Abstract
Adverse childhood experiences (ACEs) reflect childhood exposure to abuse, neglect, and family stressors and are associated with subsequent poor mental health. Maternal ACEs can have lasting effects for mothers and their children. Few studies of maternal ACEs have been conducted in low- and middle-income countries. We aimed to determine the relationship between maternal ACEs and mental health among postpartum mothers in Kenya with and without HIV. This nested cross-sectional study used data from mothers attending 6-week postnatal care visits enrolled in the HOPE study. Outcomes of interest were maternal mental health (depression symptoms, psychological distress, and well-being), and the exposure of interest was self-reported ACEs. High ACEs were defined as four or more ACEs. Log binomial regression models were used to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs). ACEs domain (abuse, neglect, and household dysfunction) was a secondary exposure of interest. Of the 1988 mothers, 49.9% were living with HIV, 17.2% had high ACEs, 3.1% had moderate/severe depression (MSD) symptoms, 3.0% had moderate/severe psychological distress (MPD), and 77.6% had moderate/high psychological well-being (MPW). Mothers with high ACEs had a higher prevalence of MSD symptoms (PR: 3.73 [95% CI: 2.29, 6.08], p < .001), and MPD (PR: 3.68 [95% CI: 2.24, 6.06], p < .001) and a lower prevalence of MPW (PR: 0.75 [95% CI: 0.69, 0.82], p < .001). Findings remained when stratified by HIV status and perceived social support. Peripartum ACEs screening may be useful to identify women who may benefit from mental health support.
Keywords: Adverse childhood experiences (ACEs), Depression, Anxiety, HIV, Peripartum, Postpartum
Introduction
Adverse childhood experiences (ACEs) reflect childhood exposure to multidimensional abuse, neglect, maltreatment, and family stressors. There is consistent evidence of associations between ACEs and poor mental health [1, 2]. The ACEs Framework posits that past traumatic experiences can have a lasting impact on physical and psychological well-being across the lifespan [3]. Toxic stress theory posits that prolonged or repeated exposure to severe physical or psychological stressors such as ACEs can disrupt the body’s natural stress regulation systems, causing long-term physical and psychological changes [4, 5]. ACEs include traumatic events that occur across emotional, physical, psychological, and interpersonal domains, typically co-occur, and tend to have a dose-response relationship. Several studies have shown that individuals who experienced a greater number of ACEs have worse mental health outcomes, including depression, anxiety, and poorer overall well-being [6]. While there is not one universally recognized threshold for high ACEs vs. low ACEs in the literature, many previous studies have found that 4 + ACEs tends to be the point at which considerable physical and psychological consequences of toxic stress can be identified [7–10].
There is emerging evidence that maternal ACEs in childhood can exert generational impact such that past experiences of ACEs in childhood can result in poor physical and mental health outcomes for mothers and their own children [11]. Experiencing ACEs in childhood is a predictor of subsequent depressive symptoms in adulthood and the perinatal period may be an especially vulnerable time for poor psychological outcomes [1]. ACEs have been shown to be associated with maternal peripartum depression and anxiety as well as adverse birth outcomes including low birth weight and gestational age [1, 2]. A greater number of maternal ACEs has also been associated with greater behavioral difficulties in children born to mothers with ACEs [12]. Because perinatal depression and psychological distress influence maternal and infant morbidity and mortality [13], it is important to better define associations between ACEs and peripartum mental health among mothers.
Few studies of maternal ACEs have been conducted in low- and middle-income countries (LMICs). Some studies have noted high prevalence of ACEs in LMICs, with between 73% and 82% of individuals experiencing at least one ACE in childhood [14, 15]. This is higher than, or comparable to, the United States where studies report prevalence ranges of 52%–80% [16–20]. Though ACEs can be experienced by anyone regardless of gender, geography, or socioeconomic status, mothers in LMICs may have a high likelihood of ACEs due to experiences that increase vulnerability to ACEs such as resource deprivation, exposure to violence, low educational attainment, and low economic independence, that may be common for women in LMIC settings [11, 21, 22]. Research in high income countries (HICs) has shown that the association between ACEs and mental health outcomes may be amplified among people living with HIV [23]. These findings demonstrate a need to better understand the relationship between maternal ACEs and mental health for mothers living with HIV in LMICs.
