Tackling inequality in maternal health: Beyond the postpartum

Maternal hypertensive disorders among Individuals of reproductive age (15-49 Years) in South Asia: A global Burden of Disease study (1990-2021) with future Projections

BACKGROUND

Maternal hypertensive disorders (HDP) remain a major contributor to maternal and perinatal morbidity and mortality worldwide, particularly in South Asia, where healthcare disparities persist.

OBJECTIVE

This study aims to analyze trends in maternal hypertensive disorders across South Asia from 1990 to 2021, leveraging data from the Global Burden of Disease (GBD) study to evaluate the effectiveness of healthcare interventions and provide actionable recommendations.

METHODS

We conducted a retrospective analysis using GBD 2021 data for Bangladesh, Bhutan, India, Nepal, and Pakistan. Health trends such as prevalence, incidence, and maternal mortality ratios (MMR) were analyzed using descriptive statistics and Join point regression. This approach allowed us to identify significant changes and trends over the studied period.

RESULTS

The study revealed significant declines in the prevalence and MMR associated with maternal hypertensive disorders across the region. Notable reductions were observed in Bangladesh, Bhutan, India, and Nepal, while Pakistan showed minimal improvement, indicating ongoing healthcare challenges. The analysis underscores substantial regional disparities, particularly in Pakistan, which reported higher prevalence rates and MMR across all age groups.

CONCLUSIONS

The findings suggest that targeted healthcare interventions can effectively reduce the burden of maternal hypertensive disorders in South Asia. However, persistent disparities in Pakistan highlight the need for region-specific strategies to address gaps in healthcare access and quality. Strengthening healthcare policies and improving intervention coverage could further mitigate the burden of HDP in South Asia.

A mixed methods study protocol to develop an educational program based on salutogenesis theory to improve the postpartum quality of life among nulliparous women

Research on postpartum quality of life (QoL) often focuses on preventing adverse health outcomes rather than promoting positive health and well-being (salutogenesis). While Salutogenesis theory (ST) has been shown to enhance the sense of coherence (SOC), its application in pregnancy and childbirth is limited. This paper presents a mixed-methods protocol for developing a salutogenic educational program to improve postpartum QoL and maternal health outcomes. Data will gather from healthcare centres in Ahvaz city, Khuzestan province, Iran. In the first phase (qualitative approach), nulliparous women's experiences of determinants of postpartum QoL will be explored by semi-structured in-depth interviews. In the second phase literature review will be conducted to identify factors which affected postpartum QoL. In the third phase, the content of the educational program will be developed. In the fourth phase (a Randomized Controlled Trial), 110 nulliparous women will be randomly allocated to intervention and control groups using blocked randomization. Two groups will be compared in terms of primary and secondary outcomes by validated instruments at baseline, immediately after the intervention, 4 weeks, and 8 weeks after delivery.

Beyond 'bouncing back': Bodily change and postpartum embodiment

This article examines findings from a longitudinal qualitative study seeking to examine the lived experience of postpartum embodiment, specifically focusing on bodily changes following pregnancy. Through 163 in depth, semi-structured interviews with 48 postpartum women, we explore the mediatized phrase of 'bouncing back' as a popular understanding of the postpartum period, and how this conceptualization of the body effectively diminishes the complexity of changes related to body image and bodily capacities. Instead, drawing on Braun and Clark's thematic analysis method, our data demonstrates that participants experience the postpartum period as a dynamic process through issues and concerns related to body shape, size, form, and function, often understood simultaneously and subjectively. These findings emphasize that postpartum experiences of corporeal change also reflect aspects of embodied agency, in which individuals work to reclaim their bodies in myriad ways. Finally, we argue that this re-interpretation of the postpartum body has important implications for maternal health and health care.

