How a mother’s stress can decide when her baby arrives

"It's a mystery why a woman's uterus goes into contraction early. Is it the baby that says I've had enough? Is it the mother who asks it to get out?"

That's how the Dean of the School of Midwifery and Nursing (SONAM) at Aga Khan University (AKU), Dr Salimah Walani, opened the session on Thursday. "Most research [on maternal health] is on how to save babies," but we don't know enough about how a mother's mental health affects her unborn child.

According to Professor and Sally Smith Chair in Nursing at Queen's University in Canada, Dr Shahirose Sadrudin Premji, research shows that when a pregnant woman's emotional well-being suffers, it increases the likelihood of pre-term births. She said that as of 2020, Pakistan had a rate of preterm births between 15.8% to 21.6%, with just over 61 infant deaths per 1000 on average, and 154 maternal deaths per 100'000 live births (over a period of 42 days).

The dissemination seminar at AKU on Maternal Mental Health During Pregnancy: Impact on Generations to Come detailed the results of seven years of work on a project on maternal mental health. Out of 190 million pregnancies in low and middle-income countries each year, 63 million women face mental health concerns during pregnancy, shared Dr Premji.

They enrolled 1,404 healthy, pregnant Pakistani women from various areas and across different socioeconomic brackets, excluding those who were users of mood-altering drugs, victims of terrorism, those suffering from pregnancy-related illnesses or HIV/AIDS. These factors would have skewed the data, she said. On average, the participants were in their late 20s and early 30s with varying educational backgrounds.

Read: Brain and Mind: Experts push for multi-layered mental health solutions, not just tertiary care

"The main objectives of the project were to understand the pathways linking psychosocial distress and preterm birth... We have 14 peer-reviewed publications that are a result of this effort."

One publication, presented by Assistant Professor at AKU-SONAM Dr Sharifa Lalani, addressed whether psychosocial distress during pregnancy could predict pre-term births (PTB). She said that all available data on this topic was gathered from high-income countries, and this was misrepresentative of Pakistani women.

"Six million Pakistani women become pregnant per year...and 20%, 720,000, report suicidal thoughts and self-harm ideation," she said. "The economic burden from mental health has increased to $16.6 billion."

In her paper, she said, her team focused on pregnancy-related anxiety (PRA) and whether this was an indicator of PTB, as well as the added effect of chronic stress on PTB. They found that pregnant women who were anxious about their pregnancies were also more likely to have pre-term births. There were many factors, ranging from the effects of socio-economic status to family planning: those women who had not planned for pregnancy were four times more likely to have an early birth than those who had planned for a pregnancy because of PRA.

She emphasised the need to identify stress and depression early in pregnancy, and target psychosocial interventions to reduce the risk of PTB.

Vice Chair and Associate Professor of the Department of Obstetrics and Gynaecology and Chief of Medical Services at AKUs Kharadar campus, Dr Sidrah Nausheen, shared some counterintuitive findings from her paper where she sought to understand the social factors that could modify the effects of PRA, general anxiety, and depression during pregnancy.

She found that women who had very little support from their families, even though it increased their anxiety, actually had reduced chances of PTBs by nearly a quarter, and for women who received familial support, they could see a "rise in PTB" despite not having chronic anxiety due to a hostile family environment.

Read More: One in three Pakistanis suffer from psychological disorders

When asked about this, she reasoned that it was possible that "since the woman is used to it [hostile home environment], she may not feel the effects of this that much".

Women with less education were found to have less anxiety about pregnancy as a whole, leading to a lower risk of PTB. "If I as a doctor get sick, I'm going to worry myself to death with every little symptom. Being ignorant about what you're going through will naturally leave you less worried," she said.

Assistant Professor for Obstetrics and Gynaecology, Dr Neelofur Babar, spoke about the need for understanding how allostatic load — the "wear and tear" on the body from chronic stress — affects PTBs in her paper. "In regular pregnancies, the body becomes less responsive to stress to protect the baby and the mother," she said, posing the question of whether there were ways to biologically predict (like through a blood cholesterol test) PTB.

She found that allostatic load directly leads to premature births (which makes sense), but maternal mental health, like feelings of anxiety and depression, did not contribute directly to PTBs.

That's not to say that mental health doesn't matter here; on the contrary, because of its effect on the body's "wear and tear", it is essential to address and keep in check.