Preventing infant and child morbidity and mortality due to maternal depression

Depression in pregnant Hispanic women: Risk factors, pregnancy outcomes and plasma cytokines

Background

Maternal depression is considered a major contributor to morbidity and mortality in pregnancy. A population at risk are U.S. born or immigrant Hispanic women, and few prenatal depression or immune studies have focused on this population.

Objective

The research questions for the study were 1) What are the occurrences, risk factors and outcomes associated with depression in Hispanic pregnant women in the United States and 2) What are the associations of plasma immune cytokines and prenatal depression in this population.

Study design

Women of self-reported Hispanic ethnicity were born in the continental United States or foreign-born. Screening of potential participants (n = 690) at a first prenatal clinic visit consisted of antibody testing for Toxoplasma gondii antibodies in a larger grant, and only the women with antibody levels below the cutoff for T. gondii positivity (N = 536) were included in the present study. All participants completed a health and demographic questionnaire, the Edinburgh Postpartum Depression (EPDS) scale, the Perceived Stress Scale (PSS), and the Medical Outcomes Study Social Support (MOS) scale. We surveyed electronic health records (EHR) for risk factors and adverse pregnancy outcomes in the sample. We further measured physical and mental health and seven plasma immune cytokines at four study visits during pregnancy in a longitudinal subsample (N = 128).

Results

The frequency of EPDS scores of 10 (depression risk) or above was 18.6 % at the time of enrollment. Socioeconomic factors such as less education, greater unemployment, and U.S. born nativity were associated with greater depression risk, but these relationships became insignificant when we corrected for false discovery rate. Depression scores were not associated with adverse birth and pregnancy outcomes. The inflammatory cytokine TNF-α was significantly higher across pregnancy in women with depression risk (p < 0.03). Other inflammatory cytokines were higher in depressed women, but only at one time point in mid-pregnancy.

Conclusions

Prenatal depression occurs in early pregnancy and then declines in Hispanic women. The frequency of depression and stress were higher in U.S. born compared to immigrant Hispanic women. There was an elevation in plasma levels of TNF-α through the pregnancy in depressed women, and elevations in other cytokines, at midpregnancy. The adverse pregnancy outcomes, including preterm delivery, known to be associated with prenatal depression were not present in this cohort.

The first three years: The association of early postpartum depressive symptoms with infant and toddler development

BACKGROUND

The influence of postpartum depression (PPD) on child development has been a source of professional interest and practical relevance.

OBJECTIVE

This study investigated the association of early PPD symptoms with developmental domains.

DESIGN AND METHOD

This historical cohort study included 574,282 children attending Mother Child Healthcare Centers in Israel from January 1, 2014 to July 31, 2020, who underwent at least one developmental screening examination by public health nurses up to age 36 months, and whose mothers completed the Edinburgh Postnatal Depression Scale (EPDS) postnatally. Developmental milestone tasks included four domains: fine and gross motor, language/communication, and social/behavioral.

RESULTS

The rate of failure to complete age-appropriate tasks was higher among children whose mothers had scored ≥ 10 on the EPDS on the majority of tasks in every domain.

DISCUSSION

This large population-based study has demonstrated the association between early maternal postnatal depressive symptoms and failure to meet developmental milestones across domains, until three years. Recommendations for practice focus on the mother, the child, and health policy.

Critical research gaps in treating growth faltering in infants under 6 months: A systematic review and meta-analysis

In 2020, 149.2 million children worldwide under 5 years suffered from stunting, and 45.4 million experienced wasting. Many infants are born already stunted, while others are at high risk for growth faltering early after birth. Growth faltering is linked to transgenerational impacts of poverty and marginalization. Few interventions address growth faltering in infants under 6 months, despite a likely increasing prevalence due to the negative global economic impacts of the COVID-19 pandemic. Breastfeeding is a critical intervention to alleviate malnutrition and improve child health outcomes, but rarely receives adequate attention in growth faltering interventions. A systematic review and meta-analysis were undertaken to identify and evaluate interventions addressing growth faltering among infants under 6 months that employed supplemental milks. The review was carried out following guidelines from the USA National Academy of Medicine. A total of 10,405 references were identified, and after deduplication 7390 studies were screened for eligibility. Of these, 227 were assessed for full text eligibility and relevance. Two randomized controlled trials were ultimately included, which differed in inclusion criteria and methodology and had few shared outcomes. Both studies had small sample sizes, high attrition and high risk of bias. A Bangladeshi study (n = 153) found significantly higher rates of weight gain for F-100 and diluted F-100 (DF-100) compared with infant formula (IF), while a DRC trial (n = 146) did not find statistically significant differences in rate of weight gain for DF-100 compared with IF offered in the context of broader lactation and relactation support. The meta-analysis of rate of weight gain showed no statistical difference and some evidence of moderate heterogeneity. Few interventions address growth faltering among infants under 6 months. These studies have limited generalizability and have not comprehensively supported lactation. Greater investment is necessary to accelerate research that addresses growth faltering following a new research framework that calls for comprehensive lactation support.

Cortical and subcortical morphological alterations in postpartum depression

Postpartum depression (PPD) is the most common postpartum psychiatric disorder, which can negatively affect both mothers and their offspring. Although the functional changes of PPD have been extensively studied, little is known about its structural abnormalities. This study aimed to examine the cortical and subcortical morphological abnormalities in PPD. High resolution T1 structural MRI data of 29 PPD women and 23 matched healthy postpartum women (HPW) were included in this study. Using surface-based morphometry, we examined the differences between the PPD and HPW group in the cortical thickness, local gyrification index and shape changes of deep gray matter nuclei. Compared with the HPW group, women with PPD showed significantly increased cortical thickness in the left superior frontal gyrus, cuneus and right lingual gyrus and fusiform gyrus, which correlated marginally with the EPDS scores of these subjects. In addition, women with PPD showed significant regional inflation in the right pallidum compared with the HPW group. These findings provided further evidence for the structural brain abnormalities in PPD.

Effect of the mHealth-supported Healthy Future programme delivered by community health workers on maternal and child health in rural China: study protocol for a cluster randomised controlled trial

INTRODUCTION

Millions of young rural children in China still suffer from poor health and malnutrition, partly due to a lack of knowledge about optimal perinatal and child care among rural mothers and caregivers. Meanwhile, there is an urgent need to improve maternal mental health in rural communities. Comprehensive home visiting programmes delivered by community health workers (CHWs) can bridge the caregiver knowledge gap and improve child health and maternal well-being in low-resource settings, but the effectiveness of this approach is unknown in rural China. Additionally, grandmothers play important roles in child care and family decision-making in rural China, suggesting the importance of engaging multiple caregivers in interventions. The Healthy Future programme seeks to improve child health and maternal well-being by developing a staged-based curriculum that CHWs deliver to mothers and caregivers of young children through home visits with the assistance of a tablet-based mHealth system. This protocol describes the design and evaluation plan for this programme.

METHODS AND ANALYSIS

We designed a cluster-randomised controlled trial among 119 rural townships in four nationally designated poverty counties in Southwestern China. We will compare the outcomes between three arms: one standard arm with only primary caregivers participating in the intervention, one encouragement arm engaging primary and secondary caregivers and one control arm with no intervention. Families with pregnant women or infants under 6 months of age are invited to enrol in the 12-month study. Primary outcomes include children's haemoglobin levels, exclusive breastfeeding rates and dietary diversity in complementary feeding. Secondary outcomes include a combination of health, behavioural and intermediate outcomes.

