Resilience in maternal, newborn, and child health in low- and middle-income countries: findings from a scoping review | Reproductive Health

Main findings

The objectives of this study were to identify and synthesise definitions and indices of resilience in the context of maternal, newborn, and child health in LMICs and propose a definition that may be used for MNCH programme implementation and interventions. We included 22 publications, with seven studies providing definitions of maternal resilience [29,30,31,32,33,34, 38], and five providing newborn and child resilience [39, 40, 43, 46, 47]. None of the included studies on maternal resilience used indices to identify resilience in mothers, while one study on newborn and child resilience used maternal characteristics to identify child resilience [41]. Additionally, a new definition of maternal newborn and child resilience was proposed as ‘A woman’s ability to prevent or adapt to significant and challenging circumstances including threats, tragedy, and trauma to herself during pregnancy, childbirth, and puerperium and to her neonates or children five years or younger.’

LMICs contribute disproportionately to the global burden of maternal, newborn, and child morbidity and mortality [3, 49]. In these settings, mothers are responsible for caring for themselves, their children, and in some instances, their husbands [50]; thus, the women must adapt and adjust dynamically to life’s stressful events, including pregnancy complications, child illnesses, and natural disasters.

Having a relatively high level of education, being married, and having a source of income might provide some leverage to maternal resilience and enhance a woman’s personal agency [51]. Yet these maternal attributes may be eroded in the face of severe and sudden stressful events, which is when the relational support of her husband, family, community, including the health and financial systems of her community, is critical to ensuring the sustenance of her resilience.

It is important to emphasise that the phrase ‘a woman’s ability to prevent or adapt to significant and challenging circumstances’ in the new MNCH-context definition of ‘resilience’ does not place a responsibility on mothers to be resilient. Rather, her ability to prevent or adapt to stressful life events is intrinsically linked to her support systems, including a good health system and a good financial environment; these resilience mediators are interdependent such that one is able to accommodate or make up for the weakness of another. For instance, a well-educated woman with financial autonomy from her husband may decide to use a private health facility to avoid the challenges inherent in using public health services in LMICs. However, in these settings, most women use public health services, although private healthcare service share for MNCH has been noted to be rising [52]. Therefore, even for women with low personal agency, the relational structures and community structures, as well as the health system structures, should be sufficient for negating the adverse effects on their personal agency, supporting them and their children to create good health outcomes.

It must be stressed that the concept of resilience, including in the MNCH context, is not straightforward, as there is ambiguity in the phrasing ‘to establish resilience’ [53]. Masten described resilience as ‘a dynamic system’s capacity to withstand or recover from significant threats to its stability, viability, or growth’, and as ‘the ability, processes, or outcomes of effective adaptation in the face of significant threats to function or growth’ [54]. Also, Lutha and Cicchetti described resilience as a ‘dynamic mechanism by which individuals demonstrate positive adaptation in the face of severe adversity or trauma’ [55]. Their explanation of resilience implies that reliance in maintaining health is dependent upon both the individual’s inherent ability and the environment. Similarly, in the context of HIV, resilience of people living with HIV infection has been proposed to align with the socio-ecological model of health to harness interpersonal, neighbourhood/community, and health system resources to attain good health outcomes for them [16]. Also, personal agency (personal negotiation skills/appropriation of resources), relations (supportive adults), and structures (health services) have been reported as building blocks for resilience to adolescents [56]. Our new proposed definition for maternal, newborn and child resilience encompasses personal, relational, community, and health system mediators and buttresses the emerging consensus that resilience mediators should be more than at the individual level.