Perinatal care in primary care for cardiovascular risk reduction

General practitioners (GPs) and multidisciplinary members of the primary care team in the UK have, since the earliest days of the NHS, played a key role in the care of women throughout their perinatal journey, particularly postnatally. With cardiometabolic complications of pregnancy becoming increasingly common, and bringing an associated increased lifetime risk of adverse maternal and neonatal outcomes, GPs and the wider primary care team play a crucial role in risk reduction and management. Managing healthcare effectively to reduce adverse maternal and neonatal outcomes and health inequalities requires a system-wide change in approach where women's pre-conception to postnatal health is optimised. GPs' role in postnatal care, and other opportunistic moments in primary care for health promotion and risk management, is a key part of the solution.

The impact of socioeconomic deprivation on the prevalence of gestational diabetes: An observational study

Background

Approximately 3.5% of pregnancies in the United Kingdom are complicated by gestational diabetes mellitus (GDM). Risk factors for this mirror those contributing to type 2 diabetes (T2DM). Though socioeconomic status (SES) is presumed to contribute to GDM, evidence in the United Kingdom is limited. In this unique study, we explored the impact of SES on GDM prevalence in a London suburb population.

Materials and Methods

Four thousand one hundred and sixty-three pregnant women who booked between July 2018 and March 2020 at Princess Royal University Hospital were retrospectively analyzed. Associations between GDM prevalence and SES trends (using multiple deprivation deciles (MDD)), and body mass index (BMI), age, ethnicity, screening uptake, birth-weights and birth outcomes, were analyzed.

Results

Patients with BMI >30 kg/m2, older than 35 years, and non-Caucasian ethnicity have an increased risk of developing GDM (p < 0.0001, p < 0.0001, p < 0.0001, respectively). No association existed between MDD and GDM prevalence (p-values over 0.05). Patients with risk factors for GDM were highest in the deprived areas p < 0.0001. MDD 1-4 (most deprived) had the highest percentage of missed screening (15% of patients with risk factors missed screening), compared to 8% in the least deprived group (p < 0.0001).

Discussion

Our data surprisingly suggest that low SES did not increase the incidence of GDM, despite a higher proportion of women with risk factors for GDM living in the most deprived postcodes. However this unclear finding may be due to low screening uptake of deprived populations, and therefore lack of GDM diagnosis, or indicate that GDM is a result of a different aetiology to T2DM. Further research is needed to explore if access to screening services, lack of health education or other health inequalities were responsible for the high proportion of missed screening opportunities in deprived areas.

Experiences and impacts of psychological support following adverse neonatal experiences or perinatal loss: a qualitative analysis

BACKGROUND

Poor parental mental health in the perinatal period has detrimental impacts on the lives and relationships of parents and their babies. Parents whose babies are born premature and/or sick and require neonatal care or those who experience perinatal loss are at increased risk of adverse mental health outcomes. In 2021 a North-West charity received funding to offer psychological support to service users of infants admitted to neonatal care or those who had experienced perinatal loss, named the Family Well-being Service (FWS). The FWS offered three different types of support - ad hoc support at the neonatal units or specialist clinics; one-to-one person-centred therapy; or group counselling. Here we report the qualitative findings from an independent evaluation of the FWS.

METHODS

Thirty-seven interviews took place online or over the phone with 16 service users (of whom two took part in a follow-up interview), eight FWS providers and 11 healthcare professionals. Interviews were coded and analysed using thematic analysis.

RESULTS

The analysis revealed two themes. 'Creating time and space for support' detailed the informational, contextual, and relational basis of the service. This theme describes the importance of tailoring communications and having a flexible and proactive approach to service user engagement. Service users valued being listened to without judgement and having the space to discuss their own needs with a therapist who was independent of healthcare. Communication, access, and service delivery barriers are also highlighted. The second theme - 'making a difference' - describes the cognitive, emotional, and interpersonal benefits for service users. These included service users being provided with tools for positive coping, and how the support had led to enhanced well-being, improved relationships, and confidence in returning to work.

