Gracia Fellmeth

Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis.

Migrant women are at risk of perinatal mental disorders due to stressors experienced before, during and after migration.

Maternal suicide risk among refugees and migrants

for patients in the public sector in 2008 (Table 1). The proportion of womenwhose primary cause of deathwas obstetric hemorrhage who were living with HIV infection has increased between 2005–2007 and 2011–2013 (Table 2). In the latest report [1], the proportion of women who died due to obstetric hemorrhage who had HIV infection was statistically lower than the proportion with HIV in the overall report (45% vs 65%; Pb0.001). However, it was also notably higher than the national HIV seroprevalence of 29% [1]. Importantly, the risk of hemorrhage was higher among women who were receiving HAART than among those not receiving HAART (relative risk 1.61, 95% confidence interval 1.15–2.25 (Table 2)). This increased tendency to bleeding in pregnancy among women with HIV infection is in line with the findings of Chweneyagae et al. [3]. On the basis of data from the report for 2008–2010 [2], they stated that for deaths due to obstetric hemorrhage, the institutional mortality ratios were 38.4 and 17.2 per 100 000 live births among women with and without HIV infection, respectively [3]. Furthermore, Bloch et al. [4] found increased rates of blood transfusions among pregnant women with HIV infection. The current reanalysis of the South African data adds to the body of evidence suggesting that the frequency of hemorrhage among pregnant women with HIV infection is increasing, which could be associated with the use of HAART. Increased bleeding among women with HIV infection could be associated with anemia, HIV-associated thrombocytopenia, or chorioamnionitis. Alternatively some form of coagulopathy or endothelial dysfunction could be the cause, but this needs further investigation.

Pregnant migrant and refugee women's perceptions of mental illness on the Thai-Myanmar border: a qualitative study.

BackgroundMental illness is a significant contributor to the global burden of disease, with prevalence highest in low- and middle-income countries. Rates are high in women of childbearing age, especially during pregnancy and the first year post-partum. Migrant and refugee populations are at risk of developing mental illness due to the multiple stressors associated with migration. The Thai-Myanmar border area is home to large populations of migrants and refugees as a result of long-standing conflict, poverty and unemployment in Myanmar. This study aims to explore perceptions of mental illness among pregnant migrants and refugees and antenatal clinic staff living and working along the Thai-Myanmar border.MethodsThirteen focus group discussions were conducted with pregnant migrants, pregnant refugees and antenatal clinic staff. Focus groups were held in one large refugee camp and two migrant health clinics along the Thai-Myanmar border. Thematic analysis was used to identify and code themes emerging from the data.ResultsA total of 92 pregnant women and 24 antenatal clinic staff participated. Discussions centered around five main themes: symptoms of mental illness; causes of mental illness; suicide; mental illness during pregnancy and the post-partum period; and managing mental illness. Symptoms of mental illness included emotional disturbances, somatic symptoms and socially inappropriate behavior. The main causes were described as current economic and family-related difficulties. Suicide was frequently attributed to shame. Mental illness was thought to be more common during and following pregnancy due to a lack of family support and worries about the future. Talking to family and friends, medication and hospitalization were suggested as means of helping those suffering from mental illness.ConclusionsMental illness was recognized as a concept by the majority of participants and there was a general willingness to discuss various aspects of it. More formal and systematic training including the development of assessment tools in the local languages would enable better ascertainment and treatment of mental illness in this population.

Educational and Skills-Based Interventions to Prevent Relationship Violence in Young People.

Objectives: To assess the efficacy of educational and skills-based interventions to prevent relationship and dating violence in adolescents and young adults. Methods: We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, and other databases for randomized, cluster-randomized, and quasi-randomized studies of interventions to prevent relationship or dating violence. We conducted meta-analyses for episodes of relationship violence, behaviors, and attitudes. Results: We included 38 studies (15,903 participants) in this review, of which we included 33 studies in the meta-analyses. The risk ratio for episodes of relationship violence was 0.77 (95% confidence interval [CI]: [0.53, 1.13]). The standardized mean difference (SMD) for attitudes toward relationship violence was 0.06 (95% CI: [−0.01, 0.15]). The SMD for behavior related to relationship violence was −0.07 (95% CI: [−0.31, 0.16]). Subgroup analyses showed no statistically significant differences by setting or type of participants. Conclusions: We found no evidence of effectiveness of interventions on episodes violence, attitudes or behaviors.

