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Ding W, Xu Y, Kondracki AJ, Sun Y. Childhood adversity and accelerated reproductive events: a systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:315-329.e31. [PMID: 37820985 DOI: 10.1016/j.ajog.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/18/2023] [Accepted: 10/02/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Accelerated female reproductive events represent the early onset of reproductive events involving puberty, menarche, pregnancy loss, first sexual intercourse, first birth, parity, and menopause. This study aimed to explore the association between childhood adversity and accelerated female reproductive events. DATA SOURCES PubMed, Web of Science, and Embase were systematically searched from September 22, 2022 to September 23, 2022. STUDY ELIGIBILITY CRITERIA Observational cohort, cross-sectional, and case-control studies in human populations were included if they reported the time of reproductive events for female individuals with experience of childhood adversity and were published in English. METHODS Two reviewers independently screened studies, obtained data, and assessed study quality, and conflicts were resolved by a third reviewer. Dichotomous outcomes were evaluated using meta-analysis, and pooled odds ratios and 95% confidence intervals were generated using random-effects models. Moderation analysis and meta-regression were used to investigate heterogeneity. RESULTS In total, 21 cohort studies, 9 cross-sectional studies, and 3 case-control studies were identified. Overall, female individuals with childhood adversity were nearly 2 times more likely to report accelerated reproductive events than those with no adversity exposure (odds ratio, 1.91; 95% confidence interval, 1.33-2.76; I2=99.6%; P<.001). Moderation analysis indicated that effect sizes for the types of childhood adversity ranged from an odds ratio of 1.61 (95% confidence interval, 1.23-2.09) for low socioeconomic status to 2.13 (95% confidence interval, 1.14-3.99) for dysfunctional family dynamics. Among the 7 groups based on different reproductive events, including early onset of puberty, early menarche, early sexual initiation, teenage childbirth, preterm birth, pregnancy loss, and early menopause, early sexual initiation had a nonsignificant correlation with childhood adversity (odds ratio, 2.70; 95% confidence interval, 0.88-8.30; I2=99.9%; P<.001). Considerable heterogeneity (I2>75%) between estimates was observed for over half of the outcomes. Age, study type, and method of data collection could explain 35.9% of the variance. CONCLUSION The literature tentatively corroborates that female individuals who reported adverse events in childhood are more likely to experience accelerated reproductive events. This association is especially strong for exposure to abuse and dysfunctional family dynamics. However, the heterogeneity among studies was high, requiring caution in interpreting the findings and highlighting the need for further evaluation of the types and timing of childhood events that influence accelerated female reproductive events.
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Affiliation(s)
- Wenqin Ding
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China
| | - Yuxiang Xu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China
| | - Anthony J Kondracki
- Department of Community Medicine, Mercer University School of Medicine, Macon, GA
| | - Ying Sun
- Department of Maternal, Child and Adolescent Health, School of Public Health, Anhui Medical University, Hefei, China; Key Laboratory of Population Health Across Life Cycle, Anhui Medical University, Ministry of Education of the People's Republic of China, Hefei, China; Anhui Provincial Key Laboratory of Population Health and Aristogenics, Anhui Medical University, Hefei, China.
