The impact of the Covid-19 pandemic on postnatal anxiety and posttraumatic stress: Analysis of two population-based national maternity surveys in England

BACKGROUND

Few studies have evaluated postnatal anxiety and posttraumatic stress (PTS) before and during the Covid-19 pandemic using comparable data across time. We used data from two national maternity surveys in England to explore the impact of the pandemic on prevalence and risk factors for postnatal anxiety and PTS.

METHODS

Analysis was conducted using population-based surveys carried out in 2018 (n = 4509) and 2020 (n = 4611). Weighted prevalence estimates for postnatal anxiety and PTS were compared across surveys. Adjusted risk ratios (aRR) were estimated for the association between risk factors and postnatal anxiety and PTS.

FINDINGS

Prevalence of postnatal anxiety increased from 13.7 % in 2018 to 15.1 % in 2020 (+1.4 %(95%CI:-0.4-3.1)). Prevalence of postnatal PTS increased from 9.7 % in 2018 to 11.5 % in 2020 (+1.8 %(95%CI:0.3-3.4)), due to an increase in PTS related to birth trauma from 2.5 % to 4.3 % (+1.8 %(95%CI:0.9-2.6); there was no increase in PTS related to non-birth trauma. Younger age (aRR = 1.31-1.51), being born in the UK (aRR = 1.29-1.59), long-term physical or mental health problem(s) (aRR = 1.27-1.94), and antenatal anxiety (aRR = 1.97-2.22) were associated with increased risk of postnatal anxiety and PTS before and during the pandemic, whereas higher satisfaction with birth (aRR = 0.92-0.94) and social support (aRR = 0.81-0.82) were associated with decreased risk.

INTERPRETATION

Prevalence of postnatal PTS was significantly higher during the pandemic, compared to before the pandemic, due to an increase in PTS related to birth trauma. Prevalence of postnatal anxiety was not significantly higher during the pandemic. Risk factors for postnatal anxiety and PTS were similar before and during the pandemic.

Women's awareness of perinatal mental health conditions and the acceptability of being asked about mental health in two regions in India: a qualitative study

BACKGROUND

Mental health conditions are common during pregnancy and the first year after childbirth. Early detection allows timely support and treatment to be offered, but identifying perinatal mental health conditions may be challenging due to stigma and under-recognition of symptoms. Asking about symptoms of mental health conditions during routine antenatal and postnatal appointments can help to identify women at risk. This study explores women's awareness of perinatal mental health conditions, their views on the acceptability of being asked about mental health and any preference for specific assessment tools in two regions in India.

METHODS

Focus group discussions (FGDs) were conducted with pregnant, post-partum and non-perinatal women in Kangra, Himachal Pradesh (northern India) and Bengaluru, Karnataka (southern India). Settings included a hospital antenatal clinic and obstetric ward, Anganwadi Centres and Primary Health Centres. FGDs were facilitated, audio-recorded and transcribed. Narratives were coded for emerging themes and analysed using thematic analysis.

RESULTS

Seven FGDs including 36 participants were conducted. Emerging themes were: manifestations of and contributors to mental health conditions; challenges in talking about mental health; and the acceptability of being asked about mental health. Difficult familial relationships, prioritising the needs of others and pressure to have a male infant were cited as key stressors. Being asked about mental health was generally reported to be acceptable, though some women felt uncomfortable with questions about suicidality. No preference for any specific assessment tool was reported.

CONCLUSIONS

Women face many stressors during the perinatal period including difficult familial relationships and societal pressure to bear a male infant. Being asked about mental health was generally considered to be acceptable, but questions relating to suicidality may be challenging in a community setting, requiring sensitivity by the interviewer. Future studies should assess the acceptability of mental health assessments in 'real world' antenatal and postnatal clinics and explore ways of overcoming the associated challenges in resource-constrained settings.

Interventions to improve perinatal outcomes among migrant women in high-income countries: a systematic review protocol

INTRODUCTION

Women who are migrants and who are pregnant or postpartum are at high risk of poorer perinatal outcomes compared with host country populations due to experiencing numerous additional stressors including social exclusion and language barriers. High-income countries (HICs) host many migrants, including forced migrants who may face additional challenges in the peripartum period. Although HICs' maternity care systems are often well developed, they are not routinely tailored to the needs of migrant women. The primary objective will be to determine what interventions exist to improve perinatal outcomes for migrant women in HICs. The secondary objective will be to explore the effectiveness of these interventions by exploring the impact on perinatal outcomes. The main outcomes of interest will be rates of preterm birth, birth weight, and number of antenatal or postnatal appointments attended.

METHODS AND ANALYSIS

This protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocols guidelines. EMBASE, EMCARE, MEDLINE and PsycINFO, CENTRAL, Scopus, CINAHL Plus, and Web of Science, as well as grey literature sources will be searched from inception up to December 2022. We will include randomised controlled trials, quasi-experimental and interventional studies of interventions, which aim to improve perinatal outcomes in any HIC. There will be no language restrictions. We will exclude studies presenting only qualitative outcomes and those including mixed populations of migrant and non-migrant women. Screening and data extraction will be completed by two independent reviewers and risk of bias will be assessed using the Quality Assessment Tool for Quantitative Studies. If a collection of suitably comparable outcomes is retrieved, we will perform meta-analysis applying a random effects model. Presentation of results will comply with guidelines in the Cochrane Handbook of Systematic Reviews of Interventions and the PRISMA statement.

