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Park S, Leon C, Zaidi A, Malik A, Rahman A, Surkan PJ. Family concerns and relationship problems in anxious pregnant women and their associations with postnatal functional disability in Pakistan. J Psychosom Res 2024; 181:111674. [PMID: 38663268 DOI: 10.1016/j.jpsychores.2024.111674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 03/25/2024] [Accepted: 04/13/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVE Expanding on existing research suggesting that strategies to reduce prenatal anxiety can decrease functional disability (e.g., difficulties in performing everyday activities and social participation), we examined if this effect varied by type of anxiety-producing problem (i.e., having family concerns and relationship problems versus other problems) reported during pregnancy. Further, we explored if perceived social support mediated this relationship. METHODS We used longitudinal data on 310 anxious Pakistani women who received any psychosocial intervention sessions as part of a program that was based on Cognitive Behavioral Therapy. The Psychological Outcome Profiles (PSYCHLOPS) was used to assess whether women had 'family concerns and relationship problems' or 'other problems.' The WHO Disability Assessment Schedule 2.0 assessed functional disability at six-weeks after delivery. Lack of support was measured using a 12-item Multi-dimensional Scale of Perceived Social Support. We employed linear regression to examine associations between types of problems reported during pregnancy and postnatal functional disability. Causal mediation analysis was used to assess whether postnatal social support mediated this relationship. RESULTS Of anxious pregnant women, 34% reported family concerns or relationship problems as primary problems in pregnancy. They were more likely to report higher functional disability at six-weeks after delivery than women who reported other problems (adjusted B = 2.40, 95% CI: 0.83-3.97). Lack of overall social support (Estimateindirect = 0.69, 95% CI: 0.04-1.38) and lack of support from friends (Estimateindirect = 0.62, 95% CI: 0.01-1.29) significantly mediated the relationship. CONCLUSIONS Findings suggest that complementing pre- and post-natal care with support programs and services that address family concerns and relationship problems, as well as enhancing social support is important to functional disability.
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Affiliation(s)
- Soim Park
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Carlued Leon
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Ahmed Zaidi
- Human Development Research Foundation, Islamabad, Pakistan.
| | - Abid Malik
- Department of Public Mental Health, Health Services Academy, Chak Shahzad, Islamabad, Pakistan.
| | - Atif Rahman
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, United Kingdom.
| | - Pamela J Surkan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Wadani ZH. Empowering Non-clinical Health Care Providers: Innovating an Ultra-Short Maternal Mental Health Screening Tool. Asia Pac J Public Health 2024; 36:295-296. [PMID: 38353462 DOI: 10.1177/10105395241230758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Affiliation(s)
- Zahid Hyder Wadani
- Department of Obstetrics and Gynaecology, The Aga Khan University, Karachi, Pakistan
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Izuka EO, Iyidobu TO, Obiora-Izuka CE, Enebe JT, Onyeabochukwu AD, Nkwo PO, Nwagha UI. Evaluation of anxiety and depression among pregnant women in Enugu, Nigeria. Niger J Clin Pract 2023; 26:1368-1376. [PMID: 37794552 DOI: 10.4103/njcp.njcp_196_23] [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] [Indexed: 10/06/2023]
Abstract
Background Maternal depression and anxiety during pregnancy are public health concerns. They are commonly reported among pregnant women from all over the world. Maternal mental health has not been prioritized, especially in low- and middle-income countries. Aim To evaluate depression and anxiety among pregnant women who receive antenatal care in four randomly selected hospitals in Enugu, Nigeria. Materials and Methods A multicenter questionnaire-based cross-sectional survey of 434 pregnant women was conducted at four selected health institutions offering antenatal services in Enugu, Enugu State. The prevalence of anxiety and depression was assessed using the hospital anxiety and depression scale (HADS). Factors associated with anxiety and depression were determined using logistic regression. P <0.05 was taken as significant. Results The mean age of study participants was 30.09 ± 5.12 years. The proportion of participants with depressive symptoms and borderline depressive symptoms was 9.7% and 11.1%, respectively. The proportion of participants with anxiety symptoms and borderline anxiety symptoms was 10.1% and 15.7%, respectively. Husband's employment status (P = 0.033, odds ratios (OR) =0.354, 95% confidence intervals (CI) =0.137-0.918) and gestational age (P = 0.042, OR = 2.066, 95% CI = 1.028-4.151) were the only factors associated with depressive symptoms, while only educational level (P = 0.001, OR = 3.552, 95% CI = 1.674-7.537) and husband's employment status (P = 0.013, OR = 0.295, 95% CI = 0.113-0.772) were the only factors associated with anxiety symptoms. Conclusions Anxiety and depressive symptoms are relatively common in antenatal women in Enugu. The factors associated with depressive and anxiety symptoms were the respondent's educational level, gestational age, and the employment status of the husband.