Different ACEs domains in childhood may be associated with different mental health outcomes in adulthood [24–26]. ACEs are often classified within domains (e.g. abuse, neglect, and household dysfunction) [27]. In HICs, selected studies note that the abuse domain may be the most predictive of depression while the neglect domain may be the most predictive of general psychological distress [24, 25]. There is scant research on the relationship between the household dysfunction domain and mental health outcomes. Additionally, research in HICs has shown that perceived social support may be a protective factor against the long-term mental health outcomes associated with ACEs [26]. It is important to examine these associations in LMICs because social support interventions may be a viable strategy for supporting mothers in LMICs who experience high ACEs.
We aimed to determine the relationship between maternal ACEs and mental health and identify potential effect modifiers of the relationship between maternal ACEs and mental health among new mothers in Kenya during the postpartum period. We hypothesized that mothers with high maternal ACEs would report poorer mental health outcomes than mothers with low maternal ACEs. We also hypothesized that HIV status and perceived social support would modify this association.
Methods
Study Design and Setting
This was a nested cross-sectional study using data from a longitudinal cohort study (HOPE Study) that assessed physical and mental health outcomes for HIV-exposed uninfected (HEU) and HIV-unexposed (HUU) infants and their mothers. Data from the HOPE Study were collected from seven public sector maternal and child health clinics in Nairobi and Western Kenya.
Study Population and Procedure
The HOPE study includes 2,000 mother-infant pairs (1,000 mothers with HIV [MWHIV]; 1,000 HIV-negative mothers). Details of the study are provided in the study protocol manuscript [28]. Briefly, mothers included in the study were at least 18 years of age and provided survey data at their 6-week (range 4–10 weeks) postnatal care visit at one of the seven participating clinics. Mothers were excluded from participation if their own HIV status was unknown or unconfirmed through testing or medical records, if their infant was living with HIV, or if the mothers had plans to relocate within the next four years. The current study used data from all mothers who attended their 6-week visit and who provided survey data about past ACEs. Data were collected at enrollment from mothers attending 6-week postnatal care visits between February 2021 and June 2022. Standardized questionnaires were administered to obtain data on demographics, medical history, socioeconomic factors, and family structures for mothers and their infants. Prior to enrollment, all participating mothers received an explanation of the study in their preferred language from study nurses. If mothers chose to participate, written consent was collected from each mother.
Outcome of Interest
The outcome of interest was maternal mental health. Mental health variables that were assessed were depressive symptoms, psychological distress, and psychological well-being. Depressive symptoms were measured using the 9-item Patient Health Questionnaire (PHQ-9) [29]. Participants who scored at least 10 out of 27 total points on the PHQ-9 were categorized as having moderate to severe depressive symptoms based on clinical cutoffs for PHQ-9 scoring [29]. Psychological distress was measured using the 10-item Kessler Psychological Distress Scale (K-10) [30]. Participants who scored at least 25 out of 50 total points on the K-10 were categorized as having moderate to severe psychological distress based on clinical cutoffs for the K-10 scale [30]. Psychological well-being was measured using the 5-item World Health Organization Well-being Index (WHO-5) [31]. Participants who scored 50 or fewer out of 100 total points on the WHO-5 were categorized as having low well-being based on the World Health Organization’s cutoff for “clinically concerning” levels of well-being [31].
Exposure of Interest
The primary exposure of interest was self-reported past ACEs. ACEs were measured using the 10-item Adverse Childhood Experiences Questionnaire (ACEs-Q; continuous, 0–10 ACEs) [3]. The ACEs-Q consists of 10 yes/no questions where participants are asked to indicate which, if any, of the adverse events they experienced prior to their 18th birthday (Table 1). Participants who reported experiencing 4 or more ACEs were categorized as having high ACEs and participants with 3 or fewer ACEs were categorized as having low to intermediate ACEs based on the recommended ACE-Q cutoff points for identifying toxic stress risk [3]. The ACE-Q also categorizes each of the 10 ACEs questions into one of three domains of ACEs (Abuse, Neglect, Household Dysfunction) which were also examined. For the present study, if a participant responded “yes” to any of the events is a particular domain, they were categorized as having experienced that domain. Similarly, participants could be categorized into multiple domains.
Table 1.