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Mamun A, Biswas T, Scott J, Sly PD, McIntyre HD, Thorpe K, Boyle FM, Dekker MN, Doi S, Mitchell M, McNeil K, Kothari A, Hardiman L, Callaway LK. Adverse childhood experiences, the risk of pregnancy complications and adverse pregnancy outcomes: a systematic review and meta-analysis. BMJ Open 2023; 13:e063826. [PMID: 37536966 PMCID: PMC10401231 DOI: 10.1136/bmjopen-2022-063826] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/03/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Adverse childhood experiences (ACEs) have a profound negative impact on health. However, the strength of the association between ACEs and pregnancy complications and adverse pregnancy outcomes is not well quantified or understood. OBJECTIVE To conduct a systematic review and meta-analysis of the association between ACEs and risk of pregnancy complications and adverse pregnancy outcomes. SEARCH STRATEGY A comprehensive search was conducted using PubMed, Embase, CINAHL, PsycINFO, ClinicalTrials.gov and Google scholar up to July 2022. DATA COLLECTION AND ANALYSIS Two reviewers independently conducted the screening and quality appraisal using a validated tool. Meta-analysis using the quality-effects model on the reported odds ratio (OR) was conducted. Heterogeneity and inconsistency were examined using the I2 statistics. RESULTS 32 studies from 1508 met a priori inclusion criteria for systematic review, with 21 included in the meta-analysis. Pooled analyses showed that exposure to ACEs increased the risk of pregnancy complications (OR 1.37, 95% CI 1.20 to 1.57) and adverse pregnancy outcomes (OR 1.31, 95% CI 1.17 to 1.47). In sub-group analysis, maternal ACEs were associated with gestational diabetes mellitus (OR 1.39, 95% CI 1.11 to 1.74), antenatal depression (OR 1.59, 95% CI 1.15 to 2.20), low offspring birth weight (OR 1.27, 95% CI 1.02 to 1.47), and preterm delivery (OR 1.41, 95% CI 1.16 to 1.71). CONCLUSION The results suggest that exposure to ACEs increases the risk of pregnancy complications and adverse pregnancy outcomes. Preventive strategies, screening and trauma-informed care need to be examined to improve maternal and child health.
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Affiliation(s)
- Abdullah Mamun
- UQ Poche Centre for Indigenous Health, University of Queensland, Saint Lucia, Queensland, Australia
| | - Tuhin Biswas
- University of Queensland, Brisbane, Queensland, Australia
| | - James Scott
- University of Queensland, Brisbane, Queensland, Australia
| | - Peter D Sly
- Queensland Childrens Medical Research Instit, University of Queensland, Herston, Queensland, Australia
| | - H David McIntyre
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - Karen Thorpe
- University of Queensland, Brisbane, Queensland, Australia
| | | | - Marloes N Dekker
- Centre for Clinical Research, University of Queensland, Brisbane, Queensland, Australia
| | - Suhail Doi
- Population Medicine, Qatar University, Doha, Ad Dawhah, Qatar
| | - Murray Mitchell
- Faculty of Health, School of Biomedical Sciences, QUT, Brisbane, Queensland, Australia
| | - Keith McNeil
- Queensland Health, Brisbane, Queensland, Australia
| | - Alka Kothari
- University of Queensland, Brisbane, Queensland, Australia
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Pace CS, Muzi S, Rogier G, Meinero LL, Marcenaro S. The Adverse Childhood Experiences - International Questionnaire (ACE-IQ) in community samples around the world: A systematic review (part I). CHILD ABUSE & NEGLECT 2022; 129:105640. [PMID: 35662684 DOI: 10.1016/j.chiabu.2022.105640] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 12/01/2021] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The Adverse Childhood Experiences International Questionnaire (ACE-IQ) collects additional data (e.g., witness community violence/terrorism) than the previous version. Despite ACE-IQ is widely used and validated in several languages, no reviews focus on this measure. OBJECTIVE The main goals are to: 1) synthesize the ACE-IQ prevalence rates and average means among community samples, both for total ACE and single dimensions (e.g., intrafamily abuse, bullying); 2) discuss these data in light of the characteristics of studies and samples; 3) identify main research lines of the field. PARTICIPANTS AND SETTING The search for studies using the ACE-IQ with community participants was conducted on seven academic databases, including retrieval of grey literature. The screening process led to include 63 documents. METHODS A systematic review following the PRISMA guidelines was performed. RESULTS 1) On average, 75% of community respondents experienced ACEs, with a mean of three, primarily emotional abuse and bullying. 2) Males experienced more ACEs, but they were underrepresented, as well as children and adolescents. Most studies were conducted in Asia or Africa, and different geographical areas showed different pathways of prevalence in subdimensions. 3) Most research focused on prevalence and relationships between ACE-IQ scores and respondents' mental and physical health, suicide and parenting, focusing on intrafamily ACEs more than on those outside the household. CONCLUSIONS Several issues emerged in terms of lack of reporting prevalence or means, lack of studies in Europe, America and Oceania, and no attention to collective/community/peer violence, plus a lack of consensus toward the dimensions of the ACE-IQ.