ETHICS AND DISSEMINATION

Ethical approval has been provided by Stanford University, Sichuan University and the University of Nevada, Reno. Trial findings will be disseminated through national and international peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

ISRCTN16800789.

Associations between postpartum pain, mood, and maternal-infant attachment and parenting outcomes

Pain and depression are interrelated, and worse postpartum pain has been associated with postpartum depression. It remains unclear whether improved pain and mood after delivery can also improve maternal parenting. Few studies have examined relationships between postpartum pain and negative mood (anxiety or depression) or their effects on parent-infant relationship outcomes. The purpose of this study was to explore the relationships between postpartum pain, mood, parent-infant attachment, parenting self-efficacy, and infant development. This was a prospective longitudinal observational pilot study of nulliparous women enrolled at the third trimester and presenting for labor and delivery at term gestation. Baseline third trimester assessments included validated inventories of pain (the brief pain inventory, BPI), depression (the Edinburgh postnatal depression screen, EPDS), anxiety (the state trait anxiety inventory, STAI), multidimensional scale of perceived social support (perceived social support scale, MSPSS) and perceived stress scale (PSS). Demographic and labor characteristics were recorded. At 6 weeks and 3 months postpartum, self-reported assessments included EPDS, STAI, BPI, maternal parent infant attachment scale (MPAS), and perceived maternal parenting self-efficacy (PMP-SE). Child development outcomes were assessed at 6 weeks and 3 months using the Ages and Stages Questionnaire (ASQ). Univariable linear regression assessed the relationships between pain and parenting outcomes (MPAS and PMP-SE), including potential interactions between pain and mood for parenting outcomes. Generalized linear modeling was used to explore the relationships between postpartum pain, parenting outcomes, and child development outcomes. Of 187 subjects, 87 had complete data on parent-infant attachment and parenting self-efficacy data at 3 months. Lower "pain right now" scores (BPI) on postpartum day 1 was associated with higher maternal-infant attachment (MPAS) at 6 weeks postpartum (Estimate - 1.8, 95% CI - 3.4 to - 0.2, P < 0.03) but not at 3 months (Estimate 0.23 95% CI - 1.1 to 1.6, P = 0.7). Higher depression (EPDS) scores at 6 weeks were also associated with lower MPAS scores at 6 weeks (Estimate - 1.24, 95% CI - 2.07 to - 0.40, P = 0.004). However, there was no evidence that the relationship between pain and MPAS varied by depression score at 6 weeks (P = 0.42). Pain scores at baseline, six weeks, or three months did not correlate with parenting outcomes (MPAS, PMP-SE) at six weeks or three months. Results of the generalized linear modeling revealed relationships between pain, age, anxiety (STAI), and depression (EPDS) predictors, and the outcomes of parenting (MPAS, PMP-SE) and gross motor and personal-social (ASQ) aspects of infant development. There is a pattern of association between worse postpartum pain, anxiety, and depression with worse parenting outcomes. Depression and pain may also affect infant development, but future work is required to replicate and characterize these potential relationships.

Perinatal depression and its impact on infant outcomes and maternal-nurse SMS communication in a cohort of Kenyan women

BACKGROUND

Perinatal depression is broadly defined as depressive symptoms during pregnancy or within the 12 months following delivery, affecting approximately 20-25% of pregnant and postpartum women in low- and middle-income countries. The wide accessibility of mobile phones allows mobile health (mHealth) interventions to be considered a solution to identify perinatal depression and provide appropriate referrals for treatment. This study, nested in a larger SMS communication project, examined the prevalence and correlates of perinatal depression, determined the association between antenatal depression and infant morbidity and mortality, and compared SMS communication patterns between women with and without perinatal depression.

METHODS

This was a prospective longitudinal cohort study of pregnant women seeking antenatal services at two public sector health clinics in Kenya. SMS messages were sent to participants with educational content related to their pregnancy and infant health and two-way SMS communication occurred with a nurse. Sociodemographic and obstetric characteristics, SMS messaging behaviors, infant health status, and depressive symptoms were assessed by a standardized questionnaire administered at enrollment (30-36 weeks gestation) and follow-up (14 weeks postpartum). Generalized estimating equation (GEE) with Poisson link was used to evaluate correlates of perinatal depressive symptoms, infant outcomes, and frequency of SMS messaging.

RESULTS

Of the 572 women with complete follow-up information, 188 (32.9%) screened positive for elevated depressive symptoms (≥10 by EPDS scale) at some time point during pregnancy or postpartum. The strongest predictors of any depressive symptoms included interpersonal abuse during pregnancy, fewer years of schooling, and maternal unemployment. Antenatal depressive symptoms were associated with an increased risk of infant illness or hospitalization (RR = 1.12, 95% CI: 1.11, 1.13). Women with antenatal or persistent perinatal depressive symptoms sent fewer SMS messages during the study period than their counterparts without depression.

CONCLUSIONS

Prevalence of elevated perinatal depressive symptoms was high in this cohort of Kenyan women. Our findings highlight the importance of screening perinatal women for experiences of symptoms of depression as well as abuse. Differences in messaging frequency between women with vs. without depressive symptoms presents an opportunity to provide more tailored support for those perinatal depression.

Association between social support and postpartum depression

Postpartum depression is common; however, little is known about its relationship to social support and postpartum depression. This study examined the association between them among South Korean women within one year of childbirth. This study was based on the 2016 Korean Study of Women’s Health-Related Issues (K-Stori), a cross-sectional survey employing nationally-representative random sampling. Participants were 1,654 postpartum women within a year of giving birth. Chi-square test and logistic regression analysis were conducted to analyze the associations between social support (and other covariates) and postpartum depression. Among participants, 266 (16.1%) had postpartum depression. Depending on the level of social support, 6.0%, 53.9%, and 40.1% of them had low, moderate, and high social support, respectively. Women with moderate or low social support were more likely to have postpartum depression (OR = 1.78, 95% CI = 1.26–2.53; OR = 2.76, 95% CI = 1.56–4.89). This trend was observed in participants with multiparity, pregnancy loss, obese body image, and employed women. Social support was associated with a decreased likelihood of postpartum depression, indicating the importance of social support, especially for women experiencing multiparity, pregnancy loss, negative body image, as well as for employed women.

Maternal-focused interventions to improve infant growth and nutritional status in low-middle income countries: A systematic review of reviews

BACKGROUND

Small and nutritionally at-risk infants under 6 months (<6m) are a vulnerable group at increased risk of mortality, morbidity, poor growth and sub-optimal development. Current national and international (World Health Organization) management guidelines focus mainly on infants' needs, yet growing evidence suggests that maternal factors also influence infant outcomes. We aimed to inform future guidelines by exploring the impacts of maternal-focused interventions on infant feeding and growth.

METHODS

We conducted a systematic review of reviews published since 2008 (PROSPERO, register number CRD 42019141724). We explored five databases and a wide variety of maternal-focused interventions based in low- and middle-income countries. Infant outcomes of interest included anthropometric status, birthweight, infant mortality, breastfeeding and complementary feeding practices. Given heterogenous interventions, we present a narrative synthesis of the extracted data.