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Affiliation(s)
- E O Izuka
- Departments of Obstetrics and Gynaecology; Palms Medical Consultants, Awkunanaw, Enugu State, Nigeria
| | - T O Iyidobu
- Psychiatry, College of Medicine, University of Nigeria, Nigeria
| | - C E Obiora-Izuka
- Department of Paediatrics, Enugu State University of Science and Technology, Parklane, Nigeria
| | - J T Enebe
- Department of Obstetrics and Gynaecology, Enugu State University of Science and Technology, Parklane, Nigeria
| | - A D Onyeabochukwu
- Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku Ozalla, Nigeria
| | - P O Nkwo
- Departments of Obstetrics and Gynaecology, Awkunanaw, Enugu State, Nigeria
| | - U I Nwagha
- Departments of Obstetrics and Gynaecology, Awkunanaw, Enugu State, Nigeria
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Kurapov A, Danyliuk I, Loboda A, Kalaitzaki A, Kowatsch T, Klimash T, Predko V. Six months into the war: a first-wave study of stress, anxiety, and depression among in Ukraine. Front Psychiatry 2023; 14:1190465. [PMID: 37234208 PMCID: PMC10206008 DOI: 10.3389/fpsyt.2023.1190465] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 04/21/2023] [Indexed: 05/27/2023] Open
Abstract
Objective This study examines the prevalence and predictors of mental health issues, specifically anxiety, depression, and stress, among Ukrainians during the military conflict with Russia. Method A cross-sectional correlational study was conducted six months after the beginning of the conflict. Sociodemographic factors, traumatic experiences, anxiety, depression, and stress were assessed. The study included 706 participants, both men and women, from different age groups and living in various regions of Ukraine. The data were collected from August till October 2022. Results The study found that a large portion of the Ukrainian population shows increased levels of anxiety, depression, and stress due to the war. Women were found to be more vulnerable to mental health issues than men, and younger people were found to be more resilient. Worsened financial and employment statuses predicted increased anxiety. Ukrainians who fled the conflict to other countries exhibited higher levels of anxiety, depression, and stress. Direct exposure to trauma predicted increased anxiety and depression, while war-related exposure to "other stressful events" predicted increased acute stress levels. Conclusion The findings of this study highlight the importance of addressing the mental health needs of Ukrainians affected by the ongoing conflict. Interventions and support should be tailored to address the specific needs of different groups, particularly women, younger individuals, and those with worsened financial and employment statuses.
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Affiliation(s)
- Anton Kurapov
- Department of Experimental and Applied Psychology, Faculty of Psychology, Taras Shevchenko National University of Kyiv, Kyiv, Ukraine
| | - Ivan Danyliuk
- Department of Experimental and Applied Psychology, Faculty of Psychology, Taras Shevchenko National University of Kyiv, Kyiv, Ukraine
| | - Andrii Loboda
- Institute of Medicine, Sumy State University, Sumy, Ukraine
| | - Argyroula Kalaitzaki
- Department of Social Work, Laboratory of Interdisciplinary Approaches to the Enhancement of Quality of Life, Health Sciences Faculty, Hellenic Mediterranean University, Crete, Greece
| | - Tobias Kowatsch
- Institute for Implementation Science in Health Care, University of Zürich, Zürich, Switzerland
- School of Medicine, University of St. Gallen, St. Gallen, Switzerland
- Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zürich, Zürich, Switzerland
| | - Tamara Klimash
- Department of Experimental and Applied Psychology, Faculty of Psychology, Taras Shevchenko National University of Kyiv, Kyiv, Ukraine
| | - Viktoriia Predko
- Department of General Psychology, Faculty of Psychology, Taras Shevchenko National university of Kyiv, Kyiv, Ukraine
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da Silva Junior CA, Marques DA, Patrone LGA, Biancardi V, Bícego KC, Gargaglioni LH. Intra-uterine diazepam exposure decreases the number of catecholaminergic and serotoninergic neurons of neonate rats. Neurosci Lett 2023; 795:137014. [PMID: 36521643 DOI: 10.1016/j.neulet.2022.137014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022]
Abstract
Benzodiazepines, such as diazepam (DZP), are used to treat anxiety disorders, and are prescribed to pregnant woman for therapeutic purposes. Concerns regarding their consequences on postnatal development rise as they cross the placenta and interact with the embryo. Occurrence of malformation and behavioral syndromes have been reported for different ages, but little is known about their effects on the brain after exposure during intrauterine life. Thus, we sought to evaluate the effects of intrauterine exposure to DZP on the number of brainstem's catecholaminergic and serotonergic neurons, implicated in respiratory control, in male and female rats on postnatal (P) day 12-13, using immunofluorescence labeling for tyrosine-hydroxylase (TH) and serotonin (5-HT). We observed a reduction in the number of catecholaminergic neurons for males and females. Special attention is given to the reduction in the density of neurons in the A6 region, involved in ventilatory responses to CO2. Interestingly, only males showed a reduction in the number of serotonergic neurons, while females were not affected. These findings suggest that in utero exposure to DZP results in deleterious neuroanatomical effects on P12-13 rats and raises a note of concern for women clinicians to make more informed choices about the use of anxiolytic treatments during gestation.
