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, 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
BACKGROUND
 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 Contd..
 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
AIM
To establish the separate and combined
contributions of healthcare use and maternal health
to pregnancy outcomes in rural Pakistan
OBJECTIVES
 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
METHODS
 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 Contd..
 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
RESULTS
 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)
REPRODUCTIVE HEALTH
CHARACTERISTIC
AGE AT MARRIAGE (YEARS) (N = 618)
< 14
15-19
20-24
25-29
> 30
NATIONAL CHARACTERISTICS (%)† ‡
N (%)
624(100)
19(3.1)
225(36.1)
257(41.2)
99(15.9)
18(2.9)
MEAN (SD) 21.0(4.1)
5.7
15.0
20.0
17.8
41.6
23.1
AGE AT FIRST PREGNANCY (YEARS)
MEDIAN
<19
20 – 29
>30
NUMBER OF PREGNANCIES IN PAST
MEAN (SD) 16.4(12.1)
20.0
163(26.1)
418(67.0)
43(6.9)
MEAN (SD) 2.03(2.03)
177(28.4)
315(50.4)
110(17.6)
22(3.5)
0
1–3
4–6
>6
NUMBER OF LIVE BIRTHS IN PAST
0
1–3
4–6
>6
HISTORY OF STILLBIRTH IN PAST
YES
NO
HISTORY OF INTRAUTERINE DEATHS IN PAST
YES
NO
212(34.0)
326(52.2)
75(12.1)
11(1.8)
52(8.3)
572(91.7)
136(21.8)
488(78.2)
21.8
NATAL CARE USE
CHARACTERISTIC
# (%) = 588(100%)
NATIONAL
CHARACTERISTICS
242(40.9)
164(27.7)
164(27.7)
38.8 % SKILLED CARE
PROVIDER PRESENT AT
BIRTH †
342(60.0)
39(6.8)
189(33.2)
64.7% GAVE BIRTH AT
HOME†
BIRTH ATTENDANT (N = 570)
SKILLED (DOCTOR/NURSE, LHV/MIDWIFE)
TRAINED (TRAINED TRADITIONAL BIRTH
ATTENDANT)
UNSKILLED (UNTRAINED DAI, FAMILY MEMBER)
PLACE OF BIRTH (N = 570)
HOME
HEALTH CENTER
HOSPITAL
MODE OF BIRTH
VAGINAL
CAESARIAN SECTION
500(84.3)
88(14.8)
USE OF MEDICAL INSTRUMENT BY ATTENDANT
YES
NO
71(12.0)
517(87.2)
7.3% had a caesarian
section for the last
pregnancy‡
SYMPTOMS OF COMMON MENTAL HEALTH
ASSESSMENT
TOOL
SCORE/CUT OFF
PREVALENCE (%)
MEAN (SD) 10.2(5.8)
EDS
22.1
33.8
41.3
48.6
55.3
>14
>12
>11
>10
>9
MEAN (SD) 8.9(4.6)
SRQ-20
>10
>8
>7
>6
>5
39.1
53.0
58.8
65.5
73.6
DETERMINANTS OF ADVERSE OUTCOME
Variable
Economic Status (National Poverty line)
Above poverty line
Below poverty line
Formal Education
Yes
No
Number of family members
Occupation of husband
Farmer
Government Servant
Laborer
Other
Age at first pregnancy
Antenatal care used
Yes
No
Able to visit care provider independently
Yes
No
Birth Attendant
Trained
Untrained
Duration of pregnancy
Antenatal Total Score SRQ-20
β
aOR
95 % CI
p- value
0.20
1.00
1.22
0.51 – 2.90
0.66
0.13
0.05
1.00
1.14
1.05
0.52 – 2.50
0.98 – 1.13
0.75
0.18
-1.44
0.05
-1.28
0.05 – 1.15
0.41 – 2.66
0.11 – 0.73
0.07
0.92
0.01
-0.10
0.24
1.05
0.28
1.00
0.91
0.83 – 0.99
0.04
-0.39
1.00
0.68
0.24 – 1.94
0.47
0.26
1.00
1.30
0.59 – 2.86
0.52
1.26
-0.10
0.11
1.00
3.54
1.10
1.11
1.54 – 8.15
0.98 – 1.23
1.02 – 1.21
0.00
0.10
0.02
CONCLUSIONS
 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
RECOMMENDATIONS
 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
THANK YOU