RESULTS

We included a total of 55 systematic reviews. Numerous maternal interventions were effective in improving infant growth or feeding outcomes. These included breastfeeding promotion, education, support and counselling interventions. Maternal mental health, while under-researched, showed potential to positively impact infant growth. There was also some evidence for a positive impact of: women's empowerment, m-health technologies, conditional cash transfers, water, sanitation and hygiene and agricultural interventions. Effectiveness was increased when implemented as part of a multi-sectoral program. Antenatal supplementation with macronutrient, multiple micronutrients, Vitamin D, zinc, iron folic acid and possibly calcium, iodine and B12 in deficient women, improved birth outcomes. In contrast, evidence for postnatal supplementation was limited as was evidence directly focusing on small and nutritionally at-risk infants; most reviews focused on the prevention of growth faltering.

CONCLUSION

Our findings suggest sufficient evidence to justify greater inclusion of mothers in more holistic packages of care for small and nutritionally at-risk infants aged <6m. Context specific approaches are likely needed to support mother-infant dyads and ensure infants survive and thrive.

The impact of maternal prenatal mental health disorders on stillbirth and infant mortality: a systematic review and meta-analysis

Evidence about the association between maternal mental health disorders and stillbirth and infant mortality is limited and conflicting. We aimed to examine whether maternal prenatal mental health disorders are associated with stillbirth and/or infant mortality. MEDLINE, Embase, PsycINFO, and Scopus were searched for studies examining the association of any maternal prenatal (occurring before or during pregnancy) mental health disorder(s) and stillbirth or infant mortality. A random-effects meta-analysis was used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). The between-study heterogeneity was quantified using the I² statistic. Subgroup analyses were performed to identify the source of heterogeneity. Of 4487 records identified, 28 met our inclusion criteria with 27 contributing to the meta-analyses. Over 60% of studies examined stillbirth and 54% of them evaluated neonatal or infant mortality. Thirteen studies investigated the association between maternal depression and anxiety and stillbirth/infant mortality, pooled OR, 1.42 (95% CI, 1.16-1.73; I², 76.7%). Another 13 studies evaluated the association between severe maternal mental illness and stillbirth/infant mortality, pooled OR, 1.47 (95% CI, 1.28-1.68; I², 62.3%). We found similar results for the association of any maternal mental health disorders and stillbirth/infant mortality (OR, 1.59; 95% CI, 1.43-1.77) and in subgroup analyses according to types of fetal/infant mortality. We found no significant evidence of publication bias. Maternal prenatal mental health disorders appear to be associated with a moderate increase in the risk of stillbirth and infant mortality, although the mechanisms are unclear. Efforts to prevent and treat these disorders may reduce the scale of stillbirth/infant deaths.

The effect of maternal depression symptoms on the outcomes of infant care

PURPOSE

This study evaluated the effect of the maternal risk of depression on the outcomes of infant care.

DESIGN AND METHODS

This study was conducted as a cross-sectional and analytical study with 229 mothers who had 6-month-old infants and who were enrolled in a family health center.

FINDINGS

The results show that mothers at risk of depression have a negative impact on the care and growth of their infants.

PRACTICE IMPLICATIONS

Providing support to the mothers is suggested for preventive infant health behaviors and monitoring their infants.

Effect of perinatal depression on risk of adverse infant health outcomes in mother-infant dyads in Gondar town: a causal analysis

BACKGROUND

Approximately one-third of pregnant and postnatal women in Ethiopia experience depression posing a substantial health burden for these women and their families. Although associations between postnatal depression and worse infant health have been observed, there have been no studies to date assessing the causal effects of perinatal depression on infant health in Ethiopia. We applied longitudinal data and recently developed causal inference methods that reduce the risk of bias to estimate associations between perinatal depression and infant diarrhea, Acute Respiratory Infection (ARI), and malnutrition in Gondar Town, Ethiopia.

METHODS

A cohort of 866 mother-infant dyads were followed from infant birth for 6 months and the cumulative incidence of ARI, diarrhea, and malnutrition were assessed. The Edinburgh Postnatal Depression Scale (EPDS) was used to assess the presence of maternal depression, the Integrated Management of Newborn and Childhood Illnesses (IMNCI) guidelines were used to identify infant ARI and diarrhea, and the mid upper arm circumference (MUAC) was used to identify infant malnutrition. The risk difference (RD) due to maternal depression for each outcome was estimated using targeted maximum likelihood estimation (TMLE), a doubly robust causal inference method used to reduce bias in observational studies.

RESULTS

The cumulative incidence of diarrhea, ARI and malnutrition during 6-month follow-up was 17.0% (95%CI: 14.5, 19.6), 21.6% (95%CI: 18.89, 24.49), and 14.4% (95%CI: 12.2, 16.9), respectively. There was no association between antenatal depression and ARI (RD = - 1.3%; 95%CI: - 21.0, 18.5), diarrhea (RD = 0.8%; 95%CI: - 9.2, 10.9), or malnutrition (RD = -7.3%; 95%CI: - 22.0, 21.8). Similarly, postnatal depression was not associated with diarrhea (RD = -2.4%; 95%CI: - 9.6, 4.9), ARI (RD = - 3.2%; 95%CI: - 12.4, 5.9), or malnutrition (RD = 0.9%; 95%CI: - 7.6, 9.5).

CONCLUSION

There was no evidence for an association between perinatal depression and the risk of infant diarrhea, ARI, and malnutrition amongst women in Gondar Town. Previous reports suggesting increased risks resulting from maternal depression may be due to unobserved confounding.

Outcome expectancies toward adherence to antiretroviral therapy for pregnant and postpartum women with HIV

Objectives:

Adherence to antiretroviral therapy and retention in care significantly drop for women with HIV during the postpartum period. We have a limited understanding of how outcome expectancies influence maternal adherence and retention in care.

Methods:

Women with HIV from an urban academic clinic completed in-depth interviews in the third trimester and at 3 to 9 months postpartum to evaluate outcome expectancies, facilitators, and barriers to antiretroviral therapy adherence and retention in care. Interviews were audio-recorded and analyzed for content. A codebook was created using deductive (based on the theory of reasoned action approach) and inductive (based on emergent themes) codes.

Results:

We conducted 21 interviews with 12 women during pregnancy and 9 women during postpartum period. Participants had a mean age of 31 (standard deviation = 5.7) and most were African American (75%). Outcome expectancies centered mostly around pediatric health to prevent perinatal transmission of HIV and to be healthy to raise their children. Other outcome expectancies included preventing transmission of HIV to their partners. Social support from partners served as a strong facilitator as they helped routinize pill-taking behaviors, provided reminders, and decreased social isolation. Barriers to antiretroviral therapy adherence included depression, the disruption of scheduling routines, and the physical demands associated with the postpartum period. These barriers were accentuated for women with multiple children.

Conclusion:

Women’s commitment to pediatric health was the primary motive for antiretroviral therapy adherence. Partners also served an important role. These findings suggest that interventions linking pediatric and maternal health, and partner support can improve maternal HIV treatment in the postpartum period.

