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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 24-29

Maternal stressful events and socioeconomic status among orofacial cleft families: A hospital-based study

1 New Look New Life Cleft Lip and Palate Foundation (Aung Clinic/Partner with Smile Train), Yangon; Mingalar Taung Nyunt Township Public Health Department, East District, Yangon Region, Ministry of Health and Sport, Mandalay, Myanmar
2 New Look New Life Cleft Lip and Palate Foundation (Aung Clinic/Partner with Smile Train), Yangon, Myanmar
3 Department of Preventive and Social Medicine, Defence Services Medical Academy, Yangon, Myanmar
4 New Look New Life Cleft Lip and Palate Foundation (Aung Clinic/Partner with Smile Train), Yangon; Department of Oral and Maxillofacial Surgery, University of Dental Medicine, Mandalay, Myanmar

Date of Submission01-Aug-2019
Date of Acceptance02-Nov-2019
Date of Web Publication20-Jan-2020

Correspondence Address:
Dr. Moe Myat Noe Phyu
1-33, Thamainbayang Street, Tawmae Township, Yangon
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_19_19

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Background and Objective: Studies have suggested that maternal stressful events are associated with an increased risk of orofacial cleft (OFC) in many populations, but none have focused on Myanmar. Socioeconomic status (SES) has been recognized as a strong predictor of pregnant mothers' perceived maternal stress. We sought to assess the SES among OFC families and determine the role of maternal stressful events during pregnancy. Materials and Methods: A cross-sectional descriptive study was performed at the New Look New Life Cleft Lip and Palate Center/Smile Train Myanmar in the Shwe Baho and Pinlon Hospital in Yangon, Myanmar, from December 2016 to December 2017. The study included 298 mothers of children under-five with OFCs. The research tool included a questionnaire used in face-to-face interviews with mothers. SES was measured with Kuppuswamy's scale. Maternal stress questions from the Kaiser Permanente/California Department of Health Study of Pregnancy and Stress were used. Results: Among the 298 families, 126 (42.28%) household heads were farmers, and the most common educational level was middle school (83, 27.85%). Two-thirds of the respondents reported a monthly family income below 180,000 Kyats (120 USD). Most OFC families (129, 43.3%) had upper lower SES. One hundred and forty-one (47%) mothers reported stressful events during pregnancy, and 106 (60%) of these mothers indicated financial-related burden as the leading cause of stress. SES was significantly related to maternal stress (P = 0.01). Conclusion: Most OFC families had low SES, which could lead to financial-related stress for pregnant mothers. Future studies need to extend the results to better understand this relationship.

Keywords: Maternal stress, Myanmar, orofacial cleft, socioeconomic status

How to cite this article:
Phyu MM, Lin Z, Tun KM, Wei TH, Maung KK. Maternal stressful events and socioeconomic status among orofacial cleft families: A hospital-based study. J Cleft Lip Palate Craniofac Anomal 2020;7:24-9

How to cite this URL:
Phyu MM, Lin Z, Tun KM, Wei TH, Maung KK. Maternal stressful events and socioeconomic status among orofacial cleft families: A hospital-based study. J Cleft Lip Palate Craniofac Anomal [serial online] 2020 [cited 2020 Aug 12];7:24-9. Available from: http://www.jclpca.org/text.asp?2020/7/1/24/276196

  Introduction Top

Orofacial clefts (OFCs) – including isolated cleft lip (CL), isolated cleft palate (CP), and CL and palate (CLP) as well as median, lateral, and oblique facial cleft (F) – are the most common congenital anomalies of craniofacial structure.[1] The worldwide incidence is 1–2/1000 live births[2] and varies on ethnicity, geographical region, and socioeconomic status (SES).[3] The prevalence is the highest in the Asian population, at 1.57 cases per 1000 live births, followed by North America, Europe, Oceania, South America, and Africa, at 1.56, 1.55, 1.33, 0.99, and 0.57 cases per 1000 live births, respectively.[4] OFC can negatively affect a child's future due to the physical deformity of the face and the inability to pronounce properly. The etiology of OFC is multifactorial, mainly due to genetic factors or certain conditions of the parents close to and during the pregnancy period and environmental factors.[5]

Stressful events include environmental and psychosocial stressors that may negatively impact health outcomes.[6] Several observational studies have asserted that maternal stressful events during pregnancy are associated with birth defects, including OFC.[7],[8],[9],[10] Many factors have been identified as potent elements in increasing or decreasing maternal stress levels. These include social support, quality of life, and SES.[11],[12],[13] Among these factors, SES is a strong predictor of maternal stress.[14],[15]

