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Keywords:

  • depression;
  • maternal health;
  • child health;
  • low birthweight;
  • premature birth;
  • Vietnam

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Objectives

To examine the association of low birthweight (LBW) and prematurity with clinically significant symptoms of antenatal common mental disorders (ACMDs) during the third trimester of pregnancy in a semi-rural area in Vietnam.

Methods

Prospective community-based cohort study. Severity of ACMD symptoms was assessed with the Edinburgh Depression Scale, low birthweight was defined as below 2500 g, and gestational age was estimated according to last menstrual period. Reproductive and socio-demographic risk factors were measured as potential confounders of the association between ACMD and the outcomes. We conducted bivariate analyses of association between ACMD and the perinatal outcomes, employing chi-square tests, crude odds ratios and 95% confidence intervals. Multiple logistic regression analysis was used to adjust for confounding.

Findings

We found a prevalence of clinically significant symptoms of ACMDs of 37.4%, which were significantly associated with preterm birth (adjusted OR 1.98, CI95% = 1.14–3.43) and low birthweight (adjusted OR 2.24, CI95% = 1.02–4.95). Among the examined risk factors for the outcome measures, only maternal age was found to be statistically significant for low birthweight and preterm birth.

Conclusions

This study confirms that clinically significant symptom levels of ACMD in Vietnam are associated with preterm birth and low birthweight. These findings highlight the importance of cost-effective public health interventions for ACMD in Vietnam and further exploration of its physiological link with preterm birth and low birthweight.

Objectifs

Examiner l'association entre le faible poids de naissance (FPN) et la prématurité avec des symptômes cliniquement significatifs de troubles mentaux prénataux courants (TMPC) au cours du troisième trimestre de la grossesse dans une zone semi-rurale au Vietnam.

Méthodes

Etude prospective de cohorte communautaire. La sévérité des symptômes de TMPC a été évaluée avec l’échelle de la dépression d'Edimbourg, le faible poids de naissance a été défini comme inférieur à 2500 grammes et l’âge gestationnel a été estimé d'après la dernière période menstruelle. Les facteurs de risque de reproduction et sociodémographiques ont été mesurés comme variables confusionnelles potentielles de l'association entre les TMPC et les résultats. Nous avons effectué des analyses bivariées de l'association entre les TMPC et les résultats périnataux, en employant les tests de Χ2, des odds ratios bruts et des intervalles de confiance à 95%. Une analyse de régression logistique multiple a été utilisée pour corriger selon les variables confusionnelles.

Résultats

Nous avons trouvé une prévalence de symptômes de TMPC cliniquement significatifs de 37,4%, qui étaient significativement associés à la prématurité (OR ajusté: 1,98; IC95% = 1,14 à 3,43) et au faible poids de naissance (OR ajusté: 2,24; IC95% = 1,02–4,95). Parmi les facteurs de risque examinés pour les mesures de résultats, seul l’âge de la mère a été trouvé statistiquement significatif pour le faible poids de naissance et la prématurité.

Conclusions

Cette étude confirme que des degrés de symptômes cliniquement significatifs de TMPC au Vietnam sont associés à la prématurité et au faible poids de naissance. Ces résultats soulignent l'importance du rapport coût-efficacité des interventions de santé publique pour les TMPC au Vietnam et l'exploration plus poussée de leur lien physiologique avec les naissances prématurées et le faible poids de naissance.

Objetivos

Examinar la asociación entre el bajo peso al nacer (BPN) y la prematuridad con síntomas clínicos significativos de de desórdenes mentales comunes prenatales (DMCP) en mujeres en el tercer trimestre de embarazo de un área semirural en Vietnam.

