Is HbA1c associated with birth weight? A multivariable analysis of Pakistani pregnant women.

AIM: Globally, one in seven infants is born with low birth weight and 3%-7% of infants are born with high birth weight, with the greatest burden noted in low- and middle-income countries. This study investigated the association between maternal prenatal glucose regulation and birth weight and the moderating effect of fetal sex among Pakistani women. METHODS: Secondary data from a prospective longitudinal study of healthy pregnant women from Pakistan (N = 189) was used. Participants provided a blood sample (12-19 weeks' gestational age) for the assessment of HbA1c (%). Birth weight (g) was collected following delivery. RESULTS: Higher maternal HbA1c was associated with higher birth weight (b = 181.81, t[189] = 2.15, p = 0.03), which was moderated by fetal sex (b = -326.27, t[189] = -2.47, p = 0.02), after adjusting for gestational age at birth, ethnicity, and pregnancy weight. Among women carrying a male fetus, every 1% increase in HbA1c predicted a 182 g increase in birth weight (b = 181.81, t[189] = 2.15, p = 0.03). CONCLUSIONS: Results extend research from high-income countries and indicate that fetal sex may have implications for glucose regulation in early to mid-pregnancy. Future research should examine sociocultural factors, which could elucidate potential mediating factors in the relation between HbA1c and birth weight in healthy pregnancies.

Individual and collective contribution of antenatal psychosocial distress conditions and preterm birth in Pakistani women.

BACKGROUND: We determined whether dimensions of psychosocial distress during pregnancy individually and collectively predicted preterm birth (PTB) in Pakistani women as it may be misleading to extrapolate results from literature predominantly conducted in high-income countries. METHODS: This cohort study included 1603 women recruited from four Aga Khan Hospital for Women and Children in Sindh, Pakistan. The primary binary outcome of PTB (i.e., livebirth before 37 completed weeks' gestation) was regressed on self-reported symptoms of anxiety (Pregnancy-Related Anxiety (PRA) Scale and Spielberger State-Trait Anxiety Inventory Form Y-1), depression (Edinburgh Perinatal Depression Scale (EPDS)), and covariates such as chronic stress (Perceived Stress Scale) assessed with standardized question and scales with established language equivalency (Sindhi and Urdu). RESULTS: All 1603 births occurred between 24 and 43 completed weeks' gestation. PRA was a stronger predictor of PTB than other types of antenatal psychosocial distress conditions. Chronic stress had no effect on the strength of association between PRA and PTB and a slight but non-significant effect on depression. A planned pregnancy significantly lowered risk of PTB among women who experienced PRA. Aggregate antenatal psychosocial distress did not improve model prediction over PRA. CONCLUSIONS: Like studies in high-income countries, PRA became a strong predictor of PTB when considering interactive effects of whether the current pregnancy was planned. Women's resilience and abilities to make sexual and reproductive health decisions are important to integrate in future research. Findings should be generalized with caution as socio-cultural context is a likely effect modifier. We did not consider protective/strength-oriented factors, such as resilience among women.

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 < 37 weeks' 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. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020208990, PROSPERO, identifier: CRD42020208990.

Psychological and situational factors associated with COVID-19 vaccine intention among postpartum women in Pakistan: a cross-sectional study.

OBJECTIVES: Contributing factors to COVID-19 vaccination intention in low-income and middle-income countries have received little attention. This study examined COVID-19-related anxiety and obsessive thoughts and situational factors associated with Pakistani postpartum women's intention to get COVID-19 vaccination. DESIGN: Cross-sectional study administering a survey by a telephone interview format between 15 July and 10 September 2020. SETTING: Four centres of Aga Khan Hospital for Women and Children-Garden, Kharadar, Karimabad and Hyderabad-in Sindh Province, Pakistan. PARTICIPANTS: Women who were enrolled in our longitudinal Pakistani cohort study were approached (n=1395), and 990 women (71%) participated in the survey, of which 941 women who were in their postpartum period were included in the final analysis. PRIMARY OUTCOME MEASURE AND FACTORS: COVID-19 vaccine intention, sociodemographic and COVID-19-related factors, Coronavirus anxiety, obsession with COVID-19 and work and social adjustment were assessed. Multiple multinomial logistic regression analysis was used to identify factors associated with women's intentions. RESULTS: Most women would accept a COVID-19 vaccine for themselves (66.7%). Only 24.4% of women were undecided about vaccination against COVID-19, and a small number of women rejected the COVID-19 vaccine (8.8%). Women with primary education were less likely to take a COVID-19 vaccine willingly than those with higher education. COVID-19 vaccine uncertainty and refusal were predicted by having no experience of COVID-19 infection, childbirth during the pandemic, having no symptoms of Coronavirus anxiety and obsession with COVID-19. Predictors for women's intention to vaccinate themselves and their children against COVID-19 were similar. CONCLUSION: Understanding the factors shaping women's intention to vaccinate themselves or their children would enable evidence-based strategies by healthcare providers to enhance the uptake of the COVID-19 vaccine and achieve herd immunity against Coronavirus.