SES is “the social standing or class of an individual or group and measured as a combination of education, income, and occupation,” as defined by the American Psychological Association.[16] SES indicates the social level of a family in society, which can predict the family's access to healthcare services. Epidemiological studies have shown that SES is associated with an increased risk of being born with OFC.[17],[18],[19],[20],[21]

According to the WHO, Myanmar has the highest prevalence of birth defects in the Southeast Asia region.[22] Active population-based surveillance systems are not available in Myanmar. The prevalence of OFC in Myanmar has been estimated according to records of the Central Women Hospital in Yangon to be between 6000 and 8000 children born with OFCs every year. New Look New Life (NLNL) Cleft Center/Smile Train Myanmar is an influential center for cleft surgery in Myanmar. In 2009, it became a local partner of the Smile Train Organization,[23],[24] providing 100% free cleft repair surgeries and comprehensive cleft care. The number of cleft patients presenting to this cleft center increases every year; cleft surgeries are provided throughout the year without a long waiting list.

To our knowledge, there has been no research on maternal stressful events and SES among OFC families in Myanmar. Given the high impacts of OFCs on developmental outcomes for children, we conducted the present study to assess the SES of OFC families and determine the causal factors of maternal stressful events during pregnancy in Myanmar.

  Materials and Methods Top

Study design

A hospital-based cross-sectional descriptive study was carried out at NLNL CLP Center in Shwe Baho Hospital and Pinlon Hospital, Yangon, Myanmar. The study included 298 participants. The inclusion criteria were mothers born with OFCs who had children up to 5 years of age with CL, CP, CLP, or F. The exclusion criteria were mothers with children above 5 years or children who were not accompanied by their mothers. To obtain the sample of 298 participants, a convenience sampling technique was employed using the Chi-square test, with a significance level (alpha) of 0.050. We recruited human subjects in compliance with the current revision of the Declaration of Helsinki (Seoul 2008). The Ethical Review Board of Defense Services Medical Research Centre, Myanmar (IRB/2016/61), approved this study. The mothers provided informed consent. Data collection was performed for 1 year from December 2016 to December 2017.


Mothers were individually interviewed using a questionnaire. We collected cleft patient data, including gender, type of cleft, syndromic cleft, and birth order. SES was measured using Kuppuswamy's socioeconomic scale, which was created by Kuppuswamy in 1976.[25] The scale generates a combined score from 3 to 29 based on family income per month, education, and occupation of the household head. This scale contains three questions. Question 1 concerns the education level of the head of household, with the score ranging from 1 to 7. Question 2 enquires about the occupational status of the head of household, with the score ranging from 1 to 10. Question 3 is about the family income per month, with the score ranging from 1 to 12. The minimum composite score for Kuppuswamy's socioeconomic scale is 3, and the maximum score is 29. The scores from the three questions are added to obtain the total SES score for family. The SES level is divided into five socioeconomic categories: upper class (score 26–29), upper middle class (score 16–25), lower middle class (score 11–15), upper lower class (score 5-10), and lower class (score 0<5).

To determine the causal factors of stressful events during pregnancy, we used questions from the Kaiser Permanente/California Department of Health Study of Pregnancy and Stress.[7] The questions referenced only significant events and required yes/no responses. Each mother was asked about financial problems, health problems, occupational stress, experience with war and disasters, death or loss of family members, marital status, family conflicts, and problems with her spouse drinking alcohol. The mothers could provide multiple answers regarding the causal factors for stress occurrence during their pregnancy. Moreover, we elicited information on mother's health and occupational-related stress during the first trimester of pregnancy and their age at the time of pregnancy.

Statistical analysis

Data entry was performed using spreadsheets (Microsoft Excel, Raymond, WA, USA), and the data were statistically analyzed using the Statistical Package for the Social Sciences version 22.0 (SPSS Inc., Chicago, IL, USA). For categorical data, the frequencies and percentages were calculated. The findings on maternal stressful events and SES were compared descriptively and with the Pearson's Chi-square test. A P < 0.05 was considered statistically significant.

  Results Top

Among the 298 families, 56% of the children with OFCs (n = 166) were male and 44% (n = 132) were female, indicating a male preponderance (M:F = 1.25:1). The types of cleft defects were as follows: CL – 30%, n = 88, CP – 11.3%, n = 34, CLP – 58%, n = 174, and F – 0.7%, n = 2. OFCs associated with other syndromes, including cerebral palsy (n = 3), Down syndrome (n = 1), and hypertelorism (n = 3), were present in 2% (n = 7) of the total population. A total of 12% (n = 36) of the children with OFCs also had anemia.

