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Mental health
Protocol
Effect of adverse perinatal outcomes on postpartum maternal mental health in low-income and middle-income countries: a protocol for systematic review
  1. Samrawit Mihret Fetene1,
  2. Tsegaye Gebremedhin Haile1,
  3. Abel Dadi2,3
  1. 1Department of Health Systems and Policy, University of Gondar, Gondar, Ethiopia
  2. 2Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
  3. 3Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
  1. Correspondence to Samrawit Mihret Fetene; samrimih21{at}gmail.com

Abstract

Introduction More than three-fourths of adverse perinatal outcomes (preterm, small for gestational age, low birth weight, congenital anomalies, stillbirth and neonatal death) occur in low-income and middle-income countries. These adverse perinatal outcomes can have both short-term and long-term consequences on maternal mental health. Even though there are few empirical studies on the effect of perinatal loss on maternal mental illness, comprehensive information on the impact of adverse perinatal outcomes in resource-limited settings is scarce. Therefore, we aim to systematically review and synthesise evidence on the effect of adverse perinatal outcomes on maternal mental health.

Methods and analysis The primary outcome of our review will be postpartum maternal mental illness (anxiety, depression, post-traumatic stress disorder and postpartum psychosis) following adverse perinatal outcomes. All peer-reviewed primary studies published in English will be retrieved from databases: PubMed, MEDLINE, CINAHL Ultimate (EBSCO), PsycINFO, Embase, Scopus and Global Health through the three main searching terms—adverse perinatal outcomes, maternal mental illness and settings, with a variant of subject headings and keywords. We will follow the Joanna Briggs Institute critical appraisal checklist to assess the quality of the studies we are including. The review findings will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. Estimate-based meta-analysis will be performed. We will assess heterogeneity between studies using the I2 statistics and publication bias will be checked using funnel plots and Egger’s test. A subgroup analysis will be conducted to explore potential sources of heterogeneity (if available). Finally, the certainty of the evidence will be evaluated using the Grading of Recommendations, Assessment, Development and Evaluation approach.

Ethics and dissemination Since this systematic review does not involve human participants, ethical approval is not required. The review will be submitted for publication in a peer-reviewed journal.

PROSPERO registration number CRD42023405980.

  • mental health
  • postpartum women
  • anxiety disorders
  • depression & mood disorders
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2023-074447

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    STRENGTHS AND LIMITATIONS OF THIS STUDY

    • Through linking adverse perinatal outcomes and postpartum maternal mental illness, we can examine the association that have not been examined at low-income and middle-income countries.

    • Use the Grading of Recommendations, Assessment, Development and Evaluation approach to determine the quality of evidence for each outcome.

    • We anticipate the possible limitation of language bias; we will include studies published in English.

    Introduction

    Adverse perinatal outcomes include both perinatal morbidity (low birth weight (LBW), small for gestational age (SGA), preterm birth or congenital anomalies) and perinatal mortality (stillbirth and neonatal death).1 2 Every year, approximately 2.4 million children die within the first 28 days of life,3 and there are 2.6 million reported stillbirth4 worldwide. Perinatal morbidity rates also remain unacceptably high globally with nearly 15 million preterm babies5 and 20 million babies with LBW each year.6 Alarmingly, 98% of these cases occur in low-income and middle-income countries.4 7 Infants suffering from perinatal morbidity are at increased risk of mortality and developmental problems. For instance, preterm babies are at high risk of hospitalisation and can suffer lifelong effects such as cerebral palsy, mental retardation, visual and hearing impairments, and poor health.1 8–11 These adverse perinatal outcomes can have significant impacts on the well-being of their parents.

    Evidence suggests that depression during pregnancy can predict preterm birth and LBW, indicating a bidirectional relationship between maternal mental health and adverse perinatal outcomes.12–14 As a result, adverse perinatal outcomes can have short-term and long-term consequences on maternal mental health and well-being.15 16 Studies have shown that perinatal mortality was associated with an increased risk of depressive and anxiety disorder.17–19 Similarly, studies showed that mothers of preterm babies or those with SGA experience higher levels of anxiety, depression, post-traumatic stress disorder (PTSD) and postpartum psychosis compared with parents of healthy term-born babies.15 20–26 This could be due to the fact that preterm babies often require hospitalisation, complex interventions such as ventilation and incubation, and longer stays in neonatal care, which can be stressful for parents.27 Other research has also found that mothers of LBW babies are more likely to experience depression21 24 28 and PTSD29–31 compared with mothers of average birth weight babies. Furthermore, parents of infants born with congenital anomalies are at high risk of developing symptoms of anxiety,32 33 depression,34–36 PTSD37 and psychological distress.38