Métodos

Estudio de cohortes, prospectivo y basado en la comunidad. La severidad de los síntomas DMCP se evaluó utilizando la Escala de Depresión de Edimburgo, el bajo peso al nacer se definió como menos de 2500 gramos, y la edad gestacional se calculó según el último periodo menstrual. Los factores de riesgos reproductivos y sociodemográficos se midieron como posibles factores de confusión de la asociación entre DMCP y los resultados. Realizamos análisis bivariados de la asociación entre DMCP y los resultados perinatales, utilizando pruebas de Χ2, razón de probabilidades e intervalos de confianza del 95%. El análisis de regresión múltiple se utilizó para realizar el ajuste por los factores de confusión.

Hallazgos

Encontramos una prevalencia de síntomas clínicos significativos de DMCP del 37.4%, que estaban significativamente asociados con el nacimiento prematuro (OR ajustado 1.98, IC95% = 1.14–3.43) y bajo peso al nacer (OR ajustado 2.24, IC95% = 1.02–4.95). Entre los factores de riesgo examinados para los resultados, solo la edad de la madre era estadísticamente significativa para el bajo peso al nacer y el nacimiento prematuro.

Conclusiones

Este estudio confirma que unos niveles clínicamente significativos de síntomas de DMCP en Vietnam están asociados con un nacimiento prematuro y un bajo peso al nacer. Estos hallazgos subrayan la importancia de las intervenciones de salud pública coste-efectivas para DMCP en Vietnam, así como de explorar más a fondo su relación fisiológica con un nacimiento prematuro y bajo peso al nacer.


Background

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Common mental disorders (CMDs) describe non-psychotic mental health conditions including depressive, anxiety, adjustment and somatoform disorders that compromise day-to-day functioning (Andersson et al. 2004), the most common of which in pregnancy are depression and anxiety (Bailey & Cole 2009). A meta-analysis of studies published up to 2011 found that the average prevalence of maternal antenatal CMD was 15.6% in low- and lower middle-income countries, which is at least 50% higher than in high-income countries (Beck et al.). Among women of childbearing age (15–44 years) (Beck et al. 2010), depression is the global leader in terms of disease-related disability (Bergman et al. 2010). In Ho Chi Minh City, Vietnam, the prevalence rate of post-partum depression (33%) is higher than the mean prevalence rate in low-income countries (19.8%) (Beck et al.; Bodnar & Wisner 2005). A recent study in north Vietnam showed a 29.9% prevalence rate of perinatal common mental disorders, with higher rates in rural regions (Bonari et al. 2004). In contrast, a small exploratory study performed at an urban antepartum clinic in Hanoi, Vietnam, with socio-economically advantaged women documented a low prevalence rate of 1.6% of antenatal depression (Boyd et al. 2005).

Preterm birth and low birthweight (LBW) are major determinants of infant mortality and morbidity (Chuc & Diwan 2003), and among the almost 8 million children that die each year, 4.6% come from South-East Asia (Cox et al. 1987). A LBW infant, that is, below 2500 g (Dayan et al. 2002), is at higher risk of facing a number of health problems, including adverse cognitive development (Dayan et al. 2006), chronic diseases (Diego et al. 2009) or inhibited growth (Dossett 2008). Preterm birth, that is, birth before 37 completed weeks of gestation, is associated with increased rates of cerebral palsy, sensory deficits, learning disabilities, respiratory illnesses and death (Field et al. 2006).

Depression during pregnancy can harm the mother and the child in serious ways concerning morbidity and mortality (Field et al. 2009), ultimately leading to suicide or infanticide (Fisher et al. 2004). Also, there is growing evidence that maternal anxiety in pregnancy can compromise the neurobiological development of the foetus (Fisher et al. 2007, 2010). Antenatal depression negatively affects pregnant women regarding attendance at antenatal care, substance abuse and lower weight gain during pregnancy (Fisher et al. 2012), which in turn increase the likelihood of preterm birth, LBW and neonatal mortality (Giang et al. 2010). While a number of studies in high-income countries have shown an association between antenatal depression/anxiety and preterm birth (Goldberg & Huxley 1992; Goldenberg et al. 2000), there is a paucity of equivalent studies performed in low-income countries. Some studies from India (Hendrick et al. 1998), Pakistan (Hoffman et al. 2008) and Bangladesh (Jehan et al. 2010) have shown an association between antenatal depression/anxiety and LBW, whereas the results from high-income countries have been more mixed (Kessler 2003; Klingberg-Allvin et al. 2010), suggesting that the association may only be apparent under certain contextual circumstances. CMD may also be a marker for another, yet undefined variable present in only certain populations (Goldberg & Huxley 1992). Thus, there is need for further research on these associations in various contexts.