Migrant perinatal depression study: a prospective cohort study of perinatal depression on the Thai-Myanmar border

Purpose Perinatal depression is a significant contributor to maternal morbidity. Migrant women in resource-poor settings may be at increased risk, yet little research has been conducted in low-income and middle-income settings. This prospective cohort study of migrant women on the Thai-Myanmar border aims to establish prevalence of perinatal depression, identify risk factors for perinatal depression and examine associations with infant outcomes. Participants Participating women are labour migrants and refugees living on the Thai-Myanmar border. A total of 568 women were recruited in their first trimester of pregnancy and are being followed up to 1-year postpartum. Findings to date At baseline, women in our study had a median age of 25 years, the predominant ethnicity was Sgaw Karen (48.9%), agriculture was the main employment sector (39.2%) and educational attainment was low with a median of 4 years of education. In the first trimester of pregnancy, a quarter (25.8%; 95% CI 22.3 to 29.5) of all women were depressed as diagnosed by the Structured Clinical Interview for the Diagnosis of DSM-IV Disorders. Future plans Follow-up is ongoing and expected to continue until January 2018. The prevalence of depression at later stages of pregnancy and during the first postpartum year will be identified, and associations between depression status and demographic, social, migration-related, medical, obstetric and infant factors will be quantified. Trial registration number NCT02790905.

Validation of the Refugee Health Screener-15 for the assessment of perinatal depression among Karen and Burmese women on the Thai-Myanmar border

Perinatal depression is common, and left untreated can have significant and long-lasting consequences for women, their children and their families. Migrant women are at particular risk of perinatal depression as a result of a multitude of stressors experienced before, during and after migration. Identification of perinatal depression among migrant women—particularly those living in low- and middle-income regions—remains challenging, partly due to the lack of locally-validated and culturally appropriate screens tools. This study formally validates Burmese and Sgaw Karen versions of the Refugee Health Screener-15 (RHS-15) as a screening tool for perinatal depression among migrant women living on the Thai-Myanmar border. The Structured Clinical Interview for the Diagnosis of DSM-IV Disorders (SCID) was used as the gold-standard comparator. Complete results were obtained for 235 Burmese-speaking and 275 Sgaw Karen-speaking women. Despite displaying reasonable psychometric properties, a number of shortcomings associated with the RHS-15 limited its utility in this setting. The Likert-type response categories of the RHS-15 proved problematic in this low-literacy population. Combined with the relative superiority and greater ease of administration of the SCID, the RHS-15 is not recommended as the tool of choice for detecting perinatal depression in this setting.

Current efforts in medical education to incorporate national health priorities

As a reflection on the Edinburgh Declaration, this conceptual synthesis presents six important challenges in relation to the role of medical education in meeting current national health priorities.

Migration and perinatal mental health: a global priority.

