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

Prenatal allostatic load and preterm birth: A systematic review

Objective: Allostatic load refers to cumulative neuroendocrine burden and has been postulated to mediate and moderate physiological and psychological stress-related responses. This may have important implications for the risk of preterm birth. This systematic review examines the evidence on the association between prenatal allostatic load and preterm birth. Data sources: A comprehensive search of seven electronic databases was conducted from inception to August 23, 2022 to identify all English-language observational and mixed methods studies examining allostatic load and preterm birth with no year or geographic restrictions. Study eligibility criteria: Studies were included if they measured allostatic load, evaluated as the cumulative effect of any combination of more than one allostatic load biomarker, during pregnancy. Studies must have observed preterm birth, defined as \u3c 37 weeks\u27 gestational age, as a primary or secondary outcome of interest. Study appraisal and synthesis methods: The Quality In Prognosis Studies tool was used to evaluate risk of bias within included studies. A narrative synthesis was conducted to explore potential associations between allostatic load and preterm birth, and sources of heterogeneity. Results: Three prospective cohort studies were identified and revealed mixed evidence for an association between allostatic load and preterm birth. One study reported a statistically significant association while the other two studies reported little to no evidence for an association. Heterogeneity in when and how allostatic load was measured, limitations in study design and cohort socio-demographics may have contributed to the mixed evidence. Conclusions: This review provides insight into key individual-, community-, and study-level characteristics that may influence the association between allostatic load and preterm birth. Knowledge gaps are identified as foci for future research, including heterogeneity in allostatic load biomarkers and allostatic load index algorithms as well as pregnancy-specific considerations for allostatic load measurement. Further investigation of the allostatic load framework in the context of perinatal mental health is needed to advance understandings of maternal, infant, and child health

Perceived stress may mediate the relationship between antenatal depressive symptoms and preterm birth: A pilot observational cohort study

Background: Screening for changes in pregnancy-related anxiety and depressive symptoms during pregnancy may further our understanding of the relationship between these two variables and preterm birth.Objectives: To determine whether changes in pregnancy-related anxiety and depressive symptoms during pregnancy influence the risk of preterm birth among Pakistani women; explore whether perceived stress moderates or mediates this relationship, and examine the relationship between the various components of pregnancy-related anxiety and preterm birth.Methods: A prospective cohort study design was used to recruit a diverse sample of 300 low-risk pregnant women from four centers of Aga Khan Hospital for Women and Children in Karachi, Pakistan. Changes in pregnancy-related anxiety and depressive symptoms during pregnancy were tested. Multiple logistic regression analysis was used to determine a predictive model for preterm birth. We then determined if the influence of perceived stress could moderate or mediate the effect of depressive symptoms on preterm birth.Results: Changes in pregnancy-related anxiety (OR = 1.1, CI 0.97-1.17, p = 0.167) and depressive symptoms (OR = 0.9, CI 0.85-1.03, p = 0.179) were insignificant as predictors of preterm birth after adjusting for the effects of maternal education and family type. When perceived stress was added into the model, we found that changes in depressive symptoms became marginally significant after adjusting for covariates (OR = 0.9, CI 0.82-1.01, p = 0.082). After adjusting for the mediation effect of change in perceived stress, the effect of change in depressive symptoms on preterm birth were marginally significant after adjusting for covariates. Among six different dimensions of pregnancy-related anxiety, mother\u27s concerns about fetal health showed a trend towards being predictive of preterm birth (OR = 1.3, CI 0.97-1.72, p = 0.078).Conclusions: There may be a relationship between perceived stress and antenatal depressive symptoms and preterm birth. This is the first study of its kind to be conducted in Pakistan. Further research is required to validate these results

Critical review of multimorbidity outcome measures suitable for low-income and middle-income country settings: perspectives from the Global Alliance for Chronic Diseases (GACD) researchers.

