"A Woman Is a Puppet." Women's Disempowerment and Prenatal Anxiety in Pakistan: A Qualitative Study of Sources, Mitigators, and Coping Strategies for Anxiety in Pregnancy

Armaan A Rowther, Asiya K Kazi, Huma Nazir, Maria Atiq, Najia Atif, Nida Rauf, Abid Malik, Pamela J Surkan, Armaan A Rowther, Asiya K Kazi, Huma Nazir, Maria Atiq, Najia Atif, Nida Rauf, Abid Malik, Pamela J Surkan

Abstract

Common mental disorders are highly prevalent among pregnant women in low- and middle-income countries, yet prenatal anxiety remains poorly understood, particularly in the sociocultural context of South Asia. Our study explored sources, mitigators, and coping strategies for anxiety among symptomatic pregnant women in Pakistan, particularly in relation to autonomy in decision-making and social support. We interviewed 19 pregnant married women aged 18-37 years recruited from 2017-2018 at a public hospital in Rawalpindi who screened positive for anxiety. Thematic analysis was based on both inductive emergent codes and deductive a priori constructs of pregnancy-related empowerment. Gender norms emerged as an important dimension of Pakistani women's social environment in both constraining pregnancy-related agency and contributing to prenatal anxiety. Women's avenues of self-advocacy were largely limited to indirect means such as appeals to the husband for intercession or return to her natal home. The levels of autonomy during pregnancy depended on the area of decision-making, and peer/family support was a critical protective factor and enabling resource for maternal mental health. Women's disempowerment is a key contextual factor in the sociocultural experience of prenatal maternal anxiety in South Asia, and further examination of the intersections between empowerment and perinatal mental illness might help inform the development of more context-specific preventive approaches.

Keywords: South Asia; anxiety; mental health; pregnancy; prenatal anxiety; women’s empowerment.

Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

Figures

Figure 1
Figure 1
Women’s empowerment, sources of anxiety, and coping strategies in pregnancy: conceptual framework adapted from Kabeer’s (1991) model for women’s empowerment and Klima et al. (2015) constructs for pregnancy-related empowerment to understand the sociocultural experience of maternal prenatal anxiety as it relates to maternal decision-making and social support in the South Asian context.
Figure 2
Figure 2
Schematized final codebook combining inductive, emergent codes with deductive, a priori themes from conceptual framework of pregnancy-related power.