Regarding the birth order of the children with OFCs, 72.48% were either the first- or second-born children, with 44.63% (n = 133) being the eldest child and 27.85% (n = 83) being the second eldest child. A total of 15.77% (n = 47) of the children were the third-born children, and 12% (n = 35) were the fourth-born child or later.

A total of 36% (n = 109) of mothers were 25 years old or younger, 45% (n = 133) of mothers were 26–34 years old, and 19% (n = 56) of mothers were 35 years old or older at the time of pregnancy.

[Table 1] shows the socioeconomic distribution according to the Kuppuswamy's socioeconomic scale. In this study, 37.92% (n = 113) of household heads were unskilled workers, and 42.28% (n = 126) were farmers. The education level of household heads was mostly middle school (27.85%, n = 83). Families with <180,000 Myanmar Kyat (<120 USD) in monthly income represented 68.12% (n = 203) of the study population. According to the Kuppuswamy's socioeconomic scale, most of the families (129, 43.3%) had upper lower SES [Figure 1].
Table 1: Occupation and education of the head of household and monthly family income according to Kuppuswamy's socioeconomic scale

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Figure 1: Socioeconomic distribution of orofacial cleft families according to Kuppuswamy's socioeconomic scale

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In this study, 47% (n = 141) of the mothers born with OFCs reported the presence of stressful events during pregnancy, while 53% (n = 157) did not report a specific cause of stress. Among the mothers who reported stressful events, 60% (n = 106) reported financial-related stress as the leading cause of stressful events during their pregnancy [Figure 2]. Stressful health problems in the first trimester of pregnancy were the second most reported. Influenza (viral infection) (n = 11), hypertension (n = 8), rheumatic fever (n = 3), diabetes (n = 1), malaria (n = 1), gastritis (n = 1), and human immunodeficiency virus (n = 1) were stressful health problems for the pregnant mothers. Occupational stress in the first trimester of pregnancy was reported by 11% (n = 19) of the mothers, being the third most frequent stressful event. The mothers also reported stress from their jobs, including working in farms (n = 6), fish import–export factories (n = 5), warehouses (n = 3), street markets (n = 2), typing and data entry centers (n = 2), and hospital nursing departments (n = 1).
Figure 2: Maternal stressful events reported by 47% of the sample. *Maternal stressful events in the first trimester of pregnancy

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  Discussion Top

Although a series of epidemiological studies have established that maternal stressful events and SES are risk factors for OFC worldwide, there has been no study among the Myanmar population. Hence, we conducted a cross-sectional descriptive study as the first step in developing a better understanding of SES and maternal stressful events among OFC families.

This study found that males are more prone to defects than females (56%, n = 166 vs. 44%, n = 132). Studies in India,[17] Estonia,[5] and Uganda[26] have also shown that males have a higher occurrence of CLP than females. However, unlike our study, Olufunmilayo et al.[27] found a female predominance in patients with CLP.

According to our study, the most commonly found issue is CLP, which was present in 58% (n = 174) of the study sample. Meanwhile, CL accounted for 30% (n = 88), CP accounted for 11% (n = 34), and F accounted for 1% (n = 2) of all OFC cases. Other studies conducted in the Indian population showed similar results,[28] but Khajanchi et al.[29] found that CL was the most common cleft abnormity.

Observations of the birth order of cleft children showed the highest percentage among first-born children, at 45% (n = 133), which is similar to the findings of a study performed by Olufunmilayo et al.[27] A total of 36% (n = 109) of the mothers in the study were 25 years old or below at the time of pregnancy. Croen and Shaw[30] found that an association between young maternal age and the presence of congenital malformations. Primigravid young mothers might have a risk of having a child with congenital disabilities.

Education and occupational status of the head of the household and monthly family income are three measures for Kuppuswamy's SES. We found that household heads typically had a low level of education, with only 10% having graduated and received professional education. Dvivedi and Dvivedi[31] found that the majority (51.95%) of parents with cleft children were illiterate. Education is a strong determinant of employment and income that influences one's position in society, access to health care, and cognitive decision-making.[32] In this study, most household heads were farmers and unskilled workers. Olufunmilayo et al.[27] also found that the majority of household heads in their sample were farmers. According to a World Bank Report,[33] an agricultural worker in Myanmar earns only $1.8–$2.5 per day during the monsoon season and $3.0–$3.5 per day during the dry season, which is much lower than the earnings in Thailand ($8.5/day) and the Philippines ($7/day). In this study, the maximum monthly income of OFC families was 75,000–120,000 Myanmar Kyats (approximately 50 USD–80 USD).

