Migrant perinatal depression study: a prospective cohort study of perinatal depression on the Thai-Myanmar border

Understanding Gender-Based Perception During Pregnancy: A Qualitative Study

Purpose

Gender-based perceptions about maternal health care during pregnancy draw attention to the existence of gender inequity in maternal health care. This study aimed to understand the gender-based perception of gender roles and norms, gender relations, social support, and psychosocial variation in maternal health care during pregnancy.

Methods

A qualitative study was conducted in three rural districts of Jimma, Ethiopia. Participants were purposefully chosen from the community groups, including male and female health development armies, religious leaders, health extension workers, midwifery nurses, and primary health care unit directors. The data was gathered through in-depth interviews and focus group discussions. The actual data was collected by men and women qualitative study experts. Atlas ti Ver 9 was used for the analysis. The data was initially coded then changed to a sub-category and at last converted to a category.

Results

Four categories emerged: Gender-based roles and norms, psychosocial variation, social support, and gender relations. The informants described men's and women's independent and shared roles improve maternal health care service usage during pregnancy. Once the women became pregnant, men undertook a variety of demanding duties to enhance maternity service consumption. Gender relations and shared decision-making were essential in facilitating maternal healthcare utilization during pregnancy and beyond.

Conclusion

This study revealed that maternal health care should not be limited to women alone. Men's and women's prior maternal health experiences, in addition to their knowledge and beliefs, have significantly impacted the utilization of maternal healthcare services during pregnancy. Policymakers and academics should consider men's essential contribution to maternal health care during pregnancy. However, in order to increase their intention to use maternal health care services, it is necessary to clearly identify the interests of women in which men should be involved.

The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis

BACKGROUND

There are one billion migrants globally, of whom 82 million are forced migrants. Pregnant migrants face pre-migration stressors such as conflict, transit stressors including poverty, and post-migration stressors including navigating the immigration system; these stressors can make them vulnerable to mental illness. We aimed to assess the global prevalence of and risk factors for perinatal mental health disorders or substance use among women who are migrants.

METHODS

In this systematic review and meta-analysis, we searched OVID MEDLINE, Embase, PsycINFO, CENTRAL, Global Health, Scopus, and Web of Science for studies published from database inception until July 8, 2022. Cohort, cross-sectional, and interventional studies with prevalence data for any mental illness in pregnancy or the postnatal period (ie, up to a year after delivery) or substance use in pregnancy were included. The primary outcome was the prevalence of perinatal common mental health disorders among women who are migrants, globally. Data for study quality and risk factors were also extracted. A random-effects meta-analysis was used to calculate pooled prevalence estimates, when appropriate. Sensitivity analyses were conducted according to study quality, sample representativeness, and method of outcome assessment. Risk factor data were synthesised narratively. This study is registered with PROSPERO, CRD42021226291.

FINDINGS

18 650 studies were retrieved, of which 135 studies comprising data from 621 995 participants met the inclusion criteria. 123 (91%) of 135 studies were conducted in high-income host countries. Five (4%) of 135 studies were interventional, 40 (30%) were cohort, and 90 (66%) were cross-sectional. The most common regions of origin of participants were South America, the Middle East, and north Africa. Only 26 studies presented disaggregated data for forced migrants or economic migrants. The pooled prevalence of perinatal depressive disorders was 24·2% (range 0·5-95·5%; I² 98·8%; τ² 0·01) among all women who are migrants, 32·5% (1·5-81·6; 98·7%; 0·01) among forced migrants, and 13·7% (4·7-35·1; 91·5%; 0·01) among economic migrants (p<0·001). The pooled prevalence of perinatal anxiety disorders was 19·6% (range 1·2-53·1; I² 96·8%; τ² 0·01) among all migrants. The pooled prevalence of perinatal post-traumatic stress disorder (PTSD) among all migrant women was 8·9% (range 3·2-33·3; I² 97·4%; τ² 0·18). The pooled prevalence of perinatal PTSD among forced migrants was 17·1% (range 6·5-44·3; I² 96·6%; τ² 0·32). Key risk factors for perinatal depression were being a recently arrived immigrant (ie, approximately within the past year), having poor social support, and having a poor relationship with one's partner.

