JOGNN
Effects of the 2011 Flood in Thailand
Correspondence
Natthananporn
Sanguanklin, PhD,
Faculty of Nursing,
Thammasat University,
99 Phaholyothin Rd.,
Khlong Nueng, Khlong
Luang, Pathum Thani,
Thailand 12120.
nsangu2@uic.edu
beesanguanklin@gmail.com
Keywords
birth outcomes
displacement
natural disaster
social support
Natthananporn
Sanguanklin, PhD, RN, is a
graduate of University of
Illinois at Chicago, College
of Nursing, Chicago, IL.
(Continued)
The authors report no con-
flict of interest or relevant
financial relationships.
http://jognn.awhonn.org
RESEARCH
on Birth Outcomes and Perceived Social
Support
Natthananporn Sanguanklin, Barbara L. McFarlin, Chang Gi Park, Carmen Giurgescu, Lorna Finnegan,
Rosemary White-Traut, and Janet L. Engstrom
ABSTRACT
Objective: To determine the effects of displacement due to flooding during pregnancy on birth outcomes (infant
birth weight and gestational age) and the moderating effect of perceived social support on the relationship between
displacement and birth outcomes.
Design: A descriptive, longitudinal study.
Setting: A university-affiliated hospital in Pathum Thani, Thailand.
Participants: Pregnant women (N = 175) in the third trimester that had uncomplicated pregnancies and no history of
mental illness.
Methods: During pregnancy, the participants completed standardized measurements of depression symptoms, per-
ceived social support, and questionnaires concerning the effect of the flood. After giving birth, infant birth weight and
gestational age at birth were retrieved from delivery records.
Results: Seventy percent (n = 123) of the participants experienced displacement during the flood. The displaced
women had a mean infant birth weight of 175 grams less than that of the nondisplaced women, t(173) = -2.38, p = .02,
whereas infant gestational age was not different. Displacement and other variables explained approximately 8% of the
variance in infant birth weight. The interaction term between displacement and perceived social support was statistically
significant and additionally explained the variance in infant birth weight, F(6, 168) = 3.24, p = .005.
Conclusion: Being displaced during pregnancy due to a natural disaster affected fetal growth rather than length of
gestation. Health care providers should closely monitor maternal weight gain and fetal growth of pregnant women who
experience displacement. Among the displaced women, social support was associated with higher infant birth weight;
therefore, high levels of perceived social support may be protective for pregnant women who experience stressful events
such as displacement from flooding.
JOGNN, 43, 435-444; 2014. DOI: 10.1111/1552-6909.12466
Accepted March 2014
revious researchers have shown that preg- ment of Disaster Prevention and Mitigation, 2012).
P nant women who have experienced disasters
are at high risk for antenatal depression and ad-
The 2011 flood was described as the worst flood-
ing in Thailand in terms of the amount of water and
verse birth outcomes (e.g., preterm birth, low birth the number of people affected as well as the length
weight) (Harville, Xiong, & Buekens, 2009; Xiong of time of the disaster. The flood affected approx-
et al., 2010). In 2011, 65 of 77 provinces in Thai- imately 12.9 million people, caused 813 deaths,
land were declared disaster zones as a result of and damaged 2.2 million houses. More than five
severe flooding that began on July 25, 2011 and million people were evacuated, and 65,000 work-
persisted in some areas until January 16, 2012. ers became unemployed. The economic impact
Due to the monsoon season and the landfall of was high at more than U.S. $45.7 billion (National
tropical storm Nock-Ten in north Vietnam, which Statistical Office, 2012). Given that pregnancy is a
borders Thailand in the north, heavy precipitation major life event and a source of enormous stress
and flooding spread from the north through the in a woman’s life (Xiong et al., 2008), pregnant
northeast and the central part of Thailand (Depart- women are particularly vulnerable to the effects of