References

    1. Fisher J., Cabral de Mello M., Patel V., Rahman A., Tran T., Holton S., Holmes W. Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: A systematic review. Bull. World Health Organ. 2012;90:139H–149H. doi: 10.2471/BLT.11.091850.
    1. Rahman A., Surkan P.J., Cayetano C.E., Rwagatare P., Dickson K.E. Grand challenges: Integrating maternal mental health into maternal and child health programmes. PLoS Med. 2013;10:e1001442. doi: 10.1371/journal.pmed.1001442.
    1. Bright K.S., Norris J.M., Letourneau N.L., King Rosario M., Premji S.S. Prenatal Maternal Anxiety in South Asia: A Rapid Best-Fit Framework Synthesis. Front. Psychiatry. 2018;9:467. doi: 10.3389/fpsyt.2018.00467.
    1. Verreault N., Da Costa D., Marchand A., Ireland K., Dritsa M., Khalifé S. Rates and risk factors associated with depressive symptoms during pregnancy and with postpartum onset. J. Psychosom. Obstet. Gynecol. 2014;35:84–91. doi: 10.3109/0167482X.2014.947953.
    1. Staneva A., Bogossian F., Pritchard M., Wittkowski A. The effects of maternal depression, anxiety, and perceived stress during pregnancy on preterm birth: A systematic review. Women Birth. 2015;28:179–193. doi: 10.1016/j.wombi.2015.02.003.
    1. Rose M.S., Pana G., Premji S. Prenatal Maternal Anxiety as a Risk Factor for Preterm Birth and the Effects of Heterogeneity on This Relationship: A Systematic Review and Meta-Analysis. Biomed. Res. Int. 2016;2016:8312158. doi: 10.1155/2016/8312158.
    1. Dunkel Schetter C., Tanner L. Anxiety, depression and stress in pregnancy: Implications for mothers, children, research, and practice. Curr. Opin. Psychiatry. 2012;25:141–148. doi: 10.1097/YCO.0b013e3283503680.
    1. Eaton J., McCay L., Semrau M., Chatterjee S., Baingana F., Araya R., Ntulo C., Thornicroft G., Saxena S. Scale up of services for mental health in low-income and middle-income countries. Lancet. 2011;378:1592–1603. doi: 10.1016/S0140-6736(11)60891-X.
    1. Saxena S., Thornicroft G., Knapp M., Whiteford H. Resources for mental health: Scarcity, inequity, and inefficiency. Lancet. 2007;370:878–889. doi: 10.1016/S0140-6736(07)61239-2.
    1. Lawn J.E., Gravett M.G., Nunes T.M., Rubens C.E., Stanton C., Group G.R. Global report on preterm birth and stillbirth (1 of 7): Definitions, description of the burden and opportunities to improve data. BMC Pregnancy Childbirth. 2010;10:S1. doi: 10.1186/1471-2393-10-S1-S1.
    1. Dennis C.-L., Falah-Hassani K., Shiri R. Prevalence of antenatal and postnatal anxiety: Systematic review and meta-analysis. Br. J. Psychiatry. 2017;210:315–323. doi: 10.1192/bjp.bp.116.187179.
    1. Kazi A., Fatmi Z., Hatcher J., Niaz U., Aziz A. Development of a stress scale for pregnant women in the South Asian context: The AZ Stress Scale. East. Mediterr. Health J. 2009;15:353–361. doi: 10.26719/2009.15.2.353.
    1. Waqas A., Raza N., Lodhi H.W., Muhammad Z., Jamal M., Rehman A. Psychosocial factors of antenatal anxiety and depression in Pakistan: Is social support a mediator? PLoS ONE. 2015;10:e0116510. doi: 10.1371/journal.pone.0116510.
    1. Niaz S., Izhar N., Bhatti M.R. Anxiety and depression in pregnant women presenting in the OPD of a teaching hospital. Pakistan J. Med. Sci. 2004;20:117–119.
    1. Rini C.K., Dunkel-Schetter C., Wadhwa P.D., Sandman C.A. Psychological adaptation and birth outcomes: The role of personal resources, stress, and sociocultural context in pregnancy. Health Psychol. 1999;18:333. doi: 10.1037/0278-6133.18.4.333.
    1. Theut S.K., Pedersen F.A., Zaslow M.J., Rabinovich B.A. Pregnancy subsequent to perinatal loss: Parental anxiety and depression. J. Am. Acad. Child Adolesc. Psychiatry. 1988;27:289–292. doi: 10.1097/00004583-198805000-00004.
    1. Levin J.S. The factor structure of the pregnancy anxiety scale. J. Health Soc. Behav. 1991 doi: 10.2307/2137104.