INTERPRETATION

One in four women who are migrants and who are pregnant or post partum experience perinatal depression, one in five perinatal anxiety, and one in 11 perinatal PTSD. The burden of perinatal mental illness appears higher among women who are forced migrants compared with women who are economic migrants. To our knowledge, we have provided the first pooled estimate of perinatal depression and PTSD among women who are forced migrants. Interpreting the prevalence estimate should be observed with caution due to the very wide range found within the included studies. Additionally, 66% of studies were cross-sectional representing low quality evidence. These findings highlight the need for community-based routine perinatal mental health screening for migrant communities, and access to interventions that are culturally sensitive, particularly for forced migrants who might experience a higher burden of disease than economic migrants.

FUNDING

UK National Institute for Health Research (NIHR); March of Dimes European Preterm Birth Research Centre, Imperial College; Imperial College NIHR Biomedical Research Centre; and Nuffield Department of Population Health, University of Oxford.

Depressive symptoms, HIV disclosure, and HIV-related stigma among migrant workers living with HIV in Chiang Mai, Thailand

Currently migrant workers living with HIV (MWLHIV) in Thailand have access to antiretroviral treatment. We determined the frequency of depressive symptoms, HIV disclosure, and HIV-related stigma in this population. The cross-sectional study was conducted at 12 HIV clinics in community hospitals in Chiang Mai, Thailand. Data were collected from MWLHIV through face-to-face interviews. A 9-item Patient Health Questionnaire-9 (PHQ-9) and a Thai-validated HIV/AIDS stigma scales were used. A total of 316 MWLHIV participated; their median age was 39 years and 65% were female. Sixty (19%) had depressive symptoms, with higher frequency of depression in females (22.4% vs.12.6%, respectively; p = .033). The overall HIV disclosure rate was 69.9%. Females were more likely than males to disclose HIV status to someone outside the clinic (72.2% vs. 65.8%, respectively; p = .234). The most prevalent type of HIV-related stigma was internalized, followed by felt stigma. Enacted stigma had the lowest prevalence. Multiple linear regression revealed that being female (β = 0.125, p = .029), enacted stigma (β = 0.152, p = .011) and felt stigma (β = 0.248, p < .001) were significantly associated with depressive scores. To ensure favorable HIV treatment outcomes, individual counseling, psychosocial support, and mental health screening should be integrated into HIV services.

Persistent depression in pregnant refugee and migrant women living along the Thai-Myanmar Border: a secondary qualitative analysis

Background Antepartum depression affects around 15% of pregnant women worldwide, and may negatively impact their infants' physical, cognitive and social development, and confer a greater risk of emotional dysregulation in their children. Risk factors for antepartum depression disproportionately affect women from resource-sparse settings. In particular, pregnant refugee and migrant women face many barriers to diagnosis and care of mental health conditions, yet this group is under-represented in the literature. This study explores what refugee and migrant women living along the Thai-Myanmar border perceive as being contributory and protective factors to their antepartum depression, through secondary qualitative analysis of responses to clinical interviews for depression. Methods Previous research investigating perinatal depression in pregnant refugee and migrant women on the Thai-Myanmar border involved assessing 568 women for depression, using the Structured Clinical Interview for the diagnosis of DSM-IV Disorders (SCID). This study analyses a subsample of 32 women, diagnosed with persistent depression during the antepartum period. Thematic analysis of responses to the SCID and social and demographic surveys was undertaken to investigate factors which contribute towards, or protect against, persistent antepartum depression. Results Major themes which women described as contributing towards persistent antepartum depression were financial problems, interpersonal violence, substance misuse among partners, social problems and poor health. Factors women considered as protecting mental wellbeing included social support, accessible healthcare and distractions, highlighting the need for focus on these elements within refugee and migrant settings. Commonly expressed phrases in local Karen and Burmese languages were summarised. Conclusions Knowledge of factors affecting mental wellbeing in the study population and how these are phrased, may equip stakeholders to better support women in the study area. This study highlighted the limitations of contextually generic diagnostic tools, and recommends the development of tools better suited to marginalised and non-English speaking groups.