OBJECTIVES: There is growing recognition around the importance of multimorbidity in low-income and middle-income country (LMIC) settings, and specifically the need for pragmatic intervention studies to reduce the risk of developing multimorbidity, and of mitigating the complications and progression of multimorbidity in LMICs. One of many challenges in completing such research has been the selection of appropriate outcomes measures. A 2018 Delphi exercise to develop a core-outcome set for multimorbidity research did not specifically address the challenges of multimorbidity in LMICs where the global burden is greatest, patterns of disease often differ and health systems are frequently fragmented. We, therefore, aimed to summarise and critically review outcome measures suitable for studies investigating mitigation of multimorbidity in LMIC settings. SETTING: LMIC. PARTICIPANTS: People with multimorbidity. OUTCOME MEASURES: Identification of all outcome measures. RESULTS: We present a critical review of outcome measures across eight domains: mortality, quality of life, function, health economics, healthcare access and utilisation, treatment burden, measures of 'Healthy Living' and self-efficacy and social functioning. CONCLUSIONS: Studies in multimorbidity are necessarily diverse and thus different outcome measures will be appropriate for different study designs. Presenting the diversity of outcome measures across domains should provide a useful summary for researchers, encourage the use of multiple domains in multimorbidity research, and provoke debate and progress in the field

Mothers‘ employment and breastfeeding continuation: Global and Pakistani perspectivesfrom the literature

Exclusive breastfeeding during the first 6 months of life, with continuation of breastfeeding up to 2 years of life with complementary feedings, offers protection against infectious disease which could potentially avert mortality and morbidity. In Pakistan the decline in breastfeeding prevalence has been attributed to the increased proportion of women in the labour force and lack of breastfeeding support in the workplace. This paper reviews the literature to explore the association of mothers’ employment on the continuation of breastfeeding, and barriers and facilitators for breastfeeding at the workplace.A systematic search of peer-reviewed databases including MEDLINE, CINAHL, Pub Med and the Cochrane Database of Systematic Reviews was undertaken. The search was augmented by reviewing the WHO and UNICEF websites, government reports available on the website, books, sociological abstracts, and reference lists of articles thought to be relevant.An association is evident between early return to work or timing of return to work and breastfeeding continuation. From a global perspective, barriers and facilitators for breastfeeding at the workplace include maternal behaviours and characteristics, support at the workplace, healthcare or work environment, and policy and law. It is difficult to glean if these same factors exist in the workplace of Pakistani lactating women. There is therefore a need to identify evidence-based strategies to support breastfeeding continuation for Pakistani women returning to the workplace shortly after the birth of their babies

Faculty practice in a private teaching institution in a developing country: embracing the possibilities.

Aim: This paper discusses a case study on implementing faculty practice in a private teaching institution in a developing country where direct \u27hands-on\u27 care is undervalued by nurses. Background: In Pakistan, faculty practice is not well known and related to indirect care. In the institution studied, faculty practice has been a major consideration to strengthen relationships between clinical and academic sectors. Data Source: MEDLINE and CINHAL were searched (1979 to July 2009). A consultative process was used by the faculty practice committee members and involved open discussions with academic and clinical service faculty in the institution studied. Discussion: There is no empirical evidence to identify effective models for implementing faculty practice. A formalized faculty practice plan was identified as an important organization factor to promote faculty practice. Implications For Nursing: Identifying a definition of faculty practice and scholarship was an important step to ensure conceptual clarity. Consistent with the literature, workload, remuneration and performance appraisal were identified as perceived threats. The hierarchy in nursing is a unique organizational factor that will need to be addressed. Given the lack of research on the effectiveness of faculty practice and its models, evaluation is imperative. Conclusion: Dissonance is an overall theme of the literature and stems from the perceived threats/risks of faculty practice. Faculty practice may fulfil institutional, personal and professional needs of individual faculty members. Faculty practice offers an opportunity to change attitudes, beliefs and values related to direct care in the institution studied and influence other institutions in Pakistan

Family-centered rounds in Pakistani pediatric intensive care settings: non-randomized pre- and post-study design