Efficacy of learning through play plus intervention to reduce maternal depression in women with malnourished children: A randomized controlled trial from Pakistan✰

BACKGROUND

The risk factors and adverse outcomes related to maternal depression and child malnutrition are a leading cause of morbidity and mortality in low and middle-income countries (LMIC) including Pakistan. Above 25% of women suffer from maternal depression. Up to 50% children are under-nourished which contributes to 35% of all under-5 deaths in the country.

AIM

To determine the efficacy of Learning through Play Plus Thinking Healthy Program (LTP Plus) intervention to reduce maternal depression in mothers with undernourished children.

METHODS

In this randomised controlled trial, all eligible mothers presenting to the paediatric departments were invited to participate in the study. Out of the total 256 mothers screened, 107 were included, 54 of those were randomly allocated to LTP Plus group and 53 to treatment as usual (TAU). Edinburgh Postnatal Depression Scale (EPDS) was used to screen for depression. Hamilton Depression Rating Scale (HDRS), Maternal Attachment Inventory (MAI), Social Support Scale (OSLO-3) and the Euro-QoL (EQ-5D) were used to measure the severity of depression, mother-child attachment, level of support and health related quality of life dimensions. Assessments were completed at baseline, end of intervention (3 months from baseline) and at 6 months from baseline.

RESULTS

Mothers in the LTP Plus group significantly showed improvements in depression (p<0.001), social support (p = 0.02) and quality of life (p<0.001) at the end of the intervention (LTP Plus), as compared to the TAU group, which were sustained up to 6 months after baseline.

CONCLUSION

The outcomes of LTP Plus intervention for mothers of malnourished children show promising results in reducing maternal depression and improving child outcomes. A full trial with longer-term outcomes and cost-effectiveness needs to be conducted.

Assessing factors associated with poor maternal mental health among mothers of children born small and sick at 24-47 months in rural Rwanda

Background

Global investments in neonatal survival have resulted in a growing number of children with morbidities surviving and requiring ongoing care. Little is known about the caregivers of these children in low- and middle-income countries, including maternal mental health which can further negatively impact child health and development outcomes. We aimed to assess the prevalence and factors associated with poor maternal mental health in mothers of children born preterm, low birthweight (LBW), and with hypoxic ischemic encephalopathy (HIE) at 24–47 months of age in rural Rwanda.

Methods

Cross-sectional study of children 24–47 months born preterm, LBW, or with HIE, and their mothers discharged from the Neonatal Care Unit (NCU) at Kirehe Hospital between May 2015–April 2016 or discharged and enrolled in a NCU follow-up program from May 2016–November 2017. Households were interviewed between October 2018 and June 2019. Mothers reported on their mental health and their child’s development; children’s anthropometrics were measured directly. Backwards stepwise procedures were used to assess factors associated with poor maternal mental health using logistic regression.

Results

Of 287 total children, 189 (65.9%) were born preterm/LBW and 34.1% had HIE and 213 (74.2%) screened positive for potential caregiver-reported disability. Half (n = 148, 51.6%) of mothers reported poor mental health. In the final model, poor maternal mental health was significantly associated with use of violent discipline (Odds Ratio [OR] 2.29, 95% Confidence Interval [CI] 1.17,4.45) and having a child with caregiver-reported disability (OR 2.96, 95% CI 1.55, 5.67). Greater household food security (OR 0.80, 95% CI 0.70–0.92) and being married (OR = 0.12, 95% CI 0.04–0.36) or living together as if married (OR = 0.13, 95% CI 0.05, 0.37) reduced the odds of poor mental health.

Conclusions

Half of mothers of children born preterm, LBW and with HIE had poor mental health indicating a need for interventions to identify and address maternal mental health in this population. Mother’s poor mental health was also associated with negative parenting practices. Specific interventions targeting mothers of children with disabilities, single mothers, and food insecure households could be additionally beneficial given their strong association with poor maternal mental health.

Expanding Access to Perinatal Depression Treatment in Kenya Through Automated Psychological Support: Development and Usability Study

Background

Depression during pregnancy and in the postpartum period is associated with poor outcomes for women and their children. Although effective interventions exist for common mental disorders that occur during pregnancy and the postpartum period, most cases in low- and middle-income countries go untreated because of a lack of trained professionals. Task-sharing models such as the Thinking Healthy Program have shown potential in feasibility and efficacy trials as a strategy for expanding access to treatment in low-resource settings; however, there are significant barriers to scale-up. We address this gap by adapting Thinking Healthy for automated delivery via a mobile phone. This new intervention, Healthy Moms, uses an existing artificial intelligence system called Tess (Zuri in Kenya) to drive conversations with users.

Objective

This prepilot study aims to gather preliminary data on the Healthy Moms perinatal depression intervention to learn how to build and test a more robust service.

Methods

We conducted a single-case experimental design with pregnant women and new mothers recruited from public hospitals outside of Nairobi, Kenya. We invited these women to complete a brief, automated screening delivered via text messages to determine their eligibility. Enrolled participants were randomized to a 1- or 2-week baseline period and then invited to begin using Zuri. We prompted participants to rate their mood via SMS text messaging every 3 days during the baseline and intervention periods, and we used these preliminary repeated measures data to fit a linear mixed-effects model of response to treatment. We also reviewed system logs and conducted in-depth interviews with participants to study engagement with the intervention, feasibility, and acceptability.

Results

We invited 647 women to learn more about Zuri: 86 completed our automated SMS screening and 41 enrolled in the study. Most of the enrolled women submitted at least 3 mood ratings (31/41, 76%) and sent at least 1 message to Zuri (27/41, 66%). A third of the sample engaged beyond registration (14/41, 34%). On average, women who engaged post registration started 3.4 (SD 3.2) Healthy Moms sessions and completed 3.1 (SD 2.9) of the sessions they started. Most interviewees who tried Zuri reported having a positive attitude toward the service and expressed trust in Zuri. They also attributed positive life changes to the intervention. We estimated that using this alpha version of Zuri may have led to a 7% improvement in mood.

Conclusions

Zuri is feasible to deliver via SMS and was acceptable to this sample of pregnant women and new mothers. The results of this prepilot study will serve as a baseline for future studies in terms of recruitment, data collection, and outcomes.

International Registered Report Identifier (IRRID)

RR2-10.2196/11800

Lessons learned evaluating the baby friendly spaces program for south Sudanese refugees in Gambella, Ethiopia: strengthening research and programmatic partnerships to address maternal and child health and psychosocial needs in humanitarian emergencies

Background

During humanitarian crises, women and children are particularly vulnerable to morbidity and mortality. To address this problem, integrated child health interventions that include support for the well-being of mothers must be adapted and assessed in humanitarian settings. Baby Friendly Spaces (BFS) is a holistic program that aims to improve the health and wellbeing of pregnant and lactating women and their children under two years of age by providing psychosocial support and enhancing positive infant and young child-care practices. Using a mixed-methods, pre-post design, this study explored ways to strengthen the implementation and acceptability of the BFS program, and assess outcomes associated with participation among South Sudanese mothers and their children living in the Nguenyyiel refugee camp in Gambella, Ethiopia.

