Psychosocial determinants of sustained maternal functional impairment: Longitudinal findings from a pregnancy-birth cohort study in rural Pakistan

Autoři: Ashley Hagaman aff001;  John A. Gallis aff003;  Sonia Bhalotra aff005;  Victoria Baranov aff006;  Elizabeth L. Turner aff003;  Siham Sikander aff007;  Joanna Maselko aff009
Působiště autorů: Department of Social Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America aff001;  Center for Methods in Implementation and Prevention Sciences, Yale University, New Haven, Connecticut, United States of America aff002;  Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America aff003;  Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, United States of America aff004;  Department of Economics, University of Essex, Essex, England, United Kingdom aff005;  Department of Economics, The University of Melbourne, Melbourne, Australia aff006;  Maternal and Neonatal Child Health Department, Health Services Academy, Islamabad, Pakistan aff007;  Human Development Research Foundation, Islamabad, Pakistan aff008;  Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America aff009
Vyšlo v časopise: PLoS ONE 14(11)
Kategorie: Research Article
doi: 10.1371/journal.pone.0225163


Function is an important marker of health throughout the life course, however, in low-and-middle-income-countries, little is known about the burden of functional impairment as women transition from pregnancy to the first year post-partum. Leveraging longitudinal data from 960 women participating in the Share Child Cohort in Pakistan, this study sought to (1) characterize functional trajectories over time among women in their perinatal period and (2) assess predictors of chronic poor functioning following childbirth. We used a group-based trajectory modeling approach to examine maternal patterns of function from the third trimester of pregnancy through 12 months post-partum. Three trajectory groups were found: persistently well-functioning (51% of women), poor functioning with recovery (39% of women), and chronically poor functioning (10% of women). When compared to mothers in the highest functioning group, psychosocial characteristics (e.g., depression, stress, and serious life events) were significantly associated with sustained poor functioning one-year following child-birth. Mothers living in nuclear households were more likely to experience chronic poor functioning. Higher education independently predicted maternal function recovery, even when controlling for psychosocial characteristics. Education, above and beyond socio-economic assets, appears to play an important protective role in maternal functional trajectories following childbirth. Public health implications related to maternal function and perinatal mental health are discussed.

Klíčová slova:

Depression – Children – Labor and delivery – Mothers – Pregnancy – Psychological and psychosocial issues – Psychological stress – Socioeconomic aspects of health


1. Üstün TB. Measuring health and disability: Manual for WHO disability assessment schedule WHODAS 2.0: World Health Organization; 2010.

2. Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. The Lancet. 2016;387(10017):462–74.

3. AbouZahr C. Global burden of maternal death and disability. British medical bulletin. 2003;67(1):1–11.

4. Rittenour CE, Colaner CW. Finding Female Fulfillment: Intersecting Role-Based and Morality-Based Identities of Motherhood, Feminism, and Generativity as Predictors of Women’s Self Satisfaction and Life Satisfaction. Sex roles. 2012;67(5):351–62. doi: 10.1007/s11199-012-0186-7

5. Pritchard KM. Multiple motherhoods: An examination of mother status on life satisfaction and psychological distress [Ph.D.]. Ann Arbor: The University of Nebraska—Lincoln; 2013.

6. Tucker JN, Grzywacz JG, Leng I, Clinch CR, Arcury TA. Return to Work, Economic Hardship, and Women’s Postpartum Health. Women & Health. 2010;50(7):618–38. doi: 10.1080/03630242.2010.522468 21104566

7. Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2015;386(9995):743–800.

8. Freedman VA, Martin LG, Schoeni RF. Recent trends in disability and functioning among older adults in the United States: a systematic review. Jama. 2002;288(24):3137–46. doi: 10.1001/jama.288.24.3137 12495394

9. Emmanuel EN, Sun J. Health related quality of life across the perinatal period among Australian women. Journal of Clinical Nursing. 2014;23(11–12):1611–9. doi: 10.1111/jocn.12265 23750859

10. Willie TC, Powell A, Kershaw T. Stress in the City: Influence of Urban Social Stress and Violence on Pregnancy and Postpartum Quality of Life among Adolescent and Young Mothers. Journal of Urban Health. 2016;93(1):19–35. doi: 10.1007/s11524-015-0021-x 26791234

11. Van der Woude DAA, Pijnenborg JMA, de Vries J. Health status and quality of life in postpartum women: a systematic review of associated factors. European Journal of Obstetrics and Gynecology and Reproductive Biology. 185:45–52. doi: 10.1016/j.ejogrb.2014.11.041 25522118

12. Murphy RA, Hagaman AK, Reinders I, Steeves JA, Newman AB, Rubin SM, et al. Depressive trajectories and risk of disability and mortality in older adults: longitudinal findings from the health, aging, and body composition study. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences. 2015;71(2):228–35.