    1. Ali N.S., Azam I.S., Ali B.S., Tabbusum G., Moin S.S. Frequency and associated factors for anxiety and depression in pregnant women: A hospital-based cross-sectional study. Sci. World J. 2012;2012 doi: 10.1100/2012/653098.
    1. Prost A., Lakshminarayana R., Nair N., Tripathy P., Copas A., Mahapatra R., Rath S., Gope R.K., Rath S., Bajpai A. Predictors of maternal psychological distress in rural India: A cross-sectional community-based study. J. Affect. Disord. 2012;138:277–286. doi: 10.1016/j.jad.2012.01.029.
    1. Portela A., Santarelli C. Empowerment of women, men, families and communities: True partners for improving maternal and newborn health. Br. Med. Bull. 2003;67:59–72. doi: 10.1093/bmb/ldg013.
    1. Yount K.M., Dijkerman S., Zureick-Brown S., VanderEnde K.E. Women’s empowerment and generalized anxiety in Minya, Egypt. Soc. Sci. Med. 2014;106:185–193. doi: 10.1016/j.socscimed.2014.01.022.
    1. Kabeer N. Resources, agency, achievements: Reflections on the measurement of women’s empowerment. Dev. Chang. 1999;30:435–464. doi: 10.1111/1467-7660.00125.
    1. Klima C.S., Vonderheid S.C., Norr K.F., Park C.G. Development of the pregnancy-related empowerment scale. Nurs. Health. 2015;3:120–127. doi: 10.13189/nh.2015.030503.
    1. Papanek H., Minault G. Separate Worlds: Studies of Purdah in South Asia. Chanakya Publications; Delhi, India: 1982.
    1. Loureiro M. Debating empowerment: men’s views of women’s access to work in public spaces in Pakistan-administered Kashmir. Contemp. South Asia. 2019;27:531–548. doi: 10.1080/09584935.2019.1688254.
    1. Kandiyoti D. Islam and patriarchy: A comparative perspective. In: Keddie N., Baron B., editors. Women in Middle Eastern History: Shifting Boundaries in Sex and Gender. Yale University Press; London, UK: 1991.
    1. Jejeebhoy S.J., Sathar Z.A. Women’s autonomy in India and Pakistan: The influence of religion and region. Popul. Dev. Rev. 2001;27:687–712. doi: 10.1111/j.1728-4457.2001.00687.x.
    1. Agarwal B., Bina A. A Field of One’s Own: Gender and Land Rights in South Asia. Volume 58. Cambridge University Press; Cambridge, UK: 1994.
    1. Pigott T.A. Gender differences in the epidemiology and treatment of anxiety disorders. J. Clin. Psychiatry. 1999;60(Suppl 18):4–15.
    1. Kuehner C. Gender differences in unipolar depression: An update of epidemiological findings and possible explanations. Acta Psychiatr. Scand. 2003;108:163–174. doi: 10.1034/j.1600-0447.2003.00204.x.
    1. Atif N., Nazir H., Zafar S., Chaudhri R., Atiq M., Mullany L.C., Rowther A.A., Malik A., Surkan P.J., Rahman A. Development of a psychological intervention to address anxiety during pregnancy in a low-income country. Front. Psychiatry. 2019;10:927. doi: 10.3389/fpsyt.2019.00927.
    1. Pasha O., Saleem S., Ali S., Goudar S.S., Garces A., Esamai F., Patel A., Chomba E., Althabe F., Moore J.L. Maternal and newborn outcomes in Pakistan compared to other low and middle income countries in the Global Network’s Maternal Newborn Health Registry: An active, community-based, pregnancy surveillance mechanism. Reprod. Health. 2015;12:S15. doi: 10.1186/1742-4755-12-S2-S15.
    1. CIA South Asia: Pakistan—The World Factbook—Central Intelligence Agency. [(accessed on 20 November 2019)]; Available online: .
    1. Zigmond A.S., Snaith R.P. The hospital anxiety and depression scale. Acta Psychiatr. Scand. 1983;67:361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x.
    1. Dodani S., Zuberi R.W. Center-based prevalence of anxiety and depression in women of the northern areas of Pakistan. J. Pak. Med. Assoc. 2000;50:138.
    1. Qadir F., Khalid A., Haqqani S., Medhin G. The association of marital relationship and perceived social support with mental health of women in Pakistan. BMC Public Health. 2013;13:1150. doi: 10.1186/1471-2458-13-1150.