ETHICS AND DISSEMINATION

Ethical approval is not required. Results will be submitted for peer-reviewed publication and presented at national and international conferences. The findings will inform the work of the Lancet Migration European Hub.

PROSPERO REGISTRATION NUMBER

CRD42022380678.

Prevalence and risk factors for postnatal mental health problems in mothers of infants admitted to neonatal care: analysis of two population-based surveys in England

BACKGROUND

Previous research suggests that mothers whose infants are admitted to neonatal units (NNU) experience higher rates of mental health problems compared to the general perinatal population. This study examined the prevalence and factors associated with postnatal depression, anxiety, post-traumatic stress (PTS), and comorbidity of these mental health problems for mothers of infants admitted to NNU, six months after childbirth.

METHODS

This was a secondary analysis of two cross-sectional, population-based National Maternity Surveys in England in 2018 and 2020. Postnatal depression, anxiety, and PTS were assessed using standardised measures. Associations between sociodemographic, pregnancy- and birth-related factors and postnatal depression, anxiety, PTS, and comorbidity of these mental health problems were explored using modified Poisson regression and multinomial logistic regression.

RESULTS

Eight thousand five hundred thirty-nine women were included in the analysis, of whom 935 were mothers of infants admitted to NNU. Prevalence of postnatal mental health problems among mothers of infants admitted to NNU was 23.7% (95%CI: 20.6-27.2) for depression, 16.0% (95%CI: 13.4-19.0) for anxiety, 14.6% (95%CI: 12.2-17.5) for PTS, 8.2% (95%CI: 6.5-10.3) for two comorbid mental health problems, and 7.5% (95%CI: 5.7-10.0) for three comorbid mental health problems six months after giving birth. These rates were consistently higher compared to mothers whose infants were not admitted to NNU (19.3% (95%CI: 18.3-20.4) for depression, 14.0% (95%CI: 13.1-15.0) for anxiety, 10.3% (95%CI: 9.5-11.1) for PTS, 8.5% (95%CI: 7.8-9.3) for two comorbid mental health problems, and 4.2% (95%CI: 3.6-4.8) for three comorbid mental health problems six months after giving birth. Among mothers of infants admitted to NNU (N = 935), the strongest risk factors for mental health problems were having a long-term mental health problem and antenatal anxiety, while social support and satisfaction with birth were protective.

CONCLUSIONS

Prevalence of postnatal mental health problems was higher in mothers of infants admitted to NNU, compared to mothers of infants not admitted to NNU six months after giving birth. Experiencing previous mental health problems increased the risk of postnatal depression, anxiety, and PTS whereas social support and satisfaction with birth were protective. The findings highlight the importance of routine and repeated mental health assessments and ongoing support for mothers of infants admitted to NNU.

The impact of the Covid-19 pandemic on postnatal depression: analysis of three population-based national maternity surveys in England (2014-2020)

Background

Few studies have evaluated postnatal depression before and during the Covid-19 pandemic using comparable data across time. We used data from three national maternity surveys in England to compare prevalence and risk factors for postnatal depression before and during the pandemic.

Methods

Analysis was conducted using population-based surveys carried out in 2014 (n = 4571), 2018 (n = 4509), and 2020 (n = 4611). Weighted prevalence estimates for postnatal depression (EPDS score ≥13) were compared across surveys. Modified Poisson regression was used to estimate adjusted risk ratios (aRR) for the association between sociodemographic, pregnancy- and birth-related, and biopsychosocial factors, and postnatal depression.

Findings

Prevalence of postnatal depression increased from 10.3% in 2014 to 16.0% in 2018 (difference = +5.7% (95% CI: 4.0-7.4); RR = 1.55 (95% CI: 1.36-1.77)) and to 23.9% in 2020 (difference = +7.9% (95% CI: 5.9-9.9); RR = 1.49 (95% CI: 1.34-1.66)). Having a long-term mental health problem (aRR range = 1.48-2.02), antenatal anxiety (aRR range = 1.73-2.12) and antenatal depression (aRR range = 1.44-2.24) were associated with increased risk of postnatal depression, whereas satisfaction with birth (aRR range = 0.89-0.92) and social support (aRR range = 0.73-0.78) were associated with decreased risk before and during the pandemic.

Interpretation

This analysis indicates that Covid-19 had an important negative impact on postnatal women's mental health and may have accelerated an existing trend of increasing prevalence of postnatal depression. Risk factors for postnatal depression were consistent before and during the pandemic. Timely identification, intervention and follow-up are key to supporting women at risk, and it is essential that mechanisms to support women are strengthened during times of heightened risk such as the pandemic.

Funding

NIHR Policy Research Programme.