Discussion

A stronger evidence-base for integrated maternal and child health interventions, like BFS, in humanitarian emergencies is needed, but effectively conducting this type of research in unstable settings means encountering and working through myriad challenges. In this paper we discuss lessons learned while implementing this study, including, challenges related to ongoing local political and tribal conflicts and extreme conditions; implementation of a new digital data monitoring system; staff capacity building and turnover; and measurement were encountered. Strategies to mitigate such challenges included hiring and training new staff members. Regular weekly skype calls were held between Action Against Hunger Paris headquarters, the Action Against Hunger team in Gambella and Johns Hopkins’ academic partners to follow study implementation progress and troubleshoot any emerging issues. Staff capacity building strategies included holding brief and focused trainings continuously throughout the study for both new and current staff members. Lastly, we engaged local Nuer staff members to help ensure study measures and interview questions were understandable among study participants.

Conclusions

Research focused on strengthening program implementation is critically important for improving maternal and child health in humanitarian emergencies. Research in such settings demands critical problem-solving skills, strong supervision systems, flexibility in timeline and logistics, and tailor-made training for program and research staff members and context- adapted strategies for retaining existing staff.

Postnatal depression and its association with adverse infant health outcomes in low- and middle-income countries: a systematic review and meta-analysis

Background

Postnatal Depression (PND) is a mood disorder that steals motherhood and affects the health and development of a newborn. While the impact of PND on motherhood and newborn in developed countries are well described, its epidemiology and health consequences in infant is not well known in middle-and low-income countries. The objective of this review was to determine the burden and association of PND with adverse infant health outcomes in low-and middle- income countries.

Methods

We searched observational studies written in the English language and conducted in middle-and low-income countries between December 1st, 2007, and December 31st, 2017. The CINHAL, MEDLINE, Emcare, PubMed, Psych Info, and Scopus databases were searched for the following search terms: PND, acute respiratory infection, pneumonia, diarrhea, exclusive breastfeeding, common infant illnesses, and malnutrition. We excluded studies in which the primary outcomes were not measured following a standardized approach. We have meta-analyzed the estimates from primary studies by adjusting for possible publication bias and heterogeneity. The analysis was conducted in Stata 14. The study was registered in PROSPERO protocol number CRD42017082624.

Result

Fifty-eight studies on PND prevalence (among 63,293 women) and 17 studies (among 32,454 infants) on infant health outcomes were included. PND prevalence was higher in the low-income countries (Pooled prevalence (PP) = 25.8%; 95%CI: 17.9–33.8%) than in the middle-income countries (PP = 20.8%; 95%CI: 18.4–23.1%) and reached its peak in five to ten weeks after birth. Poor obstetric history and social support, low economic and educational status, and history of exposure to violence were associated with an increased risk of PND. The risk of having adverse infant health outcomes was 31% higher among depressed compared to non-depressed postnatal mothers (Pooled relative risk (PRR) = 1.31; 95%CI: 1.17–1.48). Malnutrition (1.39; 1.21–1.61), non-exclusive breastfeeding (1.55; 1.39–1.74), and common infant illnesses (2.55; 1.41–4.61) were the main adverse health outcomes identified.

Conclusions

One in four and one in five postnatal mothers were depressed in low and middle-income countries, respectively. Causes of depression could be explained by social, maternal, and psychological constructs. High risk of adverse infant health outcomes was associated with PND. Timely screening of PND and evidence-based interventions were a pressing need in low and middle-income countries.

Maternal depression trajectories from 3 months to 11 years postpartum and offspring body composition in early adolescence

OBJECTIVE

To investigate the effect of maternal depressive symptom trajectories, from 3 months to 11 years postpartum, on the offspring's body composition at 11 years of age.

DESIGN

Data from the Pelotas 2004 Birth Cohort, from the perinatal interview and from the 3-, 12-, 24- and 48-month and 6- and 11-year follow-ups.

SETTING

Community-based sample from the city of Pelotas, located in southern Brazil with approximately 350 000 inhabitants. The maternal depression symptom trajectories were identified through a semi-parametric group-based modelling approach, using the Edinburgh Postnatal Depression Scale (EPDS), with data from 3 months to 11 years postpartum.

PARTICIPANTS

A total of 3467 (81·9 % of the total cohort).

RESULTS

Five trajectory groups of EPDS scores were identified ('Low', 'Moderate low', 'Increasing', 'Decreasing' and 'Chronic high'). A total of 170 women (4·9 %) from the sample belonged to the 'Chronic high' group, having scored ≥13 EPDS points at every follow-up. Mean BMI in the 'Low' trajectory group was 0·77 (z-score 1·4), compared with 0·56 (z-score 1·4) in the 'Chronic high' group. Children from mothers in the 'Chronic high' group had lower fat mass (FM) (-1·34 ± 0·64 kg), FM% (-2·02 ± 0·85 percentage points) and FM index (-0·57 ± 0·27 kg/m2), compared with children from mothers in the 'Low' trajectory group. Adjusted analyses showed that sustained or transitory maternal depressive symptoms during childhood had no effect on the offspring's body composition indices at 11 years of age.

CONCLUSION

Children raised by chronically depressed mothers have body composition indices at 11 years of age that are similar to those of children whose mothers have never been depressed.

Role of maternal mental health disorders on stillbirth and infant mortality risk: a protocol for a systematic review and meta-analysis

INTRODUCTION

Maternal mental health disorders such as anxiety and depression are major public health concerns. Evidence shows a link between maternal mental health disorders and preterm birth and low birth weight. However, the impacts of maternal mental health disorders on stillbirth and infant mortality have been less investigated and inconsistent findings have been reported. Thus, using the available literature, we plan to examine whether prenatal maternal mental health disorders impact the risk of stillbirth and infant mortality.

METHODS AND ANALYSIS

This systematic review and meta-analysis will adhere to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and will be registered with the International Prospective Register of Systematic Reviews. Systematic searches will be conducted (from database inception to December 2019) in Medline, Embase, PsycINFO and Scopus for studies examining the association of prenatal mental health disorders and stillbirth and infant mortality. The search will be limited to studies published in English language and in humans only, with no restriction on the year of publication. Two independent reviewers will evaluate records and assess the quality of individual studies. The Newcastle-Ottawa scales and GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach will be used to assess the methodological quality and bias of the included studies. In addition to a narrative synthesis, a random-effects meta-analysis will be conducted when sufficient data are available. I² statistics will be used to assess between-study heterogeneity in the estimated effect size.

ETHICS AND DISSEMINATION

As it will be a systematic review and meta-analysis based on previously published evidence, there will be no requirement for ethical approval. Findings will be published in a peer-reviewed journal and will be presented at various conferences.

PROSPERO REGISTRATION NUMBER

159834.