Suicidal ideation in the perinatal period: findings from the Thailand-Myanmar border

BACKGROUND

Suicide is a leading cause of maternal death globally. Migrant and refugee populations may experience higher risk of suicide. We report data on suicidal ideation from migrant and refugee women living on the Thailand-Myanmar border.

METHODS

Women were recruited in their first trimester of pregnancy. Depression status was assessed by diagnostic interview in the first, second and third trimesters and at 1 month post-partum. We calculated prevalence of suicidal ideation and used logistic regression to identify associated socio-demographic factors.

RESULTS

During the perinatal period, 5.3% (30/568) women experienced suicidal ideation. Refugee women were more likely to experience suicidal ideation than migrant women (8.0 versus 3.1%; P = 0.01). Most women with suicidal ideation did not have severe depression. Previous trauma (OR 2.32; 95% CI: 1.70-3.15) and unplanned pregnancy (OR 2.74; 95% CI: 1.10-6.86) were significantly associated with suicidal ideation after controlling for all other variables.

CONCLUSIONS

Suicidal ideation represents an important symptom among migrant and refugee women on the Thailand-Myanmar border. Screening only those with severe depression may be insufficient to identify women at risk of suicide. Community-level interventions addressing social and gender inequalities and prioritization of family planning programmes are needed alongside targeted suicide prevention initiatives to help lower the rates of people dying by suicide.

Mental health of adolescents in Myanmar: A systematic review of prevalence, determinants and interventions

Adolescence is a developmental phase where mental disorders typically manifest and where platforms for response (including schools and health services) change rapidly. However, data to inform public mental health responses are limited, including in countries like Myanmar which has a large adolescent population and where mental health has been identified as a priority of policy. In this paper we sought to systematically review the peer-reviewed and grey literature to determine (i) the prevalence of mental disorder among adolescents in Myanmar, (ii) determinants of mental disorder and (iii) interventions that have been implemented and evaluated. Nine publications met inclusion criteria (7 peer-reviewed and 2 grey literature) that included 7 publications reporting prevalence, 6 reporting correlates and one an intervention. The available data from the 2016 Global School-based Health Survey highlight that depression (27.2%) and suicidal ideation (9.4%) are prevalent in Myanmar, and these rates are substantially higher than regional averages. The limited available data on correlates identified violence and bullying, alcohol and substance use, and home, family and community security and cohesion as being closely related to mental health for adolescents. Only one study focussed on interventions and this found mindfulness meditation training to be an effective approach for young people whose parents were affected by HIV. These findings underscore the need to address adolescent mental health in Myanmar, but also to invest in better data collection efforts.

Perinatal depression in migrant and refugee women on the Thai-Myanmar border: does social support matter?

Migrant and refugee women are at risk of perinatal depression due to stressors experienced before, during and after migration. This study assesses the associations between social support and perinatal depression among migrant and refugee women on the Thai-Myanmar border. We conducted a cohort study of pregnant and post-partum women. Depression status was assessed using a structured clinical interview. Received support, perceived support and partner support were measured in the third trimester. Logistic regression was used to calculate associations between social support measures and perinatal depression controlling for demographic, socio-economic, migration, obstetric and psychosocial factors. Four hundred and fifty-one women (233 migrants; 218 refugees) were included. The prevalence of perinatal depression was 38.6% in migrants and 47.3% in refugees. Migrants had higher levels of received, perceived and partner support than refugees. After controlling for all other variables, higher levels of received support remained significantly associated with a lower likelihood of perinatal depression in migrants (adjusted odds ratio 0.82; 95% CI 0.68-0.99). In both groups, depression history and trauma were strongly associated with perinatal depression. Our study highlights the importance of received social support to perinatal depression in migrant women on the Thailand-Myanmar border. The perinatal period offers a valuable opportunity to ask women about their support and offer community-level or public policy interventions to nurture support networks in current locations and resettlement destinations. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Cohort profile: molecular signature in pregnancy (MSP): longitudinal high-frequency sampling to characterise cross-omic trajectories in pregnancy in a resource-constrained setting