Persistent depression in pregnant refugee and migrant women living along the Thai-Myanmar Border: a secondary qualitative analysis

Background Antepartum depression affects around 15% of pregnant women worldwide, and may negatively impact their infants' physical, cognitive and social development, and confer a greater risk of emotional dysregulation in their children. Risk factors for antepartum depression disproportionately affect women from resource-sparse settings. In particular, pregnant refugee and migrant women face many barriers to diagnosis and care of mental health conditions, yet this group is under-represented in the literature. This study explores what refugee and migrant women living along the Thai-Myanmar border perceive as being contributory and protective factors to their antepartum depression, through secondary qualitative analysis of responses to clinical interviews for depression. Methods Previous research investigating perinatal depression in pregnant refugee and migrant women on the Thai-Myanmar border involved assessing 568 women for depression, using the Structured Clinical Interview for the diagnosis of DSM-IV Disorders (SCID). This study analyses a subsample of 32 women, diagnosed with persistent depression during the antepartum period. Thematic analysis of responses to the SCID and social and demographic surveys was undertaken to investigate factors which contribute towards, or protect against, persistent antepartum depression. Results Major themes which women described as contributing towards persistent antepartum depression were financial problems, interpersonal violence, substance misuse among partners, social problems and poor health. Factors women considered as protecting mental wellbeing included social support, accessible healthcare and distractions, highlighting the need for focus on these elements within refugee and migrant settings. Commonly expressed phrases in local Karen and Burmese languages were summarised. Conclusions Knowledge of factors affecting mental wellbeing in the study population and how these are phrased, may equip stakeholders to better support women in the study area. This study highlighted the limitations of contextually generic diagnostic tools, and recommends the development of tools better suited to marginalised and non-English speaking groups.

Prevalence of perinatal anxiety in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Perinatal anxiety is associated with adverse outcomes for women and their infants. Women in low- and middle-income countries (LMIC) may be at higher risk of perinatal anxiety. We aimed to systematically review and synthesise the evidence on prevalence of perinatal anxiety in LMIC.

METHOD

We searched MEDLINE, Embase, PscyhINFO, Global Health and Web of Science to identify studies assessing prevalence of perinatal anxiety in LMIC. Studies published since January 2016 were included. Screening and data extraction was conducted independently by two reviewers. Pooled prevalence estimates were calculated using random-effect meta-analyses and sources of heterogeneity explored through subgroup analyses and meta-regression.

RESULTS

We screened 9494 titles and abstracts, reviewed 700 full-texts and included 54 studies in the systematic review and meta-analysis. The pooled prevalence of self-reported anxiety symptoms was 29.2% (95%CI 24.5-34.2; I² 98.7%; 36 studies; n = 28,755) antenatally and 24.4% (95%CI 16.2-33.7; I² 98.5%; 15 studies; n = 6370) postnatally. The prevalence of clinically-diagnosed anxiety disorder was 8.1% (95%CI 4.4-12.8; I² 88.1% 5 studies; n = 1659) antenatally and 16.0% (95% CI 13.5-18.9; n = 113) postnatally.

LIMITATIONS

Our search was limited to studies published since January 2016 in order to update a previous review on this topic.

CONCLUSION

Perinatal anxiety represents a significant burden in LMIC, with one in four women experiencing symptoms during pregnancy or postpartum. Research remains lacking in a significant proportion of LMIC, particularly in the lowest income countries. Further research should guide application of screening tools in clinical settings to identify women with anxiety disorders in order to provide appropriate treatment.

Validated tools to identify common mental disorders in the perinatal period: A systematic review of systematic reviews

BACKGROUND

Uncertainty remains regarding the validity of screening tools to detect common mental disorders (CMDs) during perinatal periods. This umbrella review aims to provide an up-to-date summary of psychometric properties of tools for the identification of perinatal CMDs.

METHODS

Reviews were identified via Ovid MEDLINE, PsychINFO, EMBASE, Global Health and Cochrane Database of Systematic Reviews electronic databases with no date or language restriction. Pooled sensitivity and specificity estimates and ranges were extracted and summarised using forest plots. Quality assessment was conducted using Measurement Tool to Assess Systematic Reviews (AMSTAR-2).

RESULTS

Of 7,891 papers identified, 31 reviews met inclusion criteria. 76 screening tools were identified; most frequently validated were Edinburgh Postnatal Depression Scale (EPDS) (n = 28 reviews), Beck's Depression Inventory (BDI) (n = 13 reviews) and Patient Health Questionnaire (PHQ) (n = 12 reviews). Forest plots demonstrated a pattern of decreasing sensitivity and increasing specificity with increasing cut-off scores. Sub-group analysis of data extracted from low quality reviews demonstrated wider 95% CIs and overall lower specificity. Validity also varied according to ethnicity, socio-economic background and age.

LIMITATIONS

Despite a low Covered Corrected Area (CCA) score the primary studies included within reviews overlapped; therefore we were unable perform meta-analysis.

CONCLUSIONS

The evidence suggests that the EPDS, PHQ and BDI are useful across a range of diverse settings but the context of tool application is a key factor determining validity. This review highlights that utilizing screening tools in clinical practice is complex and requires careful consideration of the population, context, and health system it will be used in.

Perinatal mental health in India: protocol for a validation and cohort study

BACKGROUND

Common mental disorders (CMD) are among the largest contributors to global maternal morbidity and mortality. Although research on perinatal mental health in India has grown in recent years, important evidence gaps remain, especially regarding CMD. Our study aims to improve understanding of CMD among perinatal and non-perinatal women of reproductive age across two settings in India: Bangalore (Karnataka) and Tanda (Himachal Pradesh).

METHODS

The study is embedded within the Maternal and Perinatal Health Research Collaboration India (MaatHRI). This mixed-methods observational study comprises three consecutive phases: (i) focus group discussions and individual interviews to explore women's knowledge and seek feedback on CMD screening tools; (ii) validation of CMD screening tools; and (iii) prospective cohort study to identify CMD incidence, prevalence and risk factors among perinatal and non-perinatal women. Results of the three phases will be analyzed using inductive thematic analysis, psychometric analysis and multivariable regression analysis, respectively.

