and Predictors of Stillbirth and Intrauterine deaths: A cohort study in rural Pakistan Authors: Ahmad AM 1,2* , Khalil M 2 , Minas H 3 , Fisher JRW 1,4 1 Center for Women’s Health and Gender in Society, School of Population Health, University of Melbourne, Australia 2 Development Strategies, Pakistan 3 Center for International Mental Health, School of Population Health, University of Melbourne, Australia 4 The Jean Hailes Research Unit, School of Public Health & Preventive Medicine, Monash University, Australia
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Antenatal Mental Health and Predictors of Stillbirth and Intrauterine deaths: A cohort study in rural Pakistan Authors: Ahmad AM 1,2*, Khalil M 2, Minas.
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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