The past century has been termed the ‘century of human mobility’ as a result of unprecedented migration flows globally (Skeldon, 2013). Of the estimated 1 billion people on the move today, an increasing proportion are women: according to the International Organization for Migration, women account for just under half (48.2%) of all international migrants (International Organization for Migration [IOM], 2013). Although all migrants experience a multitude of challenges, migrant women – especially those who are pregnant or have recently given birth – carry additional health needs that warrant particular attention. The perinatal mental health of migrant women is influenced by a wide array of stressors experienced across the migration trajectory (Collins, Zimmerman, & Howard, 2011). Prior to displacement, many migrant women – whether refugees or economic migrants – have been exposed to conflict, natural disaster, severe poverty or long-standing unemployment. Transit itself is often arduous, and women in particular may experience trafficking, abuse and sexual violence (Collins et al., 2011). Following resettlement, many migrant women continue to live in conditions of socioeconomic adversity as well as social isolation resulting from discrimination and cultural and linguistic differences. For pregnant and post-partum women in particular, the loss of cultural, social and material resources can have serious implications on well-being (Shishehgar, Gholizadeh, DiGiacomo, Green, & Davidson, 2017). Furthermore, access to maternity care and social support may be impeded by a combination of legal factors in the host country, a lack of trust and difficulties of navigating complex and unfamiliar health and social care systems. Pre-existing vulnerabilities thus combine with ongoing stressors to create a high-risk situation for mothers in a country that is not their own (Shishehgar et al., 2017). Contrary to media portrayal, the vast majority of global migration occurs entirely within lowand middle-income regions: in 2016, for example, developing countries hosted 84% of the world’s refugees (World Health Organization [WHO], 2017). In these low-income settings, the consequences of undetected and untreated perinatal mental disorders for women, their children and families are particularly severe. Adverse effects of conditions such as perinatal depression on infants and children – including emotional, behavioural, cognitive and physical developmental problems – are more likely to occur in circumstances of socioeconomic adversity (Stein et al., 2014). Similarly, a woman’s impaired ability to work or provide care as a result of a mental health disorder may have more serious ramifications in a resource-poor environment where household incomes are likely to be lower and more precarious and social protection mechanisms are weaker. Finally, existing mental healthcare infrastructure in resource-poor settings may be lacking or overstretched, meaning women in these contexts may be less able than those in high-income destinations to access the care they need. A systematic review and meta-analysis of migrant perinatal mental health suggested that as many as one in three (31%) migrant women from lowand middle-income countries may experience depression in the perinatal period, although high statistical heterogeneity means this figure must be interpreted with caution (Fellmeth, Fazel, & Plugge, 2017). Multiplied across the vast population of migrants worldwide, this represents a significant burden of disease, and it is imperative that health and social care systems respond appropriately with interventions ideally spanning the spectrum of primary, secondary and tertiary prevention.

Validation of the Edinburgh Postnatal Depression Scale (EPDS) on the Thai-Myanmar border.

Postnatal depression is common and may have severe consequences for women and their children. Locally validated screening tools are required to identify at-risk women in marginalised populations. The Edinburgh Postnatal Depression Scale (EPDS) is one of the most frequently used tools globally. This cross-sectional study assessed the validity and acceptability of the EPDS in Karen and Burmese among postpartum migrant and refugee women on the Thai–Myanmar border. The EPDS was administered to participants and results compared with a diagnostic interview. Local staff provided feedback on the acceptability of the EPDS through a focus group discussion. Results from 670 women showed high accuracy and reasonable internal consistency of the EPDS. However, acceptability to local staff was low, limiting the utility of the EPDS in this setting despite its good psychometrics. Further work is required to identify a tool that is acceptable and sensitive to cultural manifestations of depression in this vulnerable population.

Learning from Ward Number Six

The physician Anton Chekov (1860–1904) developed a passion for writing at an early age. Acutely aware of the social and health inequalities, his stories centre upon clinical encounters with poor and marginalised sectors of a society in turmoil. In Ward Number Six (1892), the setting is a destitute provincial hospital, the demise of which has gone unnoticed by the central authorities. The unwelcoming and rusting premises exude a ‘doomed air’. The story centres upon Andrej Ragin, the chief doctor, and his relationship with Ivan Gromov, a longterm psychiatric patient. Ragin is initially outraged by the filthy conditions and seeks to bring about change. However, the relentless flow of illness and death take their toll, and Ragin’s determination gives way to disillusionment and despair. A fatalistic attitude — ‘expel physical and moral filth from one place and it will only crop up elsewhere’ — eases his conscience and justifies his waning engagement with patients and dissipating sense of professional and moral duty. Ragin spends more and more of his time debating the purpose of life and death with Gromov. Ragin has lived a protected and comfortable life and believes that suffering and hardship are bestowed upon individuals at random and that these individuals must learn to ignore their effects. His philosophical stance is countered by