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Kuipers YJ, Bleijenbergh R, Rimaux S, Mestdagh E. Evaluation of a web-based intervention to optimize perinatal emotional wellbeing: A nested case-control study. Int J Clin Health Psychol 2024; 24:100422. [PMID: 38023371 PMCID: PMC10654235 DOI: 10.1016/j.ijchp.2023.100422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Background/Objective WazzUp Mama© is a remotely delivered web-based tailored intervention to prevent and reduce perinatal emotional distress, originally developed in the Netherlands. The current study aimed to evaluate the adapted WazzUp Mama© intervention in a Flemish (Dutch-speaking part of Belgium) perinatal population. Methods A 1:3 nested case-control study was performed. A data set including 676 participants (169 cases/507 controls) was composed based on core characteristics. Using independent t-test and chi-square, the two groups were compared for mean depression, self and perceived stigma, depression literacy scores, and for positive Whooley items and heightened depression scores. The primary analysis was adjusted for covariates. Results The number of positive Whooley items, the above cut-off depression scores, mean depression, perceived stigma, and depression literacy scores showed statistically significant differences between cases and controls, in favor of the intervention group. When adjusting for the covariates, the statistically significant differences between cases and controls remained for depression, perceived stigma, and depression literacy, for the positive Whooley items and for above cut-off depression scores. Conclusion WazzUp Mama© indicates to have a moderate to large positive effect on optimizing perinatal emotional wellbeing, to positively change perceived stigma and to increase depression literacy.
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Affiliation(s)
- Yvonne J Kuipers
- Edinburgh Napier University, School of Health and Social Care, Edinburgh EH11 4BN, Scotland, UK
- Department of Health and Life Science, School of Midwifery, AP University of Applied Sciences, Noorderplaats 2 Antwerp 2000, Belgium
| | - Roxanne Bleijenbergh
- Department of Health and Life Science, School of Midwifery, AP University of Applied Sciences, Noorderplaats 2 Antwerp 2000, Belgium
| | - Sophie Rimaux
- Department of Health and Life Science, School of Midwifery, AP University of Applied Sciences, Noorderplaats 2 Antwerp 2000, Belgium
| | - Eveline Mestdagh
- Department of Health and Life Science, School of Midwifery, AP University of Applied Sciences, Noorderplaats 2 Antwerp 2000, Belgium
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Kuehnle E, Jungk J, Brodowski L, Kohls F, Hillemanns P, Staboulidou I. Effects of Recreational Therapy and 3D Ultrasonography for High-Risk Pregnancies on Psychological Well-Being during Hospitalization and in the Puerperal Phase. J Clin Med 2023; 12:6228. [PMID: 37834871 PMCID: PMC10573943 DOI: 10.3390/jcm12196228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Hospitalization during pregnancy often produces psychosocial distress for pregnant women. In this study, 3D ultrasound and recreational therapy were compared to the standard treatment for their influence on depressive symptoms and anxiety. In this prospective one-year intervention study, women who were admitted to the hospital for any pregnancy complication, other than psychiatric, were included. A control group, with standard clinical treatment, and two intervention groups, both additionally receiving either 3D ultrasound or recreational therapy, were established. Psychological well-being was assessed at defined times by the PHQ-health-questionnaire. A total of 169/211 women were included: control group n = 79, 3D ultrasound group n = 43, and crochet group n = 83. A higher than estimated underlying depression was seen for all women on admission. The intervention groups showed less depression (p = 0.02762). No difference was seen between the intervention groups (p = 0.23029). Anxiety decreased throughout intervention, but not significantly. On admission, all women showed similar results of underlying depression, indicating that hospitalization itself already causes mild psychological stress. Both interventions decreased depressive symptoms. Intervention with either recreational therapy or 3D ultrasound can prevent the development of mild and major depression and decrease anxiety disorders, and therefore has a positive effect on well-being during hospitalization. These results emphasize the need to implement forms of interventions to improve the well-being of women, as this might improve pregnancy and neonatal outcome.
