Exploring Perinatal Global Health: A Reflective Commentary of a Nursing Student’s Experience Abroad in Uganda

Background: The first author undertook the Perinatal Global Health Internship from May to July 2016 in Kampala, Uganda as part of the Canadian Queen Elizabeth II Diamond Jubilee Scholarship Program funded by the Community Foundations of Canada. The internship was carried out in partnership with the University of Calgary, Faculty of Nursing and University of Calgary International, and the Aga Khan University – School of Nursing and Midwifery with technical support from Universities Canada.  Aim: In this paper, we explain the role of nursing in global health, explore the first author’s learning in the area of perinatal health, and invite other nursing students to engage in global health work. Discussion of Stories: A reflective commentary is used to describe the first author’s experience in a government hospital in Kampala as she learned to recognize the implications of perinatal distress, socio-ecological conditions, and resource-poor settings on the health of mothers and premature neonates. In the commentary, the first author also describes the development of an Early Childhood Development resource and the value of partnership in relation to this experience. Reflection: The first author reflects on the benefit of the internship in developing key competencies and attributes for global health work, the need for cultural competency, and barriers to creating effective change to address complex issues. Conclusion: The first author summarizes key learning from the practice, teaching, and research components of the internship. She describes growth, two-way learning, and recommendations for the internship

Perinatal distress in women in low- and middle-income countries: Allostatic load as a framework to examine the effect of perinatal distress on preterm birth and infant health

In low- and middle-income countries (LMIC), determinants of women\u27s and children\u27s health are complex and differential vulnerability may exist to risk factors of perinatal distress and preterm birth. We examined the contribution of maternal perinatal distress on preterm birth and infant health in terms of infant survival and mother-infant interaction. A critical narrative and interpretive literature review was conducted. Peer-reviewed electronic databases (MEDLINE, Embase, Global Health, CINHAL), grey literature, and reference lists were searched, followed by a consultation exercise. The literature was predominantly from high-income countries. We identify determinants of perinatal distress and explicate changes in the hypothalamic-pituitary-adrenal axis, sympathetic, immune and cardiovascular systems, and behavioral responses resulting in pathophysiological effects. We suggest cultural-neutral composite measures of allostatic mediators (i.e., several biomarkers) of maternal perinatal distress as objective indicators of dysregulation in body systems in pregnant women in LMIC. Understanding causal links of maternal perinatal distress to preterm birth in women in LMIC should be a priority. The roles of allostasis and allostatic load are considered within the context of the health of pregnant women and fetuses/newborns in LMIC with emphasis on identifying objective indicators of the level of perinatal distress and protective factors or processes contributing to resilience while facing toxic stress. We propose a prospective study design with multiple measures across pregnancy and postpartum requiring complex statistical modeling. Building research capacity through partnering researchers in high-income countries and LMIC and reflecting on unique ethical challenges will be important to generating new knowledge in LMIC

Preterm Birth a Risk Factor for Postpartum Depression in Pakistani Women

A Pakistani cohort of 170 mothers of full-term infants and 34 mothers of preterm infants were screened at 6 weeks after delivery to compare the rate of PPD, and examine the contribution of parenting stress and mother-infant interaction to PPD among mothers of preterm infants. Mothers completed the Edinburgh postnatal depression scale, and a general questionnaire. Mothers of preterm infants also completed the parental stress scale and parental bonding questionnaire. The rate of PPD was significantly higher with the adjusted odds increasing by 2.68 (95% Confidence Interval 1.16 - 6.17, p = .015) in mothers of preterm in- fants. Significantly more depressed mothers of preterm infants did not receive some level of support from their husbands (p = .014), and had some level of difficulty feeding (p = .03) or identifying the amount to feed their infant (p = .02). A large proportion of mothers reported no support from friends in rearing children

The relationship between Prenatal Stress, Depression, Cortisol and Preterm Birth: A review