PURPOSE

A successful pregnancy relies on the interplay of various biological systems. Deviations from the norm within a system or intersystemic interactions may result in pregnancy-associated complications and adverse pregnancy outcomes. Systems biology approaches provide an avenue of unbiased, in-depth phenotyping in health and disease. The molecular signature in pregnancy (MSP) cohort was established to characterise longitudinal, cross-omic trajectories in pregnant women from a resource constrained setting. Downstream analysis will focus on characterising physiological perturbations in uneventful pregnancies, pregnancy-associated complications and adverse outcomes.

PARTICIPANTS

First trimester pregnant women of Karen or Burman ethnicity were followed prospectively throughout pregnancy, at delivery and until 3 months post partum. Serial high-frequency sampling to assess whole blood transcriptomics and microbiome composition of the gut, vagina and oral cavity, in conjunction with assessment of gene expression and microbial colonisation of gestational tissue, was done for all cohort participants.

FINDINGS TO DATE

381 women with live born singletons averaged 16 (IQR 15-18) antenatal visits (13 094 biological samples were collected). At 5% (19/381) the preterm birth rate was low. Other adverse events such as maternal febrile illness 7.1% (27/381), gestational diabetes 13.1% (50/381), maternal anaemia 16.3% (62/381), maternal underweight 19.2% (73/381) and a neonate born small for gestational age 20.2% (77/381) were more often observed than preterm birth.

FUTURE PLANS

Results from the MSP cohort will enable in-depth characterisation of cross-omic molecular trajectories in pregnancies from a population in a resource-constrained setting. Moreover, pregnancy-associated complications and unfavourable pregnancy outcomes will be investigated at the same granular level, with a particular focus on population relevant needs such as effect of tropical infections on pregnancy. More detailed knowledge on multiomic perturbations will ideally result in the development of diagnostic tools and ultimately lead to targeted interventions that may disproportionally benefit pregnant women from this resource-limited population.

TRIAL REGISTRATION NUMBER

NCT02797327.

Prevention of mother-to-child transmission of hepatitis B virus: protocol for a one-arm, open-label intervention study to estimate the optimal timing of tenofovir in pregnancy

INTRODUCTION

Hepatitis B virus (HBV) remains a public health threat and the main route of transmission is from mother to child (MTCT). Tenofovir disoproxil fumarate (TDF) treatment can reduce MTCT of HBV although the optimal timing to attain undetectable HBV DNA concentrations at delivery is unknown. This protocol describes the procedures following early initiation of maternal TDF prior to 20 weeks gestation to determine efficacy, safety and feasibility of this approach in a limited-resource setting.

METHODS AND ANALYSES

One hundred and seventy pregnant women from the Thailand-Myanmar border between 12 and <20 weeks gestational age will be enrolled into a one-arm, open-label, TDF treatment study with cessation of TDF 1 month after delivery. Sampling occurs monthly prenatal, at birth and at 1, 2, 4 and 6 months post partum. Measurement of tenofovir concentrations in maternal and cord plasma is anticipated in 10-15 women who have detectable HBV DNA at delivery and matched to 20-30 women with no detectable HBV DNA. Infant HBsAg status will be determined at 2 months of age and HBV DNA confirmed in HBsAg positive cases. Adverse events including risk of flare and adherence, based on pill count and questionnaire, will be monitored. Infants will receive HBV vaccinations at birth, 2, 4 and 6 months and hepatitis B immunoglobulin at birth if the mother is hepatitis B e antigen positive. Infant growth and neurodevelopment at 6 months will be compared with established local norms.