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Affiliation(s)
- Cecilia Serena Pace
- Department of Educational Sciences, University of Genoa, Corso Podestà 2, 16128 Genoa, Italy.
| | - Stefania Muzi
- Department of Educational Sciences, University of Genoa, Corso Podestà 2, 16128 Genoa, Italy
| | - Guyonne Rogier
- Department of Educational Sciences, University of Genoa, Corso Podestà 2, 16128 Genoa, Italy
| | - Lara Lia Meinero
- Department of Educational Sciences, University of Genoa, Corso Podestà 2, 16128 Genoa, Italy
| | - Sara Marcenaro
- Department of Educational Sciences, University of Genoa, Corso Podestà 2, 16128 Genoa, Italy
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Dosani A, Yim IS, Shaikh K, Lalani S, Alcantara J, Letourneau N, Premji SS. Psychometric analysis of the Edinburgh Postnatal Depression Scale and Pregnancy Related Anxiety Questionnaire in Pakistani pregnant women. Asian J Psychiatr 2022; 72:103066. [PMID: 35334284 DOI: 10.1016/j.ajp.2022.103066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Edinburgh Postnatal Depression Scale (EPDS) and the Pregnancy-Related Anxiety Scale (PRAQ) are frequently used perinatal mental health scales. OBJECTIVE To identify the factor structure of the Urdu language versions of EPDS and PRAQ in 280 Pakistani pregnant women. METHOD The tools were administered at 12-19 weeks' and 22-29 weeks' gestational age (GA). Exploratory factor analyses were undertaken on data collected at 12-19 weeks' GA, to assess both scales. Results obtained at the second time point were used to examine test-retest reliability. The correlation between the scales was computed. RESULTS A two-factor model yielded the best fit for both scales, which is consistent with findings from previous studies. For the EPDS, acceptable reliability was attained for the overall score (α = 0.77) and for the factor related to depressive symptoms (α = 0.73), but not for the factor related to anhedonia/suicide (α = 0.64). For the PRAQ, acceptable reliability was attained for the overall score (α = 0.83) and for the factor related to pregnancy concerns (α = 0.84), but not for the factor related to childbirth (α = 0.64). Test-retest reliability was acceptable for both overall scales EPDS: r = 0.50; PRAQ: r = 0.45; both p < .001). The Pearson correlation between the EPDS and PRAQ were r = 0.145, p < .05. CONCLUSION Analysis of the tools confirmed a two-factor structure for both depression and anxiety among Pakistani pregnant women. A weak correlation was found between the EPDS and PRAQ. Further research is required to develop screening instruments for perinatal mental disorders that are applicable to cultural contexts.
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Affiliation(s)
- Aliyah Dosani
- School of Nursing and Midwifery, Mount Royal University, 4825 Mount Royal Gate S.W., Calgary, Alberta, T3E 6K6 Canada; Department of Community Health Sciences, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6 Canada; O'Brien Institute for Public Health, University of Calgary, 3rd Floor TRW Building, 3280 Hospital Drive N.W., Calgary, Alberta, T2N 4Z6 Canada.
| | - Ilona S Yim
- Department of Psychological Science, University of California, Irvine, 4562 Social and Behavioral Sciences Gateway, Irvine, CA, USA
| | - Kiran Shaikh
- School of Nursing and Midwifery, Aga Khan University, Stadium Road, P/O Box 3500, Karachi 74800, Pakistan
| | - Sharifa Lalani
- School of Nursing and Midwifery, Aga Khan University, Stadium Road, P/O Box 3500, Karachi 74800, Pakistan
| | - Jade Alcantara
- School of Nursing and Midwifery, Mount Royal University, 4825 Mount Royal Gate S.W., Calgary, Alberta, T3E 6K6 Canada
| | - Nicole Letourneau
- Department of Community Health Sciences, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6 Canada; Faculty of Nursing, University of Calgary, 2500 University Drive N.W., Calgary, Alberta, T2N 1N4 Canada; Departments of Pediatrics and Psychiatry, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta,T2N 4N1 Canada
| | - Shahirose S Premji
- School of Nursing, Faculty of Health, York University, Health, Nursing & Environmental Studies Building, Room 313, 4700 Keele St, Toronto, M3J 1P3 Canada
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Ikram N, Frost A, LeMasters K, Hagaman A, Baranov V, Gallis J, Sikander S, Scherer E, Maselko J. Adverse childhood experiences and implications of perceived stress, anxiety and cortisol among women in Pakistan: a cross-sectional study. BMJ Open 2022; 12:e052280. [PMID: 35428618 PMCID: PMC9014037 DOI: 10.1136/bmjopen-2021-052280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Adverse childhood experiences (ACEs) are linked to poor maternal mental health. The goal of this study is to examine the associations between ACEs and multiple manifestations of stress (including perceived stress, anxiety and cortisol) among mothers in rural Pakistan. DESIGN This study used a cross-sectional design. Mothers were originally recruited during their third trimester of pregnancy and followed until 36 months