Background: Involvement of family in bedside rounds is one strategy to implement family-centered care to help families get clear information about their child, and be actively involved in decision-making about care. However in developing countries such as Pakistan, daily bedside rounds include the physician, residents, medical students and a nurse/technician. Parents are not currently a part of these rounds. Objective: To assess whether family-centered rounds improve parents’ and health care professionals’ satisfaction, decrease patient length of stay, and improve time utilization when compared to traditional practice rounds in a population with a low literacy rate, socioeconomic status, and different cultural values and beliefs. Design: A non-randomized before–after study design. Setting: A private hospital in Karachi, Pakistan. Participants: A convenience sample of 82 parents, whose children were hospitalized for a minimum of 48 h, and 25 health care professionals able to attend two consecutive rounds. Methods: During the before phase, traditional bedside rounds were practiced; and during after phase, family-centered rounds were practiced. Parents and health care professionals completed a questionnaire on the second day of rounds. An observational form facilitated data collection on length of stay and time utilization during. Results: Parents’ ratings during the family-centered rounds were significantly higher for some parental satisfaction items: evidence of team work (p = 0.007), use of simple language during the rounds (p = 0.002), feeling of inclusion in discussion at rounds (p = 0.03), decision making (p = 0.01), and preference for family-centered rounds (p = Conclusion: Parents were satisfied with both forms of rounds; however, they appeared to have a greater preference for family-centered rounds than health care professionals. Family-centered rounds were a resource for Pakistani parents, enabling direct communication with the medical team without impacting on the time required to complete rounds. Family-centered rounds may improve quality of care such as decreasing length of stay or preventing critical incidents

Resilience and prenatal mental health in Pakistan: A qualitative inquiry

Background: Women in Pakistan suffer from a high rate of depression. The stress of low-income, illiteracy, exposure to violence and living in a patriarchal society are predisposing vulnerabilities for depression, particularly during and following pregnancy. The resilience of an individual plays a significant role in promoting prenatal mental health, but this has yet to be thoroughly researched. In this article, our objective is to identify the core characteristics of resilience among pregnant women, which will then help us in developing an intervention.Methods: The exploratory-descriptive study was conducted over 6 months in five different antenatal hospitals in Sindh, Pakistan. A total of 17 semi-structured interviews were conducted with pregnant women, purposefully selected with heterogeneous characteristics to explore diverse perspectives, while symptoms of depression were quantified by the Edinburgh Postnatal Depression Scale before the interview. Verbatim transcriptions were coded openly and merged into categories and themes.Result: A total of six themes emerged from in-depth thematic analysis: 1) purpose of life, 2) dealing with emotions, 3) believing in yourself, 4) optimistic approach, 5) strengthening support and relationship and 6) spirituality and humanity. Women agreed that these characteristics could help them improve their mental health.Conclusion: In conclusion, these themes were the core components of pregnant women\u27s resilience which ultimately could help to promote prenatal mental health. These pave a pathway towards developing culturally and contextually resilience interventions aimed at enhancing mental health of pregnant women which then may improve neonatal and family mental wellbeing

COVID-19 and Women’s Health : A Low- and Middle-Income Country Perspective

Corona Virus Disease (COVID-19), a contagious disease, is a global pandemic affecting the lives and health of individuals across borders, genders and races. Much of what is known about the effects of natural disasters and disease outbreaks on women’s health in particular, is based on studies conducted in high-income countries. The evolving evidence suggests that COVID-19 has a profound negative impact on the perinatal mental health of women. It is also clear that global pandemics such as COVID-19 disproportionately affect the less affluent, including individuals living in low- and middle-income countries. The purpose of this review is to summarize and critically discuss extant knowledge on COVID-19 as it relates to the perinatal health of women in low and middle-income countries, using Pakistan as a case example. We specifically highlight the effects on perinatal mental health, preterm birth, and timing of the COVID-19 exposure. Our review suggests that it is essential to consider the effects of COVID-19 within this cultural context and that findings from high-income countries do not necessarily translate to the situation in low and middle-income countries.Medicine, Faculty ofNon UBCMedical Genetics, Department ofReviewedFacultyResearcherPostdoctora