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Affiliation(s)
- Carlos Aparecido da Silva Junior
- Department of Applied Science, William & Mary, Williamsburg, VA, United States; Department of Animal Morphology and Physiology, FCAV - UNESP - São Paulo State University, Jaboticabal, SP, Brazil
| | - Danuzia A Marques
- Department of Pediatrics, Québec Heart and Lung Institute, Université Laval, Québec, QC, Canada
| | - Luís Gustavo A Patrone
- Department of Animal Morphology and Physiology, FCAV - UNESP - São Paulo State University, Jaboticabal, SP, Brazil
| | - Vivian Biancardi
- Department of Physiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Kênia C Bícego
- Department of Animal Morphology and Physiology, FCAV - UNESP - São Paulo State University, Jaboticabal, SP, Brazil
| | - Luciane H Gargaglioni
- Department of Animal Morphology and Physiology, FCAV - UNESP - São Paulo State University, Jaboticabal, SP, Brazil.
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Koc E, Baltaci N, Bal S. Does telecounseling reduce anxiety and depression during pregnancy? A randomized controlled trial. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20221213. [PMID: 37194904 DOI: 10.1590/1806-9282.20221213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE This study aims to examine the effect of telecounseling in reducing the anxiety and depression experienced by pregnant women. METHOD This randomized control trial was conducted on 100 pregnant women (50 in each intervention and control group). The intervention group received telecounseling with regard to the mother and the fetus as needed between 08:00 h and 20:00 h for 6 weeks at home. The control group received only routine care. Anxiety and depression levels were evaluated at the beginning and end of the study using the Hospital Anxiety Depression Scale. RESULTS Anxiety and depression levels were found to be lower in the intervention group than in the control group (p<0.001). In the control group, the anxiety score increased from 5.62 to 7.16, and the depression score increased from 4.92 to 5.76 without any intervention (p<0.001). CONCLUSION This study shows that telecounseling may have an effect on reducing the level of anxiety and depression of pregnant women.
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Affiliation(s)
- Emine Koc
- Ondokuz Mayis University, Faculty of Health Sciences, Department of Midwifery - Samsun, Turkey
| | - Nazlı Baltaci
- Ondokuz Mayıs University, Faculty of Health Sciences, Department of Nursing - Samsun, Turkey
| | - Sümeyye Bal
- Ondokuz Mayis University, Faculty of Health Sciences, Department of Midwifery - Samsun, Turkey
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Bhamani SS, Arthur D, Van Parys AS, Letourneau N, Wagnild G, Premji SS, Asad N, Degomme O. Resilience and prenatal mental health in Pakistan: a qualitative inquiry. BMC Pregnancy Childbirth 2022; 22:839. [PMID: 36376896 PMCID: PMC9664804 DOI: 10.1186/s12884-022-05176-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022] Open
Abstract
Background Women in Pakistan suffer from a high rate of depression. The stress of low-income, illiteracy, exposure to violence and living in a patriarchal society are predisposing vulnerabilities for depression, particularly during and following pregnancy. The resilience of an individual plays a significant role in promoting prenatal mental health, but this has yet to be thoroughly researched. In this article, our objective is to identify the core characteristics of resilience among pregnant women, which will then help us in developing an intervention. Methods The exploratory-descriptive study was conducted over 6 months in five different antenatal hospitals in Sindh, Pakistan. A total of 17 semi-structured interviews were conducted with pregnant women, purposefully selected with heterogeneous characteristics to explore diverse perspectives, while symptoms of depression were quantified by the Edinburgh Postnatal Depression Scale before the interview. Verbatim transcriptions were coded openly and merged into categories and themes. Result A total of six themes emerged from in-depth thematic analysis: 1) purpose of life, 2) dealing with emotions, 3) believing in yourself, 4) optimistic approach, 5) strengthening support and relationship and 6) spirituality and humanity. Women agreed that these characteristics could help them improve their mental health. Conclusion In conclusion, these themes were the core components of pregnant women’s resilience which ultimately could help to promote prenatal mental health. These pave a pathway towards developing culturally and contextually resilience interventions aimed at enhancing mental health of pregnant women which then may improve neonatal and family mental wellbeing.