ETHICS AND DISSEMINATION

This study has ethical approval by the Ethics Committee of the Faculty of Tropical Medicine, Mahidol University (FTM ECF-019-06), Johns Hopkins University (IRB no: 00007432), Chiang Mai University (FAM-2559-04227), Oxford Tropical Research Ethics Committee (OxTREC Reference: 49-16) and by the local Tak Community Advisory Board (TCAB-02/REV/2016). The article will be published as an open-access publication.

TRIAL REGISTRATION NUMBER

NCT02995005, Pre-results.

Screening for Detection of the Risk of Perinatal Mental Disorders among Women in Poland

The aim of the study was to assess the severity of depressive symptoms, to analyze risk factors for perinatal mental disorders and to assess dispositional optimism. A total of 106 women from Poland were included in the study at 37-week pregnant and 6 weeks after giving birth. It was demonstrated that the main predictors of perinatal mental disorders were the variables: mental health disorders before pregnancy, subjectively reported decreased mood in pregnancy, the lack of social (instrumental) support and the tendency to pessimism. The results of the study suggest how important it is to introduce clinical practice in Poland to screen for early detection of the risk of depression during pregnancy and postpartum depression.

Prevalence and determinants of perinatal depression among labour migrant and refugee women on the Thai-Myanmar border: a cohort study

BACKGROUND

Perinatal depression is a significant contributor to maternal morbidity and mortality globally. Migrant women, particularly those living in low- and middle-income settings, represent a particularly vulnerable group due to stressors experienced before, during and after migration. The vast majority of global migration flows occurring within and between low- and middle-income regions, yet existing evidence focuses predominantly on migrants in high-income destinations. This study aimed to redress this significant gap in the evidence by determining the prevalence and determinants of perinatal depression among migrant women on the Thai-Myanmar border.

METHODS

A cohort of labour migrant and refugee women was followed-up from the first trimester of pregnancy to one month post-partum. Depression status was assessed in the first, second and third trimesters of pregnancy and at one month post-partum using the Structured Clinical Interview for the Diagnosis of DSM-IV Disorders. Women diagnosed with depression had immediate access to care. Data on potential demographic, social and clinical associated factors was collected using a questionnaire. Prevalence and incidence of any depressive disorder and moderate-severe depressive disorder was calculated. Univariable and multivariable logistic regression using complete case analysis was used to estimate odds ratios (OR) of association between exposure variables and depression status.

RESULTS

Five hundred sixty-eight women participated. Period prevalence (from first trimester of pregnancy to one month post-partum) of moderate-severe perinatal depression was 18.5% (95% CI 15.4-21.9%). Overall, 15.4% (95% CI 11.8-19.6%) of women developed new-onset moderate-severe depression during the study period. Forty-two participants received treatment for depression. Risk factors were interpersonal violence (OR 4.5; 95% CI 1.9-11.1); history of trauma (OR 2.4; 95% CI 1.4-4.3); self-reported history of depression (OR 2.3; 95% CI 1.2-4.2); labour migrant status (OR 2.1; 95% CI 1.1-4.0); low social support (OR 2.1; 95% CI 1.1-3.7); and maternal age (OR 1.1 per year; 95% CI 1.0-1.1). Limitations of the study include that culturally specific manifestations of depression may have been missed.

CONCLUSIONS

Perinatal depression represents a significant burden among migrant women on the Thai-Myanmar border. Programmes to address the determinants along with early case identification and effective treatment and referral systems are key to addressing perinatal depression in this low-resource setting.