CONCLUSION

The findings complement and extend the existing literature by offering new insights into therapeutic support for service users experiencing adverse neonatal experiences or perinatal loss. Key mechanisms of effective support, irrespective of whether it is provided on a one-to-one or group basis were identified. These mechanisms include clear information, flexibility (in access or delivery), being independent of statutory provision, focused on individual needs, active listening, the use of therapeutic tools, and positive relationships with the therapist. Further opportunities to engage with those less willing to take up mental health support should be developed.

Incidence and risk factors for postpartum mood and anxiety disorders among women veterans

BACKGROUND

Our aim was to determine rates of postpartum mood and anxiety disorders (PMADs) among U.S. women Veterans and the overlap among PMADs. We further sought to identify PMAD risk factors, including those unique to military service.

METHODS

A national sample of women Veterans completed a computer-assisted telephone interview (N = 1414). Eligible participants were aged 20-45 and had separated from service within the last 10 years. Self-report measures included demographics, general health, reproductive health, military exposures, sexual assault, childhood trauma, and posttraumatic stress disorder (PTSD). The PMADs of interest were postpartum depression (PPD), postpartum anxiety (PPA) and postpartum PTSD (PPPTSD). This analysis included 1039 women Veterans who had ever been pregnant and who answered questions about PPMDs related to their most recent pregnancy.

RESULTS

A third (340/1039, 32.7%) of participants were diagnosed with at least one PMAD and one-fifth (215/1039, 20.7%) with two or more. Risk factors common for developing a PMAD included: a mental health diagnosis prior to pregnancy, a self-report of ever having had a traumatic birth experience, and most recent pregnancy occurring during military service. Additional risk factors were found for PPD and PPPTSD.

CONCLUSION

Women Veterans may be at an increased risk for developing PMADs due to high rates of lifetime sexual assault, mental health disorders, and military-specific factors including giving birth during military service and military combat deployment exposures.

Elabela is a reliable biomarker for predicting early onset preeclampsia: A comparative study

BACKGROUND

Preeclampsia (PE) is a multisystemic metabolic disease with an undetermined etiology. PE is a worldwide cause of maternal and perinatal morbidity, subdivided into early (EoPE) and late-onset (LoPE) according to 34 wk of gestation as a divider. Many researchers investigated biomarkers for predicting PE to halt its consequences on the feto-maternal outcome. Elabela (Ela) is a newly discovered peptide hormone that was implicated in PE pathogenesis. Earlier rodent studies discussed Ela's role in controlling blood pressure. Moreover, Ela deficiency was associated with PE development.

AIM

To test whether plasma Ela could serve as a reliable marker for predicting PE based on the time of onset (EoPE vs LoPE) compared to age and body mass matched healthy controls since no definitive treatment exists for PE but to terminate a pregnancy.

METHODS

This case-control study recruited (n = 90) pregnant who fulfilled inclusion criteria; they were allocated into three groups: EoPE (30/90) (< 34 wk of gestation); LoPE (30/90) (≥ 34 wk of gestation); and healthy pregnant (30/90). Demographic criteria; biochemical, hematological, and maternal plasma Ela levels were recorded for comparison.

RESULTS

Serum Ela was significantly reduced in EoPE compared to LoPE and healthy controls (P = 0.0023). The correlation confirmed a strong inverse relationship with mean atrial blood pressure (r = -0.7, P < 0.001), while gestational age and platelets count showed a moderate correlation with (r = 0.4 with P < 0.0001). No correlation was confirmed between the body mass index (BMI) and urine albumin. The predictive ability of 25 centile serum Ela had an Odds ratio of 5.21, 95% confidence interval (1.28, 21.24), P = 0.02 for predicting EoPE. The receiver operator characteristic curve defined the Ela cutoff value at > 9.156 with 96.7% and 93.3% sensitivity and specificity, P < 0.0001 in predicting EoPE.