    While many systematic review studies have focused on the effect of maternal mental illness on perinatal outcomes,13 14 39–42 only a few studies have examined the effects of adverse perinatal outcomes on maternal mental illness.16 17 24 28 37 Nearly 90% of these studies were conducted in high-income countries,43 with one systematic study assessing maternal mental illness following perinatal loss in a global context.17 Given the high incidence of adverse perinatal outcomes within low-income and middle-income settings and the lack of research, there is a pressing need to analyse maternal mental illness following adverse perinatal outcomes in low-income and middle-income countries.

    To our knowledge, no comprehensive systematic review has been conducted to estimate rates of anxiety, depression, PTSD and postpartum psychosis for mothers following adverse perinatal outcomes in low-income and middle-income countries. Therefore, our aim is to synthesise evidence on effects of adverse perinatal outcomes on postpartum maternal mental illness, including anxiety, depression, PTSD and postpartum psychosis and to identify potential moderators of these associations, such as study quality, type of adverse outcome, economic status of the study country and maternal age. We hypothesise that measures of depression, anxiety, PTSD, postpartum psychosis show a significant increase following adverse perinatal outcomes compared with the normal perinatal outcomes.

    Methods

    We will conduct a systematic review of empirical evidence regarding the effect of adverse perinatal outcomes on postpartum maternal mental illness in low-income and middle-income countries. The finding of this review will be reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement.44

    Search Strategy

    In this systematic review, the Patient/population-Intervention-Comparison-Outcomes-Type of study-Context approach is used to formulate and address the research questions.45 The population will consist of adult women aged 18 years and older who have given birth. Exposed group will be postpartum women who experienced at least one of the adverse perinatal outcomes (preterm, SGA, LBW, congenital anomalies, stillbirth and neonatal death). The comparison group will consist of postpartum women who did not experience any adverse perinatal outcome. In this review, the outcomes will be postpartum maternal mental illness which includes anxiety, depression, PTSD and postpartum psychosis. All primary studies that report on the effect of adverse perinatal outcome on maternal mental illness for at least one of the conditions in low-income and middle-income countries (defined by World Bank) will be included.

    Studies will be retrieved from seven electronic bibliographic databases, namely PubMed, MEDLINE, CINAHL Ultimate (EBSCO), PsycINFO, Embase, Scopus and Global Health. Google Scholar will also be considered to search for further literatures. Additional relevant studies from the included articles will be assessed and included (citation snowballing) in the final review. To build the search terms, subject headings and keywords related to adverse perinatal outcomes, postpartum maternal mental illness, and low-income and middle-income countries will be used (see sample MEDLINE search strategy on table 1). These terms will be linked using appropriate Boolean Operators such as “AND” and “OR” as per the requirements of the respective databases.46

    View this table:
    Table 1

    Sample searching strategy for reviewing the effect of adverse perinatal outcomes on postpartum maternal mental health in LMICs

    Inclusion and exclusion

    The review will include all peer-reviewed primary studies published in English from 1 January 2000 to the date of the review (to include the most up to date studies on the topic) that report on postpartum maternal mental illness for at least one adverse perinatal outcome in low-income and middle-income countries. As per the world bank’s definition for 2023, countries with a gross national income per capita of US$1085 or less are categorised as low-income countries, while those with a gross national per capita of US$1086–US$13 205) are deemed middle-income countries.47 Among the identified countries, there are 28 low-income countries and 108 middle-income countries. The review will exclude abstracts, review papers, qualitative studies, theoretical and conceptual articles, conference papers, randomised controlled trials and letters or editorials. Finally, the full text of all relevant studies found to meet the inclusion criteria for the final review will be retained. The detailed inclusion and exclusion criteria are summarised in table 2.

    View this table:
    Table 2

    Study inclusion and exclusion criteria

    Study selection

    Once the search strategy is developed and tested, two authors (SMF and TGH) will retrieve all relevant articles from all the databases and export them to EndNote V.20 to remove duplicates. Then, after removing the duplicates, studies will be exported to Rayyan (a systematic review management software package) for screening.48 Two authors (SMF and TGH) will screen the studies based on the title and abstract. Then the full texts of remaining articles will be retrieved and reviewed by each of two authors independently based on the inclusion and exclusion criteria as presented in table 2. Any disagreement will be discussed and handled by the senior author (AD).