Items from the ACE-Q questionnaire
| Item | Question |
|---|---|
|
| |
| ACE-Q 1 | Did a parent or other adult in the household often or very often... Swear at you, insult you, put you down, or humiliate you or act in a way that made you afraid that you might be physically hurt? |
| ACE-Q 2 | Did a parent or other adult in the household often or very often... Push, grab, slap, or throw something at you or ever hit you so hard that you had marks or were injured? |
| ACE-Q 3 | Did an adult or person at least 5 years older than you ever... Touch or fondle you or have you touch their body in a sexual way or attempt or actually have oral, anal, or vaginal intercourse with you? |
| ACE-Q 4 | Did you often or very often feel that... No one in your family loved you or thought you were important or special or your family didn’t look out for each other, feel close to each other, or support each other? |
| ACE-Q 5 | Did you often or very often feel that... You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you or your parents were too drunk or high to take care of you or take you to the doctor if you needed it? |
| ACE-Q 6 | Were your parents ever separated or divorced? |
| ACE-Q 7 | Was your mother or stepmother... Often or very often pushed, grabbed, slapped, or had something thrown at her or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard or ever repeatedly hit over at least a few minutes or threatened with a gun or knife? |
| ACE-Q 8 | Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? |
| ACE-Q 9 | Was a household member depressed or mentally ill, or did a household member attempt suicide? |
| ACE-Q 10 | Did a household member go to prison? |
Effect Modifiers of Interest
Analyses were also stratified by participants’ perceived social support and HIV status. Perceived social support was measured using the 12-item Multi-Dimensional Scale of Perceived Social Support (MSPSS) [32]. Participants who scored 35 out of 84 total points on the MSPSS were categorized as having moderate/high social support. Finally, HIV status was measured using a single-item yes/no question.
Data Analysis
Summary statistics for the demographic characteristics of the sample stratified by ACEs status were calculated. Proportions, medians, and interquartile ranges (IQR) were used to summarize demographic information. P values from two-sided t-tests and chi-squared tests were reported to determine if characteristics differed between the two groups at α = 0.05.
To examine the association between the exposure and outcome, log binomial regression models were used to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs) to compare prevalence of depression symptoms, psychological distress, and well-being by ACEs score. Analyses were run using random effects models clustered by enrollment site. Analyses were repeated after stratifying by HIV status and stratifying by perceived social support to explore potential differences in the association between ACEs score and mental health by strata.
We then examined the association between specific ACEs domains and our mental health outcomes of interest. Log binomial regression models were used to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs) to separately compare prevalence of depression symptoms, psychological distress, and well-being by presence vs. absence of each of the ACEs domains (abuse, neglect, and household dysfunction).
Results
Characteristics of the Study Population
Overall, 1,988 (99.4%) of the 2,000 mothers enrolled in the HOPE study completed the ACEs questionnaire. The median maternal age was 29 years (interquartile range [IQR] 24–33), most women had completed secondary education (895 [45.02%]), were married and monogamous (1525 [76.7%]), had little to no food insecurity (1670 [84.0%]), reported moderate to high social support (1800 [90.5%]) and few women experienced intimate partner violence (52 [2.6%]). Approximately half of the mothers were living with HIV (992 [49.9%]).
Comparison of Mothers with High ACEs to Those with Low ACEs
Of the 1,988 mothers in the study, 342 (17.2%) had high ACEs and 1,646 (82.8%) had low ACEs. 60.9% of the mothers reported at least one ACE. Among mothers with high ACEs, the median number of ACEs reported was 5 ([IQR] 4–6). Among mothers with low ACEs, the median number of ACEs reported was 1 ([IQR] 0–2).
Compared to mothers with low ACEs, mothers with high ACEs were older (median age 29 vs. 28 years, Wilcoxon rank-sum W = 260,688 p =.04), had less formal education (44.4% vs. 37.7% primary education or less, χ2 = 5.19, p =.02), were less likely to be monogamously married (68.1% vs. 78.5% in a monogamous marriage, χ2 = 16.62, p <.001), had more household food insecurity (30.1% vs. 13.1% moderate/severe hunger in household, χ2 = 60.03, p <.001), and reported lower perceived social support (81.8% vs. 92.6% moderate/high social support, χ2 = 37.56, p <.001) (Table 2). Employment status, HIV status, and experiences of intimate partner violence were similar among the two groups.
Table 2.