Preterm birth is one of the most common adverse pregnancy outcomes. Maternal risk factors such as stress and depression have been associated with preterm birth. Preterm infants are at a higher risk of poor growth and neuro developmental outcomes. The objective of this paper is to examine the relationship between maternal stress, depression, cortisol level, and preterm birth. Preterm birth is one of the most common adverse pregnancy outcomes with a global prevalence of 9.6% and one of the major contributors to infant mortality and morbidity. The association between psychosocial stress and preterm birth, although examined for more than 25 years, has not yet been fully established. A systemic review was conducted in which research studies and review articles from 1970 to 2012, published in English, focusing on human subjects, and addressing the relationship between stress, depression, cortisol and preterm birth were included in this review. The studies examining the relationship between stress, cortisol levels and preterm birth have shown inconsistent findings that may be explained by varied study designs, differences in defining and measuring stress, timing of stress measurement, sample characteristics, and study designs. The relationship between stress, cortisol levels and preterm birth may be multifactorial and complex with premature birth being the final common pathway. A longitudinal cohort study, with a large sample size and multiple measures of stress, depression, and cortisol level, as well as a measure of anxiety and other stress hormone biomarkers may add new knowledge and enhance our understanding about the contribution of psychosocial stress to preterm birth

Antenatal depression is associated with pregnancy-related anxiety, partner relations, and wealth in women in Northern Tanzania: a cross-sectional study

Psychosocial health problems, specifically depression during pregnancy, can have negative impact on birth outcomes, postnatal mental health of the mother, and infant health. Antenatal depression is more prevalent among women in low- and middle-income countries than among women in high-income countries. Risk factors for antenatal depression reported in the literature relate to pregnant women in South Asia. Consequently, this study assessed depression in pregnancy and related psychosocial risk factors among select pregnant women residing in Mwanza region, Northern Tanzania. We analysed data from 397 pregnant women recruited from three antenatal clinics for the period June-August 2013 for this cross-sectional study. Women provided data at one time point during their pregnancy by completing the Edinburgh Postnatal Depression Scale and a structured questionnaire assessing psychosocial, demographic, and behavioural risk factors related to antenatal depression. Multiple logistic regression analysis was performed to determine the relationship between risk factors examined and antenatal depression. Overall, 33.8 % (n = 134) of pregnant women had antenatal depression. Pregnancy-related anxiety was associated with antenatal depression (odds ratio (OR) 1.36, 95 % confidence interval (CI) 1.23 to 1.5). Pregnant women with poor relationship with partner and low/moderate socio-economic status had the highest OR for antenatal depression (82.34, 95 % CI 4.47, 1516.60) after adjusting for other covariates. Pregnant women with poor relationship with partner and high socio-economic status had an OR of 13.48 (95 % CI 1.71, 106.31) for antenatal depression. "Reference" pregnant women were those with very good relationship with partner and high socio-economic status. High proportion of self-reported depression among select pregnant women attending antenatal clinics in Mwanza, Tanzania merit integrating depression assessment into existing antenatal care services. Health care providers need to assess pregnancy-related risk factors (pregnancy-related anxiety), socio-demographic factors (socio-economic status), and interpersonal risk factors (relationship with partner). Future research should appraise effectiveness of interventions that enhance partner relationships in reducing antenatal depression across all wealth distributions

Prenatal Maternal Anxiety in South Asia: A Rapid Best-Fit Framework Synthesis

Background: Most research efforts toward prenatal maternal anxiety has been situated in high-income countries. In contrast, research from low- and middle-income countries has focused on maternal depression and prenatal maternal anxiety in low- and middle-income countries remains poorly understood.Objectives: To examine whether dimensions and attributes of current maternal anxiety assessment tools appropriately capture South Asia women's experiences of perinatal distress during pregnancy.Design: We conducted a rapid review with best fit framework synthesis, as we wished to map study findings to an a priori framework of dimensions measured by prenatal maternal anxiety tools.Data Sources: We searched MEDLINE, PsycINFO, and CINAHL and gray literature in November 2016. Studies were included if published in English, used any study design, and focused on women's experiences of prenatal/antenatal anxiety in South Asia.Review Methods: Study quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool and Critical Appraisal Skills Programme Qualitative Checklist. Study findings were extracted to an a priori framework derived from pregnancy-related anxiety tools.Results: From 4,177 citations, 9 studies with 19,251 women were included. Study findings mapped to the a priori framework apart from body image. A new theme, gender inequality, emerged from the studies and was overtly examined through gender disparity, gender preference of fetus, or domestic violence.Conclusions: Gender inequality and societal acceptability of domestic violence in South Asian women contextualizes the experience of prenatal maternal anxiety. Pregnancy-related anxiety tools should include domains related to gender inequality to better understand their influence on pregnancy outcomes

