Agampodi et al. BMC Pregnancy and Childbirth (2020) 20:374 https://doi.org/10.1186/s12884-020-03056-x STUDY PROTOCOL Open Access The Rajarata Pregnancy Cohort (RaPCo): study protocol Thilini Chanchala Agampodi1* , Nuwan Darshana Wickramasinghe1, Rampathige Indika Ruwan Prasanna2, Malawara Kankanamalage Lasandha Irangani3, Jayasundara Mudiyanselage Samarakoon Banda4, Pradana Mudiyanselage Bandula Jayathilake5, Ayesh Hettiarachchi1, Gayani Amarasinghe1, Imasha Jayasinghe1, Iresha Koralagedara6, Sajaan Praveena Gunarathne1, Sujanthi Wickramage7, Janith Warnasekara1, Niroshan Lokunarangoda8, Vasana Mendis9, Ajith Kumara Dissanayaka10, Jagath Premadasa11, Nandana Hettigama10, Dayaratne Koralagedara11, Manjula Weerasinghe1, Krishanthi Malawanage12, Hemali Jayakodi13, Anuprabha Wickramasinghe14 and Suneth Buddhika Agampodi1 Abstract Background: Ending preventable maternal deaths remains a global priority and in the later stages of obstetric transition, identifying the social determinants of maternal health outcomes is essential to address stagnating maternal mortality rates. Countries would hardly achieve the Sustainable Development Goal (SGD) targets on maternal health, unless the complex and context-specific socio-economic aetiologies associated with maternal mental health and suicide are identified. The Rajarata Pregnancy Cohort (RaPCo) is a prospective cohort study, designed to explore the interactions between social determinants and maternal mental health in determining pregnancy and new-born outcomes. Methods: The study will recruit all eligible pregnant women in the maternal care programme of Anuradhapura district, Sri Lanka from July to September 2019. The estimated sample size is 2400. We will assess the socio- demographic and economic status, social capital, gender-based violence and mental health, including a clinical examination and biochemical investigations during the first trimester. Participants will undergo four follow-ups at 2nd and 3rd trimesters, at delivery and in early postpartum. The new-borns will be followed up at birth, neonatal period, at 6 six months and at 1 year. Pregnancy and child outcome data will be collected using direct contact. Qualitative studies will be carried out to understand the complex social factors and behavioural dimensions related to abortion, antenatal depression, maternal deaths and near misses. (Continued on next page) * Correspondence: [email protected] 1Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Agampodi et al. BMC Pregnancy and Childbirth (2020) 20:374 Page 2 of 13 (Continued from previous page) Discussion: This is the first reported maternal cohort in Sri Lanka focusing on social determinants and mental health. As a country in stage four of obstetric transition, these findings will provide generalizable evidence on achieving SGD targets in low- and middle-income countries. The study will be conducted in a district with multi- cultural, multi-ethnic and diverse community characteristics; thus, will enable the evidence generated to be applied in many different contexts. The study also possesses the strength of using direct participant contact, data collection, measurement, examination and biochemical testing to minimise errors in routinely collected data. The RaPCo study will be able to generate evidence to strengthen policies to further reduce maternal deaths in the local, regional and global contexts particularly focusing on social factors and mental health, which are not optimally addressed in the global agenda. Keywords: Pregnancy, Cohort, Sri Lanka, Social determinants, Mental health Background by facilitating coordinated actions” [8]. Social capital is a Every day, an average of 830 pregnant women around the relatively new concept widely used in the field of social globe die due to preventable causes [1]. Despite the drastic sciences [9, 10]. More recently, with the rise in global at- reduction in maternal mortality by 45% during the period tention towards social determinants of health, social cap- of 1990–2015 [2], the global maternal health agenda is still ital is considered as an important determinant that can facing major challenges and Ending Preventable Maternal influence the health of individuals and communities Mortality (EPMM) is far from the reach [3]. The Millen- [11–14]. Few available studies on social capital and ma- nium Development Goal (MDG) target of achieving an- ternal health show that high social capital during preg- nual rate of reduction (ARR) in maternal mortality ratio nancy is associated with higher levels of self-rated health (MMR) of 5.5% was not a success. However, this target [11], lower levels of postpartum psychosis [15] and pushed the countries around the world to increase ARR health related behaviours [16]. Social capital is also asso- from 1.1% in 1990–2000 period to 4.1% in 2000–2010 ciated with health related behaviours in pregnancy [17]. period [4]. Currently, the Sustainable Development Goal It is identified that social capital in pregnancy is unique (SGD) 3 targets to reduce maternal mortality in the world and it mainly encompasses cognitive and structural to 70/100000 live births [3]. bonding in the immediate micro community of pregnant women. It is also hypothesized that these strong social ties exert a considerable impact on psychosocial well- Maternal health and social capital being of pregnant women and having a significant in- “ ” With the obstetric transition , causes of maternal verse relationship to antenatal and postpartum anxiety deaths are shifting from communicable diseases and dir- and depression [17]. Micro-geographical variations of so- ect obstetric causes such as sepsis, haemorrhage, pul- cial capital is observed through ecological studies and monary embolism (phase 1) to non-communicable may partly explain the health inequalities [18]. However, diseases and indirect causes [5] (phase 4 and 5). High- the predictive ability of social capital on pregnancy out- income countries as well as some of the middle-income come has not yet been assessed. countries are in phase four and the shift is clearly dem- onstrated in the most recent maternal death estimates [6]. However, further reduction of maternal deaths has Maternal mental health and suicides been a challenge and stagnation of MMRs is observed at Globally, maternal suicide has emerged as a leading global level [7]. cause of maternal deaths over the past few decades Social development is identified as a prime to further [19]. It has become a leading cause of maternal reduce MMR in the latter phases of obstetric transition. deaths in some countries [20–22].Suicideisonlythe Yet, the global maternal health agenda is primarily fo- tip of the iceberg. A recent systematic review shows cused on medical interventions, neglecting the effects of that the suicidal ideation is largely underreported and social determinants and social interventions as root the available tools are not capturing the actual risk causes of all proximal determinants. Some aspects of so- [23]. Pregnancy and childbirth represent a time of in- cial determinants, such as social capital in pregnancy creased vulnerability, during which a woman is and postpartum, are discussed only in few instances in exposed to many physiological and psychosocial global literature. “Social capital” in general reflects the changes, which put pregnant and postpartum women state of social interactions among people. It is defined as at increased risk of mental health problems. It has the “features of social organization, such as trust, norms been consistently shown that the prevalence of mater- and networks that can improve the efficiency of society nal mental health issues are much greater in low- Agampodi et al. BMC Pregnancy and Childbirth (2020) 20:374 Page 3 of 13 income countries (LIC) and lower-middle-income prospective study designs. For evidence informed countries (LMIC) (16% and 20%, respectively) [24] decision-making, high quality data based on robust than in high-income countries (HIC) [25]. The vari- methodologies are required. The best evidence for ability in estimates, seen especially in LIC and LMIC, this type of outcome assessments comes though co- is due to the differences in diagnostic criteria and hort studies. The Sri Lankan health system is one of timing of screening [26],