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Affiliation(s)
| | | | | | | | | | - Ismini Staboulidou
- Department of Obstetrics and Gynaecology, Hanover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
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The Tilburg Pregnancy Distress Scale revised (TPDS-R): Psychometric aspects in a longitudinal cohort study. J Psychiatr Res 2022; 156:511-519. [PMID: 36351306 DOI: 10.1016/j.jpsychires.2022.10.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
Pregnant women may be specifically prone to experience pregnancy-specific distress, which has been associated with adverse maternal, pregnancy and child outcomes. Accurately identifying pregnancy-specific distress is thus crucial. The Tilburg Pregnancy Distress Scale (TPDS) - translated into many different languages - was previously developed to measure pregnancy-specific distress, resulting in a 16-item screening scale with a partner involvement dimension (PI) and a negative affect dimension (NA). A critical evaluation of the psychometric properties of the TPDS-NA items and feedback from pregnant women over the last decade has led to the need to revise the TPDS. Therefore, in the current study, we describe the procedure for revision and evaluate the psychometric properties of the revised TPDS (TPDS-R). More specifically, we describe the revision of the TPDS-R-PI (4 items) and the TPDS-R-NA (10 items: five-item pregnancy and five-item childbirth subcomponent). A sample of 1081 pregnant women participating in the Brabant Study completed the TPDS-R at 12, 20 and 28 weeks of pregnancy. An exploratory factor analysis and confirmatory factor analysis, descriptive statistics and repeated measures ANOVA demonstrated good test-retest reliability, concurrent validity, internal consistency, and construct validity of the TPDS-R. The TPDS-R provides a robust screening tool to accurately identify pregnant women at risk of pregnancy-specific distress.
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Bartels HC, Horsch A, Cooney N, Brennan DJ, Lalor JG. Living beyond placenta accreta spectrum: parent's experience of the postnatal journey and recommendations for an integrated care pathway. BMC Pregnancy Childbirth 2022; 22:397. [PMID: 35538441 PMCID: PMC9092796 DOI: 10.1186/s12884-022-04726-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Placenta Accreta Spectrum is associated with significant clinical maternal morbidity and mortality, which has been extensively described in the literature. However, there is a dearth of research on the lived experiences of pregnant people and their support partners. The aim of this study is to describe living beyond a pregnancy and birth complicated by PAS for up to four years postpartum. Participants experiences inform the development of an integrated care pathway of family centered support interventions. METHODS An Interpretative Phenomenological Analysis approach was applied to collect data through virtual interviews over a 3-month period from February to April 2021. Twenty-nine participants shared their stories; six people with a history of PAS and their support partners were interviewed together (n = 12 participants), six were interviewed separately (n = 12 participants), and five were interviewed without their partner. Pregnant people were eligible for inclusion if they had a diagnosis of PAS within the previous 5 years. This paper focuses on the postnatal period, with data from the antenatal and intrapartum periods described separately. RESULTS One superordinate theme "Living beyond PAS" emerged from interviews, with 6 subordinate themes as follows; "Living with a different body", "The impact on relationships", "Coping strategies", "Post-traumatic growth", "Challenges with normal care" and recommendations for "What needs to change". These themes informed the development of an integrated care pathway for pregnant people and their support partners to support them from diagnosis up to one year following the birth. CONCLUSION Parents described the challenges of the postnatal period in terms of the physical and emotional impact, and how some were able to make positive life changes in the aftermath of a traumatic event. An integrated care pathway of simple supportive interventions, based on participant recommendations, delivered as part of specialist multidisciplinary team care may assist pregnant people and their support partners in alleviating some of these challenges.
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Affiliation(s)
- Helena C Bartels
- Dept of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Antje Horsch
- Institute of Higher Education and Research in Healthcare, University of Lausanne, Lausanne, Switzerland.,Woman-Mother-Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Naomi Cooney
- Placenta Accreta Ireland, Patient Support and Advocacy Group, Dublin, Ireland
| | - Donal J Brennan
- Dept of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Joan G Lalor
- School of Nursing and Midwifery, Trinity College Dublin, Dublin 2, Ireland.