Life situation and support during pregnancy among Thai expectant mothers with depressive symptoms and their partners: a qualitative study

Background

Expectant parents may have positive and negative emotions during pregnancy and receive support from different sources. Studies on life situation and support among couples have rarely been conducted. This study aims to explore life situation and support during pregnancy among expectant mothers with depressive symptoms and their partners.

Methods

Twenty-seven expectant mothers, in the last trimester of pregnancy with depressive symptoms (Edinburgh Postnatal Depression Scale score ≥ 7) from seven public antenatal care clinics in Sakonnakhon, a north-eastern province of Thailand, and their partners were interviewed. In total, 54 semi-structured interviews were subjected to content analysis.

Results

Four categories emerged: (1) Having obstacles in life, (2) Facing life transition, (3) Enhancing confidence, and (4) Dissatisfaction with support. The informants described obstacles regarding economy, fear of health problems, getting an abnormal child and partners’ behaviours. They received support from family members and social networks, but some were dissatisfied with the support from the healthcare. For example, expectant fathers wished to receive more health information and be more involved.

Conclusions

Healthcare professionals should be aware of the influence of cultural and contextual factors when providing antenatal care to expectant parents. Male involvement in the care must not be neglected.

Living with severe perinatal depression: a qualitative study of the experiences of labour migrant and refugee women on the Thai-Myanmar border

BACKGROUND

Perinatal depression is an important contributor to maternal morbidity and mortality worldwide. Migrant women, particularly those resettling within low- and middle-income settings, are at increased risk of perinatal depression due to multiple stressors experienced before, during and after migration. Evidence on migrant perinatal mental health to date has focused largely on women in high-income destination countries, leaving the voices of displaced women in low-income settings unheard. This study addresses the current evidence gap by exploring the experiences of migrant women living on the Thai-Myanmar border.

METHODS

In-depth interviews were conducted with pregnant and post-partum labour migrant and refugee women on the Thai-Myanmar border who had been diagnosed with severe depression. An interview guide covering women's current and past life experiences, social support and the impact of depression on social and occupational functioning was used as a prompt. Thematic analysis was used to identify themes emerging from women's narratives.

RESULTS

Eleven pregnant and post-partum women with severe perinatal depression took part. Participating women provided extensive insight into the many difficult aspects of their lives that they perceived as contributing to their depression status. Predominant themes emerging from women's narratives included difficult relationships with partners, challenging life situations, mechanisms for coping with depression and impressions of mental health care.

CONCLUSIONS

Labour migrant and refugee women with severe perinatal depression face a wide range of chronic stressors at the individual, household and community levels that are likely to have both short- and long-term negative effects on their mental well-being and day-to-day functioning. Participating women responded positively to the mental health support they received, and findings provide important insights into how services might further support their needs.

Validation of the Refugee Health Screener-15 for the assessment of perinatal depression among Karen and Burmese women on the Thai-Myanmar border

Perinatal depression is common, and left untreated can have significant and long-lasting consequences for women, their children and their families. Migrant women are at particular risk of perinatal depression as a result of a multitude of stressors experienced before, during and after migration. Identification of perinatal depression among migrant women-particularly those living in low- and middle-income regions-remains challenging, partly due to the lack of locally-validated and culturally appropriate screens tools. This study formally validates Burmese and Sgaw Karen versions of the Refugee Health Screener-15 (RHS-15) as a screening tool for perinatal depression among migrant women living on the Thai-Myanmar border. The Structured Clinical Interview for the Diagnosis of DSM-IV Disorders (SCID) was used as the gold-standard comparator. Complete results were obtained for 235 Burmese-speaking and 275 Sgaw Karen-speaking women. Despite displaying reasonable psychometric properties, a number of shortcomings associated with the RHS-15 limited its utility in this setting. The Likert-type response categories of the RHS-15 proved problematic in this low-literacy population. Combined with the relative superiority and greater ease of administration of the SCID, the RHS-15 is not recommended as the tool of choice for detecting perinatal depression in this setting.