    Data extraction and analysis

    A consistent Excel form will be used to record extracted data from the studies included for assessment of study quality. The abstracted data will include: (1) The study characteristics: article title, authors, year of publication, country of the study, year of publication, study design (cohort, case–control and cross-sectional); (2) Study population; (3) Participants characteristics: mean/median age, and sample size, baseline characteristics; (4) type of adverse perinatal outcomes (preterm, SGA, LBW, congenital anomalies, stillbirth and neonatal death); (5) Outcomes of the study: maternal mental illness (anxiety, depression, PTSD and postpartum psychosis) and (6) Each primary raw data will be taken to calculate the measurements of association (if any), associated variables with β coefficient or adjusted risk ratio with their CI.

    A narrative summary of maternal mental illness will be made for studies that do not report effects by systematically organising the information based on the mental illness classification. Characteristics of the studies will be described in box 1. The postpartum maternal mental illness will include anxiety, depression, PTSD and postpartum psychosis.

    Box 1

    Data abstraction sheet elements to describe the study in the final review

    Data abstraction sheet elements

    1. Author(s), year.

    2. Country.

    3. Study design.

    4. Study population/participants.

    5. Sample size.

    6. Outcome.

    7. Measurement tool.

    8. Methods of analysis.

    9. Exposure.

    10. Mental illness category.

    11. Key finding.

    In the meta-analysis, we will calculate the OR for binary variables and the standard mean difference for continuous variables with 95% CI. A random-effects model will be selected under the assumption that studies included in the meta- analysis have been carried out with heterogeneous populations. Statistical heterogeneity between studies will be evaluated using the I2 statistics (I2 test), which can quantify the heterogeneity ranging from 0% (no heterogeneity) to 100% (the differences between the effect sizes can completely be explained by chance alone).49 Subgroup and meta-regression analyses will be conducted to explore the potential source of heterogeneity. We will adopt Egger’s and Begg’s test to check the publication bias and funnel plot asymmetry to assess the effect of publication bias if the number of studies greater than or equal to 10, based on Cochrane Handbook recommendation.50 In addition, we will perform sensitivity analysis by excluding studies one at a time to ensure the stability of the results. All data will be analysed using the STATA V.16.

    Risk of bias assessment

    For the quality appraisal, the Joanna Briggs Institute critical appraisal checklist for observational studies will be used.51

    Quality of evidence assessment

    The quality of evidence for each outcome will be determined using the Grading of Recommendations, Assessment, Development and Evaluation approach.52 This system helps to evaluate the quality of evidence in the domains of risk of bias, consistency, directness, precision and publication bias. Accordingly, the quality of the evidence will be classified as high, moderate, low or very low.53 Interpretation of the grading scores is presented in table 3.

    View this table:
    Table 3

    Criteria for assessing the quality of evidence based on GRADE approach

    Patient and public involvement

    No patientsand public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

    Ethics and dissemination

    This systematic review will not directly involve human participants and requires no ethical approval. The findings of this systematic review will be disseminated through peer-reviewed publication and will be presented at international conferences related to this field. In addition, findings will be used by other relevant organisations and stakeholders for decision-making.

    Strengthens and limitations

    This study will quantify the effect of adverse perinatal outcomes on postpartum maternal mental illness in low-income and middle-income countries, focusing on common conditions such as anxiety, depression and PTSD. This will give a comprehensive picture of the burden of adverse perinatal outcomes on maternal mental illness in low-income and middle-income countries. Consequently, which help to design a system wide integrated strategies to improve maternal mental illness following adverse perinatal outcome in resource-limited settings. By publishing the research protocol, we reinforce the clarity of the strategy and minimise the risk of bias. However, we anticipate some limitations, including the use of English language limiters and heterogeneity of the studies.

    Amendments of the review

    Any change to this protocol will be updated on the PROSPERO registration database (registration number: CRD42023405980) and the updated part of the protocol will be published together with the full systematic review.

    Ethics statements

    Patient consent for publication

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    Footnotes

    • Contributors SMF and TGH conceptualised and designed the protocol, drafted the initial manuscript, and reviewed the manuscript. SMF, TGH and AD defined the concepts and search items, data extraction process and methodological appraisal of the studies. SMF and TGH planned the data extraction and statistical analysis. AD and TGH provided critical insights. All authors have approved and contributed to the final written manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.