Association between antenatal depression and low birthweight in a developing country.

OBJECTIVE: There is a high prevalence of depression in south Asian women. We aimed to examine the association between antenatal depression and low birthweight (LBW) in infants in a rural community in Rawalpindi, Pakistan. METHOD: A total of 143 physically healthy mothers with ICD-10 depression in the third trimester of pregnancy and 147 non-depressed mothers of similar gestation were followed from birth. Infant weight was measured and information collected on socioeconomic status, maternal body-mass index and sociodemographic factors. RESULTS: Infants of depressed mothers had lower birthweight (mean 2910 g) than infants of non-depressed mothers (mean 3022 g). The relative risk for LBW (< or =2500 g) in infants of depressed mothers was 1.9 (95% CI 1.3-2.9). The association remained significant after adjustment for confounders by multivariate analyses. CONCLUSION: Low birthweight is a major public health problem in developing countries. Maternal depression during pregnancy predicts LBW. Interventions aimed at maternal depression may help improve infant outcomes.

Maternal depression increases infant risk of diarrhoeal illness: --a cohort study.

AIMS: To examine the associations between postnatal depression in mothers and diarrhoeal illness in their infants in the first year of life in a low-income country. METHODS: Using a prospective cohort design, 265 infants (n = 130 of mothers having a depressive episode according to the International Classification of Diseases, 10th revision, at 3 months postnatal and n = 135 of psychologically well mothers) living in rural Rawalpindi, Pakistan, were followed up for 1 year. Frequency of diarrhoeal episodes was measured fortnightly by health workers using a standard questionnaire. RESULTS: Infants of depressed mothers had significantly more diarrhoeal episodes per year than those of controls (mean 5.5 v 4.0; 95% confidence interval (CI) 0.9 to 2.0). The relative risk of having > or =5 diarrhoeal episodes per year in infants of depressed mothers was 2.3 (95% CI 1.6 to 3.1). The association remained significant after adjustment for other risk factors by multivariate analysis. CONCLUSIONS: Maternal depression is associated with infant diarrhoeal morbidity in a low-income community setting. It is independent of the effects of known factors such as undernutrition, socioeconomic status and parental education. Preventive child health programmes targeting mothers must consider their mental health.

Mothers' mental health and infant growth: a case-control study from Rawalpindi, Pakistan.

BACKGROUND: Epidemiological studies in Pakistan show high rates of depression in women, while rates of malnutrition in children are also high. This study aimed to determine whether poor maternal mental health is associated with an increased risk of infant undernutrition. METHODS: Clinic-based case-control study. A total of 172 consecutive infants and their mothers attending for 9-month measles immunization were recruited over a 3-month period. Eighty-two undernourished infants [weight for age below the National Centre for Health Statistics (NCHS)/World Health Organization (WHO) third centile] were matched to 90 controls (weight for age above 10th centile), and their mothers interviewed for mental distress using the Self-Reporting Questionnaire (WHO SRQ-20, a psychiatric screening instrument). Infants' exposure to maternal distress (score > or = 10 on SRQ-20) and other potential risk or protective biological, social, socio-economic and family factors were measured. RESULTS: Mental distress determined by WHO SRQ-20 was associated with increased risk of undernutrition in infants (odds ratio 3.91, 95% confidence interval 1.95-7.86). This association remained significant after controlling for birthweight and social factors. CONCLUSION: Exposure to maternal mental distress is associated with undernutrition in 9-month infants in urban Pakistan. These mothers may represent a group whose children are at higher risk of ill health, and potentially be a specific target for advice on infant care. Early recognition and treatment of mental health problems in mothers may help reduce morbidity and mortality rates in children.

Tasks needed at the time of delivery.

