Adverse childhood experiences and implications of perceived stress, anxiety and cortisol among women in Pakistan: a cross-sectional study

OBJECTIVES: Adverse childhood experiences (ACEs) are linked to poor maternal mental health. The goal of this study is to examine the associations between ACEs and multiple manifestations of stress (including perceived stress, anxiety and cortisol) among mothers in rural Pakistan. DESIGN: This study used a cross-sectional design. Mothers were originally recruited during their third trimester of pregnancy and followed until 36 months post partum. Cortisol was collected at 12 months post partum, and self-report data were collected at 36 months post partum. SETTING: All participants reside in rural villages in Rawalpindi, Pakistan. The measures were administered at home visits by field interviewers. PARTICIPANTS: Data were collected from 889 mothers. All mothers in the sample provided data on ACEs and perceived stress, 623 provided data on anxiety and 90 provided hair cortisol. PRIMARY AND SECONDARY OUTCOMES MEASURES: ACEs were captured retrospectively using an adapted version of the ACE International Questionnaire, and represented as a continuous variable and subdomains (neglect, home violence, family psychological distress, community violence). Primary outcomes included perceived stress measured with the Cohen Perceived Stress Scale (PSS) and anxiety measured with the Generalised Anxiety Disorder-7 scale (GAD-7). Hair-derived cortisol was included as a secondary outcome. Generalised linear models with cluster-robust SEs were used to estimate associations between ACEs and the outcome variables. RESULTS: All models featured positive associations between ACE items and PSS. The continuous total ACE score (B=0.4; 95% CI 0.0 to 0.8) was associated with higher anxiety symptoms on the GAD-7. Home violence (B=6.7; 95% CI 2.7 to 10.8) and community violence (B=7.5; 95% CI 1.4 to 13.6) were associated with increased hair cortisol production. CONCLUSIONS: All four ACE domains were associated with elevated levels of perceived stress, anxiety and cortisol, with varying precision and strength of estimates, indicating that the type of ACE has a differential impact. This study informed our understanding of the differential impact of specific ACEs on perceived stress, anxiety and hypothalamic pituitary adrenal-axis functioning, providing implications for future clinical intervention and research development.