Overall Maternal Morbidity during Pregnancy Identified with the WHO-WOICE Instrument

Unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety during the COVID-19 pandemic

OBJECTIVE/BACKGROUND

Unmet needs in perinatal mental healthcare are an important public health issue particularly in the context of a stressful life event such as the COVID-19 pandemic but data on the extent of this problem are needed.

AIM

The aim of this study is to determine the (1) proportion of women with clinically significant symptoms of perinatal depression, anxiety or comorbid symptoms of depression and anxiety, receiving mental healthcare overall and by country and (2) factors associated with receiving mental healthcare.

METHOD

Women in the perinatal period (pregnancy or up to 6 months postpartum) participating in the Riseup-PPD-COVID-19 cross-sectional study, reported on sociodemographic, social support health-related factors, and COVID-19 related factors, and on symptoms of depression (Edinburgh Postnatal Depression Scale [EPDS]) and anxiety (Generalised Anxiety Disorder [GAD-7]) using self-report questionnaires. Clinically significant symptoms were defined as EPDS ≥ 13 for depression and GAD-7 ≥ 10 for anxiety. Mental healthcare was defined as self-reported current mental health treatment.

RESULTS

Of the 11 809 participants from 12 countries included in the analysis, 4 379 (37.1%) reported clinically significant symptoms of depression (n = 1 228; 10.4%; EPDS ≥ 13 and GAD-7 ⟨ 10), anxiety (n = 848; 7.2%; GAD-7 ≥ 10 and EPDS ⟨ 13) or comorbid symptoms of depression and anxiety (n = 2 303; 19.5%; EPDS ≥ 13 and GAD-7 ≥ 10). Most women with clinically significant symptoms of depression, anxiety, or comorbid symptoms of depression and anxiety were not receiving mental healthcare (89.0%). Variation in the proportion of women with clinically significant symptoms of depression and/or anxiety reporting mental healthcare was high (4.7% in Turkey to 21.6% in Brazil). Women in the postpartum (vs. pregnancy) were less likely (OR 0.72; 95% CI 0.59-0.88), whereas women with previous mental health problems (vs. no previous mental health problems) (OR 5.56; 95% CI 4.41-7.01), were more likely to receive mental healthcare.

CONCLUSION

There are high unmet needs in mental healthcare for women with clinically significant symptoms of perinatal depression and/or anxiety across countries during the COVID-19 pandemic. Studies beyond the COVID-19 pandemic and covering the whole range of mental health problems in the perinatal period are warranted to understand the gaps in perinatal mental healthcare.

Prevalence of Perinatal Anxiety and Related Disorders in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Importance

Anxiety disorders are associated with poor maternal and neonatal outcomes. Women in low- and middle-income countries (LMICs) are thought to be disproportionally burdened by these disorders, yet their prevalence is unclear.

Objective

To conduct a systematic review and meta-analysis to determine the prevalence of 6 anxiety and related disorders among perinatal women in LMICs.

Data Sources

Embase, MEDLINE, PsycINFO, Cochrane Library, CINAHL, and Web of Science databases were searched from inception until September 7, 2023.

Study Selection

Studies conducted in World Bank-defined LMICs and reporting prevalence of generalized anxiety disorder, obsessive-compulsive disorder, social anxiety disorder, posttraumatic stress disorder, panic disorder, or adjustment disorder during the perinatal period (conception to 12 months post partum) using a validated method were included.

Data Extraction and Synthesis

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline. Study eligibility, extracted data, and risk of bias of included studies were assessed by 2 independent reviewers. Random-effects meta-analysis was used to estimate pooled point prevalence. Subgroup analyses were performed by specific anxiety disorder.

Main Outcomes and Measures

Main outcomes were prevalence estimates of each anxiety disorder, measured as percentage point estimates and corresponding 95% CIs.

Results

At total of 10 617 studies were identified, 203 of which met the inclusion criteria and reported the outcomes of 212 318 women from 33 LMICs. Generalized anxiety disorder was the most reported (184 studies [90.6%]) and most prevalent disorder at 22.2% (95% CI, 19.4%-25.0%; n = 173 553). Posttraumatic stress disorder was the second most prevalent (8.3%; 95% CI, 5.0%-12.2%; 33 studies; n = 22 452). Adjustment disorder was least prevalent (2.9%; 95% CI, 0.0%-14.1%; 2 studies; n = 475). The prevalence of generalized anxiety varied by country income status, with the highest prevalence among lower-middle-income countries (27.6%; 95% CI, 21.6%-33.9%; 59 studies; n = 25 109), followed by low-income (24.0%; 95% CI, 15.3%-33.8%; 11 studies; n = 4961) and upper-middle-income (19.1%; 95% CI, 16.0%-22.4%; 110 studies; n = 138 496) countries.

Conclusions and Relevance

These findings suggest that 1 in 5 women living in LMICs experience anxiety disorders during pregnancy and post partum. Targeted action is needed to reduce this high burden.

Impacts of childbirth on anxiety, disability, and depression: Results from a Brazilian cohort

Conditions such as violence, drug abuse, sexual satisfaction, anxiety, depression, and disability interfere with a healthy pregnancy and can also account for maternal morbidity. The instrument WOICE was built by WHO to measure it. We applied WOICE in a prospective cohort of 125 pregnant women, using a before-after approach, during the third trimester of pregnancy, and after 42 until 90 days of childbirth. 60% had anxiety during pregnancy, decreasing to 48.8% after delivery (p = 0.07), and depression scores decreased from 7.56 to 5.80 (p = 0.014). Disability affected 62.4% and 56, respectively. 9.6% used drugs during pregnancy, reducing to 4.0% after delivery (RR 0.69, IC 0.49 - 0.69).

