238 - Maternal Perceived Stress Predicts Stillbirth and Lower Birth Length in Rural Ethiopia

Publication Number: 1225.238

Sarah K.G.. Jensen, Women & Infants Hospital of Rhode Island, Newton Centre, MA, United States; Firehiwot Workneh, Addis Continental Institute of Public Health, Addis Ababa, Adis Abeba, Ethiopia; Krysten North, Brigham and Women's Hospital, Boston, MA, United States; Theresa I. Chin, The Warren Alpert Medical School of Brown University, 200 Chestnut St, RI, United States; Blair j. Wylie, Beth Israel Deaconess Medical Center, Boston, MA, United States; Yemane Berhane, Addis Continental Institute of Public Health, Addis Ababa, Adis Abeba, Ethiopia; Anne CC Lee, Warren Alpert Medical School of Brown University, Providence, RI, United States

Background: Stunting affects more than 30% of Ethiopian children < 5 years of age. Its etiology often starts in utero with known risk factors, including undernutrition and infections. Maternal psychological stress represents an added risk factor for stunted fetal and childhood growth and adverse birth outcomes in low-resource populations already at elevated risk. Most studies of the effects of maternal prenatal stress on infant birth outcomes are conducted in high-income countries.

Objective: To examine predictors of maternal prenatal perceived stress and associations between maternal prenatal perceived stress and birth outcomes in rural Amhara, Ethiopia

Design/Methods: The 'Enhancing Nutrition and Antenatal Infection Treatment for Maternal and Child Health' (ENAT) cluster randomized controlled trial (ISRCTN15116516) enrolled pregnant women <=24 weeks gestation based on ultrasound dating from rural health centres. Maternal socio-demographic and anthropometric data were collected at enrollment. Maternal perceived stress data were collected at antenatal care visits using Cohen's Perceived Stress Scale (PSS; range 0-40), a tool previously validated in pregnant women in Ethiopia. Birth outcomes included were weight-for-age, length-for-age, head circumference, preterm birth, and stillbirth. Using secondary analysis, we model predictors of maternal perceieved stress (Table 2) and associations between stress and birth outcomes (Table 3). We use multivariate regression models with cluster-robust standard errors.

Results: Of N=2,392 women enrolled in ENAT, n=1,103 (46.1%) provided stress data in the second and third trimesters. Binary factors associated with lower stress were having some maternal education (b=-0.98; 95% CI: -1.85 to -0.10; p=0.03) and being married (b=-2.09; 95% CI: -4.01 to -0.17; p=0.04). Higher food insecurity was associated with higher stress (b= 0.65; 95% CI: 0.21 to 1.08; p=0.01). Second-trimester stress was not associated with birth outcomes. Higher third-trimester perceived stress predicted lower birth length-for-age (b = -0.02; 95% CI =-0.03 to -0.01; p=0.02) and was associated with a 12% increased stillbirth odds per one-unit increase in the stress score (OR = 1.12; 95% CI = 1.05 to 1.19; p< 0.001). Third-trimester stress was not associated with birth weight-for-age, head circumference, or preterm birth.

Conclusion(s): Prenatal perceived stress was higher among socioeconomically vulnerable women and was associated with lower birth length-for-age and increased stillbirth. Stress screening may identify women at risk for poor birth outcomes.

Table 1: Demographics for maternal stress sample from the ENAT cluster randomized trial.


Table 2: Predictors of maternal perceived stress (first response in 2nd trimester)


Table 3: Estimates and 95% confidence intervals from multivariable regression models with birth outcomes: birthweight, length at birth, head circumference, preterm birth and stillbirth. All models accounted for the clustering by site of the study data.
"-" means omitted due to no occurance of non-married and stillbirth