Cognitive-behavioral therapy-based intervention to treat symptoms of anxiety in pregnancy in a prenatal clinic using non-specialist providers in Pakistan: design of a randomised trial

INTRODUCTION

Prenatal anxiety is a prevalent condition that is harmful for women and a strong predictor of postpartum depression. This trial assesses an intervention initiated in early pregnancy to mid pregnancy among women with clinical or subclinical symptoms of anxiety in Pakistan. METHODS AND ANALYSIS: Happy Mother, Healthy Baby (HMHB) is a phase three, two-arm, single-blind, individual randomised clinical trial conducted in the outpatient department of Holy Family Hospital, a large public tertiary care facility affiliated with Rawalpindi Medical University (RMU). Pregnant women (enrolled at ≤22 weeks of gestation) receive six individual HMHB sessions based on cognitive-behavioral therapy (CBT) and relaxation techniques that are administered by non-specialist providers and tailored to address anxiety symptoms. Two to six booster sessions are given between the fifth consecutive weekly core session and the sixth core session that occurs in the third trimester. Apart from baseline data, data are collected in the third trimester, at birth and at 6-weeks postpartum. Primary outcomes include diagnoses of postpartum common mental disorders. Secondary outcomes include symptoms of anxiety and of depression, and birth outcomes including small-for-gestational age, low birth weight and preterm birth. An economic analysis will determine the cost effectiveness of the intervention.

ETHICS

Ethics approval was obtained from the Johns Hopkins Bloomberg School of Health Institutional Review Board (Baltimore, USA), the Human Development Research Foundation Ethics Committee (Islamabad, Pakistan), the RMU Institutional Research Forum (Rawalpindi, Pakistan) and the National Institute of Mental Health-appointed Global Mental Health Data Safety and Monitoring Board.

DISSEMINATION

Results from this trial will build evidence for the efficacy of a CBT-based intervention for pregnant women delivered by non-specialised providers. Identification of an evidence-based intervention for anxiety starting in early pregnancy to mid pregnancy may be transferable for use and scale-up in other low-income and middle-income countries.

TRIAL REGISTRATION NUMBER

NCT03880032.

Perinatal depression among mothers in a South African birth cohort study: Trajectories from pregnancy to 18 months postpartum

BACKGROUND

Perinatal depression affects 21-50% of women in South Africa and poses significant health risks to mothers and children. Trajectories of depressive symptoms change over time and have not been well characterized during the perinatal period in low and middle-income countries.

METHODS

Data from women enrolled in a population-based birth cohort study in Paarl, South Africa with at least 3 depression measures from pregnancy through 18 months postpartum (N = 831) were analyzed. Depressive symptoms were measured continuously using the Edinburgh Postnatal Depression Scale (EPDS). Group-based trajectory models were used to estimate trajectories of depressive symptoms during the perinatal period and multinomial multivariable models to identify predictors of trajectory group membership.

RESULTS

Five distinct trajectory patterns of depressive symptoms were identified: moderate levels of depressive symptoms during pregnancy but minimal postpartum (3.5%), minimal levels during pregnancy and increasing postpartum (3.7%), unstable levels peaking at 12 months postpartum (6.6%), mild levels with slight decrease postpartum (82.9%), and severe levels during pregnancy and postpartum (3.1%). Membership in the chronic severe symptom group was associated with stressful life events, sexual intimate partner violence and tobacco use.

LIMITATIONS

Modeling limitations prevented determining how changes in psychosocial predictors over time may influence depressive symptom trajectories.

CONCLUSIONS

Mild to severe depressive symptoms during pregnancy/postpartum were common among this South African cohort. Interventions to treat women with severe chronic depressive symptoms with co-occurring psychosocial issues are urgently needed.

Perinatal self-report of thoughts of self-harm, depressive symptoms, and personality traits: Prospective study of Japanese community women

AIM

The aim of this study was to identify women with thoughts of self-harm preceded by suicidal ideation, during the perinatal period, on cluster analysis and to clarify their psychological correlates.

METHODS

A secondary analysis was conducted using the data from a longitudinal study involving 18 obstetric clinics between 2011 and 2012 in Kumamoto Prefecture (Japan). Self-administered questionnaires including demographic data, Edinburgh Postnatal Depression Scale, Temperament and Character Inventory, and the Postnatal Bonding Questionnaire were distributed during the third trimester of pregnancy (wave 1), at 5 days (wave 2), and 1 month postpartum (wave 3).

RESULTS

On cluster analysis using the data of participants who answered all observational points, the participants were divided into two groups: cluster 1, normal (n = 201); and cluster 2, thoughts of self-harm (n = 42). Low self-directedness, low cooperativeness, higher anxiety, depression, and lack of affection and anger and rejection towards the baby were associated with cluster 2.

CONCLUSIONS

The finding that low self-directedness and low cooperativeness were related to the cluster 2 group suggests that immature personality traits may work as a predisposing factor mediating between anxiety, depression and thoughts of self-harm.

Course of perinatal depressive symptoms among South African women: associations with child outcomes at 18 and 36 months

PURPOSE

Latent modelling was used to identify trajectories of depressive symptoms among low-income perinatal women in South Africa. Predictors of trajectories and the association of trajectories with child outcomes were assessed.

METHODS

This is a secondary analysis of data collected among women living in Cape Town settlements (N = 446). Participants were eligible if pregnant and 18 years or older, and included in the analysis if allocated to the control arm (routine perinatal care). Participants were excluded in case of non-singleton birth and baby death. Follow-up assessments were at 2 weeks, 6-, 18-, and 36-month postpartum. Trajectories of depressive symptoms were based on the Edinburgh Postnatal Depression Scale scores until 18-month postpartum, using latent class growth analysis. Child physical, cognitive, socio-emotional, and behavioural outcomes were assessed at 18 and/or 36 months. Univariate and multivariate regressions were used to identify predictors of trajectories and differences in child outcomes.

RESULTS

Four trajectories were identified: chronic low (71.1%), late postpartum (10.1%), early postpartum (14.4%), and chronic high (4.5%). Low social support, unwanted pregnancy, and risky drinking were associated with the chronic high trajectory; unemployment and HIV-positive status with the early postpartum trajectory; and intimate partner violence with the late postpartum trajectory. Weight-to-length and weight-for-age z-scores at 18 months, and weight-for-age z-scores, length-for-age z-scores, emotional symptom, and peer problem scores at 36 months differed across trajectories.

CONCLUSIONS

Severe depressive symptoms in postpartum period have a lasting effect on child physical and socio-emotional outcomes. Multiple screening throughout pregnancy and 1-year postpartum is essential.

The IDO genetic polymorphisms and postpartum depressive symptoms: an association study in Chinese parturients who underwent cesarean section

Postpartum depressive symptoms (PDS) are not an uncommon mood disorder in postpartum women. Our previous research indicated a role for increased tryptophan (TRP) metabolism along the kynurenine pathway (KP) in the pathogenesis of PDS. Accordingly, this study was going to investigate the association of indoleamine-2,3-dioxygenase (IDO, a key enzyme of KP) genetic polymorphisms with PDS. Seven hundred twenty-five women receiving cesarean section were enrolled in this study. PDS was determined by an Edinburgh Postnatal Depression Scale (EPDS) score ≥ 13. Subsequently, 48 parturients with PDS and 48 parturients without PDS were selected for investigation of perinatal serum concentrations of TRP, kynurenine (KYN), and KYN/TRP ratio, the latter is the representative of IDO activity. In addition, seven single nucleotide polymorphisms of the IDO gene were examined. Following this genotyping, 50 parturients carrying the IDO rs10108662 AA genotype and 50 parturients carrying the IDO rs10108662 AC + CC genotype were selected for comparisons of TRP, KYN, and KYN/TRP ratio levels. This study showed the PDS incidence of 6.9% in the Chinese population, with PDS characterized by increased IDO activity (p < 0.05), versus women without PDS. We also found that the variations of IDO1 gene rs10108662 were significantly related to PDS incidence (p < 0.05). Furthermore, there was a significant difference in IDO activity between the IDO rs10108662 CA + AA, versus CC, genotypes. Our findings indicate a role of the kynurenine pathway in the development of PDS, rs10108662 genetic polymorphism resulting in changes of IDO activity might contribute to PDS pathogenesis.