C 2014 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses 435
RESEARCH
The prevalence of antenatal depression symptoms in displaced
women during a natural disaster is relatively high and is worth
closer investigation.
Barbara L. McFarlin, PhD,
CNM, RDMS, FACNM, is
an associate professor and
head of the Department of
Women, Children, and
Family Health Science,
College of Nursing,
University of Illinois at
Chicago, Chicago, IL.
Chang Gi Park, PhD, is a
visiting research assistant
professor in the College of
Nursing, University of
Illinois at Chicago,
Chicago, IL.
Carmen Giurgescu, PhD,
RN, WHNP, is an assistant
professor in the College of
Nursing, Wayne State
University, Detroit, MI.
Lorna Finnegan, PhD,
APN, CNP, is an associate
professor and interim Head
of the Department of Health
Systems Science, College
of Nursing, University of
Illinois, Chicago, IL.
Rosemary White-Traut,
PhD. RN, FAAN, is a
professor in the College of
Nursing, University of
Illinois at Chicago,
Chicago, IL.
Janet L. Engstrom, PhD,
RN, CNM, WHNP, is a
professor in the College of
Nursing, Rush University,
Chicago, IL.
436
Effects of the 2011 Flood in Thailand on Birth Outcomes and Perceived Social Support
the additional stress experienced during a disas-
ter (Buekens, Xiong, & Harville, 2006; Xiong et al.,
2010).
As a result of Hurricane Katrina, social support
was one of the most significant losses reported by
pregnant women (Badakhsh, Harville, & Banerjee,
2010). Social support is a factor known to con-
tribute to the health and well-being of pregnant
women (Feldman, Dunkel-Schetter, Sandman, &
Wadhwa, 2000; Hoffman & Hatch, 1996; Oakley,
1988; Orr, 2004). Under a threatening circum-
stance such as a flood disaster, where stress can-
not be prevented or eliminated, the moderating
effect of perceived social support is worth closer
investigation.
Disaster and Antenatal Depression
Symptoms
Following Hurricane Katrina, the prevalence of an-
tenatal depression symptoms ranged from 12.7%
to 25% (Savage et al., 2010; Xiong et al., 2010),
which was approximately 2 times higher than for
pregnant women in general (Bennett, Einarson,
Taddio, Koren, & Einarson, 2004). Hurricane Kat-
rina affected women’s lives in many ways: they lost
their homes and all belongings and some even
lost their jobs (Savage et al., 2010). The risk of el-
evated depression symptoms was also positively
associated with the number of severe hurricane-
related events (Xiong et al., 2010). The negative
effect of a disaster affects not only the psycholog-
ical health of pregnant women but also their birth
outcomes.
Disaster and Birth Outcomes
The impact of disasters on birth outcomes has
been studied across different types of disas-
ters yielding similar findings (Harville, Xiong, &
Buekens, 2010). For example, the rate of spon-
taneous abortion in western New York in 1973 was
significantly higher compared to the years before
and after a flood there (Janerich et al., 1981).
Neuberg, Pawlosek, Lopuszanski, and Neuberg
(1998) reported a high incidence rate of preg-
nancy losses among Polish women who were
injured from a major flood in southern Poland
in 1997. The incidence of low birth weight and
JOGNN, 43, 435-444; 2014. DOI: 10.1111/1552-6909.12466
preterm birth significantly increased following a
catastrophic flood in North Dakota, USA (Tong,
Zotti, & Hsia, 2011). Following the earthquake in
Taiwan, the prevalence of low birth weight sig-
nificantly increased (H. L. Chang, Chang, Lin,
& Kuo, 2002). It is widely recognized that the
impact of a disaster on birth outcomes is de-
termined by the severity of exposure. Pregnant
women who experienced severe events of Hurri-
cane Katrina (e.g., walking through floodwaters,
significant home damage, or feeling that one’s
life was in danger) were more likely to have
low-birth-weight infants compared to women with
nonextensive experience (Xiong et al., 2008).
One possible explanation is that the individual
and community resources contributing to healthy
pregnancy were disrupted during the disaster,
including social support (Badakhsh, Harville, &
Banerjee, 2010; Xiong et al., 2008), resulting in
adverse birth outcomes.
Perceived Social Support and Birth
Outcomes
Perceived social support, or the availability of
support when it is needed, has been shown to
have benefits regarding birth outcomes (Collins,
Dunkel-Schetter, Lobel, & Scrimshaw, 1993;
Feldman, Dunkel-Schetter, Sandman, & Wadhwa,
2000; Norbeck, 1985; Pagel, Smilkstein, Regen,
& Montano, 1990; Turner, Grindstaff, & Phillips,
1990). Oakley (1988) suggested that social sup-
port is relevant to birth outcomes because it can
help reduce stress. The mechanism by which
social support is associated with health can be
explained in terms of direct and moderating ef-
fects (Cohen & Wills, 1985). Several observational
studies have illustrated the direct effect of social
support on birth outcomes; a higher level of so-
cial support was associated with improved birth
outcomes (Orr, 2004). Although the moderating
effects of social support are an appealing mecha-
nism and provide a strategy for alleviating the im-