The aim of this study was to examine the association of LBW and preterm birth with clinically significant symptoms of antenatal common mental disorders during the third trimester of pregnancy in a semi-rural area in Vietnam.

Methods

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Setting

The study was conducted in the Ba Vi district of the Hanoi Province, which is a semi-rural area in north Vietnam. Agricultural production and livestock breeding make up 81 per cent of the area's economic activities. Data were collected through a demographic surveillance system (DSS) with 51 024 inhabitants (approximately 20% of the population) in 11 089 households from 67 clusters, selected randomly from the total of 352 clusters in the area. The DSS was created to be representative of the population in the district, and data are collected through quarterly household surveys and a baseline survey every two years, since 1999. The DSS has been funded by the Swedish International Development Agency (Sida) since 1997 (Leitner et al. 2007). The overall aim of the DSS has been to generate basic health data to supply information for health planning and policy-making, serve as a background and sampling frame for specific studies, and provide a setting for epidemiology and public health training of master and doctoral students. The funding and operation of the DSS ended in 2011, but previously gathered data are still available for research. Survey data are collected by 35 surveyors, who are in charge of approximately 300–400 households. All surveyors have at least completed secondary school and are regularly trained and supervised by supervisors. Supervisors are responsible for seven surveyors each, have some form of medical education and re-interview 10% of the participants for quality assurance. The baseline survey covers socio-demographic factors such as household income, religious affiliation, number of family members, education, etc. The tri-monthly follow-up questions concern deaths, births, pregnancies, changes in marital status and migration. In addition to collecting routine DSS survey data, we used the infrastructure of DSS data collection to collect Edinburgh Depression Scale (EDS) data through the quarterly household surveys. This was carried out in collaboration with the director of the DSS and after approval from the ethical committee at the Hanoi Medical University.

Participants

Instead of a sample size calculation, pragmatic concerns determined the sample size for this study. A cohort consisting of all pregnant women from the DSS study population was recruited during the study period between March and October 2008. Only women with singleton pregnancies were included in the study, while those who experienced stillbirths, neonatal deaths, deaths in utero and migrated out of the study area were excluded from the study. Data were collected from all remaining pregnant women (n = 355) in their third trimester. Informed consent was obtained from all participants, where an informed consent form was signed after a verbal (in case of illiteracy) or written description of the study had been given. Participants were thus informed that the EDS data collection was not a part of the routine DSS survey and that participation in the EDS survey was voluntary even if they had given consent to participate in the routine DSS data collection procedures. With regard to outcome data apart from EDS survey data, all approached participants had already previously agreed to participate in routine DSS surveys for research purposes and signed DSS informed consent forms. The study was approved by the Regional Research Ethics Committee, Stockholm, Sweden, and the Research Ethics Committee at Hanoi Medical University, Vietnam.