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da Silva Junior CA, Patrone LGA, Biancardi V, Vilela-Costa HH, Marques DA, Cristina-Silva C, da Costa Silva KS, Bícego KC, Szawka RE, Gargaglioni LH. Sexually dimorphic effects of prenatal diazepam exposure on respiratory control and the monoaminergic system of neonate and young rats. Pflugers Arch 2022; 474:1185-1200. [DOI: 10.1007/s00424-022-02730-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/05/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022]
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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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Insan N, Weke A, Forrest S, Rankin J. Social determinants of antenatal depression and anxiety among women in South Asia: A systematic review & meta-analysis. PLoS One 2022; 17:e0263760. [PMID: 35139136 PMCID: PMC8827460 DOI: 10.1371/journal.pone.0263760] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 01/26/2022] [Indexed: 11/19/2022] Open
Abstract
Background Pregnancy is a time of major psychological changes making pregnant women more susceptible to depression and anxiety. Prevalence is higher among women living in Bangladesh, India and Pakistan, compared to high-income countries, due to poor understanding and lack of mental health integration within antenatal care. Antenatal depression/anxiety is associated with adverse outcomes including postnatal depression, low birth weight and impaired fetal development. Existing systematic reviews provided only limited information on the social determinants of antenatal depression/anxiety in these South Asian countries. Objective This review aimed to identify, synthesise and appraise the evidence on the social determinants associated with antenatal depression and anxiety in women living in Bangladesh, India and Pakistan. Methods We searched five databases (MEDLINE, Embase, PsycINFO, Scopus, Web of Science) and PROSPERO. Observational studies published between 1st January 2000 and 4th January 2021 were included if they were in the English language, used validated tools for measuring depression/anxiety in pregnant women and reported statistical associations or raw numbers. Summary estimates were obtained using random-effects model. Heterogeneity and publication bias was measured using the I2 statistic and Egger’s test, respectively. This review was registered on PROSPERO (reference: CRD42020167903). Results We included 34 studies (with 27,379 women). Meta-analysis of Adjusted Odds Ratios (AOR) found that Intimate partner violence (AOR 2.48, 95% CI 1.41–4.33), unplanned pregnancy (AOR 1.53, 95% CI 1.28–1.83), male gender preference (AOR 3.06, 95% CI 1.40–6.72) and poor relationship with in-laws (AOR 2.69, 95% CI 1.25–5.80) were significantly associated with antenatal depression/anxiety. Conclusion The review identified a complex range of social determinants of antenatal depression and anxiety in Bangladesh, India and Pakistan. Screening tools to identify pregnant women at high risk should be integrated within antenatal care to prevent adverse outcomes. Knowledge of these social determinants will inform the development of such screening tools and interventions.
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Affiliation(s)
- Nafisa Insan
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
- * E-mail:
| | - Anthony Weke
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Simon Forrest
- Department of Sociology, Durham University, Durham, United Kingdom
| | - Judith Rankin
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
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Ishaq R, Shoaib M, Baloch NS, Sadiq A, Raziq A, Huma ZE, Raza S, Batool F, Haider S, Saleem F, Ahmad N, Iqbal Q, Khan AH. Profile and Predictors of Maternal Quality of Life During Physiological Pregnancy: A Cross-Sectional Analysis. Front Public Health 2022; 9:801035. [PMID: 35111720 PMCID: PMC8801871 DOI: 10.3389/fpubh.2021.801035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/15/2021] [Indexed: 12/12/2022] Open
Abstract
Background Quality of Life (QoL) and its determinants are significant in all stages of life, including pregnancy. The physical and emotional changes during pregnancy affect the QoL of pregnant women, affecting both maternal and infant health. Hence, assessing the QoL of pregnant women is gaining interest in literature. We, therefore, aimed to describe the QoL of pregnant women during physiological pregnancy and to identify its associated predictors in women attending a public healthcare institute of Quetta city, Pakistan. Methods A cross-sectional study was conducted at the Obstetrics and Gynecology Department of Sandeman Provincial Hospital Quetta city, Pakistan. The respondents were asked to answer the Urdu (lingua franca of Pakistan) version of the Quality of Life Questionnaire for Physiological Pregnancy. Data were coded and analyzed by SPPS v 21. The Kolmogorov–Smirnov test was used to establish normality of the data and non-parametric tests were used accordingly. Quality of Life was assessed as proposed by the developers. The Chi-square test was used to identify significant associations and linear regression was used to identify the predictors of QoL. For all analyses, p < 0.05 was taken significantly. Results Four hundred and three pregnant women participated in the study with a response rate of 98%. The mean QoL score was 19.85 ± 4.89 indicating very good QoL in the current cohort. The Chi-Square analysis reported a significant association between age, education, occupation, income, marital status, and trimester. Education was reported as a positive predictor for QoL (p = 0.006, β = 2.157). On the other hand, trimester was reported as a negative predictor of QoL (p = 0.013, β = −1.123). Conclusion Improving the QoL among pregnant women requires better identification of their difficulties and guidance. The current study highlighted educational status and trimester as the predictors of QoL in pregnant women. Health care professionals and policymakers should consider the identified factors while designing therapeutic plans and interventions for pregnant women.