Measurement of maternal morbidity during postpartum with the WHO-WOICE tools in Morocco

BACKGROUND

Maternal morbidity refers to any health problems or complications experienced by a woman during pregnancy, childbirth, or the postpartum period. Many studies have documented the, mostly negative, effects of maternal ill-health on functioning. Although, measurement of maternel morbidity remains underdeveloped. We aimed to evaluate the prevalence of non-severe maternal morbidities (including overall health, domestic and sexual violence, functionality, and mental health) in women during postpartum care and further analyze factors associated with compromised mental functioning and clinical health by administration of the WHO's WOICE 2.0 instrument.

METHODS

A cross-sectional study was conducted at 10 Health centers in Marrakech, Morocco with WOICE questionnaire included three sections: the first with maternal and obstetric history, sociodemographic data, risk and environment factors, violence and sexual health; the second considers functionality and disability, general symptoms and mental health; and the third includes data on physical and laboratory tests. This paper presents descriptive data on the distribution of functioning status among postpartum women.

RESULTS

A total of 253 women averaging 30 years of age participated. For self-reported health status of women, more than 40% reported good health, and just 9.09% of women had a health condition reported by the attending physician. Among postpartum women with clinical diagnoses, 16.34% had direct (obstetric) conditions and 15.56% indirect (medical) problems. When screening for factors in the expanded morbidity definition, about 20.95% reported exposure to violence. Anxiety was identified in 29.24% of cases, and depression in 17.78%. Looking into gestational results, just 14.6% delivered by cesarean section and 15.02% had preterm birth. We found also that 97% reported "good baby health" in the postpartum evaluation, with 92% of exclusive breastfeeding.

CONCLUSION

Considering these results, improving the quality of care for women requires a multi-faceted approach, including increased research, better access to care, and improved education and resources for women and healthcare providers.

Rates of depressive and anxiety symptoms in the perinatal period during the COVID-19 pandemic: Comparisons between countries and with pre-pandemic data

BACKGROUND

The COVID-19 pandemic was a significant threat to perinatal mental health. This study examined differences in clinically significant depression, anxiety, and co-morbid symptoms among pregnant and postpartum women across several countries and compared prevalence of perinatal depression and anxiety before and during the pandemic in each participating country.

METHODS

Participants were 3326 pregnant and 3939 postpartum women (up to six months postpartum) living in Brazil, Chile, Cyprus, Greece, Israel, Portugal, Spain, Turkey, and the United Kingdom. An online survey was completed between June 7th and October 31st 2020, and included the Edinburgh Postnatal Depression Scale (EPDS) and the Generalized Anxiety Disorder Screener (GAD-7). The pre-pandemic studies were identified through literature review.

RESULTS

Prevalence of clinically significant depression (EPDS≥13), anxiety (GAD-7 ≥ 10), and co-morbid (EPDS≥13 and GAD-7 ≥ 10) symptoms was 26.7 %, 20 % and 15.2 %, in pregnant women, and 32.7 %, 26.6 % and 20.3 %, in postpartum women, respectively. Significant between-country differences were found in all mental health indicators in both perinatal periods. Higher levels of symptoms were observed during (versus before) the pandemic, especially among postpartum women.

LIMITATIONS

Participants were mostly highly educated and cohabiting with a partner. The online nature of the survey may have limited the participation of women from vulnerable socio-economically backgrounds.

CONCLUSIONS

Our findings expand previous literature on the negative impact of the COVID-19 pandemic on perinatal mental health, by highlighting that this may be influenced by country of residence. Mental health care policies and interventions should consider the unique needs of perinatal women in different parts of the world.

Giving women WOICE postpartum: prevalence of maternal morbidity in high-risk pregnancies using the WHO-WOICE instrument

Background

There are no accurate estimates of the prevalence of non-severe maternal morbidities. Given the lack of instruments to fully assess these morbidities, the World Health Organization (WHO) developed an instrument called WOICE. We aimed to evaluate the prevalence of non-severe maternal morbidities in puerperal women and factors associated to impaired clinical, social and mental health conditions.

Method

A cross-sectional study with postpartum women at a high-risk outpatient clinic in southeast Brazil, from November 2017 to December 2018. The WOICE questionnaire included three sections: the first with maternal and obstetric history, sociodemographic data, risk and environment factors, violence and sexual health; the second considers functionality and disability, general symptoms and mental health; and the third includes data on physical and laboratory tests. Data collection was supported by Tablets with REDCAP software. Initially, a descriptive analysis was performed, with general prevalence of all variables contained in the WOICE, including scales on anxiety and depression (GAD-7 and PHQ-9- impaired if ≥10), functionality (WHODAS- high disability scores when ≥37.4) and data on violence and substance use. Subsequently, an evaluation of cases with positive findings was performed, with a Poisson regression to investigate factors associated to impaired non-clinical and clinical conditions.

Results

Five hundred seventeen women were included, majority (54.3%) multiparous, between 20 and 34 years (65.4%) and with a partner (75,6%). Over a quarter had (26.2%) preterm birth. Around a third (30.2%) reported health problems informed by the physician, although more than 80% considered having good or very good health. About 10% reported any substance use and 5.9% reported exposure to violence. Anxiety was identified in 19.8% of cases, depression in 36.9% and impaired functioning in 4.4% of women. Poisson regression identified that poor overall health rating was associated to increased anxiety/depression and impaired functioning. Having a partner reduced perception of women on the presence of clinical morbidities.

Conclusion

During postpartum care of a high-risk population, over one third of the considered women presented anxiety and depression; 10% reported substance use and around 6% exposure to violence. These aspects of women’s health need further evaluation and specific interventions to improve quality of care.