Assessment of antenatal common mental disorders

Severity of antenatal common mental disorder (ACMD) symptoms was assessed with the 10-item self-report EDS (Martin-Gronert & Ozanne 2007), translated to Vietnamese (Bodnar & Wisner 2005) and validated in Vietnam for perinatal common mental disorders (Nasreen et al. 2010). The EDS is the most established and widely used instrument for assessment of depression around pregnancy (O'Connor et al. 2002), as it does not rely on somatic symptoms that are normative in pregnancy. The participants were identified through the pregnancy surveys, which are conducted in each surveyed DSS household trimonthly, in case a pregnant DSS participant is identified. The length of parity was thus identified from the pregnancy survey data on last menstrual period. Thereafter, each participant was visited in their homes by one of the 35 routine DSS surveyors in their third trimester of pregnancy to collect EDS data. The surveyors were trained by the DSS data collection supervisors to administer the EDS in a standardised manner, in accordance with step-by-step written guidelines provided by the research team. The surveyors were thus instructed to complete questionnaires at the informants' homes, in a private room where they could not be overheard. This procedure was checked by the supervisors of the DSS data collection in every tenth case in the same manner as in routine DSS survey procedures described above. Both DSS surveyors and supervisors have previous experience of mental health surveys, as research projects using mental health assessments have previously been conducted within the DSS. As the informants in the study area were not accustomed to completing questionnaires, the EDS questions were delivered in an interview format by the surveyors, where surveyors filled in the questionnaire according to the verbal answer of the participant. The EDS has a maximum score of 30, and the validated cut-off score to distinguish between probable cases of common mental disorders in Vietnam is 3 of 4 (Nasreen et al. 2010).

Assessment of other risk factors

A number of reproductive and socio-demographic risk factors were measured as potential confounders of the association between ACMD and the outcomes. These risk factors were extracted from data routinely collected through the DSS household surveys by the 35 surveyors of the DSS as described above and included having two or more children, the sex of the baby, the woman's relation to the head of household (dichotomised as the woman being head of household, yes or no), the household economic status (in accordance with the classification system of the Vietnam Ministry of Labour, Invalids and Social Affairs, based on a number of variables but mainly on the total amount of rice per person/month, dichotomised as low/average or upper average/high), the woman's age less or more than/equal to 25 years and vaginal bleeding during pregnancy (yes or no). Smoking status was not considered as only one woman in the cohort smoked.

Outcome measures

Infant birthweight is measured upon birth in the labour room when the birth is institutional; in our study cohort, only one birth was at home, and the baby was thus excluded from analysis as it was not weighed. LBW was defined as 2500 g or less, and birthweight measures were collected through the women's verbal report at the household survey, of the weight measured in the labour room. Gestational age was estimated as the time between the women's self-reported first day of last menstruation and birth. Preterm birth was defined as birth before 37 completed weeks of gestation. Caesarean sections were excluded from the analyses even if they were performed preterm, because a preterm caesarean section may have been conducted due to other pregnancy complications and may thus not indicate spontaneous preterm labour.

Statistical analysis

We performed descriptive analyses on the baseline characteristics of study participants. We conducted bivariate analyses of association between clinically significant symptoms of ACMD and the perinatal outcomes, where chi-square tests, crude odds ratios and 95% confidence intervals were used. Backward stepwise multiple logistic regression analysis (significance level set to 5%) was used for adjusting for confounding, where age and economic status were used as a priori confounders.

Results

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Sample profile

Three hundred and fifty-five women were identified in their second/third trimester of pregnancy (Figure 1). All pregnant women who were approached for the study agreed to participate. Pregnancy length data were missing for two participants, who were thus excluded. Thus, three hundred and thirty-four pregnant women (94%), recruited at a mean of 36.6 (CI95% = 35.9–37) weeks of gestation, were included in the analysis of preterm birth and ACMD. The women's mean age was 24.1 years (CI95%: = 23.6–24.7), they had a mean number of 1.4 children (CI95% = 1.3–1.5), and almost 19% of the respondents were primiparas. Almost all (99%) respondents were married, while one was divorced and three were widowed. Two-thirds (66%) of the mothers were farmers and 75% lived in households with low or average economic status and 25% in households with upper average or high economic status. For the analysis of low birthweight, we excluded one woman from the sample whose baby was not weighed, leaving 333 women.

image

Figure 1. Flow chart of participants in the study.