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Nho JH, Kim HY, Kim EJ. Factors affecting quality of life in low-income overweight and obese women: The mediating effects of health-promoting behaviors. Worldviews Evid Based Nurs 2022; 19:201-210. [PMID: 35416414 DOI: 10.1111/wvn.12564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/10/2022] [Accepted: 01/16/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is necessary to comprehensively consider the personal and environmental factors of women who experience overweight or obesity and low-income households (WOOL) to improve their quality of life (QoL). AIMS The aim of this study was to test a hypothetical path model to estimate the effects of self-efficacy, psychological distress, social support, and health-promoting behaviors (HPB) on QoL and verify the mediating effects of HPB among WOOL. METHODS A total of 151 women with a monthly household income less than 50% of the national median income at eight welfare centers in South Korea participated in this study. Data were collected from January to December 2019 and analyzed using SPSS 25.0 and Amos 23.0. RESULTS The fit indices of the model were adequate (χ2 = 0.197, p = .657; normed χ2 = 0.197, GFI = 0.999, CFI = 1.000, NFI = 0.999, TLI = 1.000, RMSEA = 0.000, and SRMR = 0.005). Self-efficacy had significant indirect and total effects on QoL (β = 0.064, p = .004, 95% CI [0.015, 0.139]; β = 0.064, p = .004, 95% CI [0.015, 0.139]). HPB completely mediated the path of self-efficacy to QoL. Social support had significant total, direct, indirect, and total effects on QoL (β = 0.326, p = .001, 95% CI [0.010, 0.025]; β = 0.047, p = .015, 95% CI [0.008, 0.120]; β = 0.373, p = .001, 95% CI [0.015, 0.369]). HPB partially mediated the path of social support to QoL. Psychological distress had significant direct effects on QoL (β = -0.307, p = .001, 95% CI [-0.022, -0.007]). Self-efficacy, psychological distress, social support, and HPB explained 42.3% of the total variance in QoL. LINKING EVIDENCE TO ACTION Integrated nursing interventions that consider self-efficacy, psychological distress, social stress, and HPB can be useful for improving the QoL of WOOL.
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Affiliation(s)
- Ju-Hee Nho
- College of Nursing, Jeonbuk Research Institute of Nursing Science, Jeonbuk National University, Jeonjusi, Korea
| | - Hye Young Kim
- College of Nursing, Jeonbuk Research Institute of Nursing Science, Jeonbuk National University, Jeonjusi, Korea
| | - Eun Jin Kim
- College of Nursing, Jeonbuk National University, Jeonjusi, Korea
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Einerson BD, Watt MH, Sartori B, Silver R, Rothwell E. Lived experiences of patients with placenta accreta spectrum in Utah: a qualitative study of semi-structured interviews. BMJ Open 2021; 11:e052766. [PMID: 34732490 PMCID: PMC8572396 DOI: 10.1136/bmjopen-2021-052766] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To describe the lived experience of patients undergoing diagnosis and treatment of placenta accreta spectrum (PAS). DESIGN Qualitative study of semi-structured interviews. A content analysis was used to analyse interview data using a consistent set of codes to designate data segments that contain similar material. Codes were analysed and grouped based on thematic similarities. Thematic results were systematically reviewed, verified and audited to address trustworthiness and rigour of the data and analysis. SETTING A single PAS programme in Utah, USA, from 2017 to 2020. PARTICIPANTS Patients with PAS during the study period were eligible. Those experiencing fetal demise or termination were excluded. Of 25 patients contacted at random, 17 agreed to participate in interviews. Those included were predominantly non-Hispanic white, highly parous, with average age of 34.7 years. RESULTS The lived experiences of patients with PAS emerged across the time continuum from diagnosis, pregnancy, birth, to postpartum care and recovery. Themes common across the care continuum were: the emotional burden of diagnosis and management; fear and uncertainty related to health outcomes; and lack of autonomy and medical helplessness related to medical decision-making. Many patients experienced birth-related trauma, mourned the loss of future fertility and were dissatisfied with the lack of options for treatment for this serious pregnancy complication. CONCLUSIONS Patients undergoing diagnosis and treatment for PAS often experienced care that conflicted with their goals for pregnancy and birth. Clinical care for PAS would benefit from interventions aiming to engage patients and providers in shared decision-making and systems designed to address the social, psychological and emotional needs of patients with PAS.
