Preterm birth (PTB) is a final common outcome resulting from many interrelated etiological pathways; of particular interest is antenatal psychosocial distress (i.e., stress, anxiety, and depression). In LMI countries, both exposure to severe life stressors and rate of PTB are on average greater when compared with high-income countries. In LMI countries women are exposed to some of the most extreme psychosocial stress worldwide (e.g., absolute poverty, limited social resources). High prevalence of antenatal stress and depression have been observed in some studies from LMI countries. We propose a psychosocial, biological, and behavioral model for investigating the complex multisystem interactions in stress responses leading to PTB and explain the basis of this approach. We discuss ethical considerations for a psychosocial, biological, and behavioral screening tool to predict PTB from a LMI country perspective.
SSP conceptualized the paper, SS, ISY, FT and ML independently searched the literature to ensure reliability, SS and ISY screened for eligibility; SS, SSP, ISY independently reviewed articles deemed eligible to determine relevance for the review, SS, SSP, ISY, and FT synthesized and analyzed the data for the original draft which was written by SS and significantly edited and updated by SSP and ISY. SSP, ISY and ML critically revised and contributed to the work. All authors reviewed and approved the final manuscript.
Background
We determined whether dimensions of psychosocial distress during pregnancy individually and collectively predicted preterm birth (PTB) in Pakistani women as it may be misleading to extrapolate results from literature predominantly conducted in high-income countries.
Methods
This cohort study included 1603 women recruited from four Aga Khan Hospital for Women and Children in Sindh, Pakistan. The primary binary outcome of PTB (i.e., livebirth before 37 completed weeks’ gestation) was regressed on self-reported symptoms of anxiety (Pregnancy-Related Anxiety (PRA) Scale and Spielberger State-Trait Anxiety Inventory Form Y-1), depression (Edinburgh Perinatal Depression Scale (EPDS)), and covariates such as chronic stress (Perceived Stress Scale) assessed with standardized question and scales with established language equivalency (Sindhi and Urdu).
Results
All 1603 births occurred between 24 and 43 completed weeks’ gestation. PRA was a stronger predictor of PTB than other types of antenatal psychosocial distress conditions. Chronic stress had no effect on the strength of association between PRA and PTB and a slight but non-significant effect on depression. A planned pregnancy significantly lowered risk of PTB among women who experienced PRA. Aggregate antenatal psychosocial distress did not improve model prediction over PRA.
Conclusions
Like studies in high-income countries, PRA became a strong predictor of PTB when considering interactive effects of whether the current pregnancy was planned. Women’s resilience and abilities to make sexual and reproductive health decisions are important to integrate in future research. Findings should be generalized with caution as socio-cultural context is a likely effect modifier. We did not consider protective/strength-oriented factors, such as resilience among women.
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