In one study, women exposed to adversity demonstrated an ability to adapt and become less vulnerable, eventually becoming resilient [57]. This is an important characteristic that, if enhanced, can help vulnerable women increase their level of tolerance and reduce the risk of morbidity or death from such adverse situations. For instance, bonding between a mother and her infant has been shown to increase resistance to the risk of depressive disorder when in adverse life circumstances [58]. While some researchers portray resilience as a self-sufficient entity without the influence of relationships, a feminist viewpoint of resilience is that it is relational and ongoing, not merely a return to equilibrium [59]. This is because of the result of a dynamic relationship between inner strengths and external assistance over the course of a person’s life [59]. Coutu et al. asserts that resilient people exhibit three characteristics: acceptance of reality, a solid belief system founded on firmly held values, and the capacity to improvise or adapt. [60].

Children are considered resilient if they overcome severe hardship and stress without obvious physical manifestations [61]. Children’s resilience is a dynamic operation, not a fixed trait. As a result, resilience can be created [61, 62]. Building resilience entails minimising risks and increasing protective factors in a child’s environment. Since the 1970s, an extensive body of literature has focused on children’s resilience in the face of severe adversity. Children’s resilience is due to the existence of some attributes and protective factors [63]. The most prominent coping mechanism shared by resilient children comes from one supportive and dedicated adult, whether a parent, caregiver, or another adult [62]. Efforts to foster resilience should be directed toward areas where they can be most effective [55].

Resilience can be enhanced in several ways. Using obstetric haemorrhage, the leading cause of maternal mortality as a case study [64], women within the reproductive age group who might get pregnant should start a pregnancy with normal blood levels. To achieve this, nutritional interventions for women of reproductive age and other pre-conception care should be emphasised in LMIC settings. Providing information on the advantages of pre-conception care, the need for women wanting pregnancy to use pre-conception care services, during which they will be certified to be in good health for pregnancy, should be advocated. Those found with suboptimal health for pregnancy should subsequently be optimised by addressing any identified risks before conception. Pregnant women should have good dietary intake, register for antenatal care, preferably in the first trimester of pregnancy, and consistently use prescribed blood-forming medications and drugs for the intermittent preventive therapy for malaria in pregnancy [65]. Furthermore, health facilities should have personnel knowledgeable about evidence-based interventions to prevent anaemia in pregnancy, skills to manage obstetric haemorrhaging, and life-saving consumables, including a well-stocked blood bank to manage obstetric haemorrhage. This case study shows how a combination of resilience mediators will influence the prevention of—or recovery from—a significant situation to attain good health outcomes, including reduced risk for mortality.

As the appreciation of vulnerability in regard to women and children is required to understand the need for efforts to support resilience in MNCH, vulnerability in MNCH has been extensively discussed as part of this overall research project [66]. In addition, an analysis of the gender dimensions of vulnerability and resilience has been investigated [50]. A framework of sociodemographic indices of vulnerability and resilience, with emphasis on mediators of resilience, has also been proposed as part of the project [67], to engender improved maternal newborn and child health outcomes.

While the scoping review focused on resilience in MNCH in LMICs, it is essential to recognize that the findings have significant applicability to high-income countries (HICs) as well. The concept of resilience in MNCH is relevant across diverse economic contexts, as the factors influencing resilience, such as personal agency, family support, and structural factors, are universal [68]. These factors contribute to an individual’s ability to cope with and adapt to adversity, regardless of the economic status of their country [69].

However, it is crucial to recognize that the unique challenges faced by women and children in LMICs, such as limited access to healthcare, resources, and education, may necessitate a more targeted approach to understanding and promoting resilience in these settings [47]. The social, economic, and environmental factors that contribute to vulnerability in LMICs can exacerbate the impact of adversity on maternal and child well-being [70]. Therefore, research focused on resilience in MNCH in LMICs is essential to identify context-specific factors and develop interventions tailored to the needs of these populations.

In HICs, women and children may face unique challenges that can impact their resilience, such as work-life balance issues, social isolation, and mental health concerns [71]. For example, in the United States, the prevalence of postpartum depression ranges from 10 to 20%, [72] which can have significant consequences for maternal and child well-being. Research has shown that maternal resilience can serve as a protective factor against postpartum depression and promote positive child development outcomes [73].