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Affiliation(s)
- Rabia Ishaq
- Faculty of Pharmacy & Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Maryam Shoaib
- Department of Gynecology and Obstetrics, Sandeman Provincial Hospital, Quetta, Pakistan
| | | | - Abdul Sadiq
- Department of Biochemistry, Jhalawan Medical College Khuzdar, Khuzdar, Pakistan
| | - Abdul Raziq
- Department of Statistics, University of Baluchistan, Quetta, Pakistan
| | - Zil e Huma
- Department of Zoology, Sardar Bahadur Khan Women's University, Quetta, Pakistan
| | - Shanaz Raza
- Department of Pharmacy, Sardar Bahadur Khan Women's University, Quetta, Pakistan
| | - Fakhra Batool
- Department of Pharmacy, Sardar Bahadur Khan Women's University, Quetta, Pakistan
| | - Sajjad Haider
- Faculty of Pharmacy & Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Fahad Saleem
- Faculty of Pharmacy & Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Nafees Ahmad
- Faculty of Pharmacy & Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Qaiser Iqbal
- Faculty of Pharmacy & Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Amer Hayat Khan
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
- *Correspondence: Amer Hayat Khan
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Mei X, Mei R, Liu Y, Wang X, Chen Q, Lei Y, Ye Z. Associations among fear of childbirth, resilience and psychological distress in pregnant women: A response surface analysis and moderated mediation model. Front Psychiatry 2022; 13:1091042. [PMID: 36590638 PMCID: PMC9797834 DOI: 10.3389/fpsyt.2022.1091042] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Prenatal psychological distress is prevalent during pregnancy. This study aimed to estimate the associations among fear of childbirth, resilience and psychological distress. METHODS A total of 1,060 Chinese pregnant women were enrolled from Be Resilient to Postpartum Depression (ChiCTR2100048465) and the following instruments were administered to them: Childbirth Attitudes Questionnaire, Connor-Davidson Resilience Scale, Perceived Social Support Scale, General Self-Efficacy Scale, Adverse Childhood Experience scale and Hospital Anxiety and Depression Scale. A dominance, a response surface analysis and a moderated mediation analysis were performed. RESULTS In terms of psychological distress, resilience and fear of childbirth could explain 41.6% (0.148/0.356) and 33.1% (0.118/0.356), respectively. Pregnant women with high resilience-low fear of childbirth had significantly lower levels of psychological distress than those with low resilience-high fear of childbirth. The indirect effects of fear of childbirth on psychological distress through resilience was significantly (B = 0.054, 95% CI 0.038 to 0.070). The interactions between fear of childbirth and adverse childhood experiences (β = 0.114, 95% CI -0.002 to 0.231, p = 0.054) and between resilience and adverse childhood experiences (β = -0.118, 95% CI -0.222 to -0.012, p < 0.05) were significant. CONCLUSION Resilience, fear of childbirth and adverse childhood experiences may be three important factors to psychological distress in Chinese pregnant women.
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Affiliation(s)
- Xiaoxiao Mei
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Ranran Mei
- Affiliated Cancer Hospital and Institute of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yuling Liu
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Xinqin Wang
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Qianwen Chen
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Youjin Lei
- The First Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Zengjie Ye
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
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13
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Atif M, Halaki M, Raynes-Greenow C, Chow CM. Perinatal depression in Pakistan: A systematic review and meta-analysis. Birth 2021; 48:149-163. [PMID: 33580505 DOI: 10.1111/birt.12535] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/11/2021] [Accepted: 01/16/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To estimate the prevalence and associated risk factors of perinatal depression in Pakistan. METHODS We conducted a systematic search of Medline, PsycINFO, CINAHL, EMBASE, and Global health, up through May 31, 2019. Studies reporting on the prevalence of perinatal depression in Pakistan with or without associated risks factors were included. RESULTS Forty-three studies reporting data from 17 544 women met the eligibility criteria and were included. Overall, the pooled prevalence of antenatal depression was 37% (95% CI: 30-44), while that of postnatal depression was 30% (95% CI: 25-36). The prevalence of perinatal depression in women residing in urban areas and those living in rural settings was not significantly different. The most frequently reported risk factors for antenatal depression were intimate partner violence and poor relationship with spouse, and that reported for postnatal depression was low-income level. An unintended pregnancy was significantly associated with perinatal depression in Pakistan. CONCLUSIONS We identified variability in prevalence rate of perinatal depression in Pakistan. It is difficult to gauge the true magnitude of this problem potentially due to differing risk factors between the antenatal and postnatal periods and the lack of uniformity of data collection protocols and procedures. The high prevalence rates of 30%-37% compared to global estimates suggest policy makers and stakeholders should direct additional resources toward improving perinatal mental health in Pakistan.
