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Background Few studies have evaluated postnatal depression before and during the Covid-19 pandemic using comparable data across time. We used data from three national maternity surveys in England to compare prevalence and risk factors for postnatal depression before and during the pandemic. Methods Analysis was conducted using population-based surveys carried out in 2014 (n = 4571), 2018 (n = 4509), and 2020 (n = 4611). Weighted prevalence estimates for postnatal depression (EPDS score ≥13) were compared across surveys. Modified Poisson regression was used to estimate adjusted risk ratios (aRR) for the association between sociodemographic, pregnancy- and birth-related, and biopsychosocial factors, and postnatal depression. Findings Prevalence of postnatal depression increased from 10.3% in 2014 to 16.0% in 2018 (difference = +5.7% (95% CI: 4.0–7.4); RR = 1.55 (95% CI: 1.36–1.77)) and to 23.9% in 2020 (difference = +7.9% (95% CI: 5.9–9.9); RR = 1.49 (95% CI: 1.34–1.66)). Having a long-term mental health problem (aRR range = 1.48–2.02), antenatal anxiety (aRR range = 1.73–2.12) and antenatal depression (aRR range = 1.44–2.24) were associated with increased risk of postnatal depression, whereas satisfaction with birth (aRR range = 0.89–0.92) and social support (aRR range = 0.73–0.78) were associated with decreased risk before and during the pandemic. Interpretation This analysis indicates that Covid-19 had an important negative impact on postnatal women's mental health and may have accelerated an existing trend of increasing prevalence of postnatal depression. Risk factors for postnatal depression were consistent before and during the pandemic. Timely identification, intervention and follow-up are key to supporting women at risk, and it is essential that mechanisms to support women are strengthened during times of heightened risk such as the pandemic. Funding NIHR Policy Research Programme.

Background Common mental disorders (CMD) are among the largest contributors to global maternal morbidity and mortality. Although research on perinatal mental health in India has grown in recent years, important evidence gaps remain, especially regarding CMD. Our study aims to improve understanding of CMD among perinatal and non-perinatal women of reproductive age across two settings in India: Bangalore (Karnataka) and Tanda (Himachal Pradesh). Methods The study is embedded within the Maternal and Perinatal Health Research Collaboration India (MaatHRI). This mixed-methods observational study comprises three consecutive phases: (i) focus group discussions and individual interviews to explore women’s knowledge and seek feedback on CMD screening tools; (ii) validation of CMD screening tools; and (iii) prospective cohort study to identify CMD incidence, prevalence and risk factors among perinatal and non-perinatal women. Results of the three phases will be analyzed using inductive thematic analysis, psychometric analysis and multivariable regression analysis, respectively. Conclusion Improving understanding, detection and management of CMD among women is key to improving women’s health and promoting gender equality. This study will provide evidence of CMD screening tools for perinatal and non-perinatal women in two diverse Indian settings, produce data on CMD prevalence, incidence and risk factors and enhance understanding of the specific contribution of the perinatal state to CMD.

Background Uncertainty remains regarding the validity of screening tools to detect common mental disorders (CMDs) during perinatal periods. This umbrella review aims to provide an up-to-date summary of psychometric properties of tools for the identification of perinatal CMDs. Methods Reviews were identified via Ovid MEDLINE, PsychINFO, EMBASE, Global Health and Cochrane Database of Systematic Reviews electronic databases with no date or language restriction. Pooled sensitivity and specificity estimates and ranges were extracted and summarised using forest plots. Quality assessment was conducted using Measurement Tool to Assess Systematic Reviews (AMSTAR-2). Results Of 7,891 papers identified, 31 reviews met inclusion criteria. 76 screening tools were identified; most frequently validated were Edinburgh Postnatal Depression Scale (EPDS) (n=28 reviews), Beck's Depression Inventory (BDI) (n=13 reviews) and Patient Health Questionnaire (PHQ) (n=12 reviews). Forest plots demonstrated a pattern of decreasing sensitivity and increasing specificity with increasing cut-off scores. Sub-group analysis of data extracted from low quality reviews demonstrated wider 95% CIs and overall lower specificity. Validity also varied according to ethnicity, socio-economic background and age. Limitations Despite a low Covered Corrected Area (CCA) score the primary studies included within reviews overlapped; therefore we were unable perform meta-analysis. Conclusions The evidence suggests that the EPDS, PHQ and BDI are useful across a range of diverse settings but the context of tool application is a key factor determining validity. This review highlights that utilizing screening tools in clinical practice is complex and requires careful consideration of the population, context, and health system it will be used in.