With Kuppuswamy's socioeconomic scale, the SES of OFC families was classified according to their scores.[25] Most studies have shown that low SES is highly associated with cleft defects,[17],[18],[21],[31] and we found a similar result that the majority of the subjects belonged to the upper lower class (43.3%, n = 129). A correlation might exist between the family SES and the risk of having a child with an OFC. Maternal nutritional deficiency[19] and unhygienic parental living conditions[20] could be confounding factors for the occurrence of OFCs in low SES families. A detailed investigation of possible environmental factors influencing the relationship of SES with the occurrence of OFC is needed for future work.

Carmichael et al.[7] found that stressful events experienced by the mother around the time of conception were associated with an increased risk of birth defects, including OFCs. In our study, 47% (n = 141) of mothers reported the occurrence of stressful events during pregnancy. Gitau et al.[34] suggested that excessive cortisone levels due to stressful events may result in higher cortisol concentrations in the fetus and as a result, teratogenic effects in early pregnancy. Regarding the second aim of our study, we explored the causal factors for maternal stressful events during pregnancy. We found that maternal stress due to financial-related burden was the common source of stress (n = 106). SES had a significant relationship with maternal stressful events (P = 0.01), indicating that pregnant women with low SES experience higher stress than those with middle SES [Figure 3]. Oyedeji[35] found that emotional stress associated with poverty is common in pregnant women with lower SES, especially in developing countries. However, Shishehgar et al.[13] found no significant relationship between SES and pregnancy stress levels.
Figure 3: Association between maternal stressful events and socioeconomic status. P value based on the Pearson Chi-square test: Chi-square = 5.81, P = 0.01

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The second most common cause of stress was maternal health problems. Among such problems, influenza (viral infection) in the first trimester of pregnancy was the most common type of maternal health problem. Luteijn et al.[36] found that first-trimester maternal influenza exposure was associated with an increased risk of the OFC.

Mothers' occupational stress in the first trimester of pregnancy represented 11% of the reports of maternal stress. Among the pregnant mothers who reported occupational stress, the highest percentage worked at farms and factories. Spinder et al.[37] showed that maternal occupational exposure to pesticides and dust was the risk factor for oral clefts in offspring. The impact of hard work, such as large stock raising and exposure to chemical fertilizer and pesticides, causes a teratogenic effect on developing babies.[5]

Myanmar has the highest maternal mortality in Southeast Asia, with 282 maternal deaths per 100,000 live births.[38] According to the 2014 Myanmar Population and Housing Census Report,[38] maternal mortality is the most preventable of all causes of death for women and is determined by the SES of the mother. In our study, much of the sample was involved in agricultural pursuits, had low income, and had inadequate education levels, leading to low SES. Low SES contributing to emotional stress in the periconceptional period due to financial-related burden results in poor general health and insufficient maternal health care, which might lead to offspring born with OFCs. Thus, it is important that healthcare providers strive to provide adequate social support and financial resources to ensure maternal psychological well-being. Moreover, healthcare providers should train mothers in relaxation with stress reduction programs and promote health awareness among pregnant women, especially in low economic families.

The present research has some limitations. This study was performed only at the major cleft centers at two hospitals in Yangon, the most economically important city and the largest city of Myanmar. A multicenter study could be performed in the future to determine whether the public hospitals and charity cleft centers in all regions of Myanmar show better situations. The benefits of multicenter research are that it includes a larger number of participants, allows for increased geographical variation, and allows for the comparison results among centers; in addition, the results can cover national populations. Second, this study was a cross-sectional study, and the moods of the mothers at the time of answering the questionnaire might have influenced their responses. It would be beneficial to conduct future longitudinal studies to overcome the assumed bias.

  Conclusion Top

We found that occupation, education, and income status of OFC families can provide useful clues, indicating the inequalities that need to be addressed by healthcare providers for the improvement of cleft care management with OFC patients. Maternal stressful events in pregnancy were related to family SES; as maternal stress increased, SES decreased. As this is the first study on this topic among OFC families in Myanmar, our results provide baseline information on maternal stressful events and SES among these families. A more diverse sample is needed to better understand the relationship between maternal stress and SES.


Special thanks to NLNL CLP Foundation (Aung Clinic/Partner with Smile Train) financial support in this study.

Financial support and sponsorship

NLNL CLP Foundation (Aung Clinic/Partner with Smile Train) Yangon, Myanmar, supported grant in this study.

Conflicts of interest

There are no conflicts of interest.

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