post partum. Cortisol was collected at 12 months post partum, and self-report data were collected at 36 months post partum. SETTING All participants reside in rural villages in Rawalpindi, Pakistan. The measures were administered at home visits by field interviewers. PARTICIPANTS Data were collected from 889 mothers. All mothers in the sample provided data on ACEs and perceived stress, 623 provided data on anxiety and 90 provided hair cortisol. PRIMARY AND SECONDARY OUTCOMES MEASURES ACEs were captured retrospectively using an adapted version of the ACE International Questionnaire, and represented as a continuous variable and subdomains (neglect, home violence, family psychological distress, community violence). Primary outcomes included perceived stress measured with the Cohen Perceived Stress Scale (PSS) and anxiety measured with the Generalised Anxiety Disorder-7 scale (GAD-7). Hair-derived cortisol was included as a secondary outcome. Generalised linear models with cluster-robust SEs were used to estimate associations between ACEs and the outcome variables. RESULTS All models featured positive associations between ACE items and PSS. The continuous total ACE score (B=0.4; 95% CI 0.0 to 0.8) was associated with higher anxiety symptoms on the GAD-7. Home violence (B=6.7; 95% CI 2.7 to 10.8) and community violence (B=7.5; 95% CI 1.4 to 13.6) were associated with increased hair cortisol production. CONCLUSIONS All four ACE domains were associated with elevated levels of perceived stress, anxiety and cortisol, with varying precision and strength of estimates, indicating that the type of ACE has a differential impact. This study informed our understanding of the differential impact of specific ACEs on perceived stress, anxiety and hypothalamic pituitary adrenal-axis functioning, providing implications for future clinical intervention and research development.
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Affiliation(s)
- Naira Ikram
- Department of Program II, Duke University, Durham, North Carolina, USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Allison Frost
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Katherine LeMasters
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ashley Hagaman
- Department of Social and Behavioral Sciences, Yale University, New Haven, Connecticut, USA
| | - Victoria Baranov
- Department of Economics, University of Melbourne, Melbourne, Victoria, Australia
| | - John Gallis
- Department of Biostatistics & Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Siham Sikander
- Department of Public Health, Human Development Research Foundation, Islamabad, Pakistan
| | - Elissa Scherer
- RTI International, Research Triangle Park, North Carolina, USA
| | - Joanna Maselko
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA
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Imran N, Liaqat S, Bodla ZH, Zeshan M, Naveed S. Impact of Adverse Childhood Experiences on the Mother-Infant Social-Emotional Well-Being in Low- and Middle-Income Countries. Psychiatr Ann 2021. [DOI: 10.3928/00485713-20210609-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sulaiman S, Premji SS, Tavangar F, Yim IS, Lebold M. Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review. Matern Child Health J 2021; 25:1581-1594. [PMID: 34036452 DOI: 10.1007/s10995-021-03176-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Total adverse childhood experiences (ACEs) are gaining prominence as a risk factor for preterm birth (PTB). The emerging literature examining this relationship reports inconsistent findings. The purpose of this systematic review was to summarize the available evidence exploring whether total ACEs predict PTB. METHODS A total of 386 studies were returned from searches on PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Nine studies were selected for final analysis and synthesis based on reporting of total ACEs and preterm birth gestational weeks or standard definition of birth before 37 weeks' gestational age. A systematic review rather than meta-analysis was selected to present the findings given the clinical and methodological (e.g., sample studied, measurement tools) heterogeneity of the retrieved studies and pregnancy outcomes measured. RESULTS The nine studies report on birth outcomes for 6,087 women from a range of sociodemographic and ethnic backgrounds. Despite a wide range of study designs, measurement tools, and timings of ACEs exposure across studies, seven of the nine included studies showed significant relationships between ACEs and PTB. CONCLUSION Systematic review of the literature suggests that total ACEs are associated with PTB and provides an overview on the known associations. However, to date only nine studies have assessed this link, and more studies are needed, to explore the associations between ACEs and PTB using appropriate and valid instruments and doing so among more diverse populations. Future research should also explore possible biological mechanisms (allostatic load), and moderating and mediating variables.