Background Common mental disorders (CMD) in the perinatal period are associated with significant adverse outcomes for women and their families. Prevalence of perinatal CMD is significant in low- and middle-income countries such as India, where women living in socio-economic deprivation, those experiencing intimate partner violence and those with low societal status are at high risk of perinatal mental disorders. Early detection and treatment of perinatal CMD can minimise adverse effects and improve outcomes. However, tools must be validated against a gold-standard locally to assess their psychometric validity and ensure they are culturally appropriate. We aimed to systematically review and synthesise the current evidence on screening tools for perinatal CMD that have been validated in India. Methods We searched MEDLINE, Embase, PsycINFO, Global Health, Cochrane Library, Web of Science and Google Scholar without language or date restrictions using search terms for CMD, perinatal status, screening and India. Studies assessing the validity of a screening tool for CMD against a gold standard in women who were pregnant or up to 12 months post-partum in India was included. Two reviewers independently screened titles, abstracts and full-texts and extracted data. Study quality was assessed using the QUADAS-2 tool. We used bivariate and hierarchical summary receiver operating characteristic models to calculate pooled summary estimates of sensitivity and specificity. Results We identified 8306 records of which 2838 were duplicates, 5390 were excluded by title and abstract and 76 were excluded by full-text. Five additional records were identified through grey literature searches. Seven studies were included in the review of which six (1003 participants) were included in meta-analysis. All included studies assessed the validity of the Edinburgh Postnatal Depression Scale (EPDS) in identifying perinatal depression. No studies tested the validity of screening tools for perinatal anxiety. At a threshold of ≥13 the EPDS had a pooled sensitivity of 88·9% (95% CI 77·4–94·9) and pooled specificity of 93·4 (95% CI 81·5–97·8). Two studies had a low risk of bias across all domains; all others had unclear or high risk of bias across at least one domain. Conclusion The EPDS appears to be psychometrically valid for identifying perinatal depression in India. There is a scarcity of evidence around the validity of other screening tools for perinatal CMD in India, with no studies of screening tools for perinatal anxiety identified. Evidence reviews should include rigorous searches of the grey literature to avoid missing studies published in non-indexed journals. Further research is required to inform decisions around screening tools for the identification of women with perinatal CMD in India.

BackgroundAntepartum depression affects around 15% of pregnant women worldwide, and may negatively impact their infants' physical, cognitive and social development, and confer a greater risk of emotional dysregulation in their children. Risk factors for antepartum depression disproportionately affect women from resource-sparse settings. In particular, pregnant refugee and migrant women face many barriers to diagnosis and care of mental health conditions, yet this group is under-represented in the literature. This study explores what refugee and migrant women living along the Thai-Myanmar border perceive as being contributory and protective factors to their antepartum depression, through secondary qualitative analysis of responses to clinical interviews for depression.MethodsPrevious research investigating perinatal depression in pregnant refugee and migrant women on the Thai-Myanmar border involved assessing 568 women for depression, using the Structured Clinical Interview for the diagnosis of DSM-IV Disorders (SCID). This study analyses a subsample of 32 women, diagnosed with persistent depression during the antepartum period. Thematic analysis of responses to the SCID and social and demographic surveys was undertaken to investigate factors which contribute towards, or protect against, persistent antepartum depression.ResultsMajor themes which women described as contributing towards persistent antepartum depression were financial problems, interpersonal violence, substance misuse among partners, social problems and poor health. Factors women considered as protecting mental wellbeing included social support, accessible healthcare and distractions, highlighting the need for focus on these elements within refugee and migrant settings. Commonly expressed phrases in local Karen and Burmese languages were summarised.ConclusionsKnowledge of factors affecting mental wellbeing in the study population and how these are phrased, may equip stakeholders to better support women in the study area. This study highlighted the limitations of contextually generic diagnostic tools, and recommends the development of tools better suited to marginalised and non-English speaking groups.