Sociodemographic characteristics by aces score
| Maternal characteristics | Overall Sample N = 1988 (N/% or Median/IQR) |
High ACEs N = 342 (N/% or Median/IQR) |
Low ACEs N = 1646 (N/% or Median/IQR) |
χ2/W Test Statistic | p-value |
|---|---|---|---|---|---|
|
| |||||
| Mother age (years) | 29 (24–33) | 29 (25–34) | 28 (24–33) | 260,688 | 0.04 |
| Education | 5.19 | 0.02 | |||
| Primary or less | 772 (38.8%) | 152 (44.4%) | 620 (37.7%) | -- | -- |
| Secondary or above | 1216 (61.2%) | 190 (55.6%) | 1026 (62.3%) | -- | -- |
| Marital status | 16.62 | <0.001 | |||
| Married (monogamous) | 1525 (76.7%) | 233 (68.1%) | 1292 (78.5%) | -- | -- |
| Other relationship status | 462 (23.3%) | 109 (31.9%) | 353 (21.5%) | -- | -- |
| Household food insecurity | 60.03 | <0.001 | |||
| Little to no hunger in household | 1670 (84.0%) | 239 (69.9%) | 1431 (86.9%) | -- | -- |
| Moderate/severe hunger in household | 318 (16.0%) | 103 (30.1%) | 215 (13.1%) | -- | -- |
| Employment status | 0.09 | 0.76 | |||
| Employed | 574 (28.9%) | 96 (28.1%) | 478 (29.0%) | -- | -- |
| Unemployed | 1414 (71.1%) | 246 (71.9%) | 1168 (71.0%) | -- | -- |
| HIV status | 0.66 | 0.42 | |||
| Living with HIV | 992 (49.9%) | 178 (52.0%) | 814 (49.5%) | -- | -- |
| ACEs characteristics | |||||
| Number of ACEs | 1 (0–3) | 5 (4–6) | 1 (0–2) | <0.001 | |
| Proportion endorsed for each ACE domain | |||||
| Abuse | 707 (35.6%) | 301 (88.0%) | 406 (24.7%) | 493.08 | <0.001 |
| Neglect | 459 (23.1%) | 275 (80.4%) | 184 (11.2%) | 760.38 | <0.001 |
| Household dysfunction | 969 (48.7%) | 339 (99.1%) | 630 (38.3%) | 417.20 | <0.001 |
| Social support | 37.56 | <0.001 | |||
| Moderate to high social support | 1800 (90.7%) | 279 (81.8%) | 1521 (92.6%) | -- | -- |
| Low social support | 184 (9.3%) | 62 (18.2%) | 122 (7.4%) | -- | -- |
| Intimate partner violence | 52 (2.6%) | 12 (3.5%) | 40 (2.4%) | 0.87 | 0.35 |
Mothers with high ACEs had a 3.73-fold higher prevalence of moderate/severe depressive symptoms (PR: 3.73 [95% CI: 2.29, 6.08], p <.001), a higher prevalence of moderate/severe psychological distress (PR: 3.68 [95% CI: 2.24, 6.06], p <.001) and a lower prevalence of psychological well-being (PR: 0.75 [95% CI: 0.69, 0.82], p <.001) (Table 3).
Table 3.
Prevalence ratios for mental health outcomes by aces score for the total sample, high social support, and low social support
| Maternal mental health | Total sample | High social support only | Low social support only | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|
||||||||||
| High ACEs N = 342 |
Low ACEs N = 1646 |
High ACEs N = 279 |
Low ACEs N = 1521 |
High ACEs N = 62 |
Low ACEs N = 122 | |||||||
|
|
|
|
||||||||||
| Prevalence | Prevalence | Prevalence ratio (95% CI) | P value | Prevalence | Prevalence | Prevalence ratio (95% CI) | P value | Prevalence | Prevalence | Prevalence ratio (95% CI) | P value | |
|
| ||||||||||||
| Wellbeing (Score of 50% or higher) | 61.0% (208/341) | 81.1% (1334/1645) | 0.75 (0.69, 0.82) | <0.001 | 66.5% (185/278) | 81.7% (1242/1520) | 0.81 (0.75, 0.89) | <0.001 | 35.5% (22/62) | 73.0% (89/122) | 0.49 (0.34, 0.69) | <0.001 |
| Depression Symptoms (moderate or higher) | 8.0% (27/339) | 2.1% (35/1640) | 3.73 (2.29, 6.08) | <0.001 | 5.8% (16/278) | 1.8% (27/1516) | 3.24 (1.77, 5.94) | <0.001 | 18.0% (11/61) | 6.6% (8/122) | 2.75 (1.17, 6.48) | 0.016 |
| Psychological Distress Symptoms (moderate or higher) | 7.6% (26/341) | 2.1% (34/1643) | 3.68 (2.24, 6.06) | <0.001 | 6.1% (17/278) | 1.6% (25/1519) | 3.72 (2.03, 6.79) | <0.001 | 14.5% (9/62) | 7.4% (9/122) | 1.97 (0.82,4.71) | 0.123 |
Comparison of Mothers with High and Low ACEs, Stratified by Maternal HIV Status
Similar patterns emerged in analyses stratified by maternal HIV status. Among mothers living with HIV, mothers with high ACEs had a higher prevalence of moderate/severe depressive symptoms (PR: 2.86 [95% CI: 1.32, 6.19], p =.012), a higher prevalence of moderate/severe psychological distress (PR: 2.39 [95% CI: 1.17, 4.87], p =.014) and a lower prevalence of psychological well-being (PR: 0.78 [95% CI: 0.68, 0.88], p = < 0.001). Among mothers without HIV, mothers with high ACEs had a higher prevalence of moderate/severe depressive symptoms (PR: 4.59 [95% CI: 2.44, 8.64], p <.001), a higher prevalence of moderate/severe psychological distress (PR: 5.88 [95% CI: 2.85, 12.11], p <.001) and a lower prevalence of psychological well-being (PR: 0.73 [95% CI: 0.65, 0.83], p <.001) (Table 4).