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Affiliation(s)
- Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Melissa H Watt
- Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah, USA
| | - Brittney Sartori
- College of Nursing, University of Utah Health, Salt Lake City, Utah, USA
| | - Robert Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Erin Rothwell
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
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Fontein Kuipers YJ, Mestdagh E. The experiential knowledge of migrant women about vulnerability during pregnancy: A woman-centred mixed-methods study. Women Birth 2021; 35:70-79. [PMID: 33745823 DOI: 10.1016/j.wombi.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/24/2021] [Accepted: 03/08/2021] [Indexed: 11/30/2022]
Abstract
PROBLEM Within maternity care policies and practice, pregnant migrant women are regarded as a vulnerable population. BACKGROUND Women's experiential knowledge is a key element of woman-centred care but is insufficiently addressed in midwifery practice and research that involves migrant women. AIM To examine if pregnant migrant women's experiential knowledge of vulnerability corresponds with sets of criteria of vulnerability, and to explore how migrant women make sense of vulnerability during pregnancy. METHODS A sequential two-phased mixed-methods study, conducted in the Netherlands, integrating survey data of 89 pregnant migrant women and focus group data obtained from 25 migrant mothers - living in deprived areas according to the Dutch socio-economic index. RESULTS Criteria associated with vulnerability were reported by 65.2% of the participants and 62.9% of the participants reported adverse childhood experiences. On a Visual Analogue Scale, ranging from 0 (not vulnerable) to 10 (very vulnerable), participants self-reported sense of vulnerability showed a mean score of 4.2 (±2.56). Women's experiential knowledge of vulnerability significantly correlated with the mean sum score of clinical criteria of vulnerability (r .46, p .002) and with the mean sum score of adverse childhood experiences (r .48, p<.001). Five themes emerged from the focus group discussions: "Look beyond who you think I am and see and treat me for who I really am", "Ownership of truth and knowledge", "Don't punish me for being honest", "Projection of fear" and "Coping with labelling". CONCLUSION Pregnant migrant women's experiential knowledge of vulnerability is congruent with the criteria. Calling upon experiential knowledge is an attribute of the humane woman-midwife relationship.
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Affiliation(s)
- Yvonne J Fontein Kuipers
- Rotterdam University of Applied Sciences, School of Midwifery, Rochussenstraat 198, 3015 EK Rotterdam, Netherlands; Artesis Plantijn University of Applied Sciences, Department of Health & Social Care, Noorderplaats 2, 2000 Antwerp, Belgium; Antwerp University, Universiteitsplein 1, 2610 Wilrijk, Belgium.
| | - Eveline Mestdagh
- Artesis Plantijn University of Applied Sciences, Department of Health & Social Care, Noorderplaats 2, 2000 Antwerp, Belgium; Antwerp University, Universiteitsplein 1, 2610 Wilrijk, Belgium
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Kuipers J, Henrichs J, Evans K. A comparison of the Fear of Childbirth Scale with the Tilburg Pregnancy Distress Scale to identify childbirth-related fear in a sample of Dutch pregnant women: a diagnostic accuracy comparative cross-sectional study. Int J Nurs Stud 2020; 109:103615. [PMID: 32553993 DOI: 10.1016/j.ijnurstu.2020.103615] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Because of the considerable negative effects of women's childbirth-related anxiety, fear and worries, and the time constraints that midwives perceive to assess women's antenatal emotional wellbeing, it is important that midwives can identify women with a more severe fear of birth with an easy to administer, validated tool. OBJECTIVE To investigate the ability of the two-item Fear of Childbirth Scale (FOBS) to discriminate between pregnant women with and without birth-related fear, compared with the 16-item Tilburg Pregnancy Distress Scale (TPDS). METHODS A diagnostic accuracy comparative cross-sectional study was performed, comparing two screening tests. Sensitivity, specificity, positive and negative predictive values and accuracy and discriminant property of the FOBS were determined and compared with the TPDS and with the negative affect 11-items TPDS (TPDS-NA) subscale. The TPDS and TPDS-NA were treated as reference standard to establish the discriminative potential of the FOBS for the presence or absence of antenatal birth-related fear. PARTICIPANTS A sample of 396 Dutch women with uncomplicated pregnancies. RESULTS When compared with the 16-items TPDS, the FOBS showed a higher specificity (95%) than sensitivity (70%) to detect fear of childbirth. The FOBS items had a good predictive ability for fear and worries about the forthcoming birth (79%) and a conclusive ability for negative case-finding (92%). The FOBS showed good accuracy (89%). The FOBS discriminated women who were or were not classified as being fearful according to the TPDS (AUC .86). When compared with the 11 items TPDS-NA subscale, the FOBS validity and accuracy decreased: sensitivity: 51%; specificity 92%; positive predictive ability 65%; negative predictive ability 88%; accuracy 83%; AUC .82. CONCLUSION When compared with the 16-items TPDS, the two-item FOBS shows to be an accurate tool for identifying the presence of antenatal birth-related fear in a sample of Dutch women with uncomplicated pregnancies.