BACKGROUND: Early identification of postnatal depression is important in order to minimize adverse outcomes. The Edinburgh Postnatal Depression Scale (EPDS) is commonly used as a screening tool but a single, direct question on depression may offer an alternative means of identifying women in need of support. This study examines the agreement between these methods and characteristics of women who self-identify as depressed and those with EPDS ≥ 13. METHODS: Secondary analysis of two national maternity surveys conducted in England and Northern Ireland. Agreement between the direct question and EPDS scores was assessed using Cohen's kappa. Logistic regression was used to identify characteristics of women in each group. RESULTS: 6752 women were included. At three months postpartum, 6.1% of women self-identified as having depression, 9.1% scored EPDS ≥ 13, 2.8% were positive on both. Agreement between the two methods was minimal (Cohen's kappa 40 years (OR 1.8; 95% CI 1.2-2.8). EPDS ≥ 13 was associated with LIMITATIONS: Low survey response limits the representativeness of findings. The absence of a diagnostic interview limits conclusions on accuracy or internal validity of the measures. CONCLUSIONS:A direct question about postnatal depression may offer a valuable addition to screening tools to identify women in need of support.

Migrant and refugee women are at risk of perinatal depression due to stressors experienced before, during and after migration. This study assesses the associations between social support and perinatal depression among migrant and refugee women on the Thai–Myanmar border. We conducted a cohort study of pregnant and post-partum women. Depression status was assessed using a structured clinical interview. Received support, perceived support and partner support were measured in the third trimester. Logistic regression was used to calculate associations between social support measures and perinatal depression controlling for demographic, socio-economic, migration, obstetric and psychosocial factors. Four hundred and fifty-one women (233 migrants; 218 refugees) were included. The prevalence of perinatal depression was 38.6% in migrants and 47.3% in refugees. Migrants had higher levels of received, perceived and partner support than refugees. After controlling for all other variables, higher levels of received support remained significantly associated with a lower likelihood of perinatal depression in migrants (adjusted odds ratio 0.82; 95% CI 0.68–0.99). In both groups, depression history and trauma were strongly associated with perinatal depression. Our study highlights the importance of received social support to perinatal depression in migrant women on the Thailand–Myanmar border. The perinatal period offers a valuable opportunity to ask women about their support and offer community-level or public policy interventions to nurture support networks in current locations and resettlement destinations.This article is part of the theme issue ‘Multidisciplinary perspectives on social support and maternal–child health’.

Background Suicide is a leading cause of maternal death globally. Migrant and refugee populations may experience higher risk of suicide. We report data on suicidal ideation from migrant and refugee women living on the Thailand–Myanmar border. Methods Women were recruited in their first trimester of pregnancy. Depression status was assessed by diagnostic interview in the first, second and third trimesters and at 1 month post-partum. We calculated prevalence of suicidal ideation and used logistic regression to identify associated socio-demographic factors. Results During the perinatal period, 5.3% (30/568) women experienced suicidal ideation. Refugee women were more likely to experience suicidal ideation than migrant women (8.0 versus 3.1%; P = 0.01). Most women with suicidal ideation did not have severe depression. Previous trauma (OR 2.32; 95% CI: 1.70–3.15) and unplanned pregnancy (OR 2.74; 95% CI: 1.10–6.86) were significantly associated with suicidal ideation after controlling for all other variables. Conclusions Suicidal ideation represents an important symptom among migrant and refugee women on the Thailand–Myanmar border. Screening only those with severe depression may be insufficient to identify women at risk of suicide. Community-level interventions addressing social and gender inequalities and prioritization of family planning programmes are needed alongside targeted suicide prevention initiatives to help lower the rates of people dying by suicide.