Table 4.
Prevalence ratios of mental health outcomes by aces score, stratified by HIV status
| Maternal mental health | Mothers with HIV | Mothers without HIV | ||||||
|---|---|---|---|---|---|---|---|---|
|
|
|
|
||||||
| High ACEs N = 178 |
Low ACEs N = 814 |
High ACEs N = 164 |
Low ACEs N = 832 |
|||||
|
|
||||||||
| Prevalence | Prevalence | Prevalence ratio (95% CI) | P value | Prevalence | Prevalence | Prevalence ratio (95% CI) | P value | |
|
| ||||||||
| Wellbeing (Score of 50% or higher) | 60.1% (107/178) | 77.5% (631/814) | 0.78 (0.68, 0.88) | <0.001 | 62.0% (101/163) | 84.6% (703/831) | 0.73 (0.65, 0.83) | <0.001 |
| Depression Symptoms (moderate or higher) | 5.6% (10/177) | 2.0% (16/809) | 2.86 (1.32, 6.19) | 0.012 | 10.5% (17/162) | 2.3% (19/831) | 4.59 (2.44, 8.64) | <0.001 |
| Psychological Distress Symptoms (moderate or higher) | 6.2% (11/178) | 2.6% (21/813) | 2.39 (1.17, 4.87) | 0.014 | 9.2% (15/163) | 1.6% (13/830) | 5.88 (2.85, 12.11) | <0.001 |
Comparison of Mothers with High and Low ACEs, Stratified by Social Support
Among mothers with moderate/high perceived social support, high ACEs remained associated with moderate/severe depressive symptoms (PR: 3.24 [95% CI: 1.77, 5.94], p <.001), moderate/severe psychological distress (PR: 3.72 [95% CI: 2.03, 6.79], p <.001) and psychological well-being (PR: 0.81 [95% CI: 0.75, 0.89], p = < 0.001). Among mothers with low perceived social support, high ACEs remained associated with moderate/severe depressive symptoms (PR: 2.75 [95% CI: 1.17, 6.48], p =.016) and psychological well-being (PR: 0.49 [95% CI: 0.34, 0.69], p <.001), but the association with moderate/severe psychological distress was no longer statistically significant (PR: 1.97 [95% CI: 0.82, 4.71], p =.123) (Table 3).
ACEs Domain and Associations with Mental Health Outcomes
We found significant associations between each ACE domain and mental health outcomes. Mothers who reported any past abuse had a higher prevalence of moderate/severe depressive symptoms (PR: 3.81 [95% CI: 2.26, 6.44], p <.001), a higher prevalence of moderate/severe psychological distress (PR: 4.59 [95% CI: 2.64, 7.99], p = < 0.001) and a lower prevalence of psychological well-being (PR: 0.78 [95% CI: 0.74, 0.83], p <.001) than mothers without any past abuse. Similarly, we found that mothers who reported any past neglect had a higher prevalence of moderate/severe depressive symptoms (PR: 2.41 [95% CI: 1.47, 3.95], p = < 0.001), a higher prevalence of moderate/severe psychological distress (PR: 2.73 [95% CI: 1.66, 4.48], p = < 0.001) and a lower prevalence of psychological well-being (PR: 0.81 [95% CI: 0.75, 0.87], p = < 0.001) than mothers without any past neglect. Finally, mothers who reported any past household dysfunction had a higher prevalence of moderate/severe depressive symptoms (PR: 2.05 [95% CI: 1.22, 3.45], p =.005), a higher prevalence of moderate/severe psychological distress (PR: 3.16 [95% CI: 1.77, 5.62], p <.001) and a lower prevalence of psychological well-being (PR: 0.84 [95% CI: 0.80, 0.88], p <.001) than mothers without any past household dysfunction (Table 5).