    1. Mumford D.B., Tareen I.A.K., Bajwa M.A.Z., Bhatti M.R., Karim R. The translation and evaluation of an Urdu version of the Hospital Anxiety and Depression Scale. Acta Psychiatr. Scand. 1991;83:81–85. doi: 10.1111/j.1600-0447.1991.tb07370.x.
    1. First M.B., Spitzer R.L., Gibbon M., Williams J.B.W. User’s Guide for the Structured Clinical Interview for DSM-IV Axis I Disorders SCID-I: Clinician Version. American Psychiatric Pub; Washington, DC, USA: 1997.
    1. Pallant J.F., Tennant A. An introduction to the Rasch measurement model: An example using the Hospital Anxiety and Depression Scale (HADS) Br. J. Clin. Psychol. 2007;46:1–18. doi: 10.1348/014466506X96931.
    1. Spinhoven P.H., Ormel J., Sloekers P.P.A., Kempen G., Speckens A.E.M., Van Hemert A.M. A validation study of the Hospital Anxiety and Depression Scale (HADS) in different groups of Dutch subjects. Psychol. Med. 1997;27:363–370. doi: 10.1017/S0033291796004382.
    1. Saldaña J. The Coding Manual for Qualitative Researchers. Sage; Thousand Oaks, CA, USA: 2015.
    1. Braun V., Clarke V. Using thematic analysis in psychology. Qual. Res. Psychol. 2006;3:77–101. doi: 10.1191/1478088706qp063oa.
    1. Prata N., Tavrow P., Upadhyay U. Women’s empowerment related to pregnancy and childbirth: Introduction to special issue. BMC Pregnancy Childbirth. 2017;17:352. doi: 10.1186/s12884-017-1490-6.
    1. Kazi A., Fatmi Z., Hatcher J., Kadir M.M., Niaz U., Wasserman G.A. Social environment and depression among pregnant women in urban areas of Pakistan: Importance of social relations. Soc. Sci. Med. 2006;63:1466–1476. doi: 10.1016/j.socscimed.2006.05.019.
    1. Mumtaz Z., Salway S.M. Gender, pregnancy and the uptake of antenatal care services in Pakistan. Sociol. Health Illn. 2007;29:1–26. doi: 10.1111/j.1467-9566.2007.00519.x.
    1. Sathar Z.A., Kazi S. Women’s Autonomy, Livelihood and Fertility: A Study of Rural Punjab. Pakistan Institute of Development Economics (PIDE); Islamabad, Pakistan: 1997. Women’s autonomy, livelihood and fertility: A study of rural Punjab.
    1. Chan C.Y., Lee A.M., Lam S.K., Lee C.P., Leung K.Y., Koh Y.W., Tang C.S.K. Antenatal anxiety in the first trimester: Risk factors and effects on anxiety and depression in the third trimester and 6-week postpartum. Open J. Psychiatry. 2013 doi: 10.4236/ojpsych.2013.33030.
    1. Mubarak A.R. A comparative study on family, social supports and mental health of rural and urban Malay women. Med. J. Malays. 1997;52:274–284.
    1. Norbeck J.S., Anderson N.J. Life stress, social support, and anxiety in mid-and late-pregnancy among low income women. Res. Nurs. Health. 1989;12:281–287. doi: 10.1002/nur.4770120503.
    1. Rahman A., Iqbal Z., Harrington R. Life events, social support and depression in childbirth: Perspectives from a rural community in the developing world. Psychol. Med. 2003;33:1161–1167. doi: 10.1017/S0033291703008286.
    1. Jones C.C.G., Jomeen J., Hayter M. The impact of peer support in the context of perinatal mental illness: A meta-ethnography. Midwifery. 2014;30:491–498. doi: 10.1016/j.midw.2013.08.003.
    1. Ali N.S., Ali B.S., Azam I.S. Post partum anxiety and depression in peri-urban communities of Karachi, Pakistan: A quasi-experimental study. BMC Public Health. 2009;9:384. doi: 10.1186/1471-2458-9-384.
    1. Karmaliani R., Asad N., Bann C.M., Moss N., Mcclure E.M., Pasha O., Wright L.L., Goldenberg R.L. Prevalence of anxiety, depression and associated factors among pregnant women of Hyderabad, Pakistan. Int. J. Soc. Psychiatry. 2009;55:414–424. doi: 10.1177/0020764008094645.
    1. Shaikh B.T., Hatcher J. Health seeking behaviour and health service utilization in Pakistan: Challenging the policy makers. J. Public Health. 2004;27:49–54. doi: 10.1093/pubmed/fdh207.