Background Perinatal common mental disorders are associated with significant adverse outcomes for women and their families, particularly in low- and middle-income settings. Early detection through screening with locally-validated tools can improve outcomes. Methods We searched MEDLINE, Embase, PsycINFO, Global Health, Cochrane Library, Web of Science and Google Scholar for articles on the validation of screening tools for common mental disorders in perinatal women in India, with no language or date restrictions. Quality was assessed using the QUADAS-2 tool. We used bivariate and hierarchical summary receiver operating characteristic models to calculate pooled summary estimates of sensitivity and specificity. Heterogeneity was assessed by visualising the distance of individual studies from the summary curve. Results Seven studies involving 1003 women were analysed. All studies assessed the validity of the Edinburgh Postnatal Depression Scale (EPDS) in identifying perinatal depression. No validation studies of any other screening tools were identified. Using a common threshold of ≥13 the EPDS had a pooled sensitivity and specificity of 88·9% (95%CI 77·4–94·9) and 93·4 (95%CI 81·5–97·8), respectively. Using optimal thresholds (range ≥ 9 to ≥13) the EPDS had a pooled sensitivity and specificity of 94·4% (95%CI 81·7–98·4) and 90·8 (95%CI 83·7–95·0), respectively. Conclusion The EPDS is psychometrically valid in diverse Indian settings and its use in routine maternity care could improve detection of perinatal depression. Further research is required to validate screening tools for other perinatal common mental disorders in India.

Summary 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. Context This paper presents a conceptual synthesis of current efforts in medical education to incorporate national health priorities as a reflection on how the field has evolved since the Edinburgh Declaration. Considering that health needs vary from country to country, our paper focuses on three broad and cross‐cutting themes: health equity, health systems strengthening, and changing patterns of disease. Methods Considering the complexity of this topic, we conducted a targeted search to broadly sample and critically review the literature in two phases. Phase 1: within each theme, we assessed the current challenges in the field of medical education to meet the health priority. Phase 2: a search for various strategies in undergraduate and postgraduate education that have been tested in an effort to address the identified challenges. We conducted a qualitative synthesis of the literature followed by mapping of the identified challenges within each of the three themes with targeted efforts. Findings We identified six important challenges: (i) mismatch between the need for generalist models of health care and medical education curricula's specialist focus; (ii) attitudes of health care providers contributing to disparities in health care; (iii) the lack of a universal approach in preparing medical students for 21st century health systems; (iv) the inability of medical education to keep up with the abundance of new health care technologies; (v) a mismatch between educational requirements for integrated care and poorly integrated, specialised health care systems; and (vi) development of a globally interdependent education system to meet global health challenges. Examples of efforts being made to address these challenges are offered. Discussion Although strategies for combatting these challenges exist, the effectiveness of educational models depends on them being locally adaptable and applicable. Curricular reform must go hand‐in‐hand with research and evaluation to develop comprehensive futuristic models of teaching and learning that will adequately prepare health professionals to address the challenges.

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.

Background The number of people migrating for labour is growing around the world, particularly in low- and middle-income countries. Parents often move for work, leaving their children behind. In China alone there are 61 million left-behind children and adolescents (LBCA). Methods We conducted a systematic review including studies on parental migration and LBCA aged 0–19 years in low- and middle-income countries. Our outcomes were the 10 main causes of disability-adjusted life years in the under-5, 5–9 and 10–19 year age groups. These included nutrition, mental health, unintentional injuries, infectious disease, substance use, unprotected sex, early pregnancy and abuse among. We searched databases including MEDLINE, EMBASE and CINAHL from inception to April 2017, with no language restrictions. We conducted meta-analyses, sensitivity analyses based on the quality of studies, subgroup analyses (internal and international migration and one or two parent absence), and meta-regression to investigate child gender and age. A revised version of the Newcastle-Ottawa tool was used to assess bias. The protocol was registered with PROSPERO (CRD42017064871). Results We identified 111 studies, including 2 64 967 children and adolescents. 91 studies were conducted in China, all of which focused on internal migration. The other 20 studies were largely related to international migration in Asia. LBCA had an increased risk of depression (risk ratio (RR) 1.52; 95% confidence interval (CI) 1.27,1.82) and higher depression scores (standardised mean difference (SMD) 0.16; 0.10,0.21), anxiety (RR 1.85;95% CI 1.36,2.53 and SMD 0.18; 95% CI 0.11,0.26), suicidal ideation (RR 1·70; 95% CI 1.28,2.26), conduct disorder (SMD 0.16; 95% CI 0.04,0.28) and substance use (RR 1.24; 95% CI 1.00,1.52). There was an increased risk of malnutrition: wasting (RR 1.13; 95% CI 1.02,1.24) and stunting (RR 1.12; 95% CI 1.00,1.26). We found no difference for other nutrition outcomes, unintentional injury, abuse or diarrhoea. Removing low quality studies made little difference to the outcomes, as did subgroup analyses. Meta-regression showed no significant effect of gender or mean age on any outcomes. Conclusions Parental labour migration is associated with morbidity in LBCA, with no evidence of any benefit. The strongest evidence exists in China, with more research required in the rest of the world.