Expanding Access to Depression Treatment in Kenya Through Automated Psychological Support: Protocol for a Single-Case Experimental Design Pilot Study

Background

Depression during pregnancy and in the postpartum period is associated with a number of poor outcomes for women and their children. Although effective interventions exist for common mental disorders that occur during pregnancy and the postpartum period, most cases in low- and middle-income countries go untreated because of a lack of trained professionals. Task-sharing models such as the Thinking Healthy Program have shown great potential in feasibility and efficacy trials as a strategy for expanding access to treatment in low-resource settings, but there are significant barriers to scale-up. We are addressing this gap by adapting Thinking Healthy for automated delivery via a mobile phone. This new intervention, Healthy Moms, uses an existing artificial intelligence system called Tess (Zuri in Kenya) to drive conversations with users.

Objective

The objective of this pilot study is to test the Healthy Moms perinatal depression intervention using a single-case experimental design with pregnant women and new mothers recruited from public hospitals outside of Nairobi, Kenya.

Methods

We will invite patients to complete a brief, automated screening delivered via text messages to determine their eligibility. Enrolled participants will be randomized to a 1- or 2-week baseline period and then invited to begin using Zuri. Participants will be prompted to rate their mood via short message service every 3 days during the baseline and intervention periods. We will review system logs and conduct in-depth interviews with participants to study engagement with the intervention, feasibility, and acceptability. We will use visual inspection, in-depth interviews, and Bayesian estimation to generate preliminary data about the potential response to treatment.

Results

Our team adapted the intervention content in April and May 2018 and completed an initial prepilot round of formative testing with 10 women from a private maternity hospital in May and June. In preparation for this pilot study, we used feedback from these users to revise the structure and content of the intervention. Recruitment for this protocol began in early 2019. Results are expected toward the end of 2019.

Conclusions

The main limitation of this pilot study is that we will recruit women who live in urban and periurban centers in one part of Kenya. The results of this study may not generalize to the broader population of Kenyan women, but that is not an objective of this phase of work. Our primary objective is to gather preliminary data to know how to build and test a more robust service. We are working toward a larger study with a more diverse population.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11800

Course of major depressive disorder after pregnancy and the postpartum period

BACKGROUND

Maternal major depressive disorder (MDD) has an adverse effect on child development and increases risk for child psychopathology. It is paramount to understand the course of maternal depression during the childhood years particularly before, during, and after pregnancy.

OBJECTIVE

To follow the course of MDD in women with prior histories of depression followed during an index pregnancy.

METHODS

Subjects were women with histories of MDD who had participated in prior prospective, observational studies during pregnancy. In the follow-up, participants completed a structured interview that addressed (1) the course of MDD since their index pregnancy, (2) new psychiatric diagnoses, and (3) the course of MDD and treatment across subsequent pregnancies.

RESULTS

Out of 129 eligible women, 48.8% participated (N = 63) with an average/mean time of 12.9 years (SD = 1.9, 8.8-16.7) elapsed since participation in the prior pregnancy studies. Although approximately one third reported sustained remission from MDD since the pregnancy during which they had been originally followed, of the remaining two thirds of women who reported subsequent depressive episodes, almost one fifth (∼12% of the total sample) endorsed depression more than 50% of the time following their index pregnancy. A total of 6.3% of the women with previous validated diagnoses of MDD reported new diagnoses of bipolar disorder. Women reported similar treatment choices regarding the use of antidepressants during pregnancies subsequent to the one followed in the previous study.

CONCLUSION

Women with MDD experienced high rates of recurrent depression across the childbearing years. This represents a critical variable for clinical care and research.

Prevalence and factors associated with postnatal depression among women in two rural districts of Manicaland, Zimbabwe

Background

Low- and middle-income countries are disproportionately affected by postnatal depression (PND). High prevalence of PND in urban Zimbabwe has been reported but the situation in rural settings is largely unknown and this is one of the first studies to report prevalence of PND in Chipinge and Mutasa districts.

Objectives

This study explored the prevalence and associated factors of PND among women attending postnatal care services in two rural districts of Chipinge and Mutasa, Manicaland, Zimbabwe between August and September 2017.

Methods

One hundred and ninety-two women were recruited consecutively as they attended postnatal services at 7 days and 42 days post-delivery. The Diagnostic and Statistical Manual for Mental Disorders, fifth edition criteria was used to classify depression among participants. Prevalence of PND and 95.0% confidence intervals (CIs) were estimated and associations with key socio-demographic and risk factors assessed.

Results

The mean age of participants was 23.7 years (standard deviation = 6.14). Pooled prevalence of PND across the two districts was 26.0% (95% CI: 19.04–31.74). There was a higher prevalence of PND in Mutasa (31.0%) as compared to Chipinge (21.48%) but this was not statistically significant (p = 0.142). Having insufficient food in the household, intimate partner violence and having a child with birthweight under 2500 g significantly increased the likelihood of PND twofold: adjusted odds ratio (aOR) = 2.8 (95% CI: 1.2–6.1), aOR = 2.5 (95% CI: 1.2–5.3) and aOR = 2.4 (95% CI: 1.1–5.6), respectively.

Conclusion

The high prevalence of PND and its associated risk factors indicates the need for routine screening and targeted interventions for PND in Zimbabwe, especially in rural areas.

Standardizing the measurement of maternal morbidity: Pilot study results

Objective

To field test a standardized instrument to measure nonsevere morbidity among antenatal and postpartum women.

Methods

A cross‐sectional study was conducted in Jamaica, Kenya, and Malawi (2015–2016). Women presenting for antenatal care (ANC) or postpartum care (PPC) were recruited if they were at least 28 weeks into pregnancy or 6 weeks after delivery. They were interviewed and examined by a doctor, midwife, or nurse. Data were collected and securely stored electronically on a WHO server. Diagnosed conditions were coded and summarized using ICD‐MM.

Results

A total of 1490 women (750 ANC; 740 PPC) averaging 26 years of age participated. Most women (61.6% ANC, 79.1% PPC) were healthy (no diagnosed medical or obstetric conditions). Among ANC women with clinical diagnoses, 18.3% had direct (obstetric) conditions and 18.0% indirect (medical) problems. Prevalences among PPC women were lower (12.7% and 8.6%, respectively). When screening for factors in the expanded morbidity definition, 12.8% (ANC) and 11.0% (PPC) self‐reported exposure to violence.

Conclusion

Nonsevere conditions are distinct from the leading causes of maternal death and may vary across pregnancy and the puerperium. This effort to identify and measure nonsevere morbidity promotes a comprehensive understanding of morbidity, incorporating maternal self‐reporting of exposure to violence, and mental health. Further validation is needed.

A pilot study of a novel instrument to holistically measure maternal morbidity found that nonsevere conditions are distinct from the leading causes of maternal death.