    1. Dyson T., Moore M. On kinship structure, female autonomy, and demographic behavior in India. Popul. Dev. Rev. 1983;9:35–60. doi: 10.2307/1972894.
    1. Mumtaz Z., Salway S. ‘I never go anywhere’: Extricating the links between women’s mobility and uptake of reproductive health services in Pakistan. Soc. Sci. Med. 2005;60:1751–1765. doi: 10.1016/j.socscimed.2004.08.019.
    1. Davison C., Frankel S., Smith G.D. The limits of lifestyle: Re-assessing ‘fatalism’in the popular culture of illness prevention. Soc. Sci. Med. 1992;34:675–685. doi: 10.1016/0277-9536(92)90195-V.
    1. Glanz K., Rimer B.K., Viswanath K. Theory, Research, and Practice in Health Behavior and Health Education. Jossey-Bass; San Francisco, CA, USA: 2008.
    1. Smedley B.D., Syme S.L. Promoting health: Intervention strategies from social and behavioral research. Am. J. Health Promot. 2001;15:149–166.
    1. Drew E.M., Schoenberg N.E. Deconstructing fatalism: Ethnographic perspectives on women’s decision making about cancer prevention and treatment. Med. Anthropol. Q. 2011;25:164–182. doi: 10.1111/j.1548-1387.2010.01136.x.
    1. Straughan P.T., Seow A. Fatalism reconceptualized: A concept to predict health screening behavior. J. Gend. Cult. Health. 1998;3:85–100. doi: 10.1023/A:1023278230797.
    1. Surkan P.J., Hamdani S.U., Huma Z., Nazir H., Atif N., Rowther A.A., Chaudhri R., Zafar S., Mullany L.C., Malik A., et al. Cognitive–behavioral therapy-based intervention to treat symptoms of anxiety in pregnancy in a prenatal clinic using non-specialist providers in Pakistan: Design of a randomised trial. BMJ Open. 2020;10:e037590. doi: 10.1136/bmjopen-2020-037590.
    1. Bernard H.R. Research Methods in Anthropology: Qualitative and Quantitative Approaches. Rowman & Littlefield; Lanham, MD, USA: 2017.
    1. Mattingly C., Garro L.C. Narrative and the Cultural Construction of Illness and Healing. Univ of California Press; Berkeley, CA, USA: 2000.
    1. Husain N., Rahman A., Husain M., Khan S.M., Vyas A., Tomenson B., Cruickshank K.J. Detecting depression in pregnancy: Validation of EPDS in British Pakistani mothers. J. Immigr. Minor. Health. 2014;16:1085–1092. doi: 10.1007/s10903-014-9981-2.
    1. Clifford C., Day A., Cox J., Werrett J. A cross-cultural analysis of the use of the Edinburgh Post-Natal Depression Scale (EPDS) in health visiting practice. J. Adv. Nurs. 1999;30:655–664. doi: 10.1046/j.1365-2648.1999.01115.x.
    1. Biaggi A., Conroy S., Pawlby S., Pariante C.M. Identifying the women at risk of antenatal anxiety and depression: A systematic review. J. Affect. Disord. 2016;191:62–77. doi: 10.1016/j.jad.2015.11.014.
    1. Atif N., Krishna R.N., Sikander S., Lazarus A., Nisar A., Ahmad I., Raman R., Fuhr D.C., Patel V., Rahman A. Mother-to-mother therapy in India and Pakistan: Adaptation and feasibility evaluation of the peer-delivered Thinking Healthy Programme. BMC Psychiatry. 2017;17:79. doi: 10.1186/s12888-017-1244-z.
    1. Flory J.D., Yehuda R. Comorbidity between post-traumatic stress disorder and major depressive disorder: Alternative explanations and treatment considerations. Dialogues Clin. Neurosci. 2015;17:141.
    1. Nazneen S., Hossain N., Chopra D. Introduction: Contentious women’s empowerment in South Asia. Contemp. South Asia. 2019 doi: 10.1080/09584935.2019.1689922.
    1. Patil C.L., Klima C.S., Leshabari S.C., Steffen A.D., Pauls H., McGown M., Norr K.F. Randomized controlled pilot of a group antenatal care model and the sociodemographic factors associated with pregnancy-related empowerment in sub-Saharan Africa. BMC Pregnancy Childbirth. 2017;17:336. doi: 10.1186/s12884-017-1493-3.

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