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 incre...

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.

Background: This study examines the prevalence and determinants of perinatal depression among migrant women on the Thai-Myanmar border. Methods: A cohort of labour migrant and refugee women was followed-up from the first trimester of pregnancy to one month post-partum. Depression status was assessed in the first, second and third trimesters and at one month post-partum using a structured clinical interview. Outcomes: A sample of 568 women was recruited. Period prevalence of moderate-severe perinatal depression was 18.5% (95% CI 15.4-21.9%). Overall, 15.4% (95% CI 11.8-19.6%) of women developed new-onset moderate-severe depression during the study period. Risk factors were interpersonal violence (OR 4.5; 95% CI 1.9-11.1); history of trauma (OR 2.4; 95% CI 1.4-4.3); self-reported history of depression (OR 2.3; 95% CI 1.2-4.2); labour migrant status (OR 2.1; 95% CI 1.1-4.0); low social support (OR 2.1; 95% CI 1.1-3.7); and maternal age (OR 1.1; 95% CI 1.0-1.1). Interpretation: Perinatal depression represents a significant burden among migrant women on the Thai-Myanmar border. Programmes to address the determinants along with early case identification and effective treatment and referral systems are key to addressing perinatal depression in this low-resource setting. Funding Statement: SMRU is part of the Mahidol Oxford Tropical Medicine Research Unit funded by the Wellcome Trust (WT-106698). Declaration of Interests: All authors declare no conflict of interests. Ethics Approval Statement: Ethical approval was granted by the University of Oxford Tropical Research Ethics Committee (OxTREC 28-15), the Mahidol University Faculty of Tropical Medicine Ethics Committee (TMEC 15-045) and the Tak Border Community Advisory Board (T-CAB 6/2/2015).

Background Adolescent pregnancy remains a global health concern, contributing to 11% of all births worldwide and 23% of the overall burden of disease in girls aged 15–19 years. Premature motherhood can create a negative cycle of adverse health, economic and social outcomes for young women, their babies and families. Refugee and migrant adolescent girls might be particularly at risk due to poverty, poor education and health infrastructure, early marriage, limited access to contraception and traditional beliefs. This study aims to explore adolescents’ perceptions and experiences of pregnancy in refugee and migrant communities on the Thailand-Myanmar border. Methods In June 2016 qualitative data were collected in one refugee camp and one migrant clinic along the Thailand-Myanmar border by conducting 20 individual interviews with pregnant refugee and migrant adolescents and 4 focus group discussions with husbands, adolescent boys and non-pregnant girls and antenatal clinic staff. Inductive thematic analysis was used to identify codes and themes emerging from the data. Results Study participants perceived adolescent pregnancy as a premature life event that could jeopardise their future. Important themes were premarital sex, forced marriage, lack of contraception, school dropout, fear of childbirth, financial insecurity, support structures and domestic violence. Supportive relationships with mothers, husbands and friends could turn this largely negative experience into a more positive one. The main underlying reasons for adolescent pregnancy were associated with traditional views and stigma on sexual and reproductive health issues, resulting in a knowledge gap on contraception and life skills necessary to negotiate sexual and reproductive choices, in particular for unmarried adolescents. Conclusions Adolescents perceive pregnancy as a challenging life event that can be addressed by developing comprehensive adolescent-friendly sexual and reproductive health services and education in refugee and migrant communities on the Thailand-Myanmar border. Creating a more tolerant and less stigmatising environment in these communities and their governing bodies will help to achieve this goal.

