Adverse childhood experiences and depression among women in rural Pakistan

Women are at an elevated risk for depression during the perinatal period, which can impair a woman’s health, increase her risk of suicide, and impact her child’s growth and development [1‐3]. Additionally, women experiencing perinatal depression are at risk for recurrent depressive episodes, which cause further deleterious outcomes for maternal and child health [3]. In low- and middle-income countries (LMIC), the pooled prevalence of postpartum depression (beginning in pregnancy up to 1 year postpartum) is estimated to be 19.8% [4]. The highest burden of postpartum depression is in LMIC, exacerbating economic and social inequalities and making depression a global health priority [1, 2].

Adverse childhood experiences (ACEs), measured by the ACE questionnaire and classified as abuse, neglect, household dysfunction, and community disfunction, are a common pathway to long-term social, emotional, and cognitive impairments, including depression [1, 5]. Globally, the majority of individuals (57%) experience at least one ACE [6]. The prevalence of ACEs also varies by context, with LMIC settings consistently reporting higher rates than high-income countries [7]. Prior research has found ACEs to be related to prenatal depressive symptoms and postpartum depression [6, 8]. Additionally, there is a dose-response relationship between how many ACEs a woman experiences and the likelihood of perinatal depressive symptoms [9].

However, there is a lack of consensus about which types of ACEs (i.e., abuse; household dysfunction) are related to women’s depression, as this relationship likely varies by context [10]. For instance, one study in the United States (US) found ACE score and maltreatment to be associated with prenatal depression but found no relationship between household dysfunction and depression [11]. However, a study in Canada found household dysfunction and abuse to be related to maternal depression [10]. Lastly, most research has measured this relationship during pregnancy and 1 year postpartum, so it is not understood if ACEs are related to depression beyond this high-risk window.

Further, ACEs research, including research assessing relationships between ACEs and women’s depression in adulthood is concentrated in high-income countries [1, 6]. ACEs may manifest differently in LMIC due to different norms and resources. The ACE-International Questionnaire (ACE-IQ), designed and adapted to study ACEs outside the US, adds items to assess the experience of peer violence, exposure to collective violence, and witnessing community violence, which are more commonly experienced in LMIC [12].

In Pakistan, a LMIC and the setting of the current study, research has linked the ACE-IQ to physical and mental health outcomes among a student population in an urban setting [13, 14]. However, the impact on adult rural women’s mental health of ACEs exposure, overall or by type, has not been investigated. Additionally, the prevalence of postpartum depression in Pakistan is estimated to be higher than other countries in South Asia and than most LMIC at 28–36% [4, 15, 16]. Specific aspects of the social context of rural Pakistan may be particularly relevant to understanding this relationship among adult women. For example, over two-thirds of rural families live in multigeneration or extended family homes [17, 18], 15% of women have completed secondary education, the fertility rate is 3.9, and over 30% of families live in poverty [19, 20]. Women’s exposure to marital intimate partner violence is also quite prevalent, as it is elsewhere in South Asia [21, 22].

This study estimates the overall relationship between ACEs and women’s depression at 36 months postpartum in Pakistan and assesses which ACE domains are related to women’s depression. As depression can impair women’s well-being, understanding underlying risk factors (i.e., ACEs) can lead to developing interventions to improve mental health [23]. Additionally, by investigating this relationship in a LMIC, global health practitioners can better target mental health interventions to those at highest risk of depression.

In sum, 58% reported at least one ACE and 7% reported four or more. The most common were physical and emotional abuse and physical neglect. Collective violence, being bullied, having an incarcerated family member, and living with someone that was mentally ill were rare with less than 2% experiencing them. By domain, home violence was most common. ACEs were associated with MDE and symptom severity with those experiencing four or more ACEs having a strong relationship with worse mental health. By domain, psychological distress, home violence, and community violence were associated with MDE and symptom severity.