Table 5.
Prevalence ratios for mental health outcomes by ACE domain
| Any abuse N = 707 |
No abuse N = 1281 |
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|---|---|---|---|---|
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|
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| Prevalence | Prevalence | Prevalence ratio (95% CI) | P value | |
|
| ||||
| Abuse | ||||
| Depressive symptoms | 6.0% (42/703) | 1.6% (20/1276) | 3.81 (2.26, 6.44) | <0.001 |
| Psychological distress | 6.1% (43/705) | 1.3% (17/1279) | 4.59 (2.64, 7.99) | <0.001 |
| Well-being | 65.8% (464/705) | 84.2% (1078/1281) | 0.78 (0.74, 0.83) | <0.001 |
|
| ||||
| Any neglect N = 459 |
No neglect N = 1529 |
|||
|
|
||||
| Prevalence | Prevalence | Prevalence ratio (95% CI) | P value | |
|
| ||||
| Neglect | ||||
| Depressive symptoms | 5.7% (26/456) | 2.4% (36/1523) | 2.41 (1.47, 3.95) | <0.001 |
| Psychological distress | 5.9% (27/458) | 2.2% (33/1526) | 2.73 (1.66, 4.48) | <0.001 |
| Well-being | 65.6% (300/457) | 81.2% (1242/1529) | 0.81 (0.75, 0.87) | <0.001 |
|
| ||||
| Any household dysfunction N = 969 |
No household dysfunction N = 1019 |
|||
|
|
||||
| Prevalence | Prevalence | Prevalence ratio (95% CI) | P value | |
|
| ||||
| Household dysfunction | ||||
| Depressive symptoms | 4.2% (41/965) | 2.1% (21/1014) | 2.05 (1.22, 3.45) | 0.005 |
| Psychological distress | 4.7% (45/967) | 1.5% (15/1017) | 3.16 (1.77, 5.62) | <0.001 |
| Well-being | 70.5% (682/968) | 84.4% (860/1019) | 0.84 (0.80, 0.88) | <0.001 |
Discussion
In this cross-sectional study of almost 2000 mothers in Kenya, 17.2% had high ACEs. This is consistent with other studies conducted in LMICs that estimate the prevalence of high ACEs among mothers to be between 7% and 39% [33, 34]. Women with high ACEs in our cohort were older, less educated, less likely to be monogamously married, and more likely to be food insecure. Overall, 60.9% of women reported at least one ACE. This is lower than other estimates suggesting that about 75% of people in LMICs experience at least one ACE in childhood [14]. There are multiple reasons why experiencing at least one ACE was less common in this sample than in other studies. Much of the existing research on ACEs in LMICs does not focus exclusively on the experiences of women and in mixed gender samples in LMICs, a higher proportion of men than women tend to report experiencing at least one ACE [15, 35, 36]. However, previous studies with mixed-gender samples still demonstrated high prevalence of at least one ACEs among women [14, 15, 36]. This could be the result of different measures of ACEs being used across studies. Other ACEs measures that have been used in studies in LMICs assess for additional experiences that were not captured in our study and have a relatively high prevalence in other studies including witnessing community violence (23% to 29.8% prevalence) [15, 36] and experiencing the death of a parent (26.6% to 37.2% prevalence) [15, 36]. It is possible that the prevalence of experiencing at least one ACE would have been higher in our sample had we assessed for these additional traumatic experiences.
Mothers with high ACEs had a 2.86-fold higher prevalence of moderate/severe depressive symptoms than mothers with low ACEs, supporting previous work demonstrating a link between ACEs and depression [2, 6]. The postpartum period is a time of considerable risk for depression, and maternal depression can have a substantial negative impact on health and well-being for mothers and their children [37] such as increased risk for pregnancy loss, preterm birth, and delayed infant development [38, 39]. Screening mothers for ACEs, as well as depression, early in pregnancy could lead to early intervention for potential negative outcomes during pregnancy.