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.

A young refugee woman attended antenatal clinic on the Thai-Myanmar border at 9 weeks' gestation. As part of an ongoing study of perinatal mental health, she underwent a structured psychiatric interview during which she described occasional depressed mood, anhedonia and passive suicidal ideation. Her husband was a young refugee known to use alcohol and drugs. 2 days later, the couple committed suicide together by herbicide ingestion. Refugee populations are at risk of developing mental disorders as a result of their marginalised status, socioeconomic disadvantage and exposures to trauma. Pregnancy may have exacerbated feelings of hopelessness in this couple. The prevalence of mental disorders such as depression is increased in the perinatal period and suicide is the second leading cause of death in young women globally. Prevention programmes and early recognition of mental disorders may improve detection and lead to better support for vulnerable individuals.

Background Migrant women are at risk of perinatal mental disorders due to stressors experienced before, during and after migration. Objectives This systematic review and meta-analysis summarises the prevalence, associated factors and interventions for perinatal mental disorders in migrant women from low- and middle-income countries (LMIC). Search Strategy We systematically searched nine electronic databases and the grey literature using a predefined search strategy. Selection Criteria Studies were included if they assessed pregnant or postpartum migrants from LMIC, used a structured tool and a case-control, cross-sectional, cohort or intervention study design. Data collection and analysis Data was double-extracted. We calculated pooled prevalence of depression and weighted mean anxiety and depression scores. We calculated crude odds ratios from risk factor studies and summarised intervention studies descriptively. Main results Forty studies were identified from 10 123 references. Pooled prevalence was 31% [95% condidence interval (CI) 23%–40%] for any depressive disorder and 17% (95% CI 12–23%) for major depressive disorder. Previous depression and lower social support were associated with perinatal depression. There were insufficient data to assess the burden of anxiety, post-traumatic stress disorder or psychosis in this population. Conclusions One in three migrant women from LMIC experiences symptoms of perinatal depression. Social support is an important protective factor. Evidence on LMIC women relocating to other LMIC is lacking. Given the adverse consequences of perinatal mental illness on women and their children, further research in low-resource settings is a priority. Tweetable Abstract One in three migrant women from low- and middle-income countries has symptoms of perinatal depression.

Suicide is a leading cause of maternal mortality across all income settings. Published data underestimates the true burden because these deaths are frequently reported as accidental. Pregnancy-related suicide in refugee and migrant populations is rarely reported, although risk is probably increased as a result of multiple psychosocial and socioeconomic stresses. Data on suicide rates of refugees and migrants before resettlement are particularly scarce. Shoklo Malaria Research Unit has

SUMMARYThe 2009 novel H1N1 influenza pandemic had a significant impact on Shenzhen's population with 2063 laboratory-confirmed human H1N1 cases and five deaths being reported. We used parameters from two population-based surveys and the Shenzhen Influenza Surveillance System to estimate the total number of H1N1 influenza infections in Shenzhen in the 2009 pandemic. The attack rate of influenza-like illness (ILI) in family households was 11·2% (95% CI 9·4–13·0), with 80·2% (95% CI 77·8–82·5) seeking medical care. The ILI attack rate in workers was 38·1% (95% CI 34·3–41·7) with 72·5% (95% CI 66·9–78·0) seeking medical care. The average H1N1 positive rate in individuals reporting ILI and testing by polymerase chain reaction was 22·7%. A total of 611 000–768 000 people, or 4·7–5·9% of the Shenzhen population, are estimated to have experienced H1N1 influenza. The estimated total number of cases of H1N1 is likely to be 330 times greater than the number of laboratory-confirmed cases.

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.

Background: Mental 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. Methods: Thirteen 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. Results: A 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. Conclusions: Mental 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.