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Prevalence and determinants of ACMD

Among the mothers who were included in the analysis, 37.4% (n = 125, CI95% = 32.2–42.6%) of individuals scored above three in the EDS. The mean score of the mothers included in the analysis was 3.54 (CI95% = 3.08–3.99). A clinically significant symptom level of ACMD was not significantly associated with any of the examined risk factors (number of children, baby's sex, relation to head of household, household economic status, age and vaginal bleeding).

Prevalence and determinants of low birthweight

The proportion of LBW infants was 8.4% (n = 28, CI95% = 5.4–11.4%). ACMD was significantly associated with LBW (OR = 2.40 and CI95% = 1.09–5.25). In the univariate analyses with LBW as outcome variable, LBW was not significantly associated with any of the explanatory variables apart for maternal age over 25 years. Thus, the odds ratio was only adjusted for confounding by a priori confounder's age and economic status (Table 1). The multivariate logistic regression model including all presumed risk factors is shown in Table 2.

Table 1. Association of baseline socio-economic characteristics and ACMD with LBW
Baseline characteristics (n = 333)Incident cases of LBW, n (%)Incident cases of birthweight > 2500 g, n (%)OR (CI95%)Adjusted OR
  1. OR (odds ratio), Econ. Stat. (economic status).

Antenatal common mental disorders
Yes16 (13%)109 (87%)2.40 (1.09–5.25)2.24 (1.02–4.95)
No12 (6%)196 (94%)
Age, years
≥ 2523 (11%)191 (89%)2.75 (1.02–7.42)2.59 (0.95–7.04)
< 255 (4%)114 (96%)
Econ. stat.
Low Average/High23 (9%)225 (91%)1.64 (0.60–4.45)1.51 (0.55–4.17)
age/High5 (6%)80 (94%)
Table 2. Association of examined risk factors with LBW
Baseline characteristics (n = 333)Incident cases of LBW, n (%)Incident cases of birthweight > 2500 g, n(%)OR (CI95%)Adjusted OR
  1. OR (odds ratio), Econ. Stat. (economic status), N. children (number of children), Vag. Bleeding (vaginal bleeding during pregnancy), HOHH (head of household).

Antenatal common mental disorders
Yes16 (13%)109 (87%)2.40 (1.09–5.25)2.17 (0.98–4.82)
No12 (6%)196 (94%)
Age, years
≥ 2523 (11%)191 (89%)2.75 (1.02–7.42)2.77 (0.95–8.02)
< 255 (4%)114 (96%)
Econ. Stat.
Low23 (9%)225 (91%)1.64 (0.60–4.45)1.58 (0.57–4.41)
Average/High5 (6%)80 (94%)
Baby sex
Girl16 (10%)152 (90%)1.34 (0.61–2.93)1.32 (0.59–2.94)
Boy12 (7%)152 (93%)
N. children
≤ 225 (9%)261 (91%)1.41 (0.41–4.85)0.83 (0.21–3.20)
> 23 (6%)44 (94%)
Vag. Bleeding
Yes2 (14%)7 (78%)3.28(0.65–16.58)3.73 (0.67–20.94)
No26 (8%)298 (92%)
HOHH
No28 (9%)294 (91%)
Yes0 (0%)11 (100%)

Prevalence and determinants of preterm birth

The proportion of preterm infants was 19.8% (n = 66, CI95% = 15.5–24.1%). ACMD was significantly associated with preterm birth (OR = 2.07 and CI95% = 1.20–3.56). This association was maintained in the multivariate logistic regression model (Table 3). Apart from ACMD, preterm birth was only significantly associated with maternal age over 25 years (OR: 1.95, CI95%: 1.06–3.61). Thus, the odds ratio was only adjusted for confounding by a priori confounder's age and economic status (Table 3). The multivariate logistic regression model including all presumed risk factors is shown in Table 4.

Table 3. Association of baseline socio-economic characteristics and ACMD with preterm birth
Baseline characteristics (n = 334)Incident cases of preterm birth, n (%)Incident cases of birth at term, n (%)OR (CI95%)Adjusted OR
  1. OR (odds ratio), Econ. Stat. (economic status).