pact of stress, the evidence illustrating its moder-
ating effect on birth outcomes is limited. The 2011
flood in Thailand provided a unique opportunity to
examine the role of perceived social support.
During the 2011 flood in Thailand, many women
were evacuated out of the flooding area (dis-
placed women), though some women were not
directly affected by the flood (nondisplaced
women). It was hypothesized that the nega-
tive consequences of the flood on psychologi-
cal health and birth outcomes may have been
worse among the displaced women, particularly
http://jognn.awhonn.org
Sanguanklin, N. et al.
those with low levels of perceived social support.
Displacement depended upon the severity of the
flooding in the women’s residence. The purposes
of this study were to compare the prevalence of
antenatal depression symptoms between the dis-
placed and nondisplaced women; to examine the
effect of displacement on birth outcomes (infant
birth weight and gestational age at birth); and to
examine the moderating effect of perceived social
support on the relationship between displacement
and birth outcomes.
Methods
This was a descriptive, longitudinal study. The set-
ting was a university-affiliated hospital in Pathum
Thani province, Thailand. Bordering Bangkok in
the north, Pathum Thani is one of the major indus-
trial estates in the central part of Thailand. During
the flood, many manufacturing companies in this
area were inundated and workers were temporar-
ily unemployed. The university-affiliated hospital
serves the residences in this province and sur-
rounding area, with an average of 50 to 80 preg-
nant women receiving antenatal care at the hospi-
tal per day.
Participants
The participants were part of a larger re-
search study designed to examine the relation-
ship between job strain and psychological dis-
tress among employed pregnant Thai women
(Sanguanklin et al., 2014). Eligible participants
were at least age 18 years, were employed full-
time, were between 26 and 38 weeks of gestation,
had uncomplicated pregnancies and had no his-
tory of mental illness based on a chart review, and
had a singleton intrauterine pregnancy. To deter-
mine the sample size, a previous study that used
a similar conceptual framework and variables was
used to estimate the effect size. According to
Costa, Dritsa, Larouche, & Brender, 2000, infant
gestational age significantly explained about 19%
out of 44% of the variance in infant birth weight.
However, infant gestational age was one of the out-
come variables of this study. Therefore, a medium
effect size was used to estimate the sample size.
Using the G∗Power program version 3.2.1 with
a medium effect size, a sample size of 130 was
needed to achieve a power of .80 and an alpha of
.05 (Erdfelder, Faul, & Buchner, 1996).
Measures
Infant birth weight in grams and gestational age
were collected from the delivery records. Gesta-
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RESEARCH
tional age at birth was calculated as number of
weeks based on the woman’s last menstrual pe-
riod (LMP), or ultrasonography if the LMP was not
provided. Infant birth weight and gestational age
were treated as continuous variables in the analy-
ses. To describe the prevalence of low birth weight
and preterm birth, dichotomous variables were
also created. Low birth weight was defined as in-
fant birth weight fewer than 2,500 grams. Preterm
birth was defined as infants born before 37 weeks.
The Thai translated version of the Center for
Epidemiological Studies-Depression Scale (CES-
D) was used to screen the current level of an-
tenatal depression symptoms (Boonpongmanee,
Zauszniewski, & Morris, 2003). The CES-D has 20
items on a 4-point Likert-type scale (0 = rarely or
none of the time, 3 = most of the time). The possi-
ble scores ranged from zero to 60. The Thai stan-
dard cut-off point (CES-D ࣙ 19) was used to iden-
tify pregnant women that were at risk of depression
(Kuptniratsaikul & Pekuman, 1997). Concurrent
validity was supported by clinical and other self-
report criteria (Radloff, 1977). This scale has been
used widely with pregnant Thai women and has
demonstrated acceptable reliability. The Cron-
bach’s alpha of the CES-D was .88 in this study.
The Medical Outcome Study-Social Support Sur-
vey (MOS-SSS) was used to measure percep-
tions of the availability of support and whether
the support by partners, family, and close friends
was adequate. The Thai version of the MOS-SSS
has one item assessing the number of support-
ers and 15 items assessing the four dimensions
of support (emotional/informational, tangible, pos-
itive social interaction, and affectionate) (Run-
gruangsiripan, Sitthimongkol, Maneesriwongul,
Talley, & Vorapongsathorn, 2011). The 15 items
were on a 5-point Likert-type scale ranging from
1 (none of the time) to 5 (all the time). The possible
scores ranged from 15 to 75, with higher scores
indicating higher perception of the availability of
social support. The Cronbach’s alpha was .95 in
this study.
Participants were asked these two questions to as-
sess the personal effect of the flooding: (a) Were