CONCLUSION

A strong correlation of serum Ela with PE parameters with excellent sensitivity and specificity in distinguishing EoPE independent of the BMI, age, and blood pressure which makes Ela a recommendable marker in screening. Further research is warranted to explore prognostic and therapeutic applications for Ela in PE.

Clinical implication of platelet to lymphocyte ratio in early onset preeclampsia: A single-center experience

BACKGROUND

Preeclampsia (PE) is a pregnancy syndrome of undetermined etiology; inflammation was one of the proposed theories for its development.

AIM

To examine the platelet to lymphocyte ratio (PLR), an inflammatory biomarker, as a marker to predict poor maternal-neonatal outcomes in early-onset PE (EoPE).

METHODS

A cross-sectional study enrolled 60 pregnant women with EoPE (at 32-30 wk of gestation) at a university hospital. Demographic criteria and hematological indices were collected, including platelet counts and indices (mean platelet volume and platelet distribution width), PLR, and the Doppler study, which calculated estimated fetal weight (EFW), amniotic fluid index (AFI), resistance index (RI), and pulsatility index (PI). Participants were followed until delivery, where maternal outcomes were recorded, including; delivery mode and reason for cesarean section, and neonatal outcomes, including fetal growth restriction (FGR), meconium-stained liquid, the 5-min Apgar score, and admission to the intensive care unit.

RESULTS

There was a trend of insignificant increases in cesarean sections. Sixty-one-point two percent (37/60) fetuses were admitted to the neonatal care unit; 70.0% of admitted fetuses were meconium-stained liquor, and 56.7% of them had FGR. PLR was positively correlated with AFI and EFW as r = 0.98, 0.97, P < 0.001; PLR showed negative correlations with PI and RI as r = -0.99, -0.98, P < 0.001. The Apgar score and the number of days admitted to the intensive care unit had a positive and negative correlation (0.69, -0.98), P < 0.0001, respectively. Receiver operating characteristic calculated a PLR cutoff value (7.49) that distinguished FGR at 100% sensitivity and 80% specificity.

CONCLUSION

Strong, meaningful relationships between PLR and FGR parameters and a poor neonatal outcome with a significant P value make it a recommendable biomarker for screening EoPE-related complications. Further studies are suggested to see the impact on maternal-neonatal health.

Disparities in who is asked about their perinatal mental health: an analysis of cross-sectional data from consecutive national maternity surveys

BACKGROUND

The perinatal period is a vulnerable time, with one in five women experiencing mental health problems. Antenatal and postnatal appointments are key contact points for identifying women in need of support. Since 2014, the UK National Institute for Health and Care Excellence (NICE) has recommended that all women be asked about their mental health at their antenatal booking appointment and early in the postnatal period. The aim of this study was to assess the proportions of women who reported being asked about their mental health during the perinatal period across consecutive national maternity surveys (NMS) in England and to evaluate sociodemographic disparities in who was asked.

METHODS

Secondary analysis was performed on cross-sectional data from the NMS in 2014-2020. In each survey, women reported whether they had been asked about their mental health antenatally (during their booking appointment) and postnatally (up to six months after giving birth). The proportions of women in each survey who reported being asked about their mental health were calculated and compared according to key sociodemographic characteristics and across survey years. Logistic regression was conducted to identify disparities in who was asked.

RESULTS

The proportion of women who reported being asked about their mental health antenatally increased from 80.3% (95%CI:79.0-81.5) in 2014 to 83.4% (95%CI:82.1-84.7) in 2020, yet the proportion of women who reported being asked postnatally fell from 88.2% (95%CI:87.1-89.3) in 2014 to 73.7% (95%CI:72.2-75.2) in 2020. Ethnic minority women (aOR range:0.20 ~ 0.67) were less likely to report being asked about their mental health antenatally and postnatally across all surveys compared to White women. Women living in less socioeconomically advantaged areas (aOR range:0.65 ~ 0.75) and women living without or separately from a partner (aOR range:0.61 ~ 0.73) were also less likely to report being asked about their mental health, although there was less consistency in these disparities across the antenatal and postnatal periods and across surveys.