Antenatal common mental disorders
Yes8 (42%)11 (58%)2.07 (1.20–3.56)1.98 (1.14–3.43)
No58 (18%)257 (82%)
Age, years
≥ 2550 (23%)165 (77%)1.95 (1.06–3.61)1.86 (1.00–3.47)
< 2516 (13%)103 (87%)
Econ. stat.
Low52 (21%)197 (79%)1.34 (0.70–2.561.25 (0.65–2.43)
Average/High14 (16%)71 (84%)
Table 4. Association of examined risk factors with preterm birth
Baseline characteristics (n = 334)Incident cases of preterm birth, n (%)Incident cases of birth at term, n(%)OR (CI95%)Adjusted OR
  1. OR (odds ratio), Econ. Stat. (economic status), Vag. Bleeding (vaginal bleeding during pregnancy), HOHH (head of household).

Antenatal common mental disorders
Yes8 (42%)11 (58%)2.07 (1.20–3.56)2.00 (1.13–3.40)
No58 (18%)257 (82%)
Age, years
≥ 2550 (23%)165 (77%)1.95 (1.06–3.61)1.82 (0.96–3.45)
< 2516 (13%)103 (87%)
Econ. Stat.
Low52 (21%)197 (79%)1.34 (0.70–2.561.27 (0.65–2.46)
Average/High14 (16%)71 (84%)
Vag. Bleeding
Yes2 (22%)7 (78%)1.17 (0.24–5.74)1.19 (0.23–6.15)
No64 (20%)261 (80%)
HOHH
No65 (20%)258 (80%)0.40 (0.05–3.16)0.73 (0.09–6.21)
Yes1 (9%)10 (91%)

Discussion

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

This study found a prevalence of clinically significant symptom levels of antenatal common mental disorders of 37.4% when estimated with the Edinburgh Depression Scale. ACMD was significantly associated with LBW and preterm birth. None of the other examined risk factors were found to be statistically significant for ACMD. None of the other examined risk factors, apart for maternal age over 25 years, were statistically significant for LBW and preterm birth.

We are aware of some limitations in our study. We were not able to recruit participants according to a sample size calculation due to resource restrictions. A larger sample size may also have shown association with additional risk factors. As a screening instrument, the EDS does not compensate for a clinical diagnosis. However, it is the most widely used screening scale for post-natal depression and common mental disorders in the world, and its validity in various settings has been assessed (Patel & Prince 2006). A recent validation study among women in the perinatal period in Vietnam found that it has a sensitivity of 69.7%, a specificity of 72.9% and a correct classification rate of 69.7% in detecting perinatal common mental disorders (Nasreen et al. 2010).

We did not have the possibility to personally weigh the newborns, but had to rely on the mothers' verbal account of the weight taken in the delivery room. Although the procedures for weighing newborns are standardised in the Vietnamese healthcare setting, we cannot be sure whether standard procedures were followed for each individual case. Thus, there was possibly some rate of measurement bias in the birthweight measures. We are not able to estimate the error in ascertainment of birthweight in the study, but we do not expect this form of bias to have been systematic in terms of the exposure (ACMD) status. Intimate partner violence may be an additional important confounder of the association between ACMD and preterm birth (Beck et al. ; Patel et al. 2003), and not including this risk factor in our study can be regarded a weakness.

The reliability of LMP measures for estimating length of parturition in both high- and low-income country settings is a topic of continued discussion (Rahman et al. 2007; Rosenberg et al. 2009), although its main weakness is in predicting post-term birth (Rahman et al. 2007; Sanchez et al. 2012). LMP is widely used to estimate the duration of pregnancy (Rosenberg et al. 2009; Sanchez et al. 2012). Factors decreasing the reliability of LMP include recall bias and vaginal bleeding in early pregnancy, which tends to be more common for women with antenatal stress and anxiety. This could be a possible confounder of the association between preterm birth and ACMD, although such confounding was not observed in our study.