Mothers with high ACEs also had a 3.68-fold higher prevalence of moderate/severe psychological distress than mothers with low ACEs, similarly supporting previous studies demonstrating a link between maternal ACEs and psychological distress [6]. Much like maternal depression, maternal psychological distress is associated with poorer infant outcomes including delays in cognitive, socioemotional, and psychomotor development [40]. Though the overall prevalence of psychological distress was relatively low in the present study (3.1%), previous research has demonstrated a much higher prevalence of psychological distress among postpartum mothers in Kenya ranging from 26% to 65% [41, 42]. However, the other studies referenced recruited participants who may have experienced higher baseline psychological distress than typical (e.g. women experiencing pre-term birth) [41]. Additionally, the mothers in our sample reported relatively low intimate partner violence and high social support overall (Table 2), both of which are predictors of lower psychological distress [43]. Finally, a previous study examining the longitudinal trajectory of adverse maternal mental health in Kenya demonstrated that maternal mental health was worst during pregnancy with 24.5% of participants reporting moderate-to-severe adverse mental health. The proportion of women reporting adverse mental health continued to decrease over time with 16.8% at post-partum, 12.2% at 6-weeks post-partum, and 10.5% at 9-months post-partum [43]. In the present study, mothers were assessed at their 6-week post-partum visit which would coincide with a period of improvement in mental health outcomes for post-partum mothers. In the context of the higher prevalence of psychological distress found in other studies, it may be especially beneficial to identify interventions that can decrease the association between maternal ACEs and psychological distress for Kenyan mothers and such interventions could have the greatest benefit if administered during pregnancy or early in the post-partum period.
Mothers with high ACEs had a substantially lower prevalence of psychological well-being than mothers with low ACEs, but the effect size for the impact of ACEs on well-being was lower than that of the associations with depression or psychological distress. Research on psychological well-being in pregnancy is less common, but positive psychological well-being in pregnancy has been associated with beneficial infant outcomes including greater cognitive development and language acquisition [44]. It is not surprising that high ACEs not only increased the risk of adverse mental health outcomes but also decreased likelihood of positive outcomes such as well-being. Our findings illustrate the holistic sustained impact of early childhood experiences on mental health outcomes. Understanding approaches to ameliorate adverse outcomes and increase beneficial outcomes in the context of prior ACEs is important to optimize maternal mental health.
Surprisingly, we did not find that maternal HIV status was associated with high ACEs. This may be because women recruited from the same clinic and similar residential areas had similar patterns of ACEs, although this does not completely explain the lack of an association. We would still expect higher prevalence of ACEs in mothers with HIV as seen in other studies [45–47]. However, in analyses stratified by HIV status, associations of poor psychological outcomes with ACEs were higher among mothers without HIV than among mothers with HIV. This differed from previous work demonstrating that psychological outcomes were worse among people living with HIV with high ACEs [23]. This may be because prior work was in HICs or because HIV status does not have as much of an impact on the relationship between maternal ACEs and psychological outcomes in a setting with high HIV prevalence. In Kenya, the prevalence of HIV is approximately 4.3%, whereas the prevalence is less than 1% in all high-income countries ranging from 0.04% to 0.8% [48–50]. Women with high ACEs were less likely to have moderate/high social support than women with low ACEs, but still >80% of women with high ACEs reported moderate/high social support. This may reflect the network/community connections of women in the community in general in this cohort. In analyses stratified by social support, most associations persisted in all subgroups. However, among mothers with low perceived social support, associations between ACEs and psychological distress were not retained. These findings are likely due to the limited statistical power to detect a difference in the low perceived social support group (N = 184). There is considerable evidence that social support may buffer against poor mental health outcomes [51]. However, social support is difficult to measure, and there was limited heterogeneity in social support in our cohort. In addition, the benefits and outcomes related to social support differ depending on cultural context [52] and while the MSPSS has previously been validated in similar settings [53–56], the measure used to assess social support may have had less relevance for this cohort in Kenya.