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Affiliation(s)
- Maria Atif
- Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark Halaki
- Discipline of Exercise and Sport Science, Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | - Camille Raynes-Greenow
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Chin-Moi Chow
- Discipline of Exercise and Sport Science, Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
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Prevalence and Correlates of Prenatal Depression, Anxiety and Suicidal Behaviours in the Volta Region of Ghana. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115857. [PMID: 34072525 PMCID: PMC8198850 DOI: 10.3390/ijerph18115857] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/11/2021] [Accepted: 05/26/2021] [Indexed: 12/28/2022]
Abstract
Pregnancy is associated with several physical and psychosocial challenges that influence women's health and wellbeing. However, prenatal mental health has received little attention. Therefore, this study examined the prevalence and correlates of prenatal depression, anxiety and current suicidal behaviors among pregnant women in the Volta Region of Ghana. Two hundred and fourteen (n = 214) pregnant women recruited from two hospitals responded to the hospital depression and anxiety scale (HADS), the insomnia severity index, and a set of psycho-behavioral, socioenvironmental and demographic characteristic questions. Chi-squared, bivariate and multivariate logistic regression were used for data analysis. Prevalence of prenatal depression, anxiety and current suicidal behaviors was 50.5%, 35.5% and 3.3%, respectively. After controlling for other variables, average monthly income, insomnia, non-nutritious food consumption (pica), and body image satisfaction were significantly associated with depression. Marital status, insomnia, lifetime suicidal behavior and partner support were significantly associated with anxiety. Current partner abuse was the only factor significantly associated with current suicidal behavior. The high prevalence rates of anxiety and depression among pregnant women and intimate partner violence remain important maternal health issues in the region. Therefore, brief mental health screening and counseling services should be integrated into prenatal healthcare services.
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Parreira BDM, Goulart BF, Ruiz MT, Monteiro JCDS, Gomes-Sponholz FA. Sintomas de ansiedade entre mulheres rurais e fatores associados. ESCOLA ANNA NERY 2021. [DOI: 10.1590/2177-9465-ean-2020-0415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Objetivos identificar os sintomas de ansiedade em mulheres rurais e a influência de variáveis sociodemográficas, econômicas, comportamentais e de saúde reprodutiva sobre os sintomas de ansiedade. Método estudo observacional e transversal. Participaram 280 mulheres residentes na área rural. Foi utilizado o inventário de ansiedade Traço-Estado. Na análise bivariada, foram usados o teste t-Student e a correlação de Pearson. Para a análise multivariada, foi realizada a regressão linear múltipla. Resultados os escores médios das mulheres foram de 38,3 e 41,4 pontos na ansiedade-estado e ansiedade-traço respectivamente. As mulheres que referiram convivência “ruim” com o companheiro apresentaram maiores escores de sintomas de ansiedade-estado e ansiedade-traço. A variável número de filhos foi preditora dos escores dos sintomas de ansiedade-estado e ansiedade-traço e a variável idade, preditora do escore dos sintomas de ansiedade-traço. Conclusão os resultados evidenciaram a influência de diferentes fatores com os sintomas de ansiedade entre as mulheres rurais. A identificação dos sintomas e os fatores associados, por parte da equipe de saúde, pode contribuir para ações específicas e encaminhamentos adequados.
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Michael J, Iqbal Q, Haider S, Khalid A, Haque N, Ishaq R, Saleem F, Hassali MA, Bashaar M. Knowledge and practice of adolescent females about menstruation and menstruation hygiene visiting a public healthcare institute of Quetta, Pakistan. BMC WOMENS HEALTH 2020; 20:4. [PMID: 31906921 PMCID: PMC6945726 DOI: 10.1186/s12905-019-0874-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 12/27/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND The current study is aimed to assess menstruation-related knowledge and practices of adolescent females visiting a public health care institute of Quetta city, Pakistan. METHODS A questionnaire-based cross-sectional survey was conducted. Nine hundred and twenty three female adolescents attending general out-patient departments of Mohtarma Shaheed Benazir Bhutto Hospital Quetta, Balochistan, was approached for data collection. Based on the objectives of the study, descriptive analysis was conducted and SPSS v. 21.0 was used for the data analysis. RESULTS Demographic characteristics revealed that the mean age of the respondents was 15 years. Mothers' (67%) were the main source of menstruation-related information. Majority (77.7%) of our respondents never had a class or session regarding menstruation-related education in their schools. About (44%) knew that menstruation is a physiological phenomenon while 60.2% knew that menstrual blood comes from the vagina. Nearly 40% of our study respondents missed their schools because of menarche. The use of absorbent material was frequent (90%) among the adolescent females and (68.7%) used commercially available sanitary napkins/pads. Although majority of the respondents (58.2%) were not taking baths during menstruation, 80.5% do cleaned their genitalia with water during menstruation. CONCLUSION Female adolescents of our study had certain misconception regarding menstruation because of poor access to health-related education. Education can be provided at healthcare facilities, residential area as well as religious centers. Adolescent reproductive health should be included in the school curriculum; this will influence general reproductive health of females.