CONCLUSION

Improving understanding, detection and management of CMD among women is key to improving women's health and promoting gender equality. This study will provide evidence of CMD screening tools for perinatal and non-perinatal women in two diverse Indian settings, produce data on CMD prevalence, incidence and risk factors and enhance understanding of the specific contribution of the perinatal state to CMD.

Suicidal ideation in the perinatal period: findings from the Thailand-Myanmar border

BACKGROUND

Suicide is a leading cause of maternal death globally. Migrant and refugee populations may experience higher risk of suicide. We report data on suicidal ideation from migrant and refugee women living on the Thailand-Myanmar border.

METHODS

Women were recruited in their first trimester of pregnancy. Depression status was assessed by diagnostic interview in the first, second and third trimesters and at 1 month post-partum. We calculated prevalence of suicidal ideation and used logistic regression to identify associated socio-demographic factors.

RESULTS

During the perinatal period, 5.3% (30/568) women experienced suicidal ideation. Refugee women were more likely to experience suicidal ideation than migrant women (8.0 versus 3.1%; P = 0.01). Most women with suicidal ideation did not have severe depression. Previous trauma (OR 2.32; 95% CI: 1.70-3.15) and unplanned pregnancy (OR 2.74; 95% CI: 1.10-6.86) were significantly associated with suicidal ideation after controlling for all other variables.

CONCLUSIONS

Suicidal ideation represents an important symptom among migrant and refugee women on the Thailand-Myanmar border. Screening only those with severe depression may be insufficient to identify women at risk of suicide. Community-level interventions addressing social and gender inequalities and prioritization of family planning programmes are needed alongside targeted suicide prevention initiatives to help lower the rates of people dying by suicide.

Perinatal depression in migrant and refugee women on the Thai-Myanmar border: does social support matter?

Migrant and refugee women are at risk of perinatal depression due to stressors experienced before, during and after migration. This study assesses the associations between social support and perinatal depression among migrant and refugee women on the Thai-Myanmar border. We conducted a cohort study of pregnant and post-partum women. Depression status was assessed using a structured clinical interview. Received support, perceived support and partner support were measured in the third trimester. Logistic regression was used to calculate associations between social support measures and perinatal depression controlling for demographic, socio-economic, migration, obstetric and psychosocial factors. Four hundred and fifty-one women (233 migrants; 218 refugees) were included. The prevalence of perinatal depression was 38.6% in migrants and 47.3% in refugees. Migrants had higher levels of received, perceived and partner support than refugees. After controlling for all other variables, higher levels of received support remained significantly associated with a lower likelihood of perinatal depression in migrants (adjusted odds ratio 0.82; 95% CI 0.68-0.99). In both groups, depression history and trauma were strongly associated with perinatal depression. Our study highlights the importance of received social support to perinatal depression in migrant women on the Thailand-Myanmar border. The perinatal period offers a valuable opportunity to ask women about their support and offer community-level or public policy interventions to nurture support networks in current locations and resettlement destinations. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Validated screening tools to identify common mental disorders in perinatal and postpartum women in India: a systematic review and meta-analysis

BACKGROUND

Perinatal common mental disorders are associated with significant adverse outcomes for women and their families, particularly in low- and middle-income settings. Early detection through screening with locally-validated tools can improve outcomes.

METHODS

We searched MEDLINE, Embase, PsycINFO, Global Health, Cochrane Library, Web of Science and Google Scholar for articles on the validation of screening tools for common mental disorders in perinatal women in India, with no language or date restrictions. Quality was assessed using the QUADAS-2 tool. We used bivariate and hierarchical summary receiver operating characteristic models to calculate pooled summary estimates of sensitivity and specificity. Heterogeneity was assessed by visualising the distance of individual studies from the summary curve.

RESULTS

Seven studies involving 1003 women were analysed. All studies assessed the validity of the Edinburgh Postnatal Depression Scale (EPDS) in identifying perinatal depression. No validation studies of any other screening tools were identified. Using a common threshold of ≥13 the EPDS had a pooled sensitivity and specificity of 88·9% (95%CI 77·4-94·9) and 93·4 (95%CI 81·5-97·8), respectively. Using optimal thresholds (range ≥ 9 to ≥13) the EPDS had a pooled sensitivity and specificity of 94·4% (95%CI 81·7-98·4) and 90·8 (95%CI 83·7-95·0), respectively.

CONCLUSION

The EPDS is psychometrically valid in diverse Indian settings and its use in routine maternity care could improve detection of perinatal depression. Further research is required to validate screening tools for other perinatal common mental disorders in India.

Shortening the Edinburgh postnatal depression scale using optimal test assembly methods: Development of the EPDS-Dep-5

AIMS

This study used a large database to develop a reliable and valid shortened form of the Edinburgh Postnatal Depression Scale (EPDS), a self-report questionnaire used for depression screening in pregnancy and postpartum, based on objective criteria.

METHODS

Item responses from the 10-item EPDS were obtained from 5157 participants (765 major depression cases) from 22 primary screening accuracy studies that compared the EPDS to the Structured Clinical Interview for DSM (SCID). Unidimensionality of the EPDS latent construct was verified using confirmatory factor analysis, and an item response theory model was fit. Optimal test assembly (OTA) methods identified a maximally informative shortened form for each possible scale length between 1 and 9 items. The final shortened form was selected based on pre-specified validity and reliability criteria and non-inferiority of screening accuracy of the EPDS as compared to the SCID.