PIP: Task setting is a practical way to match service provision with what is needed to resolve specific problems, it provides an opportunity to set quality guidelines for later use in evaluating services, and it provides an opportunity to set objectives for staff to update their skills or serve as the framework for initial training. Regular training sessions need to be arranged for all categories of health care providers in hospitals and health centers. The World Health Organization has recently prepared a poster which identifies the education and training needs, as well as the opportunities available to prevent maternal death from the main medical causes of infection, hypertensive disorders of pregnancy, abortion, hemorrhage, and obstructed labor. Tasks required at the time of delivery are considered at the community, health center, district hospital, and national levels.^ieng

How well are hospitals preventing iatrogenic HIV? A study of the appropriateness of blood transfusions in three hospitals in the Ashanti region, Ghana.

A study on the appropriateness of blood and blood product transfusions took place in three hospitals over a 3-week period in July/August 1990 in the Ashanti region of Ghana. Clinical records of all blood transfusion recipients within the period were examined for the appropriateness of the transfusions based on preset criteria. Nearly 1 in 5 (17%) of all blood transfusion episodes in the hospitals were avoidable according to these criteria. Surgical practices were associated, perhaps habitually, with many more avoidable blood transfusions than non-surgical medical practices. The need to minimize the use of transfusion therapy is reemphasized since human immunodeficiency virus screening is imperfect. There is the need for hospitals to develop reasonable, practical guidelines for transfusions in all departments.

Targeted interventions and infant mortality.

PIP: The main causes of infant mortality in 71% of the cases are diarrhea, measles, acute respiratory infection, and neonatal tetanus. A UN child survival strategy includes growth monitoring, oral rehydration, breast feeding, immunization, fertility, food and female literacy (GOBI-FFF). Previous research has shown a correlation between low levels of infant mortality and high levels of female literacy. Educated women are more likely to delay marriage, and childbearing. Child mortality is much higher for those born to women under 20 years old and also much higher for those born within 1 or 2 after the previous birth. Maternal mortality is also higher for mothers under 20 and with closely spaced births of 3 or more children. The majority of adults in developing countries have knowledge of family planning but teen pregnancy is a concern. Better nutrition during pregnancy would decrease infant deaths. Growth monitoring is another way to reduce infant mortality and morbidity. The difficulties are in the reluctance to adapt programs to local traditional methods of growth monitoring and going to direct recording scales. Immunization is estimated to have prevented over 3 million deaths from measles, tetanus, whooping cough and polio in 1984 alone. In spite of progress, only 50% of children in developing countries are immunized against diphtheria, pertussis, polio, and tetanus by the age of 1 year. these activities must be integrated into primary health care and community development projects to make better contact with people needing this service. oral rehydration therapy not only reduces mortality from diarrhea but can reduce morbidity by reducing the duration of the illness and by increasing the weight gain. Breast feeding has been shown in many studies to reduce the risk of deaths of infants. The promotion of breast feeding includes the issues of maternity leave, job security, and child care at the work place.^ieng

Adolescents and AIDS.

PIP: Several "rules of thumb" may be helpful in imparting to adolescents the information they need to know about AIDS. 1. Start where they are at. Pop concerts, holiday resorts, and schools are good places to reach young people, but devices must be used to catch their attention, such as "secret" questionnaires, letters to Tatta Christie's agony column, or agree/disagree lists of questions. 2. Remember that they like risky behavior. Unprotected sex is attractive to young people in the same way as trying alcohol or drugs. 3. Use multi-media and many information channels, including personal experience sharing. Television characters, such as "Condom Man," cartoons, booklets, call-in programs, teachers, clubs, health workers, and family planning clinics are some suggested channels of information. The International Clearinghouse on Adolescent Fertility's "Information Summary" is a good guide to use in educating adolescents about AIDS.^ieng

Lack of family planning leading to induced abortion in rural Greece.