Similarly, a study by Sójta et al. [74] found that lower levels of resilience during pregnancy may be a significant predictor of increased severity of depressive symptoms and higher levels of anxiety related to childbirth among the perinatal population in Poland, highlighting the importance of resilience in promoting maternal mental health in HIC. The study also identified social support as a key factor in fostering resilience, emphasizing the role of family and community in promoting maternal well-being.

In addition to maternal resilience, child resilience is a critical area of research in HICs. Children in HICs may face adversities such as poverty, family instability, and exposure to violence, which can have lasting effects on their development and well-being [75]. A study followed a cohort of children from birth to adulthood and found that one-third of the children who were exposed to significant adversity demonstrated resilience and were able to overcome their challenges [76]. The study identified several protective factors, such as a supportive family environment and strong social connections, that contributed to their resilience.

Research on resilience in MNCH in HICs can provide valuable insights into the universal aspects of resilience and inform the development of interventions and policies aimed at promoting maternal and child well-being. For example, a systematic review of resilience-promoting interventions for children and families in HICs, found that effective interventions targeted multiple levels of influence, including individual, family, and community factors [77]. The study highlighted the importance of a holistic approach to promoting resilience, which is relevant across diverse economic contexts.

Furthermore, comparative studies examining resilience in MNCH in both LMICs and HICs can contribute to a more comprehensive understanding of the factors that influence resilience across diverse settings. A study by Ungar et al. examined resilience among youth in 14 communities across 11 countries, including both LMICs and HICs, and found that resilience was influenced by a complex interplay of individual, family, and community factors [78]. The study highlighted the importance of considering cultural and contextual factors in understanding and promoting resilience.

While this scoping review focused on resilience in MNCH in LMICs, the findings have significant applicability to HICs as well. Research on resilience in MNCH in HICs can provide valuable insights into the universal aspects of resilience and inform the development of interventions and policies aimed at promoting maternal and child well-being. Comparative studies examining resilience in MNCH in both LMICs and HICs can contribute to a more comprehensive understanding of the factors that influence resilience across diverse settings. By recognizing the relevance of resilience in MNCH across economic contexts, researchers and policymakers can work towards developing a global framework for promoting maternal and child well-being. Future research could explore the similarities and differences in resilience factors across diverse economic contexts to further inform interventions and policies aimed at enhancing MNCH resilience globally. Comparative studies examining resilience in MNCH in both LMICs and high-income countries could provide valuable insights into the universal and context-specific aspects of resilience [79]. Such research could contribute to the development of a more comprehensive framework for understanding and promoting resilience in MNCH across diverse settings.

Although the proposed definition of resilience in MNCH emphasizes the woman’s ability to prevent or adapt to significant challenges, it is crucial to recognize the interdependence of maternal, newborn, and child resilience. The well-being and resilience of newborns and children are closely tied to the resilience of their mothers or primary caregivers [80]. Maternal resilience can serve as a protective factor for child development, as it influences the quality of caregiving, attachment, and the overall family environment [81].

While the scoping review did not yield sufficient information to develop separate definitions for newborn and child resilience, it is important to acknowledge that resilience is a dynamic process that evolves throughout an individual’s lifespan [82]. The factors contributing to resilience may vary at different stages of child development, and the role of maternal resilience in shaping child outcomes may also change over time [83]. For example, during infancy and early childhood, the mother’s ability to provide responsive caregiving and a nurturing environment may be critical for promoting resilience [84]. As children grow older, their own individual characteristics, such as temperament, cognitive abilities, and social skills, may become increasingly important in fostering resilience [85].

Future research should explore the unique factors contributing to resilience at different stages of child development and the role of maternal resilience in shaping child outcomes. Longitudinal studies examining the trajectories of maternal and child resilience over time could provide valuable insights into the dynamic nature of resilience and the interplay between maternal and child factors [86]. Additionally, research investigating the mechanisms through which maternal resilience influences child resilience, such as parenting practices, mother–child interactions, and the transmission of coping strategies, could inform the development of interventions aimed at promoting resilience in both mothers and their children [81].