you displaced during the flood? and (b) Did you
lose your job during the flood? Other factors that
are known to be related to birth outcomes were
also measured and controlled in the analyses. The
questionnaires included sociodemographic data
of age, educational level, income, job title, work-
place; and pregnancy characteristics of gesta-
tional age, pregnancy intent, and parity.
437
RESEARCH Effects of the 2011 Flood in Thailand on Birth Outcomes and Perceived Social Support
The mean infant birth weight of displaced women was
significantly lower than the mean infant birth weight of
nondisplaced women.
Data Collection
The study was approved by the Institutional Re-
view Boards of the University of Illinois at Chicago
(USA) and Thammasat University (Thailand), with
which the hospital is affiliated. Data were collected
soon after the flood, from the beginning of Febru-
ary to the end of April 2012. Pregnant women who
met the inclusion criteria were invited to partici-
pate in the study by their health care providers.
The potential participant received a full expla-
nation of the study from the principal investiga-
tor. Two parts of the informed consent were will-
ingness to participate in the study, and allowing
the research team to access the delivery records
to collect birth outcome data (infant birth weight
and gestational age). After informed consent was
obtained, the participants completed the self-
administered questionnaires in paper-and-pencil
format in a private hospital room. After giving birth,
birth outcome data were retrieved from delivery
records.
Data Analysis
The statistical package SPSS version 20 was
used for the analyses. Outcome variables be-
tween displaced and nondisplaced women were
compared by using independent samples t-tests
or chi-squared tests based on the levels of mea-
surement. Multiple linear regression analyses were
performed to determine the effect of displacement
on infant birth weight and gestational age. Hier-
archical multiple linear regression analyses were
performed to determine the moderating effect of
perceived social support on the relationship be-
tween displacement and infant birth weight.
Results
Two hundred and 10 pregnant women completed
the self-administered questionnaires. However,
175 (84%) out of 210 participants gave birth at
the study hospital. Birth outcome data were not
collected for the 35 participants who gave birth at
other hospitals. This left 175 participants who had
completed the data at two time points. There were
no significant differences in maternal characteris-
tics between the participants who did and did not
give birth at the study hospital.
438 JOGNN, 43, 435-444; 2014. DOI: 10.1111/1552-6909.12466
The mean age of the participants was 29 years.
More than one half of the participants (n = 98,
56%) had an unplanned pregnancy. The mean
gestational age at prenatal data collection was 30
weeks. Approximately, one half of the participants
(n = 91, 52%) had been working as semiskilled
workers (e.g., service workers, factory workers,
and laborers) whereas the others (n = 84, 48%)
were skilled workers (e.g., managers, professional
workers, and accountants). Seventy percent of
the participants (n = 123) were displaced and
had temporarily lost their jobs during the flood.
The number of women (n = 77) who underwent
a cesarean section was 44%. Almost 35% of the
participants had scores on the CES-D ࣙ 19, sug-
gesting antenatal depression symptoms. CES-D
scores ࣙ 19 were reported to the women’s health
care provider, who evaluated the women before
they left the clinic. None of the women was sui-
cidal. The mean infant birth weight was 3,094
grams. The average infant gestational age was
38 weeks. The prevalence of preterm birth and low
birth weight in this population was about 10.3%
(see Table 1).
The displaced women had a mean infant birth
weight that was 175 grams lower than that of the
nondisplaced women, t(173) = –2.38, p = 02.
However, the mean scores of infant gestational
age were not significantly different. Chi-squared
tests indicated that the proportion of sociode-
mographic, obstetric characteristics, antenatal
depression symptoms, preterm birth, and low
birth weight among the displaced and nondis-
placed women were not significantly different (see
Table 2).
Factors Associated with Infant Birth
Weight
In the linear regression model, parity, job char-
acteristics, displacement, antenatal depression
symptoms, and perceived social support ex-
plained 8.1% of the variance in infant birth weight.
In addition to displacement, parity and job charac-
teristics had a substantial and statistically signifi-
cant effect on infant birth weight. However, ante-
natal depression symptoms and perceived social
support did not significantly explain the variance
in infant birth weight.
The results from the hierarchical multiple linear re-
gression model indicated that the interaction term
between displacement and perceived social sup-
port was significant, F(6,168) = 3.24, p = .005,
and explained an additional 2.3% of the variance
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Sanguanklin, N. et al. RESEARCH