RESULTS

A 5-item short form of the EPDS (EPDS-Dep-5) was selected. The EPDS-Dep-5 had a Cronbach's alpha of 0.82. Sensitivity and specificity of the EPDS-Dep-5 for a cutoff of 4 or greater were 0.83 (95% CI, 0.73, 0.89) and 0.86 (95% CI, 0.80, 0.90) and were statistically non-inferior to the EPDS. The correlation of total scores with the full EPDS was high (r = 0.91).

CONCLUSION

The EPDS-Dep-5 is a valid short form with minimal loss of information when compared to the full-length EPDS. The EPDS-Dep-5 was developed with OTA methods using objective, pre-specified criteria, but the approach is data-driven and exploratory. Thus, there is a need to replicate results of this study in different populations.

Identifying postnatal depression: Comparison of a self-reported depression item with Edinburgh Postnatal Depression Scale scores at three months postpartum

BACKGROUND

Early identification of postnatal depression is important in order to minimize adverse outcomes. The Edinburgh Postnatal Depression Scale (EPDS) is commonly used as a screening tool but a single, direct question on depression may offer an alternative means of identifying women in need of support. This study examines the agreement between these methods and characteristics of women who self-identify as depressed and those with EPDS ≥ 13.

METHODS

Secondary analysis of two national maternity surveys conducted in England and Northern Ireland. Agreement between the direct question and EPDS scores was assessed using Cohen's kappa. Logistic regression was used to identify characteristics of women in each group.

RESULTS

6752 women were included. At three months postpartum, 6.1% of women self-identified as having depression, 9.1% scored EPDS ≥ 13, 2.8% were positive on both. Agreement between the two methods was minimal (Cohen's kappa < 0.3). Women who self-identified as having depression had higher odds of being aged > 40 years (OR 1.8; 95% CI 1.2-2.8). EPDS ≥ 13 was associated with < 16 years of education (OR 1.4; 95% CI 1.1-1.8), minority ethnicity (OR 1.4; 95% CI 1.1-1.9), living without a partner (OR 1.7; 95% CI 1.3-2.2), and a less than happy reaction to the pregnancy (OR 1.7; 95% CI 1.4-2.1).

LIMITATIONS

Low survey response limits the representativeness of findings. The absence of a diagnostic interview limits conclusions on accuracy or internal validity of the measures.

CONCLUSIONS

A direct question about postnatal depression may offer a valuable addition to screening tools to identify women in need of support.

Health impacts of parental migration on left-behind children and adolescents: a systematic review and meta-analysis

BACKGROUND

Globally, a growing number of children and adolescents are left behind when parents migrate. We investigated the effect of parental migration on the health of left behind-children and adolescents in low-income and middle-income countries (LMICs).

METHODS

For this systematic review and meta-analysis we searched MEDLINE, Embase, CINAHL, the Cochrane Library, Web of Science, PsychINFO, Global Index Medicus, Scopus, and Popline from inception to April 27, 2017, without language restrictions, for observational studies investigating the effects of parental migration on nutrition, mental health, unintentional injuries, infectious disease, substance use, unprotected sex, early pregnancy, and abuse in left-behind children (aged 0-19 years) in LMICs. We excluded studies in which less than 50% of participants were aged 0-19 years, the mean or median age of participants was more than 19 years, fewer than 50% of parents had migrated for more than 6 months, or the mean or median duration of migration was less than 6 months. We screened studies using systematic review software and extracted summary estimates from published reports independently. The main outcomes were risk and prevalence of health outcomes, including nutrition (stunting, wasting, underweight, overweight and obesity, low birthweight, and anaemia), mental health (depressive disorder, anxiety disorder, conduct disorders, self-harm, and suicide), unintentional injuries, substance use, abuse, and infectious disease. We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs) using random-effects models. This study is registered with PROSPERO, number CRD42017064871.

FINDINGS

Our search identified 10 284 records, of which 111 studies were included for analysis, including a total of 264 967 children (n=106 167 left-behind children and adolescents; n=158 800 children and adolescents of non-migrant parents). 91 studies were done in China and focused on effects of internal labour migration. Compared with children of non-migrants, left-behind children had increased risk of depression and higher depression scores (RR 1·52 [95% CI 1·27-1·82]; SMD 0·16 [0·10-0·21]), anxiety (RR 1·85 [1·36-2·53]; SMD 0·18 [0·11-0·26]), suicidal ideation (RR 1·70 [1·28-2·26]), conduct disorder (SMD 0·16 [0·04-0·28]), substance use (RR 1·24 [1·00-1·52]), wasting (RR 1·13 [1·02-1·24]) and stunting (RR 1·12 [1·00-1·26]). No differences were identified between left-behind children and children of non-migrants for other nutrition outcomes, unintentional injury, abuse, or diarrhoea. No studies reported outcomes for other infectious diseases, self-harm, unprotected sex, or early pregnancy. Study quality varied across the included studies, with 43% of studies at high or unclear risk of bias across five or more domains.

INTERPRETATION

Parental migration is detrimental to the health of left-behind children and adolescents, with no evidence of any benefit. Policy makers and health-care professionals need to take action to improve the health of these young people.

FUNDING

Wellcome Trust.

