Abstract
Women in post-conflict, low-income, post-conflict (LI-PC) countries are at risk of exposure to the traumatic events (TEs) of war and intimate partner violence (IPV), forms of stress that are known to lead to depression and other adverse mental health outcomes. We aimed to assess an index of exposure to these two forms of trauma to identify pregnant women attending antenatal clinics in conflict-affected Timor-Leste at high risk of depression and other forms of stress. A large, cross-sectional study of women in the second trimester of pregnancy was conducted in the four main government antenatal clinics in Dili district of Timor-Leste, between May 2014, and January 2015. The sample consisted of 1672 consecutive women, 3 to 6 months pregnant, with a response rate of 96%. We applied the Edinburgh Postnatal Depression Scale, the Kessler-10 psychological distress scale and the Harvard Trauma Questionnaire. IPV was assessed by the World Health Organisation measure. Composite categories of conflict-related TEs and severity of IPV showed a dose–response relationship with depressive symptoms: for exposure to four or more conflict-related TEs and severe psychological IPV, the adjusted odds ratio (AOR) was 3.95 (95% confidence interval (CI) 2.10–7.40); for four or more TEs and physical abuse, AOR 8.16 (95% CI 3.53–18.85); and for four or more TEs and severe psychological and physical abuse, AOR 9.78 (95% CI 5.31–18.02). For any mental distress, the AOR for four or more TEs and severe psychological abuse was 3.60 (95% CI 2.08–6.23); for four or more TEs and physical abuse 7.03 (95% CI 3.23–15.29); and for four or more TEs and severe psychological and physical abuse the AOR was 10.45 (95% CI 6.06–18.01). Of 184 women (11% of the sample) who reported ⩾4 TEs and either physical abuse alone or in combination with severe psychological abuse, 78 (42%) reached threshold for depressive symptoms and 93 (51%) for any mental distress, a 10-fold increase in depressive and other mental health symptoms. Priority should be directed to providing urgent mental health and social interventions for this group of women. Our findings offer a framework for a tiered approach to detection, guiding prevention and intervention strategies for IPV and associated mental health problems in low-income post-conflict countries.
Highlights
High-fertility rates in low-income countries result in women spending a considerable time in pregnancy.1 In low-income countries that have experienced mass conflict, women are at risk of exposure to both the traumatic events (TEs) of warfare and intimate partner violence (IPV),2–5 stressors that may increase risk of antenatal depression and related forms of mental distress
In our past studies in Timor-Leste, we found that the majority of the population endorsed at least one trauma and that this level of exposure makes a negligible contribution to risk of mental disorder, a finding confirmed in studies undertaken at an international level
To the best of our knowledge, our study is the first conducted in a LI-PC country to identify an ultra-high group of pregnant women, defined by exposure to past traumas of conflict and IPV, who manifested a high level of depressive and other stress-related symptoms
Summary
High-fertility rates in low-income countries result in women spending a considerable time in pregnancy. In low-income countries that have experienced mass conflict, women are at risk of exposure to both the traumatic events (TEs) of warfare and intimate partner violence (IPV), stressors that may increase risk of antenatal depression and related forms of mental distress. High-fertility rates in low-income countries result in women spending a considerable time in pregnancy.. In low-income countries that have experienced mass conflict, women are at risk of exposure to both the traumatic events (TEs) of warfare and intimate partner violence (IPV), stressors that may increase risk of antenatal depression and related forms of mental distress. High fertility rates in LI-PC countries result in a large portion of women in early and mid-adulthood spending a considerable time in pregnancy, thereby increasing the period of risk for depression.. A considerable number of pregnant women in LI-PC countries have been exposed to past TEs of conflict and IPV, making it important to distinguish those in the highest risk group for depression and other stress-related mental disorders, to ensure that limited resources are directed to those with the greatest need of intervention.
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