The rates of clinically significant symptoms of ACMD found in our study were high compared with global rates, but similar to rates found in three other studies in Vietnam, which varied from 20% to 33% in both rural and urban populations (Bonari et al. 2004; Bodnar & Wisner 2005; Santos et al. 2007). One Vietnamese study found very low rates of antenatal depression among socio-economically advantaged urban residents (Boyd et al. 2005). Another study in the same setting as the present one found a 6.8% prevalence rate of mental distress among women (Stewart 2005), which is much lower than our result. These variations may reflect both methodological factors and the variance in the contextual distribution of risk and protective factors. In addition, the validated EDS cut-off score used in our study was much lower than that in the other studies that used the EDS (Bodnar & Wisner 2005; Boyd et al. 2005).

The association found in our study between ACMD and preterm birth is consistent with a number of studies in high-income countries (Goldberg & Huxley 1992; Goldenberg et al. 2000; Kessler 2003). This link may be due to a number of reasons such as poor self-care among depressed/anxious mothers (Hendrick et al. 1998), which may increase the occurrence of other risk factors such as intrauterine infection (Suri et al. 2007), and effects mediated through the hypothalamic–pituitary axis (Tran et al. 2011). We also found an association between ACMD and LBW, which was a replication of findings in other low-income country settings including India (Hendrick et al. 1998), Pakistan (Hoffman et al. 2008) and Bangladesh (Tuan et al. 2003). Results from high-income countries on such an association have been more mixed (Kessler 2003; Klingberg-Allvin et al. 2010), and positive associations have been reported mainly in studies of disadvantaged populations where socio-economic status has acted as a modifier (Dossett 2008). Thus, it is of interest for future studies to examine why such associations exist mainly in conditions of socio-economic adversity. The association may be mediated through psychoneuroendocrine function (UNDP 2008) as well as maternal behaviour factors such as reduced attendance at antenatal care, increased substance use and lower weight gain during pregnancy (Wadhwa et al. 2004). Another plausible explanation for the association may be that ACMD and preterm birth have some risk factors in common. A recent review of risk factors for perinatal common mental disorders in low- and middle-income countries (Beck et al. ) indicated rural residence and intimate partner violence as important – both of which may also act as risk factors for preterm birth/LBW (Patel et al. 2003; Wardlaw et al. 2004).

The rate of preterm birth in our study was high (19.8%), but corresponds to previous findings in the same setting (WHO 2008). A recent meta-analysis has found a rate of 11% for preterm births in South-East Asia (Chuc & Diwan 2003). A possible reason for the high rate is that using LMP as a measure may cause overestimation of preterm birth rates (Rosenberg et al. 2009). However, we would not expect an eventual overestimation to have changed the association between ACMD and preterm birth. On the other hand, the rates of LBW (8.4%) found in our study were similar to those found in a previous study: In 2004, the rate of LBW for Vietnam was estimated at 9% (You et al. 2011). Surprisingly, we did not find any association between almost any of the examined outcomes and risk factors, although the evidence base for such associations is vast. This may reflect low statistical power of the study.

Implications

Despite its weaknesses, this study also has strengths. The study population was selected to be representative of a typical rural district in Vietnam – 70% of the population in Vietnam live in rural settings (Zscheck & Murray 1990). The use of an internationally widely used rating scale for depression allows comparison with other studies worldwide. Also, the association found in our study between ACMD and preterm birth and ACMD and LBW was strong.

Conclusions

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

This prospective community-based cohort study confirms findings made in high-income country settings, and the repeated finding of an association between LBW and ACMD in the South Asian region was replicated in the Vietnam setting. These findings, together with the predicted increase in depression rates worldwide, highlight the importance of cost-effective public health interventions for ACMD in Vietnam. Further exploration of the physiological link between ACMD and preterm birth and LBW is recommended, so that the common antecedents can be addressed.

References

  1. Top of page
  2. Abstract
  3. Background
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
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