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Affiliation(s)
- Salima Sulaiman
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | | | - Farideh Tavangar
- Faculty of Health, School of Nursing, York University, Toronto, ON, Canada
| | - Ilona S Yim
- Department of Psychological Science, University of California, Irvine, CA, USA
| | - Margaret Lebold
- Faculty of Health, School of Nursing, York University, Toronto, ON, Canada
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Perceived stress may mediate the relationship between antenatal depressive symptoms and preterm birth: A pilot observational cohort study. PLoS One 2021; 16:e0250982. [PMID: 33945579 PMCID: PMC8096039 DOI: 10.1371/journal.pone.0250982] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/16/2021] [Indexed: 11/19/2022] Open
Abstract
Background Screening for changes in pregnancy-related anxiety and depressive symptoms during pregnancy may further our understanding of the relationship between these two variables and preterm birth. Objectives To determine whether changes in pregnancy-related anxiety and depressive symptoms during pregnancy influence the risk of preterm birth among Pakistani women; explore whether perceived stress moderates or mediates this relationship, and examine the relationship between the various components of pregnancy-related anxiety and preterm birth. Methods A prospective cohort study design was used to recruit a diverse sample of 300 low-risk pregnant women from four centers of Aga Khan Hospital for Women and Children in Karachi, Pakistan. Changes in pregnancy-related anxiety and depressive symptoms during pregnancy were tested. Multiple logistic regression analysis was used to determine a predictive model for preterm birth. We then determined if the influence of perceived stress could moderate or mediate the effect of depressive symptoms on preterm birth. Results Changes in pregnancy-related anxiety (OR = 1.1, CI 0.97–1.17, p = 0.167) and depressive symptoms (OR = 0.9, CI 0.85–1.03, p = 0.179) were insignificant as predictors of preterm birth after adjusting for the effects of maternal education and family type. When perceived stress was added into the model, we found that changes in depressive symptoms became marginally significant after adjusting for covariates (OR = 0.9, CI 0.82–1.01, p = 0.082). After adjusting for the mediation effect of change in perceived stress, the effect of change in depressive symptoms on preterm birth were marginally significant after adjusting for covariates. Among six different dimensions of pregnancy-related anxiety, mother’s concerns about fetal health showed a trend towards being predictive of preterm birth (OR = 1.3, CI 0.97–1.72, p = 0.078). Conclusions There may be a relationship between perceived stress and antenatal depressive symptoms and preterm birth. This is the first study of its kind to be conducted in Pakistan. Further research is required to validate these results.
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Comorbid Anxiety and Depression among Pregnant Pakistani Women: Higher Rates, Different Vulnerability Characteristics, and the Role of Perceived Stress. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17197295. [PMID: 33036215 PMCID: PMC7579342 DOI: 10.3390/ijerph17197295] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/27/2022]
Abstract
Anxiety and depression commonly co-occur during pregnancy and may increase risk of poor birth outcomes including preterm birth and low birth weight. Our understanding of rates, patterns, and predictors of comorbid anxiety and depression is hindered given the dearth of literature, particularly in low- and middle-income (LMI) countries. The aim of this study is (1) to explore the prevalence and patterns of comorbid antenatal anxiety and depressive symptoms in the mild-to-severe and moderate-to-severe categories among women in a LMI country like Pakistan and (2) to understand the risk factors for comorbid anxiety and depressive symptoms. Using a prospective cohort design, a diverse sample of 300 pregnant women from four centers of Aga Khan Hospital for Women and Children in Pakistan were enrolled in the study. Comorbid anxiety and depression during pregnancy were high and numerous factors predicted increased likelihood of comorbidity, including: (1) High level of perceived stress at any time point, (2) having 3 or more previous children, and (3) having one or more adverse childhood experiences. These risks were increased if the husband was employed in the private sector. Early identification and treatment of mental health comorbidities may contribute to decreased adverse birth outcomes in LMI countries.
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