Finally, we found that associations persisted for each ACE domain. Mothers who experienced any past abuse, neglect, or household dysfunction had a higher prevalence of depressive symptoms and psychological distress and a lower prevalence of psychological well-being than mothers who experienced no abuse, neglect, or household dysfunction respectively. Our findings contrast with prior studies that demonstrated that specific ACEs domains were more strongly associated with particular psychological outcomes [16, 25, 26]. For example, previous work found that a history of family mental illness (household dysfunction domain) and experiencing sexual abuse (abuse domain) were the only ACEs associated with a diagnosis of depression later in life [16]. Another study found that abuse and neglect predicted subsequent depression, anxiety, and trauma, while household dysfunction only predicted subsequent anxiety [25]. However, these studies were conducted using nationally representative, mixed-gender samples from the United States. It is likely that the context for a sample of exclusively postpartum women in a limited-resource setting in Kenya is different enough that we would not see similar patterns. Similarly, the present study measured mental health symptoms using screening tools, whereas many ACEs studies utilize diagnostic tools for the purpose of diagnosing mental illness. There may be slight variations in constructs used across studies that could be contributing to differing findings. Another potential reason we did not see differences by domain in this study could be because of the specific ACEs measure used. The present study used the 10-item ACEs-Q which has 3 ACEs domains, whereas other common ACEs measures used are the 19-item Comprehensive Trauma Interview with two domains and the 13-item Adverse Childhood Experiences International Questionnaire with five domains. This could similarly contribute to the relatively low proportion of mothers in this study reporting at least one ACE (60.9%). Studies reporting higher prevalence of ACEs among participants also appear to be using measures with more items to assess ACEs, suggesting that longer measures may be more sensitive for identifying past ACEs. Future studies of ACEs and maternal mental health in LMICs may wish to test multiple ACEs measures to see if different patterns emerge related to ACEs domains.
A strength of the current study is that it is one of the few studies to examine the interplay of maternal ACEs, psychological outcomes, and HIV in a LMIC. Additionally, our study had a large sample size with a wide variety of ACEs and psychological outcome scores. Measures of outcomes and exposures may have had limitations due to cultural differences in our LMIC cohort and between regions assessed in the study. Though there were significant differences in marital status, educational attainment, and food insecurity between women with high ACEs and those with low ACEs, marital status [57], educational attainment [58], and food insecurity [59], are all likely on the causal pathway between maternal ACEs and mental health, so we did not adjust for these variables. Further mediation analyses may be useful to elucidate pathways between ACEs and mental health outcomes. There are some general limitations that should be considered for this study. This study utilized cross-sectional data where participants were asked to report on experiences that happened in childhood, making the exposure measure vulnerable to recall bias. Additionally, the outcome measures assessed maternal mental health and may have led to selection bias if mothers with more severe mental health outcomes declined to participate in the study due to poor mental health. Finally, mothers with more extreme ACEs scores or mental health scores may have declined to answer these questions, however, data from only 12 of the 2,000 mothers were excluded due to missing ACEs or mental health scores and is unlikely to have a meaningful impact on the results.
Overall, we found that high maternal ACEs (4+) are associated with poorer mental health outcomes for new mothers in Kenya regardless of HIV status. Similarly, these patterns persisted when comparing mothers with presence vs. absence of each of the three domains independently. Our study adds to recent research demonstrating that maternal ACEs are associated with poor psychological outcomes in LMICs [11, 21, 33, 60]. ACEs reflect exposures that occurred many years ago during childhood, but exert long-term adverse outcomes [1, 2]. The impact of these early exposures underscores the need to address ACEs in childhood. There is a potentially unique opportunity among mother/infant pairs in the peripartum period to prevent a recurring generational effect of ACEs. Screening women for ACEs, targeted counseling to explore the impact and residue of ACEs and ways to avoid ACEs for the new infant, and specifically designing trauma-informed interventions for perinatal women may be strategies that could yield long-term impact.
Funding
This publication was made possible by primary funding from the National Institutes of Health (NIH) under award R33HD103079. This publication was supported in part by Fogarty International Center (FIC) 1K43TW011422–01 A to IN. Additional support was provided by the UW Global Center for Integrated Health of Women, Adolescents and Children (Global WACh) and UW/Fred Hutch Center for HIV/AIDS Research (CFAR) P30 AI027757. KAL’s time was supported by T32CA009168 from the National Cancer Institute of the NIH. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The funders have no role in design, collection, analysis, or interpretation of data.
Footnotes
Declarations
Competing Interests Authors have no competing interests to declare.
Ethical Approval This study involves data from human participants enrolled in a cohort study and was approved by Kenyatta National Hospital Ethics and Research Committee P400/07/2020 and University of Washington Institutional Review Board STUDY00010495. The procedures used in this study adhere to the tenets of the Declaration of Helsinki and all participants gave informed consent to participate in the study before taking part.
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