function indicators, alongside self-reported psychological distress provide a more comprehensive and biologically grounded understanding of how maternal mental health impacts fetal brain development?