Developing and validating a perinatal depression screening tool in Kenya blending Western criteria with local idioms: A mixed methods study

BACKGROUND

Routine screening for perinatal depression is not common in most primary health care settings. The U.S. Preventive Services Task Force only recently updated their recommendation on depression screening to specifically recommend screening during the pre- and postpartum periods. While practitioners in high-income countries can respond to this new recommendation by implementing one of several existing depression screening tools developed in Western contexts, such as the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire-9 (PHQ-9), these tools lack strong evidence of cross-cultural equivalence, validity for case finding, and precision in measuring response to treatment in developing countries. Thus, there is a critical need to develop and validate new screening tools for perinatal depression that can be used by lay health workers, primary health care personnel, and patients.

METHODS

Working in rural Kenya, we used free listing, card sorting, and item analysis methods to develop a locally-relevant screening tool that blended Western psychiatric concepts with local idioms of distress. We conducted a validation study with a random sample of 193 pregnant women and new mothers to test the diagnostic accuracy of this scale along with the EPDS and PHQ-9.

RESULTS

The sensitivity/specificity of the EPDS and PHQ-9 was estimated to be 0.70/0.72 and 0.70/0.73, respectively. This compared to sensitivity/specificity of 0.90/0.90 for a new 9-item locally-developed tool called the Perinatal Depression Screening (PDEPS). Across these three tools, internal consistency reliability ranged from 0.77 to 0.81 and test-retest reliability ranged from 0.57 to 0.67. The prevalence of depression ranges from 5.2% to 6.2% depending on the clinical reference standard.

CONCLUSION

The EPDS and PHQ-9 are valid and reliable screening tools for perinatal depression in rural Western Kenya, the PDEPS may be a more useful alternative. At less than 10%, the prevalence of depression in this region appears to be lower than other published estimates for African and other low-income countries.

Effect of maternal postpartum depression on offspring's growth

BACKGROUND

Previous studies have linked maternal depression to different child offspring's growth outcomes. However, its effect has not been well established. The aim of this review was to evaluate the available evidence on the effect of maternal postpartum depression on offspring weight and height growth outcomes.

METHODS

A systematic review of longitudinal studies that evaluated the effect of maternal depression on child's growth outcomes was conducted in PubMed, LILACs, Web of Science, Science Direct and PsyInfo databases, using maternal postpartum depression related keywords, according to each database searching tool.

RESULTS

A total of 9608 articles were screened and 20 met the final inclusion criteria. The child's first-year growth was the most affected by the exposure to maternal depression. Children of depressed mothers had a higher chance of being underweight and stunted in the first year of life. Maternal depression was also associated with child's linear growth impairment after the first year.

LIMITATIONS

As a literature review, a publication bias could not be ruled out. The diversity of the published data made it unfeasible for a pooled effect to be estimated.

CONCLUSIONS

Considering the results observed on child's first year of life growth, physicians should engage in assessing maternal depression, as it is a treatable and manageable disease, thus avoiding unnecessary harm on child's physical development.

The influence of maternal psychosocial circumstances and physical environment on the risk of severe wasting in rural Gambian infants: a mixed methods approach

BACKGROUND

Severe wasting affects 16 million under 5's and carries an immediate risk of death. Prevalence remains unacceptably high in sub-Saharan Africa and early infancy is a high-risk period. We aimed to explore risk factors for severe wasting in rural Gambian infants.

METHODS

We undertook a case-control study from November 2014 to June 2015, in rural Gambia. Cases had WHO standard weight-for-length z-scores (WLZ) < -3 on at least 1 occasion in infancy. Controls with a WLZ > -3 in the same interval, matched on age, gender, village size and distance from the clinic were selected. Standard questionnaires were used to assess maternal socioeconomic status, water sanitation and hygiene and maternal mental health. Conditional logistic regression using a multivariable model was used to determine the risk factors for severe wasting. Qualitative in depth interviews were conducted with mothers and fathers who were purposively sampled. A thematic framework was used to analyse the in-depth interviews.

RESULTS

Two hundred and eighty (77 cases and 203 controls) children were recruited. In-depth interviews were conducted with 16 mothers, 3 fathers and 4 research staff members. The mean age of introduction of complementary feeds was similar between cases and controls (5.2 [SD 1.2] vs 5.1 [SD 1.3] months). Increased odds of severe wasting were associated with increased frequency of complementary feeds (range 1-8) [adjusted OR 2.06 (95%: 1.17-3.62), p = 0.01]. Maternal adherence to the recommended infant care practices was influenced by her social support networks, most importantly her husband, by infant feeding difficulties and maternal psychosocial stressors that include death of a child or spouse, recurrent ill health of child and lack of autonomy in child spacing.

CONCLUSION

In rural Gambia, inappropriate infant feeding practices were associated with severe wasting in infants. Additionally, adverse psychosocial circumstances and infant feeding difficulties constrain mothers from practising the recommended child care practices. Interventions that promote maternal resilience through gender empowerment, prioritising maternal psychosocial support and encouraging the involvement of fathers in infant and child care promotion strategies, would help prevent severe wasting in these infants.

Effect of alcohol consumption and psychosocial stressors on preterm and small-for-gestational-age births in HIV-infected women in South Africa: a cohort study

OBJECTIVES

Psychosocial stressors such as depression and stress, intimate partner violence (IPV) and alcohol use have been linked to preterm and small-for-gestational-age (SGA) births in general populations. The prevalence of psychosocial stressors and alcohol abuse is high in many HIV-infected (HIV+) populations. Our objective was to evaluate the effects of psychosocial stressors and alcohol abuse on birth outcomes in HIV-infected women.

METHODS

Antenatal depression and non-specific psychological distress, periconception IPV and alcohol consumption were measured during the second trimester among HIV+ women initiating antiretroviral treatment with efavirenz + emtricitibine + tenofovir in Cape Town, South Africa. Log binomial regression models were used to estimate the risk ratios (RR) and 95% CIs of the effects of psychosocial stressors and periconception alcohol consumption on birth outcomes: SGA (birth weight <10th centile for gestational age) and preterm (<37 weeks) births.

RESULTS

Of the 571 mother-infant pairs, 26% of women reported hazardous alcohol consumption (Alcohol Use Disorders Identification Test-C score ≥3) periconception periods, 11% reported depressive symptoms, 7% reported non-specific psychological distress and 15% reported experiencing physical or psychological IPV. 14% of infants were born preterm and 12% were SGA. Infants born to women reporting hazardous drinking were twice (adjusted RR 2.00 (95% CI 1.13 to 3.54)) as likely to be SGA compared with women reporting low alcohol intake. Alcohol consumption did not have a significant effect on the incidence of preterm birth. Depressive symptoms, non-specific psychological distress, physical and psychological IPV did not increase the risk of SGA or preterm birth significantly.

CONCLUSIONS

The observed elevated risk of SGA births associated with periconception alcohol consumption underscores the urgent need to reduce alcohol consumption among women of childbearing age. Interventions targeting modifiable risk factors of adverse birth outcomes need to be integrated into HIV prevention and maternal child health programmes to improve the long-term health of HIV-exposed children.

TRIAL REGISTRATION NUMBER

NCT01933477; Pre-results.