The Rajarata Pregnancy Cohort (RaPCo): study protocol.

BACKGROUND: Ending preventable maternal deaths remains a global priority and in the later stages of obstetric transition, identifying the social determinants of maternal health outcomes is essential to address stagnating maternal mortality rates. Countries would hardly achieve the Sustainable Development Goal (SGD) targets on maternal health, unless the complex and context-specific socio-economic aetiologies associated with maternal mental health and suicide are identified. The Rajarata Pregnancy Cohort (RaPCo) is a prospective cohort study, designed to explore the interactions between social determinants and maternal mental health in determining pregnancy and new-born outcomes. METHODS: The study will recruit all eligible pregnant women in the maternal care programme of Anuradhapura district, Sri Lanka from July to September 2019. The estimated sample size is 2400. We will assess the socio-demographic and economic status, social capital, gender-based violence and mental health, including a clinical examination and biochemical investigations during the first trimester. Participants will undergo four follow-ups at 2nd and 3rd trimesters, at delivery and in early postpartum. The new-borns will be followed up at birth, neonatal period, at 6 six months and at 1 year. Pregnancy and child outcome data will be collected using direct contact. Qualitative studies will be carried out to understand the complex social factors and behavioural dimensions related to abortion, antenatal depression, maternal deaths and near misses. DISCUSSION: This is the first reported maternal cohort in Sri Lanka focusing on social determinants and mental health. As a country in stage four of obstetric transition, these findings will provide generalizable evidence on achieving SGD targets in low- and middle-income countries. The study will be conducted in a district with multi-cultural, multi-ethnic and diverse community characteristics; thus, will enable the evidence generated to be applied in many different contexts. The study also possesses the strength of using direct participant contact, data collection, measurement, examination and biochemical testing to minimise errors in routinely collected data. The RaPCo study will be able to generate evidence to strengthen policies to further reduce maternal deaths in the local, regional and global contexts particularly focusing on social factors and mental health, which are not optimally addressed in the global agenda.

Suicidal ideation and intentional self-harm in pregnancy as a neglected agenda in maternal health; an experience from rural Sri Lanka.

BACKGROUND: Suicide only present the tip of the iceberg of maternal mental health issues. Only a fraction of pregnant women with suicidal ideation proceeds to intentional self-harm (ISH) and even a smaller proportion are fatal. The purpose of the present study was to determine the prevalence of depression, suicidal ideation (present and past) and history of ISH among pregnant mothers in rural Sri Lanka. METHODS: We have conducted a hospital based cross sectional study in the third largest hospital in Sri Lanka and an another tertiary care center. Pregnant women admitted to hospital at term were included as study participants. The Edinburgh Postpartum Depression Scale (EPDS), a self-administered questionnaire for demographic and clinical data and a data extraction sheet to get pregnancy related data from the pregnancy record was used. RESULTS: The study sample consisted of 475 pregnant women in their third trimester. For the tenth question of EPDS "the thought of harming myself has occurred to me during last seven days" was answered as "yes quite a lot" by four (0.8%), "yes sometimes" by eleven (2.3%) and hardly ever by 13 (2.7%). Two additional pregnant women reported that they had suicidal ideation during the early part of the current pregnancy period though they are not having it now. Four (0.8%) pregnant women reported having a history of ISH during the current pregnancy. History of ISH prior to this pregnancy was reported by eight women and five of them were reported to hospitals, while others were managed at home. Of the 475 pregnant females included in the study, 126 (26.5%) had an EPDS score more than nine, showing probable anxiety and depression. Pregnant women who had primary/post-primary or tertiary education compared to those who were in-between those two categories were at higher risk of high EPDS score with a OR of 1.94 (95% CI 1.1-3.3). Reported suicidal ideation prior to pregnancy was also associated with high EPDS with a OR of 6.4 (95% CI 2.3-17.5). CONCLUSIONS: Based on our data, we conservatively estimate around 500 pregnant women each year having suicidal ideation and, 130 ISH annually in Anuradhapura, which should be considered as a high priority for an urgent intervention.

Non-alcoholic fatty liver disease (NAFLD): a significant predictor of gestational diabetes mellitus (GDM) and early pregnancy miscarriages-prospective study in Rajarata Pregnancy Cohort (RaPCo).

BACKGROUND AND AIMS: Non-alcoholic fatty liver disease (NAFLD) is increasing globally with a mounting body of evidence on various adverse effects on pregnancy. Yet, prospective studies, especially from low-income and middle-income countries, are lacking in examining the impact of NAFLD in pregnancy. In this study, we explored the effect of NAFLD on the development of gestational diabetes mellitus (GDM) and early pregnancy miscarriages. METHODS: A population-based prospective cohort study was conducted among first-trimester pregnant women who registered in the national pregnancy care programme during July-September 2019 in Anuradhapura district, Sri Lanka. Baseline clinical-biochemical parameters and ultrasound scan (USS) of the liver were done to assess fatty liver. Those who were normoglycaemic based on WHO criteria were followed up, and a repeat oral glucose tolerance test was performed between 24 and 28 weeks of gestation. RESULTS: Of the 632 pregnant women studied, 90 (14%) and 234 (37%) were diagnosed as having fatty liver grade (FLG) II and I, respectively. The cumulative incidence of GDM in FLG 0, I, and II were 11, 44, and 162 per 1000 pregnancies, respectively. After adjusting for age and other known risk factors, women with FLG II had a relative risk (RR) of 12.5 (95% CI 2.2 to 66.4) for developing GDM compared with FLG 0. In addition, women with FLG I (RR 2.1, 95% CI 1.01 to 4.64) and FLG II (RR 4.5, 95% CI 2.1 to 9.9) were significant risk factors for early pregnancy miscarriages, and FLG II remained as the only independent predictor of miscarriages after adjusting for age, parity, body mass index, blood sugar, blood pressure, and haemoglobin level (adjusted OR 4.2 (95% CI 1.9 to 9.1)). CONCLUSION: In this rural south Asian community, NAFLD is shown to be a major risk factor for GDM and early pregnancy miscarriages. Therefore, routine identification of NAFLD through a simple USS may help in the early identification of high-risk mothers.