13. Upton J. Psychosocial Factors. Encyclopedia of Behavioral Medicine. 2013:1580–1.

14. Gelaye B, Rondon MB, Araya R, Williams MA. Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. The Lancet Psychiatry. 2016;3(10):973–82. doi: 10.1016/S2215-0366(16)30284-X 27650773

15. Bitew T, Hanlon C, Kebede E, Medhin G, Fekadu A. Antenatal depressive symptoms and maternal health care utilisation: a population-based study of pregnant women in Ethiopia. BMC Pregnancy and Childbirth. 2016;16(1):301. doi: 10.1186/s12884-016-1099-1 27724876

16. Baron EC, Hanlon C, Mall S, Honikman S, Breuer E, Kathree T, et al. Maternal mental health in primary care in five low- and middle-income countries: A situational analysis. BMC Health Services Research. 2016;16(1). doi: 10.1186/s12913-016-1291-z 26880075

17. Fisher J, Mello MCd, Patel V, Rahman A, Tran T, Holton S, et al. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Bulletin of the World Health Organization. 2012;90:139–49.

18. Setse R, Grogan R, Pham L, Cooper LA, Strobino D, Powe NR, et al. Longitudinal study of depressive symptoms and health-related quality of life during pregnancy and after delivery: the Health Status in Pregnancy (HIP) study. Maternal and Child Health Journal. 2009;13(5):577–87. doi: 10.1007/s10995-008-0392-7 18931832

19. Li J, Mao J, Du Y, Morris JL, Gong G, Xiong X. Health-Related Quality of Life Among Pregnant Women With and Without Depression in Hubei, China. Maternal and Child Health Journal. 2012;16(7):1355–63. doi: 10.1007/s10995-011-0900-z 22045020

20. Senturk V, Hanlon C, Medhin G, Dewey M, Araya M, Alem A, et al. Impact of perinatal somatic and common mental disorder symptoms on functioning in Ethiopian women: The P-MaMiE population-based cohort study. Journal of Affective Disorders. 2012;136(3):340–9. 22196052

21. Chen HH, Hwang FM, Lin LJ, Han KC, Lin CL, Chien LY. Depression and Social Support Trajectories During 1 Year Postpartum Among Marriage-Based Immigrant Mothers in Taiwan. Archives of psychiatric nursing. 2016;30(3):350–5. Epub 2016/06/04. doi: 10.1016/j.apnu.2015.12.008 27256940.

22. Gelaye B, Williams MA, VanderWeele TJ, Zhong Q-Y, Sanchez SE. Causal Model of the Association of Social Support With Antepartum Depression: A Marginal Structural Modeling Approach. American Journal of Epidemiology. 2018;187(9):1871–9. doi: 10.1093/aje/kwy067 29617921

23. Turner EL, Sikander S, Bangash O, Zaidi A, Bates L, Gallis J, et al. The effectiveness of the peer-delivered Thinking Healthy PLUS (THPP+) Program for maternal depression and child socioemotional development in Pakistan: study protocol for a randomized controlled trial. Trials. 2016;17(1):442. Epub 2016/09/10. doi: 10.1186/s13063-016-1530-y 27608926.

24. Sikander S, Ahmad I, Bates LM, Gallis J, Hagaman A, O’Donnell K, et al. Cohort Profile: Perinatal depression and child socioemotional development; the Bachpan cohort study from rural Pakistan. BMJ Open. 2019; 9(5):e025644. doi: 10.1136/bmjopen-2018-025644 31061029

25. Sikander S, Ahmad I, Atif N, Zaidi A, Vanobberghen F, Weiss HA, et al. Delivering the Thinking Healthy Programme for perinatal depression through volunteer peers: a cluster randomised controlled trial in Pakistan. The Lancet Psychiatry. 2019;6(2):128–39. doi: 10.1016/S2215-0366(18)30467-X 30686386

26. Maselko J, Bates L, Bhalotra S, Gallis JA, O’Donnell K, Sikander S, et al. Socioeconomic status indicators and common mental disorders: Evidence from a study of prenatal depression in Pakistan. Social Science & Medicine—Population Health. 2018;4:1–9.

