1. 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 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

2.  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

3.  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..

4. To establish the separate and combined contributions of healthcare use and maternal health to pregnancy outcomes in rural Pakistan AIM

5.  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

6.  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

7.  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..

8.  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..

9.  625 pregnant women enrolled during 2 nd 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

10. CHARACTERISTICN (%) 624(100) NATIONAL CHARACTERISTICS (%) † ‡ AGE AT MARRIAGE (YEARS) (N = 618) < 14 15-19 20-24 25-29 > 30 MEAN (SD) 19(3.1) 225(36.1) 257(41.2) 99(15.9) 18(2.9) 21.0(4.1) 5.7 15.0 20.0 17.8 41.6 23.1 AGE AT FIRST PREGNANCY (YEARS) MEAN (SD) MEDIAN <19 20 – 29 >30 16.4(12.1) 20.0 163(26.1) 418(67.0) 43(6.9) 21.8 NUMBER OF PREGNANCIES IN PAST MEAN (SD) 0 1 – 3 4 – 6 > 6 2.03(2.03) 177(28.4) 315(50.4) 110(17.6) 22(3.5) NUMBER OF LIVE BIRTHS IN PAST 0 1 – 3 4 – 6 > 6 212(34.0) 326(52.2) 75(12.1) 11(1.8) HISTORY OF STILLBIRTH IN PAST YES NO 52(8.3) 572(91.7) HISTORY OF INTRAUTERINE DEATHS IN PAST YES NO 136(21.8) 488(78.2) REPRODUCTIVE HEALTH

11. 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) 38.8 % SKILLED CARE PROVIDER PRESENT AT BIRTH † PLACE OF BIRTH (N = 570) HOME HEALTH CENTER HOSPITAL 342(60.0) 39(6.8) 189(33.2) 64.7% GAVE BIRTH AT HOME † MODE OF BIRTH VAGINAL CAESARIAN SECTION 500(84.3) 88(14.8) 7.3% had a caesarian section for the last pregnancy ‡ USE OF MEDICAL INSTRUMENT BY ATTENDANT YES NO 71(12.0) 517(87.2) NATAL CARE USE

12. ASSESSMENT TOOL SCORE/CUT OFFPREVALENCE (%) 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 >573.6 SYMPTOMS OF COMMON MENTAL HEALTH

13. VariableβaOR95 % CIp- value Economic Status (National Poverty line) Above poverty line Below poverty line 0.20 1.00 1.22 0.51 – 2.90 0.66 Formal Education Yes No 0.13 1.00 1.14 0.52 – 2.50 0.75 Number of family members0.051.050.98 – 1.130.18 Occupation of husband Farmer Government Servant Laborer Other -1.44 0.05 -1.28 0.24 1.05 0.28 1.00 0.05 – 1.15 0.41 – 2.66 0.11 – 0.73 0.07 0.92 0.01 Age at first pregnancy-0.100.910.83 – 0.990.04 Antenatal care used Yes No -0.39 1.00 0.68 0.24 – 1.94 0.47 Able to visit care provider independently Yes No 0.26 1.00 1.30 0.59 – 2.86 0.52 Birth Attendant Trained Untrained 1.26 1.00 3.54 1.54 – 8.15 0.00 Duration of pregnancy-0.101.100.98 – 1.230.10 Antenatal Total Score SRQ-200.111.111.02 – 1.210.02 DETERMINANTS OF ADVERSE OUTCOME

14.  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

15.  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 RECOMMENDATIONS

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