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Affiliation(s)
- Jacoba Kuipers
- Antwerp University, Faculty of Medicine and Health Sciences - Nursing & Midwifery, Campus Drie Eiken, Universiteitsplein 1, 2610 Wilrijk, Belgium.
| | - Jens Henrichs
- Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Department of Midwifery Science AVAG-Amsterdam Public Health research institute, van der Boechhorststraat 7, 1091 BT Amsterdam, the Netherlands.
| | - Kerry Evans
- University of Nottingham, School of Health Sciences, University Park, Nottingham NG7 2RD, United Kingdom.
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Woldetensay YK, Belachew T, Biesalski HK, Ghosh S, Lacruz ME, Scherbaum V, Kantelhardt EJ. The role of nutrition, intimate partner violence and social support in prenatal depressive symptoms in rural Ethiopia: community based birth cohort study. BMC Pregnancy Childbirth 2018; 18:374. [PMID: 30219050 PMCID: PMC6139168 DOI: 10.1186/s12884-018-2009-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 09/06/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depression during pregnancy has far-reaching adverse consequences on mothers, children and the whole family. The magnitude and determinants of prenatal depressive symptoms in low-resource countries are not well established. This study aims to describe the prevalence of prenatal depressive symptoms and whether it is associated with maternal nutrition, intimate partner violence and social support among pregnant women in rural Ethiopia. METHODS This study is based on the baseline data from a large prospective, community-based, birth cohort study conducted in the South Western part of Ethiopia from March 2014 to March 2016. A total of 4680 pregnant women were recruited between 12 and 32 weeks of gestation. Depressed mood was assessed using the Patient Health Questionnaire (PHQ-9) scale and a cut off of ≥8 was taken to define prenatal depressive symptoms. Data collection was conducted electronically on handheld tablets and submitted to a secured server via an internet connection. Bivariate and multivariate logistic regression analyses were computed using IBM SPSS version 20 software. RESULT The community based prevalence of depressive symptoms during pregnancy was 10.8% (95%Confidence Interval (CI): 9.92-11.70). Adjusting for confounding variables, moderate household food insecurity (OR 1.74; 95% CI: 1.31-2.32), severe household food insecurity (OR 7.90; 95% CI: 5.87-10.62), anaemia (OR = 1.30; 95% CI: 1.04-1.61) and intimate partner violence (OR 3.08; 95% CI: 2.23-4.25) were significantly associated with prenatal depressive symptoms. On the other hand, good social support from friends, families and husband reduced the risk of prenatal depressive symptoms by 39% (OR 0.61; 95% CI: 0.50-0.76). CONCLUSION Prenatal depressive symptomatology is rather common during pregnancy in rural Ethiopia. In this community based study, household food insecurity, anaemia and intimate partner violence were significantly associated with prenatal depressive symptoms. Good maternal social support from friends, families and spouse was rather protective. The study highlights the need for targeted screening for depression and intimate partner violence during pregnancy. Policies aimed at reducing household food insecurity, maternal anaemia and intimate partner violence during pregnancy may possibly reduce depression.
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Affiliation(s)
- Yitbarek Kidane Woldetensay
- Institute of Biological Chemistry and Nutrition (140a), University of Hohenheim, Stuttgart, Germany. .,Food Security Center, University of Hohenheim, Stuttgart, Germany. .,Department of Population and Family Health, College of Health Sciences, Jimma University, Jimma, Ethiopia.
| | - Tefera Belachew
- Department of Population and Family Health, College of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Hans Konrad Biesalski
- Institute of Biological Chemistry and Nutrition (140a), University of Hohenheim, Stuttgart, Germany.,Food Security Center, University of Hohenheim, Stuttgart, Germany
| | - Shibani Ghosh
- Tufts University, Freidman School of Nutrition Science and Policy, Boston, USA
| | - Maria Elena Lacruz
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Faculty of Medicine, Martin-Luther University, Halle, Germany
| | - Veronika Scherbaum
- Institute of Biological Chemistry and Nutrition (140a), University of Hohenheim, Stuttgart, Germany.,Food Security Center, University of Hohenheim, Stuttgart, Germany
| | - Eva Johanna Kantelhardt
- Department of Gynecology, Faculty of Medicine, Martin-Luther University, Halle, Germany.,Institute of Medical Epidemiology, Biostatistics, and Informatics, Faculty of Medicine, Martin-Luther University, Halle, Germany
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