title: A high-risk group of pregnant women with elevated levels of conflict-related trauma, intimate partner violence, symptoms of depression and other forms of mental distress in post-conflict Timor-Leste.
abstract: Women in low-income, post-conflict (LI-PC) [Corrected] 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.
authors.affiliation: Psychiatry Research and Teaching Unit, University of New South Wales and Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, NSW, Australia.
authors.forename: S J
authors.initials: SJ
authors.lastname: Rees
authors.affiliation: Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
authors.forename: W
authors.initials: W
authors.lastname: Tol
authors.affiliation: Psychiatry Research and Teaching Unit, University of New South Wales and Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, NSW, Australia. School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
authors.forename: M
authors.initials: M
authors.lastname: Mohsin
authors.affiliation: Psychiatry Research and Teaching Unit, University of New South Wales and Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, NSW, Australia.
authors.forename: M
authors.initials: M
authors.lastname: Mohammad
authors.affiliation: Psychiatry Research and Teaching Unit, University of New South Wales and Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, NSW, Australia.
authors.forename: A K
authors.initials: AK
authors.lastname: Tay
authors.affiliation: Psychiatry Research and Teaching Unit, University of New South Wales and Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, NSW, Australia.
authors.forename: N
authors.initials: N
authors.lastname: Tam
authors.affiliation: Psychiatry Research and Teaching Unit, University of New South Wales and Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, NSW, Australia.|Child and Maternal Health, Alola Women's Foundation, Dili, Timor-Leste.
authors.forename: N
authors.initials: N
authors.lastname: dos Reis
authors.affiliation: Psychiatry Research and Teaching Unit, University of New South Wales and Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, NSW, Australia.|Child and Maternal Health, Alola Women's Foundation, Dili, Timor-Leste.
authors.forename: E
authors.initials: E
authors.lastname: da Costa
authors.affiliation: Psychiatry Research and Teaching Unit, University of New South Wales and Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, NSW, Australia.|Child and Maternal Health, Alola Women's Foundation, Dili, Timor-Leste.
authors.forename: C
authors.initials: C
authors.lastname: Soares
authors.affiliation: Psychiatry Research and Teaching Unit, University of New South Wales and Academic Mental Health Unit, Mental Health Centre, Liverpool Hospital, Sydney, NSW, Australia.
authors.forename: D M
authors.initials: DM
authors.lastname: Silove
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D003866:Depressive Disorder / Q000453:epidemiology / Q000523:psychology*; D005260:Female; D006801:Humans; D000066511:Intimate Partner Violence / Q000523:psychology* / Q000706:statistics & numerical data; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology / Q000523:psychology*; D013315:Stress, Psychological / Q000453:epidemiology / Q000523:psychology*; D011795:Surveys and Questionnaires; D049648:Timor-Leste / Q000453:epidemiology; D014857:Warfare; D055815:Young Adult
references.citation: JAMA. 1996 Oct 9;276(14):1172-7
references.pmid: 8827972
references.citation: Trauma Violence Abuse. 2011 Jul;12(3):127-34
references.pmid: 21511685
references.citation: Bull World Health Organ. 2012 Feb 1;90(2):139G-149G
references.pmid: 22423165
references.citation: Lancet Glob Health. 2013 Oct;1(4):e187-207
references.pmid: 25104345
references.citation: Lancet Glob Health. 2014 May;2(5):e293-300
references.pmid: 25103168
references.citation: Depress Anxiety. 2014 Feb;31(2):130-42
references.pmid: 23983056
references.citation: Soc Sci Med. 2015 Apr;130:284-91
references.pmid: 25753169
references.citation: Arch Gen Psychiatry. 2008 Oct;65(10):1205-12
references.pmid: 18838637
references.citation: Soc Sci Med. 2013 Jan;77:41-9
references.pmid: 23219850
references.citation: Violence Against Women. 2008 Jun;14(6):634-54
references.pmid: 18535306
references.citation: PLoS One. 2013 Aug 07;8(8):e69207
references.pmid: 23950885
references.citation: Clin Psychol Rev. 2000 Aug;20(5):561-92
references.pmid: 10860167
references.citation: Int Health. 2013 Mar;5(1):29-37
references.pmid: 24029843
references.citation: Violence Vict. 1999 Spring;14(1):55-67
references.pmid: 10397626
references.citation: PLoS One. 2012;7(12):e51740
references.pmid: 23300562
references.citation: J Affect Disord. 2013 Sep 25;150(3):1242-6
references.pmid: 23835102
references.citation: BMC Public Health. 2014 Apr 10;14:339
references.pmid: 24716478
references.citation: Violence Vict. 1999 Spring;14(1):3-23
references.pmid: 10397623
references.citation: JAMA. 2011 Aug 3;306(5):513-21
references.pmid: 21813429
references.citation: Lancet. 2006 Oct 7;368(9543):1260-9
references.pmid: 17027732
references.citation: JAMA. 2012 Aug 15;308(7):677-8
references.pmid: 22893163
references.citation: J Nerv Ment Dis. 2007 Feb;195(2):152-7
references.pmid: 17299303
references.citation: JAMA. 2009 Aug 5;302(5):537-49
references.pmid: 19654388
references.citation: Violence Vict. 1999 Spring;14(1):89-104
references.pmid: 10397628
references.citation: Soc Sci Med. 2010 Jan;70(1):80-8
references.pmid: 19853342
references.citation: Trauma Violence Abuse. 2009 Apr;10(2):125-42
references.pmid: 19383630
references.citation: BMJ Open. 2014 Feb 25;4(2):e003644
references.pmid: 24568959