CONCLUSIONS

Despite NICE recommendations, many women are still not asked about their mental health during the perinatal period, particularly after giving birth. Women from ethnic minority backgrounds are less likely to be asked and these disparities have persisted over time.

Addressing inequalities in the identification and management of perinatal mental health difficulties: The perspectives of minoritised women, healthcare practitioners and the voluntary sector

Background

Perinatal mental health (PMH) difficulties affect approximately one in five birthing women. If not identified and managed appropriately, these PMH difficulties can carry impacts across generations, affecting mental health and relationship outcomes. There are known inequalities in identification and management across the healthcare pathway. Whilst barriers and facilitators have been identified there is a lack of clarity about how these relate to the avoidable and unfair inequalities experienced by various groups of women. Further research is required to understand how to address inequalities in PMH.

Aim

To understand the key factors that enable and hinder access to PMH care for women from minoritised groups across the PMH care pathway, and how these have been affected by the COVID-19 pandemic.

Methods

A sequential mixed-methods approach gathered views and experiences from stakeholders in one region in northern England. This included an online survey with 145 NHS healthcare practitioners and semi-structured interviews with 19 women from ethnic minority and/or socio-economically deprived backgrounds who had experienced PMH difficulties, and 12 key informants from the voluntary and community sector workforce. Quantitative data were analysed using descriptive statistics and framework analysis was applied to qualitative data.

Findings

Barriers and facilitators were mapped using a socio-technical framework to understand the role of (i) processes, (ii) people (organised as women, practitioners and others), (iii) technology, and (iv) the system as a whole in deepening or alleviating inequalities. Influences that were identified as pertinent to inequalities in identification and management included provision of interpreters, digital exclusion, stigma, disempowerment, distrust of services, practitioner attitudes, data capture, representation in the workforce, narrow rules of engagement and partnership working. Stakeholder groups expressed that several barriers were further compounded by the COVID-19 pandemic.

Discussion

The findings highlight the need for change at the system level to tackle inequalities across the PMH care pathway. Four inter-connected recommendations were developed to enable this systems change: building emotional safety between professionals and women; making PMH a part of core healthcare business; increasing cultural competency specific to PMH; and enhanced partnership working.

A qualitative study of minority ethnic women's experiences of access to and engagement with perinatal mental health care

Background

Approximately one in five women will experience mental health difficulties in the perinatal period. However, for a large group of women, symptoms of adverse perinatal mental health remain undetected and untreated. This is even more so for women of ethnic minority background, who face a variety of barriers which prevents them from accessing appropriate perinatal mental health care.

Aims

To explore minority ethnic women’s experiences of access to and engagement with perinatal mental health care.

Methods

Semi-structured interviews were conducted with 18 women who had been diagnosed with perinatal mental health difficulties and who were supported in the community by a specialist perinatal mental health service in South London, United Kingdom. Women who self-identified as being from a minority ethnic group were purposefully selected. Data were transcribed verbatim, uploaded into NVivo for management and analysis, which was conducted using reflective thematic analysis.

Results

Three distinct overarching themes were identified, each with two or three subthemes: ‘Expectations and Experiences of Womanhood as an Ethnic Minority’ (Shame and Guilt in Motherhood; Women as Caregivers; Perceived to Be Strong and Often Dismissed), ‘Family and Community Influences’ (Blind Faith in the Medical Profession; Family and Community Beliefs about Mental Health and Care; Intergenerational Trauma and Family Dynamics) and ‘Cultural Understanding, Empowerment, and Validation’ (The Importance of Understanding Cultural Differences; The Power of Validation, Reassurance, and Support).