Psychometric analysis of the Edinburgh Postnatal Depression Scale and Pregnancy Related Anxiety Questionnaire in Pakistani pregnant women.

BACKGROUND: The Edinburgh Postnatal Depression Scale (EPDS) and the Pregnancy-Related Anxiety Scale (PRAQ) are frequently used perinatal mental health scales. OBJECTIVE: To identify the factor structure of the Urdu language versions of EPDS and PRAQ in 280 Pakistani pregnant women. METHOD: The tools were administered at 12-19 weeks' and 22-29 weeks' gestational age (GA). Exploratory factor analyses were undertaken on data collected at 12-19 weeks' GA, to assess both scales. Results obtained at the second time point were used to examine test-retest reliability. The correlation between the scales was computed. RESULTS: A two-factor model yielded the best fit for both scales, which is consistent with findings from previous studies. For the EPDS, acceptable reliability was attained for the overall score (α = 0.77) and for the factor related to depressive symptoms (α = 0.73), but not for the factor related to anhedonia/suicide (α = 0.64). For the PRAQ, acceptable reliability was attained for the overall score (α = 0.83) and for the factor related to pregnancy concerns (α = 0.84), but not for the factor related to childbirth (α = 0.64). Test-retest reliability was acceptable for both overall scales EPDS: r = 0.50; PRAQ: r = 0.45; both p < .001). The Pearson correlation between the EPDS and PRAQ were r = 0.145, p < .05. CONCLUSION: Analysis of the tools confirmed a two-factor structure for both depression and anxiety among Pakistani pregnant women. A weak correlation was found between the EPDS and PRAQ. Further research is required to develop screening instruments for perinatal mental disorders that are applicable to cultural contexts.

Associations Between Maternal Depression, Antidepressant Use During Pregnancy, and Adverse Pregnancy Outcomes: An Individual Participant Data Meta-analysis.

OBJECTIVE: To evaluate the associations of depressive symptoms and antidepressant use during pregnancy with the risks of preterm birth, low birth weight, small for gestational age (SGA), and low Apgar scores. DATA SOURCES: MEDLINE, EMBASE, ClinicalTrials.gov, and PsycINFO up to June 2016. METHODS OF STUDY SELECTION: Data were sought from studies examining associations of depression, depressive symptoms, or use of antidepressants during pregnancy with gestational age, birth weight, SGA, or Apgar scores. Authors shared the raw data of their studies for incorporation into this individual participant data meta-analysis. TABULATION, INTEGRATION, AND RESULTS: We performed one-stage random-effects meta-analyses to estimate odds ratios (ORs) with 95% CIs. The 215 eligible articles resulted in 402,375 women derived from 27 study databases. Increased risks were observed for preterm birth among women with a clinical diagnosis of depression during pregnancy irrespective of antidepressant use (OR 1.6, 95% CI 1.2-2.1) and among women with depression who did not use antidepressants (OR 2.2, 95% CI 1.7-3.0), as well as for low Apgar scores in the former (OR 1.5, 95% CI 1.3-1.7), but not the latter group. Selective serotonin reuptake inhibitor (SSRI) use was associated with preterm birth among women who used antidepressants with or without restriction to women with depressive symptoms or a diagnosis of depression (OR 1.6, 95% CI 1.0-2.5 and OR 1.9, 95% CI 1.2-2.8, respectively), as well as with low Apgar scores among women in the latter group (OR 1.7, 95% CI 1.1-2.8). CONCLUSION: Depressive symptoms or a clinical diagnosis of depression during pregnancy are associated with preterm birth and low Apgar scores, even without exposure to antidepressants. However, SSRIs may be independently associated with preterm birth and low Apgar scores. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42016035711.

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's 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.

Comorbid Anxiety and Depression among Pregnant Pakistani Women: Higher Rates, Different Vulnerability Characteristics, and the Role of Perceived Stress.

Anxiety and depression commonly co-occur during pregnancy and may increase risk of poor birth outcomes including preterm birth and low birth weight. Our understanding of rates, patterns, and predictors of comorbid anxiety and depression is hindered given the dearth of literature, particularly in low- and middle-income (LMI) countries. The aim of this study is (1) to explore the prevalence and patterns of comorbid antenatal anxiety and depressive symptoms in the mild-to-severe and moderate-to-severe categories among women in a LMI country like Pakistan and (2) to understand the risk factors for comorbid anxiety and depressive symptoms. Using a prospective cohort design, a diverse sample of 300 pregnant women from four centers of Aga Khan Hospital for Women and Children in Pakistan were enrolled in the study. Comorbid anxiety and depression during pregnancy were high and numerous factors predicted increased likelihood of comorbidity, including: (1) High level of perceived stress at any time point, (2) having 3 or more previous children, and (3) having one or more adverse childhood experiences. These risks were increased if the husband was employed in the private sector. Early identification and treatment of mental health comorbidities may contribute to decreased adverse birth outcomes in LMI countries.