Prevalence of ACEs in this sample was higher than in most high-income settings [6] but lower than in other LMIC (i.e., Kenya) [6, 33]. High prevalence of both abuse and neglect in childhood signal child maltreatment that can lead to mental health problems in adulthood [8]. Low prevalence of family psychological distress may indicate either that women in this area experience or report less family distress as children than others or that the questions may be leading to some degree of under-reporting. Prior work in Pakistan has found that ACEs may be more difficult to disclose in collectivist cultures such as Pakistan where the role of the natal family remains important through adulthood [13]. It may be necessary to modify the ACE-IQ to better fit this cultural context by conducting cognitive interviewing or focus group testing. For example, one study in South Africa deleted two ACE-IQ items after conducting focus groups that inquired about the items’ cultural relevance [34]. Another reason for the low ACEs prevalence in comparison to other LMIC may be because we removed sexual abuse questions due to concerns about sexual abuse histories being under-reported. If disclosed, sexual abuse could potentially put women at risk from their marital families by implying any sexual experience before marriage even though not consensual. Lastly, it is possible that the prevalence of ACEs is lower than expected in this setting. Prior work has found that in South Asia, women are protected until early adulthood when they rapidly transition to marriage, pregnancy, and childbirth and then experience more adversity [35]. Additionally, the Punjab Province government has pushed to increase girls’ education in recent years, which may further protect them from adversity [36].

Given that we found similarly strong relationships between ACEs and symptom severity and ACEs and MDE, ACEs may contribute to both heightened depressive symptom severity and clinical depressive levels. The positive association between ACEs and depression at 36 months postpartum [37] extends previous work in high-income countries focused on depression within 1 year postpartum and corroborates a recent finding that this relationship still exists at 36 months [9].

Additionally, while we did not find evidence of a linear dose-response relationship, we found that women with four or more ACEs exhibited the highest depressive symptomology. A dose-response relationship between ACEs and adverse health has been observed in high-income settings and other LMIC. This provides support for the theory of toxic stress in which high-level exposure to early life adversity increases risk for poor health throughout life [8, 17, 38]. It is possible that at lower levels of ACEs women can draw from resources that reduce risk for depression, but at higher levels of ACEs, these supportive resources are unavailable or overwhelmed. In support of this postulation, a recent study found increased ACEs to be associated with lower amounts of support from family and friends, and that this support mediated the relationship between ACEs and prenatal depression [39]. Future research should expand on the pathways between ACEs and mental health to leverage them into interventions.

Our findings also indicate that ACE domains have unique relationships with women’s depression. Family psychological distress, community violence, and home violence are related to MDE and symptom severity. Community and home violence were associated with maternal depression in Kenya and family psychological distress was in Canada [10, 33]. These exposures to violence and interpersonal trauma in childhood are known to be associated with poor mental health in adulthood. Yet, our study did not align with previous studies regarding the importance of neglect [33]. It is possible that neglect, related to deprivation, has a different relationship to women’s depression than ACEs closely related to threats (i.e., violence) as deprivation and violence may differentially influence neural pathways [40, 41].

The need for future research that conceptualizes ACEs in different sociocultural contexts is reinforced by discordance about the relationship between specific ACE domains and depression by region. Context is instrumental in determining exposure type and frequency and influences the ways individuals learn to process adverse experiences [42]. Additionally, ACE domains likely affect physical and mental health through diverse mechanisms. For example, some neurologic research has demonstrated that different abuse and maltreatment exposures result in various altered brain structures and pathways [43]. ACE domains varying by context and ACE domains differentially affecting adult mental health deserve attention.

Our findings suggest that interventions aimed at both reducing the occurrence of ACEs and mitigating their deleterious impact would be promising in reducing women’s mental health risk in high adversity settings [23]. These interventions are particularly needed in the current global context of the novel coronavirus pandemic, which poses significant mental health threats, particularly for those that have been exposed to ACEs [45]. Our findings also indicate a need to develop context-specific interventions that prevent ACEs from occurring. Perinatal depression and early childhood parenting interventions can reduce ACEs for the next generation [33]. Among women exposed to ACEs, it is important to mitigate their impact on mental illness in adulthood [33, 46]. Prior work has found trauma-focused cognitive-behavioral therapies to be effective at preventing poor mental health among adults exposed to ACEs though this needs to be explored further in LMIC settings [46]. Our findings signal a need for public health practitioners in LMICs to more broadly recognize and address women’s childhood experiences within mental health interventions. Doing so will ensure that women receive appropriate psychosocial and mental health support that accounts for their lifelong experiences rather than only current adversities.