Background: Educational and skills‐based interventions are often used to prevent relationship and dating violence among young people. Objectives: To assess the efficacy of educational and skills‐based interventions designed to prevent relationship and dating violence in adolescents and young adults. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, six other databases and a trials register on 7 May 2012. We handsearched the references lists of key articles and two journals (Journal of Interpersonal Violence and Child Abuse and Neglect). We also contacted researchers in the field. Selection criteria: Randomised, cluster‐randomised and quasi‐randomised studies comparing an educational or skills‐based intervention to prevent relationship or dating violence among adolescents and young adults with a control. Data collection and analysis: Two review authors independently assessed study eligibility and risk of bias. For each study included in the meta‐analysis, data were extracted independently by GF and one other review author (either CH, JN, SH or DS). We conducted meta‐analyses for the following outcomes: episodes of relationship violence, behaviours, attitudes, knowledge and skills. Main results: We included 38 studies (15,903 participants) in this review, 18 of which were cluster‐randomised trials (11,995 participants) and two were quasi‐randomised trials (399 participants). We included 33 studies in the meta‐analyses. We included eight studies (3405 participants) in the meta‐analysis assessing episodes of relationship violence. There was substantial heterogeneity (I2 = 57%) for this outcome. The risk ratio was 0.77 (95% confidence interval (CI) 0.53 to 1.13). We included 22 studies (5256 participants) in the meta‐analysis assessing attitudes towards relationship violence. The standardised mean difference (SMD) was 0.06 (95% CI ‐0.01 to 0.15). We included four studies (887 participants) in the meta‐analysis assessing behaviour related to relationship violence; the SMD was ‐0.07 (95% CI ‐0.31 to 0.16). We included 10 studies (6206 participants) in the meta‐analysis assessing knowledge related to relationship violence; the results showed an increase in knowledge in favour of the intervention (SMD 0.44, 95% CI 0.28 to 0.60) but there was substantial heterogeneity (I2 = 52%). We included seven studies (1369 participants) in the meta‐analysis assessing skills related to relationship violence. The SMD was 0.03 (95% CI ‐0.11 to 0.17). None of the included studies assessed physical health, psychosocial health or adverse outcomes. Subgroup analyses showed no statistically significant differences by intervention setting or type of participants. The quality of evidence for all outcomes included in our meta‐analysis was moderate due to an unclear risk of selection and detection bias and a high risk of performance bias in most studies. Authors' conclusions: Studies included in this review showed no evidence of effectiveness of interventions on episodes of relationship violence or on attitudes, behaviours and skills related to relationship violence. We found a small increase in knowledge but there was evidence of substantial heterogeneity among studies. Further studies with longer‐term follow‐up are required, and study authors should use standardised and validated measurement instruments to maximise comparability of results.

Background: While several studies of smoking behaviors in rural-to-urban Chinese migrants exist, none to our knowledge have focused on factory workers, estimated to represent between 10% and 20% of China’s total rural-to-urban migratory population. This paper assesses factors associated with smoking behavior among rural-to-urban migrant factory workers in Shenzhen, China. Methods: A cross-sectional survey of migrant workers from 44 randomly selected factories in Shenzhen, China. Participants were migrant factory workers aged 16–59 years and holding nonlocal household registration. The main outcome measures were demographic, migration-related, and behavioral factors associated with smoking status. Results: Four thousand and eighty-eight completed questionnaires were obtained (response rate 95.5%). Overall smoking prevalence (including occasional, daily, and heavy daily smoking) was 19.1%. The prevalence of daily smoking (including heavy daily smoking) was higher in men (27.3%) than women (0.7%). These rates are significantly lower than national smok ing rates (59.5% in men, 3.7% in women) and rates found in a similar study. A high-risk group of men who smoke heavily and consume alcohol frequently was identified. Longer working hours and less rest were associated with higher rates of smoking. Frequent Internet use and lack of insurance were associated with lifetime smoking. Gender-adjusted models showed that poorer mental health and an accumulated working time in Shenzhen of 2–3 years increased female workers’ likelihood of smoking. Conclusions: Migrant factory workers in Shenzhen had lower rates of smoking than other population groups in China. The identification of risk factors for heavy smoking may help to effectively target health promotion interventions.

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