Ethnic disparity and exposure to supplements rather than adverse childhood experiences linked to preterm birth in Pakistani women.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with prenatal mental health and negative pregnancy outcomes in high income countries, but whether the same association exists in Pakistan, a low- to middle-income (LMI) country, remains unclear. METHODS: Secondary data analyses of a prospective longitudinal cohort study examining biopsychosocial measures of 300 pregnant women at four sites in Karachi, Pakistan. A predictive multiple logistic regression model for preterm birth (PTB; i.e., <37 weeks' gestation) was developed from variables significantly (P < 0.05) or marginally (P < 0.10) associated with PTB in the bivariate analyses. RESULTS: Of the 300 women, 263 (88%) returned for delivery and were included in the current analyses. The PTB rate was 11.1%. We found no association between ACE and PTB. Mother's education (P = 0.011), mother's ethnicity (P = 0.010), medications during pregnancy (P = 0.006), age at birth of first child or current age if primiparous (P = 0.049) and age at marriage (P = 0.091) emerged as significant in bivariate analyses. Mother's ethnicity and taking medications remained predictive of PTB in the multivariate model. LIMITATIONS: Findings are limited by the relatively small sample size which precludes direct testing for possible interactive effects. CONCLUSIONS: In sum, pathways to PTB for women in LMI countries may differ from those observed in high-income countries and may need to be modelled differently to include behavioural response to emotional distress and socio-cultural contexts.

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.

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.

Postpartum depression in Pakistan: a neglected issue.

Postpartum depression (PPD) is common among women in Pakistan, with a prevalence rate ranging from 28 percent to 63 percent, placing it among the highest in Asia. PPD has devastating effects on mothers, infants and families. Several factors contribute to the development of PPD in Pakistan, including environmental, cultural and social factors. Pakistani women living in other countries are also at risk. Nurses can play an important role in identifying women at risk and helping them get the necessary treatment.

The association between parity, infant gender, higher level of paternal education and preterm birth in Pakistan: a cohort study.

BACKGROUND: High rates of antenatal depression and preterm birth have been reported in Pakistan. Self reported maternal stress and depression have been associated with preterm birth; however findings are inconsistent. Cortisol is a biological marker of stress and depression, and its measurement may assist in understanding the influence of self reported maternal stress and depression on preterm birth. METHODS: In a prospective cohort study pregnant women between 28 to 30 weeks of gestation from the Aga Khan Hospital for Women and Children completed the A-Z Stress Scale and the Centre for Epidemiology Studies Depression Scale to assess stress and depression respectively, and had a blood cortisol level drawn. Women were followed up after delivery to determine birth outcomes. Correlation coefficients and Wilcoxon rank sum test was used to assess relationship between preterm birth, stress, depression and cortisol. Logistic regression analysis was used to determine the key factors predictive of preterm birth. RESULTS: 132 pregnant women participated of whom 125 pregnant women had both questionnaire and cortisol level data and an additional seven had questionnaire data only. Almost 20% of pregnant women (19·7%, 95% CI 13·3-27·5) experienced a high level of stress and nearly twice as many (40·9%, 95% CI 32·4-49·8%) experienced depressive symptoms. The median of cortisol level was 27·40 ug/dl (IQR 22·5-34·2). The preterm birth rate was 11·4% (95% CI 6·5-18). There was no relationship between cortisol values and stress scale or depression. There was a significant positive relationship between maternal depression and stress. Preterm birth was associated with higher parity, past delivery of a male infant, and higher levels of paternal education. Insufficient numbers of preterm births were available to warrant the development of a multivariable logistic regression model. CONCLUSIONS: Preterm birth was associated with higher parity, past delivery of a male infant, and higher levels of paternal education. There was no relationship between stress, and depression, cortisol and preterm birth. There were high rates of stress and depression among this sample suggesting that there are missed opportunities to address mental health needs in the prenatal period. Improved methods of measurement are required to better understand the psychobiological basis of preterm birth.

Disclosure of medical error.

With the advancement of medical sciences, lives are being prolonged and practice of medicine is considered an art and no longer as science. 'To Err is Human Report' has been released and gives data of medical errors in United States which opened people's eyes but there is grieving need that health professional in Pakistan also report the medical errors. Medical errors are common, costly, and often preventable. This could only happen when health professional are trained and made aware to report the errors. Evidences shows that full and honest disclosure of error and restitution are factors that may lead to significant improvement in responsibility of medical cases.