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Affiliation(s)
- Judy Michael
- Faculty of Pharmacy & Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Qaiser Iqbal
- Faculty of Pharmacy & Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Sajjad Haider
- Faculty of Pharmacy & Health Sciences, University of Balochistan, Quetta, Pakistan
| | | | - Naheed Haque
- Faculty of Pharmacy & Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Rabia Ishaq
- Faculty of Pharmacy & Health Sciences, University of Balochistan, Quetta, Pakistan
| | - Fahad Saleem
- Faculty of Pharmacy & Health Sciences, University of Balochistan, Quetta, Pakistan
| | | | - Mohammad Bashaar
- SMART Afghan International Trainings & Consultancy, Kabul, Afghanistan.
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Magnitude of Antenatal Depression and Associated Factors among Pregnant Women in West Badewacho Woreda, Hadiyya Zone, South Ethiopia: Community Based Cross Sectional Study. DEPRESSION RESEARCH AND TREATMENT 2020; 2020:2950536. [PMID: 32411456 PMCID: PMC7212330 DOI: 10.1155/2020/2950536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/07/2019] [Accepted: 11/15/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Antenatal depression is prevalent and serious problems that is associated with psychosocial factors, obstetric history, and history of psychiatric illness. Evidence on prevalence and factors associated with antenatal depression at community level is limited in Ethiopia. The aim of this study was assessing the prevalence of antenatal depression and associated factors among pregnant women in West Badewacho Woreda, Hadiyya Zone, South Ethiopia, 2018. METHODS A community based cross sectional study was conducted from March 15 to April 12, 2018. To draw a total sample size of 541 pregnant women, multistage sampling technique was used. Pretested semi-structured questionnaire and standardized scale was used to collect data from each study subject. Data were entered and cleaned using Epi-Data version 3.1 and exported to SPSS version 23 for analysis. Bivariate analysis was carried out to see crude association between each independent variable and outcome variable. Odds ratios at 95%CI were computed to measure the strength of the association between the outcome and the independent variables. P-value < 0.05 was considered as statistically significant in multivariate analysis. RESULTS The prevalence of antenatal depression in the study population was 23.3% (CI: 19.8-26.8). Factors significantly associated with antenatal depression were marital status other than married (single, widowed, divorced) [AOR: (2.807; 95%CI: (1.268, 6.227); p-value = 0.042], history of previous depression [AOR: 3.414; 95%CI: (1.154, 12.999); p-value = 0.001] family history of mental illness [AOR: 3.874; 95%CI: (1.653, 7.052); p-value = 0.028], recent violence from intimate partner [AOR: 3.223; 95%CI: (1.359, 7.643); p-value = 0.008], unsatisfactory marital relation [AOR: 7.568; 95%CI: (3.943, 14.523); p-value < 0.001], lack of adequate social support [AOR: 5.491; 95%CI: (2.086, 14.451); p-value < 0.001] and unplanned current pregnancy [AOR: 2.013; 95%CI: (1.025, 3.953); p-value = 0.042]. CONCLUSION The prevalence of antenatal depression in west Badewacho woreda was high and it is associated with marital status, unplanned current pregnancy, history of previous depression, family history of mental illness, recent violence from intimate partner, poor marital satisfaction level, and poor social support. Improving maternal and child health services and introducing screening for depression as part of routine antenatal assessment to curb antenatal depression should get due attention.
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Matsumoto K, Sato K, Hamatani S, Shirayama Y, Shimizu E. Cognitive behavioral therapy for postpartum panic disorder: a case series. BMC Psychol 2019; 7:53. [PMID: 31439043 PMCID: PMC6704562 DOI: 10.1186/s40359-019-0330-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/25/2019] [Indexed: 11/10/2022] Open
Abstract
Background Clinical anxiety is common during the perinatal period, and anxiety symptoms often persist after childbirth. Ten to 30 % of perinatal women are diagnosed with panic disorder (PD)—far more than the 1.5–3% rate among the general population. Although cognitive behavioral therapy (CBT) has been determined to be an effective treatment for PD, few studies have been conducted on CBT effectiveness in treating postpartum PD and, to the best of the knowledge of the present authors, no research has been conducted on postpartum PD among Japanese women. In this manuscript, we report on our administration of CBT to three postpartum patients with PD, detailing the improvement in their symptoms. Case presentation All patients in this study were married, in their thirties, and diagnosed using the Mini-International Neuropsychiatric Interview as having PD with agoraphobia. The Panic Disorder Severity Scale (PDSS) was used to evaluate patients’ panic symptoms and their severity. All patients received a total of 16 weekly 50-min sessions of CBT, and all completed the treatment. All patients were exceedingly preoccupied with the perception that a “mother must protect her child,” which reinforced the fear that “the continuation of their perinatal symptoms would prevent them from rearing their children”. After treatment, all participants’ panic symptoms were found to have decreased according to the PDSS, and two no longer met clinical criteria: Chihiro’s score changed from 13 to 3, Beth’s PDSS score at baseline from 22 to 6, and Tammy’s score changed from 7 to 1. Conclusions CBT provides a therapeutic effect and is a feasible method for treating postpartum PD. It is important that therapists prescribe tasks that patients can perform collaboratively with their children. Electronic supplementary material The online version of this article (10.1186/s40359-019-0330-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kazuki Matsumoto
- Research Center for Child mental Development, Chiba University, Chiba, Japan. .,Department of Psychiatry, Teikyo University Chiba Medical Center, 3426-3, Anegasaki, Ichihara-shi, Chiba, Japan.