A more comprehensive understanding of the interplay between maternal, newborn, and child resilience can inform the development of targeted interventions to promote the well-being of both mothers and their children. Interventions that focus on strengthening maternal resilience, such as parenting support programs, stress management techniques, and access to social support networks, may have cascading positive effects on child resilience [87]. Similarly, interventions that target child resilience, such as early childhood education programs and social-emotional learning initiatives, may also indirectly support maternal resilience by reducing parenting stress and enhancing family well-being [80].

One of the objectives of this scoping review was to identify indices of resilience in MNCH in LMICs. However, the review revealed a paucity of studies using standardized indices to measure resilience in this context. The lack of validated resilience indices specific to MNCH in LMICs highlights a significant gap in the literature and presents an opportunity for future research [88]. The development and validation of context-specific resilience indices can help researchers and practitioners assess resilience levels, identify factors contributing to resilience, and evaluate the effectiveness of interventions aimed at promoting resilience in MNCH [89].

The complex nature of resilience, which involves the interplay of individual, family, and community factors, poses challenges for its measurement [90]. Existing resilience indices, such as the Connor-Davidson Resilience Scale (CD-RISC) and the Resilience Scale for Adults (RSA), have been developed and validated primarily in high-income countries and may not fully capture the unique cultural and contextual factors influencing resilience in LMICs [88]. The adaptation and validation of these indices in LMIC settings, as well as the development of new indices tailored to the specific challenges faced by women and children in these contexts, are necessary steps to advance research on resilience in MNCH.

Furthermore, the use of standardized indices can facilitate comparisons across studies and populations, contributing to a more comprehensive understanding of resilience in MNCH globally. The ability to compare resilience levels and identify common resilience factors across different LMIC settings can inform the development of evidence-based interventions and policies aimed at promoting resilience in MNCH [90]. Standardized indices can also enable researchers to track changes in resilience over time, assess the impact of adverse events on resilience, and evaluate the effectiveness of resilience-promoting interventions [89].

In addition to the development and validation of resilience indices, there is a need for more qualitative research exploring the lived experiences of women and children in LMICs and the factors that contribute to their resilience. Qualitative studies can provide valuable insights into the cultural, social, and contextual factors that shape resilience in MNCH and inform the development of culturally sensitive and context-specific resilience indices [90]. A mixed-methods approach, combining qualitative and quantitative methods, can provide a more comprehensive understanding of resilience in MNCH and strengthen the validity and reliability of resilience indices [91].

The paucity of studies using standardized indices to measure resilience in MNCH in LMICs underscores the need for further research in this area. The development, validation, and use of context-specific resilience indices, along with qualitative and mixed-methods research, can contribute to a more nuanced understanding of resilience in MNCH and inform the development of effective interventions and policies to promote the well-being of women and children in LMICs.

Limitations and strengths

Included studies defined resilience differently, with different connotations making the synthesis of a definition of resilience in MNCH difficult. Additionally, few studies have used a definition in their research. The same applies to the use of indices to identify mothers or children who are resilient. In the systematic review of resilience in HIV, only two studies defined resilience, and the majority examined factors of individual resilience. Another limitation is that the scope of the review was restricted to LMICs. Otherwise, the review’s strengths include a detailed search of the literature, including grey literature, which led to the identification of studies that used personal, interpersonal, community, and health system variables to infer resilience mediators. The review also included young pregnant women, a group often excluded from MNCH research.

Another strength of this review is the generation of suggested new definitions, and the one elected preferred (chosen by consensus of a voting panel of experts), despite the heterogeneity of the definitions and focuses of the included studies. The use of the main constructs of definitions made word cloud aggregation possible to generate new definitions. Finally, for programmatic purposes, the proposed definition of ‘newborn and child resilience’ recognises the upper age limit of five years might be extended to nine years for a child, as proposed by the WHO.