Living with severe perinatal depression: a qualitative study of the experiences of labour migrant and refugee women on the Thai-Myanmar border

BACKGROUND

Perinatal depression is an important contributor to maternal morbidity and mortality worldwide. Migrant women, particularly those resettling within low- and middle-income settings, are at increased risk of perinatal depression due to multiple stressors experienced before, during and after migration. Evidence on migrant perinatal mental health to date has focused largely on women in high-income destination countries, leaving the voices of displaced women in low-income settings unheard. This study addresses the current evidence gap by exploring the experiences of migrant women living on the Thai-Myanmar border.

METHODS

In-depth interviews were conducted with pregnant and post-partum labour migrant and refugee women on the Thai-Myanmar border who had been diagnosed with severe depression. An interview guide covering women's current and past life experiences, social support and the impact of depression on social and occupational functioning was used as a prompt. Thematic analysis was used to identify themes emerging from women's narratives.

RESULTS

Eleven pregnant and post-partum women with severe perinatal depression took part. Participating women provided extensive insight into the many difficult aspects of their lives that they perceived as contributing to their depression status. Predominant themes emerging from women's narratives included difficult relationships with partners, challenging life situations, mechanisms for coping with depression and impressions of mental health care.

CONCLUSIONS

Labour migrant and refugee women with severe perinatal depression face a wide range of chronic stressors at the individual, household and community levels that are likely to have both short- and long-term negative effects on their mental well-being and day-to-day functioning. Participating women responded positively to the mental health support they received, and findings provide important insights into how services might further support their needs.

Adolescents' perceptions and experiences of pregnancy in refugee and migrant communities on the Thailand-Myanmar border: a qualitative study

BACKGROUND

Adolescent pregnancy remains a global health concern, contributing to 11% of all births worldwide and 23% of the overall burden of disease in girls aged 15-19 years. Premature motherhood can create a negative cycle of adverse health, economic and social outcomes for young women, their babies and families. Refugee and migrant adolescent girls might be particularly at risk due to poverty, poor education and health infrastructure, early marriage, limited access to contraception and traditional beliefs. This study aims to explore adolescents' perceptions and experiences of pregnancy in refugee and migrant communities on the Thailand-Myanmar border.

METHODS

In June 2016 qualitative data were collected in one refugee camp and one migrant clinic along the Thailand-Myanmar border by conducting 20 individual interviews with pregnant refugee and migrant adolescents and 4 focus group discussions with husbands, adolescent boys and non-pregnant girls and antenatal clinic staff. Inductive thematic analysis was used to identify codes and themes emerging from the data.

RESULTS

Study participants perceived adolescent pregnancy as a premature life event that could jeopardise their future. Important themes were premarital sex, forced marriage, lack of contraception, school dropout, fear of childbirth, financial insecurity, support structures and domestic violence. Supportive relationships with mothers, husbands and friends could turn this largely negative experience into a more positive one. The main underlying reasons for adolescent pregnancy were associated with traditional views and stigma on sexual and reproductive health issues, resulting in a knowledge gap on contraception and life skills necessary to negotiate sexual and reproductive choices, in particular for unmarried adolescents.

CONCLUSIONS

Adolescents perceive pregnancy as a challenging life event that can be addressed by developing comprehensive adolescent-friendly sexual and reproductive health services and education in refugee and migrant communities on the Thailand-Myanmar border. Creating a more tolerant and less stigmatising environment in these communities and their governing bodies will help to achieve this goal.

Validation of the Refugee Health Screener-15 for the assessment of perinatal depression among Karen and Burmese women on the Thai-Myanmar border

Perinatal depression is common, and left untreated can have significant and long-lasting consequences for women, their children and their families. Migrant women are at particular risk of perinatal depression as a result of a multitude of stressors experienced before, during and after migration. Identification of perinatal depression among migrant women-particularly those living in low- and middle-income regions-remains challenging, partly due to the lack of locally-validated and culturally appropriate screens tools. This study formally validates Burmese and Sgaw Karen versions of the Refugee Health Screener-15 (RHS-15) as a screening tool for perinatal depression among migrant women living on the Thai-Myanmar border. The Structured Clinical Interview for the Diagnosis of DSM-IV Disorders (SCID) was used as the gold-standard comparator. Complete results were obtained for 235 Burmese-speaking and 275 Sgaw Karen-speaking women. Despite displaying reasonable psychometric properties, a number of shortcomings associated with the RHS-15 limited its utility in this setting. The Likert-type response categories of the RHS-15 proved problematic in this low-literacy population. Combined with the relative superiority and greater ease of administration of the SCID, the RHS-15 is not recommended as the tool of choice for detecting perinatal depression in this setting.

Migrant perinatal depression study: a prospective cohort study of perinatal depression on the Thai-Myanmar border

PURPOSE

Perinatal depression is a significant contributor to maternal morbidity. Migrant women in resource-poor settings may be at increased risk, yet little research has been conducted in low-income and middle-income settings. This prospective cohort study of migrant women on the Thai-Myanmar border aims to establish prevalence of perinatal depression, identify risk factors for perinatal depression and examine associations with infant outcomes.

PARTICIPANTS

Participating women are labour migrants and refugees living on the Thai-Myanmar border. A total of 568 women were recruited in their first trimester of pregnancy and are being followed up to 1-year postpartum.