| | - Koichi Sato
- Department of Psychiatry, Teikyo University Chiba Medical Center, 3426-3, Anegasaki, Ichihara-shi, Chiba, Japan
| | - Sayo Hamatani
- Research Center for Child mental Development, Chiba University, Chiba, Japan.,Department of Psychiatry, Teikyo University Chiba Medical Center, 3426-3, Anegasaki, Ichihara-shi, Chiba, Japan.,Research Fellow of japan Society for the Promotion of Science, Chiba, Japan
| | - Yukihiko Shirayama
- Department of Psychiatry, Teikyo University Chiba Medical Center, 3426-3, Anegasaki, Ichihara-shi, Chiba, Japan
| | - Eiji Shimizu
- Research Center for Child mental Development, Chiba University, Chiba, Japan.,Department of Cogntiive Behavioral Physiology, Guraduate School of Medicine, Chiba University, Chiba, Japan
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Ma X, Wang Y, Hu H, Tao XG, Zhang Y, Shi H. The impact of resilience on prenatal anxiety and depression among pregnant women in Shanghai. J Affect Disord 2019; 250:57-64. [PMID: 30831542 DOI: 10.1016/j.jad.2019.02.058] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/12/2019] [Accepted: 02/25/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND Prenatal anxiety/depression has been a major public health problem globally with higher prevalence in developing countries, which leads to negative health outcomes for both mothers and children. Maternal stress varies over the course of pregnancy and the stress occurring in early pregnancy is the most critical. However, few studies have focused on the impact of resilience to stress on mental health of pregnant women. AIMS To explore the effect of resilience to stress on prenatal anxiety/depression in pregnant women. METHODS 2813 participants were recruited from Shanghai Maternal-Child Pairs Cohort (Shanghai MCPC) in this study. The Life Event Scale for Pregnancy Women (LESPW) was used to assess stress at 12-16 weeks of pregnancy and at 32-36 weeks of pregnancy, respectively. Resilience was assessed by the revised Resilience Scale for Adults (RSA) at 12-16 weeks of pregnancy. The prenatal anxiety and depression were assessed at 32-26 weeks of pregnancy by Self-Rating Anxiety Scale (SAS) and the Center for Epidemiological Survey, Depression Scale (CES-D), respectively. Hierarchical linear regression analyses were conducted to explore the direct effect of stress and resilience on prenatal anxiety and depression. The indirect effects of mediation were analyzed by structural equation models, and the indirect effect of modification was examined by stratification analysis. RESULTS There were 11.1% and 10.3% of pregnant women in Shanghai MCPC indicating anxiety and depressive mood, respectively. The stress caused by both subjective and objective events at 32-36 weeks of pregnancy is less than that at 12-16weeks of pregnancy. We found that resilience was a protective factor for maternal mental health and meanwhile it was both an effect modifier and a mediator to the association between stress and prenatal anxiety/depression, with the mediating effect ratio of 15.1% and 23.8%, respectively. LIMITATIONS The existence of recall bias, missing data, and restricted residential areas of the participants may limit the generalizability of the study. The measurements of resilience, prenatal anxiety, and depression were not designed specifically for pregnant women, so that they might have missed some important indications of mental issues related to pregnant women only. CONCLUSIONS Resilience could be a direct and indirect protective factor for prenatal anxiety and depression caused by pregnancy stress.
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Affiliation(s)
- Xuemei Ma
- Department of Maternal, Child and Adolescent Health, School of Public Health, Fudan University, Shanghai, China
| | - Ying Wang
- Shanghai Songjiang Maternal Child Health Hospital, Shanghai, China
| | - Hua Hu
- Shanghai Pudong Hospital/ Fudan University Pudong Medical Center, Shanghai, China
| | - Xuguang Grant Tao
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Yunhui Zhang
- Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China
| | - Huijing Shi
- Department of Maternal, Child and Adolescent Health, School of Public Health, Fudan University, Shanghai, China.
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