PIP: 29 (31%) of the 94 mothers interviewed in a domiciliary study of the use of mother and child health services in rural northwest Greece reported they had undergone an induced abortion. Most of these women, between 30-40 years of age, had at least 2 children. There was no correlation with the mother's literacy, father's occupation, and family's socioeconomic situation. The rate of abortion reported in this study is consistent with the findings of other Greek studies in urban settings. In the current study it was difficult to identify the exact time when women had undergone the abortion as the topic was delicate. Yet, all women were prompt and sincere in their answers and willing to share their anxieties and their fears about possible effects on subsequent pregnancies. The women had gone to considerable efforts to obtain an induced abortion. These included the inconvenience of going to a doctor in the main town (40 miles away) and incurring travel costs as well as the cost of the operation, which is currently about 10,000 drachmas. Few women (36%) were using any contraceptive method. The 36% included 27% who used condoms and coitus interruptus, 7% the rhythm method, and 2% all 3 methods. Only a few of the more educated women had heard or read about other methods. All of the women were concerned about the risk of becoming pregnant when they used no method or a risky method. In Greece induced abortion is clearly a response to unwanted pregnancies, which follow the lack of family planning or birth spacing services. The government introduced legislation concerning the provision of family planning services in 1980, but the provision of these services has been very slow. Currently, only a few family planning clinics are operational and mainly in the large cities. 1 way to make some progress may be to develop interest in the provision of more appropriate primary health care and more appropriate training of doctors and other health workers. There are few experienced doctors practicing in rural Greece at this time. The key person for providing family planning care could be the rural midwife who is already a respected provider of family advice in the community. Needed is an active program to expand the provision of family planning services to the rural areas of Greece. Contraceptive services must be provided to enable people to limit the size of their family to the size they want without having to resort to abortion. It is time for health care providers to stop saying that what is needed is family planning education and to start providing the actual services.^ieng

A household study of the pattern of utilization of mother and child health services in rural Greece and variation by socioeconomic status.

PIP: A household study of all families with children under age 6 in 3 villages in rural northwest Greece was conducted during August-September 1981. 94 mothers were interviewed about each of their children to find out who they had consulted seeking advice and care during pregnancy, for delivery, during the postnatal period, for child immunization, and in cases of mild or severe child illness. All 142 children were examined physically and developmentally. Information was also collected on the socioeconomic status of the family. Particular causes for concern were the findings that 30% of the mothers said they experienced at least 1 induced abortion; 5% had delivered without the help of any trained birth attendant; most of those who delivered in the district town (usually the more affluent) had not received postnatal care; 37% of the children had not seen a doctor during their 1st year of life either for sickness or for a developmental assessment. Only 41% of the children were fully immunized for their age, and 23% of those who should have begun their immunizations had not. Most of the 30 children who had been severely or chronically ill had bypassed the local doctor and sought services in the district town. There was clear variation in the pattern of health services use and socioeconomic status as shown by the availability of household facilities including water and electricity. The poorer mothers (30% of the sample) were more likely than the more affluent mothers to have delivered at home. Many had had the help of the local midwife, but those who had no help from a trained attendant came from poorer families. Postnatal care was provided to most (79%) of the families by the midwife. The poorer the family, the more likely that a sick child would be treated with a home remedy. Children from poor families were likely never to have seen a doctor and if a child did go, it was likely to be older at the time of the 1st visit. Very few poor families had ever consulted a specialist. Mothers who were better off were more likely to have delivered in the district town at a private clinic with an obstetrician. They were unlikely to have received any postnatal care. Their children were likely to be younger when 1st taken to the doctor for a routine developmental checkup, usually during the 1st year of life. Home remedies were less likely to be used for child illnesses. It is suggested that the experienced rural community midwife is providing excellent service to mothers from all social strata antenatally; in delivery and postnatal care for poorer mothers, and in informal child care for all. She is well-respected in the community and knows and is well-known to all the children. It is suggested that the trend for more affluent mothers to go to the town for private health care may undermine the crucial role of the midwife at the village level in rural Greece in protecting the health of the poor and less educated mother.^ieng