Antenatal Mental Health and Predictors of Stillbirth and Intrauterine deaths: A

cohort study in rural Pakistan

Authors: Ahmad AM1,2*, Khalil M2, Minas H3, Fisher JRW1,4

1 Center for Women’s Health and Gender in Society, School of Population Health, University of Melbourne, Australia2 Development Strategies, Pakistan3 Center for International Mental Health, School of Population Health, University of Melbourne, Australia4 The Jean Hailes Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia

Occurrence of adverse pregnancy outcomes (stillbirths and intrauterine deaths) is considered to be high in the South Asian region

Pakistan carries one of the highest burden of such adverse outcomes

Differential for females as compared to males in relation to various social, cultural and factors related to health seeking and health care utilization

BACKGROUND

Dearth of trained and skilled female healthcare providers who are qualified to handle maternal health and complications

Incidence of common mental health problems (anxiety and depression) may increase among women during the maternal period especially during the postpartum phase

BACKGROUND Contd..

To establish the separate and combined contributions of healthcare use and maternal health to pregnancy

outcomes in rural Pakistan

AIM

To describe the incidence of stillbirths or intrauterine deaths among pregnant women registered in the primary health care system in rural Pakistan

To determine the association of women’s reproductive health, antenatal mental health status, and healthcare use with stillbirth or intrauterine death in rural Pakistan

OBJECTIVES

Study design: Prospective cohort

Study site: Ten BHUs and catchment population in district Attock (Tehsils Fateh Jang, Hassan abdal, Attock)

Study population: Pregnant women of 20-24 weeks gestation who were registered with the primary health care system

METHODS

Sampling Unit: A BHU in these 3 tehsils along with its catchment population

Sampling element: Pregnant woman who was a permanent resident within the catchment population of a selected sampling unit (BHU) and the pregnancy had been registered with either a LHW and/or a Lady Health Visitor (LHV) in the primary health care system.

Sample size: 620 women participants

METHODS Contd..

Data collection tools (Pretested/validated):

Antenatal study specific questionnaire

Data extraction tool – PHC records

Self Reporting Quest-20 and Edinburgh Depression Scale

Data Management:

Data computerization – Epi Info 6.04

Data Analysis – SPSS version 17

METHODS Contd..

625 pregnant women enrolled during 2nd trimester

Follow-up completed – 591 women (95%)

544 (92%) recorded live births

47 (8%) stillbirths/intrauterine deaths

Age – Mean (SD) – 27.1 years (5.7)

Formal education – 56.3%

Household size – Mean (SD) – 6.9 (5.4)

Economic status – 35.9% living below national poverty line (Rs 944.7/month/capita-2007-08)

RESULTS

CHARACTERISTIC N (%)624(100)

NATIONAL CHARACTERISTICS (%)† ‡

AGE AT MARRIAGE (YEARS) (N = 618)< 14 15-19 20-2425-29> 30

MEAN (SD)

 19(3.1)

225(36.1)257(41.2)99(15.9)18(2.9)

21.0(4.1)

 5.7

15.020.017.841.6

23.1AGE AT FIRST PREGNANCY (YEARS)

MEAN (SD)MEDIAN

<1920 – 29>30

 16.4(12.1)20.0

163(26.1)418(67.0)

43(6.9)

  21.8

 

NUMBER OF PREGNANCIES IN PASTMEAN (SD)

01 – 34 – 6> 6

 2.03(2.03)

177(28.4)315(50.4)110(17.6)

22(3.5)

  

 

NUMBER OF LIVE BIRTHS IN PAST01 – 34 – 6> 6

 212(34.0)326(52.2)75(12.1)11(1.8)

 

HISTORY OF STILLBIRTH IN PASTYESNO

 52(8.3)

572(91.7)

  

HISTORY OF INTRAUTERINE DEATHS IN PASTYESNO

 136(21.8)488(78.2)

   

REPRODUCTIVE HEALTH

CHARACTERISTIC # (%) = 588(100%)

NATIONAL CHARACTERISTICS

BIRTH ATTENDANT (N = 570)SKILLED (DOCTOR/NURSE, LHV/MIDWIFE) TRAINED (TRAINED TRADITIONAL BIRTH ATTENDANT) UNSKILLED (UNTRAINED DAI, FAMILY MEMBER)

 242(40.9)164(27.7)164(27.7)

 38.8 % SKILLED CARE PROVIDER

PRESENT AT BIRTH †

PLACE OF BIRTH (N = 570)HOMEHEALTH CENTERHOSPITAL

 342(60.0)

39(6.8)189(33.2)

 64.7% GAVE

BIRTH AT HOME†

MODE OF BIRTH VAGINALCAESARIAN SECTION

 500(84.3)88(14.8)

7.3% had a caesarian section for the last

pregnancy‡

USE OF MEDICAL INSTRUMENT BY ATTENDANTYESNO

 71(12.0)

517(87.2)

 

NATAL CARE USE

ASSESSMENT TOOL

SCORE/CUT OFF PREVALENCE (%)

EDS

MEAN (SD) 10.2(5.8)>14 22.1

>12 33.8

>11 41.3

>10 48.6

>9 55.3

SRQ-20

MEAN (SD) 8.9(4.6)>10 39.1

>8 53.0

>7 58.8

>6 65.5

>5 73.6

SYMPTOMS OF COMMON MENTAL HEALTH

Variable β aOR 95 % CI p- value

Economic Status (National Poverty line)Above poverty lineBelow poverty line

  

0.20

 1.001.22

  

0.51 – 2.90

  

0.66

Formal EducationYesNo

  

0.13

 1.001.14

  

0.52 – 2.50

  

0.75Number of family members 0.05 1.05 0.98 – 1.13 0.18

Occupation of husbandFarmerGovernment ServantLaborerOther

 -1.440.05-1.28

 

 0.241.050.281.00

 0.05 – 1.150.41 – 2.660.11 – 0.73

 0.070.920.01

Age at first pregnancy -0.10 0.91 0.83 – 0.99 0.04Antenatal care usedYesNo

  

-0.39

 1.000.68

  

0.24 – 1.94

  

0.47Able to visit care provider independentlyYesNo

  

0.26

 1.001.30

  

0.59 – 2.86

  

0.52

Birth AttendantTrained Untrained

  

1.26

 1.003.54

  

1.54 – 8.15

  

0.00Duration of pregnancy -0.10 1.10 0.98 – 1.23 0.10

Antenatal Total Score SRQ-20 0.11 1.11 1.02 – 1.21 0.02

DETERMINANTS OF ADVERSE OUTCOME

Adverse pregnancy outcome was predicted by Antenatal symptoms of common mental

health problems, Younger age at first pregnancy Untrained attendant at the time of birth

CONCLUSIONS

Promoting screening for antenatal symptoms of common mental health problems

Raising awareness and promoting skilled attendance at the time of birth

Discouraging young marriages

Is anticipated to help in preventing adverse pregnancy outcomes

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