FINDINGS TO DATE

At baseline, women in our study had a median age of 25 years, the predominant ethnicity was Sgaw Karen (48.9%), agriculture was the main employment sector (39.2%) and educational attainment was low with a median of 4 years of education. In the first trimester of pregnancy, a quarter (25.8%; 95% CI 22.3 to 29.5) of all women were depressed as diagnosed by the Structured Clinical Interview for the Diagnosis of DSM-IV Disorders.

FUTURE PLANS

Follow-up is ongoing and expected to continue until January 2018. The prevalence of depression at later stages of pregnancy and during the first postpartum year will be identified, and associations between depression status and demographic, social, migration-related, medical, obstetric and infant factors will be quantified.

TRIAL REGISTRATION NUMBER

NCT02790905.

Current efforts in medical education to incorporate national health priorities

As a reflection on the Edinburgh Declaration, this conceptual synthesis presents six important challenges in relation to the role of medical education in meeting current national health priorities.

CONTEXT

This paper presents a conceptual synthesis of current efforts in medical education to incorporate national health priorities as a reflection on how the field has evolved since the Edinburgh Declaration. Considering that health needs vary from country to country, our paper focuses on three broad and cross-cutting themes: health equity, health systems strengthening, and changing patterns of disease.

METHODS

Considering the complexity of this topic, we conducted a targeted search to broadly sample and critically review the literature in two phases. Phase 1: within each theme, we assessed the current challenges in the field of medical education to meet the health priority. Phase 2: a search for various strategies in undergraduate and postgraduate education that have been tested in an effort to address the identified challenges. We conducted a qualitative synthesis of the literature followed by mapping of the identified challenges within each of the three themes with targeted efforts.

FINDINGS

We identified six important challenges: (i) mismatch between the need for generalist models of health care and medical education curricula's specialist focus; (ii) attitudes of health care providers contributing to disparities in health care; (iii) the lack of a universal approach in preparing medical students for 21st century health systems; (iv) the inability of medical education to keep up with the abundance of new health care technologies; (v) a mismatch between educational requirements for integrated care and poorly integrated, specialised health care systems; and (vi) development of a globally interdependent education system to meet global health challenges. Examples of efforts being made to address these challenges are offered.

DISCUSSION

Although strategies for combatting these challenges exist, the effectiveness of educational models depends on them being locally adaptable and applicable. Curricular reform must go hand-in-hand with research and evaluation to develop comprehensive futuristic models of teaching and learning that will adequately prepare health professionals to address the challenges.

Validation of the Edinburgh Postnatal Depression Scale (EPDS) on the Thai-Myanmar border

Postnatal depression is common and may have severe consequences for women and their children. Locally validated screening tools are required to identify at-risk women in marginalised populations. The Edinburgh Postnatal Depression Scale (EPDS) is one of the most frequently used tools globally. This cross-sectional study assessed the validity and acceptability of the EPDS in Karen and Burmese among postpartum migrant and refugee women on the Thai–Myanmar border. The EPDS was administered to participants and results compared with a diagnostic interview. Local staff provided feedback on the acceptability of the EPDS through a focus group discussion. Results from 670 women showed high accuracy and reasonable internal consistency of the EPDS. However, acceptability to local staff was low, limiting the utility of the EPDS in this setting despite its good psychometrics. Further work is required to identify a tool that is acceptable and sensitive to cultural manifestations of depression in this vulnerable population.

Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Migrant women are at risk of perinatal mental disorders due to stressors experienced before, during and after migration.

OBJECTIVES

This systematic review and meta-analysis summarises the prevalence, associated factors and interventions for perinatal mental disorders in migrant women from low- and middle-income countries (LMIC).

SEARCH STRATEGY

We systematically searched nine electronic databases and the grey literature using a predefined search strategy.

SELECTION CRITERIA

Studies were included if they assessed pregnant or postpartum migrants from LMIC, used a structured tool and a case-control, cross-sectional, cohort or intervention study design.

DATA COLLECTION AND ANALYSIS

Data was double-extracted. We calculated pooled prevalence of depression and weighted mean anxiety and depression scores. We calculated crude odds ratios from risk factor studies and summarised intervention studies descriptively.

MAIN RESULTS

Forty studies were identified from 10 123 references. Pooled prevalence was 31% [95% condidence interval (CI) 23%-40%] for any depressive disorder and 17% (95% CI 12-23%) for major depressive disorder. Previous depression and lower social support were associated with perinatal depression. There were insufficient data to assess the burden of anxiety, post-traumatic stress disorder or psychosis in this population.

CONCLUSIONS

One in three migrant women from LMIC experiences symptoms of perinatal depression. Social support is an important protective factor. Evidence on LMIC women relocating to other LMIC is lacking. Given the adverse consequences of perinatal mental illness on women and their children, further research in low-resource settings is a priority.

TWEETABLE ABSTRACT

One in three migrant women from low- and middle-income countries has symptoms of perinatal depression.

Paired suicide in a young refugee couple on the Thai-Myanmar border

A young refugee woman attended antenatal clinic on the Thai-Myanmar border at 9 weeks' gestation. As part of an ongoing study of perinatal mental health, she underwent a structured psychiatric interview during which she described occasional depressed mood, anhedonia and passive suicidal ideation. Her husband was a young refugee known to use alcohol and drugs. 2 days later, the couple committed suicide together by herbicide ingestion. Refugee populations are at risk of developing mental disorders as a result of their marginalised status, socioeconomic disadvantage and exposures to trauma. Pregnancy may have exacerbated feelings of hopelessness in this couple. The prevalence of mental disorders such as depression is increased in the perinatal period and suicide is the second leading cause of death in young women globally. Prevention programmes and early recognition of mental disorders may improve detection and lead to better support for vulnerable individuals.