Investigating associations between maternal stress, smoking and adverse birth outcomes: evidence from the All Our Families cohort

Abstract Background Independently, active maternal and environmental tobacco smoke exposure and maternal stress have been linked to an increased risk of preterm birth and low birth weight. An understudied relationship is the potential for interactive effects between these risk factors. Methods Data was obtained from the All Our Families cohort, a study of 3,388 pregnant women < 25 weeks gestation recruited from those receiving prenatal care in Calgary, Canada between May 2008 and December 2010. We investigated the joint effects of active maternal smoking, total smoke exposure (active maternal smoking plus environmental tobacco smoke) and prenatal stress (Perceived Stress Scale, Spielberger State-Trait Anxiety Inventory), measured at two time points (< 25 weeks and 34–36 weeks gestation), on preterm birth and low birth weight. Results A marginally significant association was observed with the interaction active maternal smoking and Spielberger State-Trait Anxiety Inventory scores in relation to low birth weight, after imputation (aOR = 1.02, 95%CI: 1.00-1.03, p = 0.06). No significant joint effects of maternal stress and either active maternal smoking or total smoke exposure with preterm birth were observed. Active maternal smoking, total smoke exposure, Perceived Stress Scores, and Spielberger State-Trait Anxiety Inventory scores were independently associated with preterm birth and/or low birth weight. Conclusions Findings indicate the role of independent effects of smoking and stress in terms of preterm birth and low birthweight. However, the etiology of preterm birth and low birth weight is complex and multifactorial. Further investigations of potential interactive effects may be useful in helping to identify women experiencing vulnerability and inform the development of targeted interventions

Psychobiobehavioral model for preterm birth in pregnant women in low- and middle-income countries

Preterm birth (PTB) is a final common outcome resulting from many interrelated etiological pathways; of particular interest is antenatal psychosocial distress (i.e., stress, anxiety, and depression). In LMI countries, both exposure to severe life stressors and rate of PTB are on average greater when compared with high-income countries. In LMI countries women are exposed to some of the most extreme psychosocial stress worldwide (e.g., absolute poverty, limited social resources). High prevalence of antenatal stress and depression have been observed in some studies from LMI countries. We propose a psychosocial, biological, and behavioral model for investigating the complex multisystem interactions in stress responses leading to PTB and explain the basis of this approach. We discuss ethical considerations for a psychosocial, biological, and behavioral screening tool to predict PTB from a LMI country perspective

Harmonization of data from cohort studies– potential challenges and opportunities

Introduction Pooling data from cohort studies can be used to increase sample size. However, individual datasets may contain variables that measure the same construct differently, posing challenges in the usefulness of combined datasets. Variable harmonization (an effort that provides comparable view of data from different studies) may address this issue. Objectives and Approach This study harmonized existing datasets from two prospective pregnancy cohort studies in Alberta Canada (All Our Families (n=3,351) and Alberta Pregnancy Outcome and Nutrition (n=2,187)). Given the comparability of the characteristics of the two cohorts and similarities of the core data elements of interest, data harmonization was justifiable. Data harmonization was performed considering multiple factors, such as complete or partial variable matching regarding question asked/responded, the response coded (value level, value definition, data type), the frequency of measurement, the pregnancy time-period of measurement, and missing values. Multiple imputation was used to address missing data resulting from the data harmonization process. Results Several variables such as ethnicity, income, parity, gestational age, anxiety, and depression were harmonized using different procedures. If the question asked/answered and the response recorded was the same in both datasets, no variable manipulation was done. If the response recorded was different, the response was re-categorized/re-organized to optimize comparability of data from both datasets. Missing values were created for each resulting unmatched variables and were replaced using multiple imputation if the same construct was measured in both datasets but using different ways/scales. A scale that was used in both datasets was identified as a reference standard. If the variables were measured in multiple times and/or different time-periods, variables were synchronized using pregnancy trimesters data. Finally, harmonized datasets were then combined/pooled into a single dataset (n=5,588). Conclusion/Implications Variable harmonization is an important aspect of conducting research using multiple datasets. It provides an opportunity to increase study power through maximizing sample size, permitting more sophisticated statistical analyses, and to answer novel research questions that could not be addressed using a single study