Conclusion

Women of ethnic minority background identified barriers to accessing and engaging with perinatal mental health support on an individual, familial, community and societal level. Perinatal mental health services should be aware ethnic minority women might present with mental health difficulties in different ways and embrace principles of cultural humility and co-production to fully meet these women’s perinatal mental health needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04698-9.

Experiences of Perinatal Mental Health Care among Minority Ethnic Women during the COVID-19 Pandemic in London: A Qualitative Study

(1) Background: Approximately one in five women will experience mental health difficulties in the perinatal period. Women from ethnic minority backgrounds face a variety of barriers that can prevent or delay access to appropriate perinatal mental health care. COVID-19 pandemic restrictions created additional obstacles for this group of women. This study aims to explore minority ethnic women's experiences of perinatal mental health services during COVID-19 in London. (2) Methods: Eighteen women from ethnic minority backgrounds were interviewed, and data were subject to a thematic analysis. (3) Results: Three main themes were identified, each with two subthemes: 'Difficulties and Disruptions to Access' (Access to Appointments; Pandemic Restrictions and Disruption), 'Experiences of Remote Delivery' (Preference for Face-to-Face Contact; Advantages of Remote Support); and 'Psychosocial Experiences' linked to COVID-19 (Heightened Anxiety; Social Isolation). (4) Conclusions: Women from ethnic minority backgrounds experienced disrupted perinatal mental health care and COVID-19 restrictions compounding their mental health difficulties. Services should take women's circumstances into account and provide flexibility regarding remote delivery of care.

How Key Psychological Theories Can Enrich Our Understanding of Our Ancestors and Help Improve Mental Health for Present and Future Generations: A Family Historian’s Perspective

Family historians could increase their understanding of their ancestors and themselves and improve the mental health of living and future generations if they consider the psychological history of their forebears. Genealogists could then begin to recognize their family’s unique psychological inheritance that can appear as a result of trauma, depression, or addiction. The author explores three generations of a Parker family branch from Huntingdon/Norfolk, England, to show family historians how such considerations can shed light on their family’s psychological legacy. The author does this by introducing us to her great-grandmother Ann grandfather Walter, and mother Doreen through the lens of attachment theory, and their adverse childhood experiences (ACEs) such as poverty, bereavement, and addiction. Attachment matters because it affects not only how safe we feel, our ability to regulate our emotions and stress, our adaptability, resilience, and lifelong mental and physical health, but attachment style can also be passed on. In addition, this paper utilizes attachment theory to speculate on the likely attachment styles for the three generations of the Parker family and looks at the possible parenting behavior in the first two, the effect of alcoholism and the intergenerational impact of trauma and depression.

Using the Consolidated Framework for Implementation Research to design and implement a perinatal education program in a large maternity hospital

BACKGROUND

Implementation science aims to embed evidence-based practice as 'usual care' using theoretical underpinnings to guide these processes. Conceptualising the complementary purpose and application of theoretical approaches through all stages of an implementation project is not well understood and is not routinely reported in implementation research, despite call for this. This paper presents the synthesis and a collective approach to application of a co-design model, a model for understanding need, theories of behaviour change with frameworks and tools to guide implementation and evaluation brought together with the Consolidated Framework for Implementation Research (CFIR).

METHOD

Using a determinant framework such as the CFIR provides a lens for understanding, influencing, and explaining the complex and multidimensional variables at play within a health service that contribute to planning for and delivering effective patient care. Complementary theories, models, frameworks, and tools support the research process by providing a theoretical and practical structure to understanding the local context and guiding successful local implementation.

RESULTS

This paper provides a rationale for conceptualising the multidimensional approach for implementation using the worked example of a pregnancy, birth, postnatal and early parenting education intervention for expectant and new parents at a large maternity hospital.

CONCLUSION

This multidimensional theoretical approach provides useful, practical guidance to health service researchers and clinicians to develop project specific rationale for their theoretical approach to implementation projects.