Pregnant migrant and refugee women's perceptions of mental illness on the Thai-Myanmar border: a qualitative study

Background

Mental illness is a significant contributor to the global burden of disease, with prevalence highest in low- and middle-income countries. Rates are high in women of childbearing age, especially during pregnancy and the first year post-partum. Migrant and refugee populations are at risk of developing mental illness due to the multiple stressors associated with migration. The Thai-Myanmar border area is home to large populations of migrants and refugees as a result of long-standing conflict, poverty and unemployment in Myanmar. This study aims to explore perceptions of mental illness among pregnant migrants and refugees and antenatal clinic staff living and working along the Thai-Myanmar border.

Methods

Thirteen focus group discussions were conducted with pregnant migrants, pregnant refugees and antenatal clinic staff. Focus groups were held in one large refugee camp and two migrant health clinics along the Thai-Myanmar border. Thematic analysis was used to identify and code themes emerging from the data.

Results

A total of 92 pregnant women and 24 antenatal clinic staff participated. Discussions centered around five main themes: symptoms of mental illness; causes of mental illness; suicide; mental illness during pregnancy and the post-partum period; and managing mental illness. Symptoms of mental illness included emotional disturbances, somatic symptoms and socially inappropriate behavior. The main causes were described as current economic and family-related difficulties. Suicide was frequently attributed to shame. Mental illness was thought to be more common during and following pregnancy due to a lack of family support and worries about the future. Talking to family and friends, medication and hospitalization were suggested as means of helping those suffering from mental illness.

Conclusions

Mental illness was recognized as a concept by the majority of participants and there was a general willingness to discuss various aspects of it. More formal and systematic training including the development of assessment tools in the local languages would enable better ascertainment and treatment of mental illness in this population.

Tobacco smoking among migrant factory workers in Shenzhen, China

BACKGROUND

While several studies of smoking behaviors in rural-to-urban Chinese migrants exist, none to our knowledge have focused on factory workers, estimated to represent between 10% and 20% of China's total rural-to-urban migratory population. This paper assesses factors associated with smoking behavior among rural-to-urban migrant factory workers in Shenzhen, China.

METHODS

A cross-sectional survey of migrant workers from 44 randomly selected factories in Shenzhen, China. Participants were migrant factory workers aged 16-59 years and holding nonlocal household registration. The main outcome measures were demographic, migration-related, and behavioral factors associated with smoking status.

RESULTS

Four thousand and eighty-eight completed questionnaires were obtained (response rate 95.5%). Overall smoking prevalence (including occasional, daily, and heavy daily smoking) was 19.1%. The prevalence of daily smoking (including heavy daily smoking) was higher in men (27.3%) than women (0.7%). These rates are significantly lower than national smoking rates (59.5% in men, 3.7% in women) and rates found in a similar study. A high-risk group of men who smoke heavily and consume alcohol frequently was identified. Longer working hours and less rest were associated with higher rates of smoking. Frequent Internet use and lack of insurance were associated with lifetime smoking. Gender-adjusted models showed that poorer mental health and an accumulated working time in Shenzhen of 2-3 years increased female workers' likelihood of smoking.

CONCLUSIONS

Migrant factory workers in Shenzhen had lower rates of smoking than other population groups in China. The identification of risk factors for heavy smoking may help to effectively target health promotion interventions.

Epidemiology of community-onset Clostridium difficile infection in a community in the South of England

BACKGROUND AND AIMS

Clostridium difficile infection (CDI) has traditionally been considered a hospital acquired infection but there are a rising number of infections in the community. This study estimates the prevalence of community-onset CDI (CO-CDI), defined as onset of symptoms in a community setting and outside the hospital, and examines the risk factors for CO-CDI in 2-64 year-olds.

METHODS

A standard questionnaire was used to retrospectively obtain information on the CDI risk factors of 58 cases of CO-CDI diagnosed between 1st April 2008 and 31st March 2009 in a community in the South of England. Each case was reviewed for the presence of 'established' risk factors for CDI, i.e., age ≥65 years, in-patient hospital stay, and recent (within ≤4 weeks) receipt of broad spectrum antibiotics, and other, 'non-established' risk factors for CDI, such as exposure to antibiotics more than 4 weeks preceding symptom onset, out-patient and day-surgery hospital exposure, contact with a hospitalised patient, and travel outside of the UK.

RESULTS

Fifty-eight cases of CO-CDI were diagnosed among a total community population of 418,000, representing an estimated prevalence of CO-CDI of 1.29 per 10,000. All 58 cases were successfully contacted, representing a 100% response rate. Four cases were excluded from further analysis due to co-infection with Salmonella spp. and Campylobacter spp. Cases were more likely to be female, aged between 31 and 40 years, and present in the spring season (March-May), 2009. 46.3% (25/54) of cases had established risk factors for CDI, 20.4% (11/54) had non-established risk factors, 16.7% (9/54) had no risk factors and in the remaining 16.7% (9/54), available information was insufficient to classify by risk factor category.

CONCLUSIONS

This study suggests that CDI should be included in the differential diagnosis of community-onset diarrhea in patients with or without established risk factors for CDI.