27. MacLeod MA, Tremblay PF, Graham K, Bernards S, Rehm J, Wells S. Psychometric properties and a latent class analysis of the 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) in a pooled dataset of community samples. International Journal of Methods in Psychiatric Research. 2016;25(4):243–54. doi: 10.1002/mpr.1523 27634553

28. Kader M, Perera NKP, Sohrab Hossain M, Islam R. Socio-demographic and injury-related factors contributing to activity limitations and participation restrictions in people with spinal cord injury in Bangladesh. Spinal cord. 2018;56(3):239–46. Epub 2017/11/03. doi: 10.1038/s41393-017-0001-y 29093546.

29. Downing NR, Kim J-I, Williams JK, Long JD, Mills JA, Paulsen JS. WHODAS 2.0 in prodromal Huntington disease: measures of functioning in neuropsychiatric disease. European Journal of Human Genetics. 2014;22(8):958. doi: 10.1038/ejhg.2013.275 24327189

30. O’Hare MA, Wallis L, Murphy GC. Social support pairs predict daily functioning following traumatic spinal cord injury: An exploratory study. The Open Rehabilitation Journal. 2011;4(1):51–8.

31. Silveira C, Parpinelli MA, Pacagnella RC, de Camargo RS, Costa ML, Zanardi DM, et al. Cross-cultural adaptation of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) into Portuguese. Revista da Associação Médica Brasileira (English Edition). 2013;59(3):234–40.

32. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9—Validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. doi: 10.1046/j.1525-1497.2001.016009606.x 11556941

33. Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. Journal of Health and Social Behavior. 1983;24(4):385–96. doi: 10.2307/2136404 6668417

34. Dahlem NW, Zimet GD, Walker RR. The multidimensional scale of perceived social support: a confirmation study. Journal of clinical psychology. 1991;47(6):756–61. doi: 10.1002/1097-4679(199111)47:6<756::aid-jclp2270470605>;2-l 1757578

35. Rahman A, Iqbal Z, Harrington R. Life events, social support and depression in childbirth: perspectives from a rural community in the developing world. Psychological medicine. 2003;33(7):1161–7. doi: 10.1017/s0033291703008286 14580070

36. Ellsberg M, Jansen H, Heise L, Watts CH, Garcia-Moreno C. WHO Multi-country Study on Women’s Health and Domestic Violence against Women Study Team. Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence: an observational study. Lancet. 2008;371(9619):1165–72. doi: 10.1016/S0140-6736(08)60522-X 18395577

37. Jones BL, Nagin DS. Advances in group-based trajectory modeling and an SAS procedure for estimating them. Sociological Methods & Research. 2007;35(4):542–71.

38. Moilanen KL, Crockett LJ, Raffaelli M, Jones BL. Trajectories of sexual risk from middle adolescence to early adulthood. Journal of Research on Adolescence. 2010;20(1):114–39.

39. Nagin DS, Odgers CL. Group-based trajectory modeling in clinical research. Annual review of clinical psychology. 2010;6.

40. Rahman A, Creed F. Outcome of prenatal depression and risk factors associated with persistence in the first postnatal year: Prospective study from Rawalpindi, Pakistan. Journal of Affective Disorders. 2007;100(1–3):115–21. doi: 10.1016/j.jad.2006.10.004 17098291

41. Halfon N, Larson K, Lu M, Tullis E, Russ S. Lifecourse health development: past, present and future. Maternal and child health journal. 2014;18(2):344–65. doi: 10.1007/s10995-013-1346-2 23975451

42. Piperata BA, Schmeer KK, Rodrigues AH, Salazar Torres VM. Food insecurity and maternal mental health in Leon, Nicaragua: Potential limitations on the moderating role of social support. Social Science & Medicine (1982). 2016;171:9–17. Epub 2016/11/18. doi: 10.1016/j.socscimed.2016.10.029 27855323.

43. Osborne C, Berger LM, Magnuson K. Family structure transitions and changes in maternal resources and well-being. Demography. 2012;49(1):23–47. Epub 2012/01/05. doi: 10.1007/s13524-011-0080-x 22215507.

44. Manuel JI, Martinson ML, Bledsoe-Mansori SE, Bellamy JL. The influence of stress and social support on depressive symptoms in mothers with young children. Social Science & Medicine. 2012;75(11):2013–20.

45. Mirowsky J. Education, social status, and health: Routledge; 2017.

46. Lorant V, Deliège D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. American Journal of Epidemiology. 2003;157(2):98–112. doi: 10.1093/aje/kwf182 12522017

47. Link BG, Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior. 1995:80–94. 7560851

Článek vyšel v časopise


2019 Číslo 11