Table 1: Characteristics and birth outcomes of participants (N = 175)

Characteristics n % M SD Range
Age (year) 29.57 5.05 19 – 43

Education

Less than high school 52 29.7

High school or higher 123 70.3

Income per month (US dollars)

< $333 18 10.3

ࣙ $333 157 89.7

Marital status

Single/separated 11 6.3

Married 164 93.7

Gestational age when data were collected 30.37 3.81 26 – 37

Pregnancy intent

Unplanned 98 56

Planned 77 44

Parity

Primigravid 70 40

Multigravid 105 60

Job characteristics

Skilled workers 84 48

Semiskilled workers 91 52

Lost job during the flood

No 42 24

Yes 133 76

Displaced during the flood

Were displaced 123 70.3

Were not displaced 52 29.7

Depression symptoms

CES-D < 19 114 65.1

CES-D ࣙ 19 61 34.9

Infant gestational age (week) 38.16 1.75 33 – 41

Infant birth weight (grams) 3094.86 450.84 1,680 – 4,750

Infant gestational age

< 37 completed weeks 18 10.3

ࣙ 37 completed weeks 157 89.7

Infant birth weight (gram)

< 2500 gram 18 10.3

ࣙ 2500 gram 157 89.7

Type of delivery

Vaginal 98 56

Cesarean 77 44

Note. CESD = Center for Epidemiological Studies-Depression Scale.

JOGNN 2014; Vol. 43, Issue 4 439

RESEARCH Effects of the 2011 Flood in Thailand on Birth Outcomes and Perceived Social Support

Table 2: Comparison of Sociodemographics, Obstetric Characteristics, Antenatal Depres-

sion Symptoms, Social Support, and Birth Outcomes among Displaced and Nondisplaced
Women

Displaced (n=123) Nondisplaced (n=52)

n(%) n(%) χ2 t df p
Education level

Less than high school 26(21.1) 13(25) .13

High school or higher 97(78.9) 39(75)

Income (U.S. dollars)

< $333 11(8.9) 7(13.5) .39

ࣙ $333 112(91.1) 45(86.5)

Job characteristics

Skilled workers 63(51.2) 21(40.4) .13

Semiskilled workers 60(48.8) 31(59.6)

Parity

Primigravid 51(41.5) 19(36.5) .19

Multigravid 72(58.5) 33(63.5)

Planned pregnancy

Unplanned 73(59.3) 25(48.1) 1.45

Planned 50(40.7) 27(51.9)

Depression symptoms

CES-D < 19 82(66.7) 32(61.5) .23

CES-D ࣙ 19 41(33.3) 20(38.5)

Social support, M (SD) 60.81 (10.8) 59 (11.85) −1.03 173 .30

Number of supporters, M (SD) 4.14 (2.23) 4.21 (2.78) .19 173 .85

Infant birth weight, M (SD) 3042 (434) 3217 (469) −2.38 173 .02∗

Infant gestational age, M (SD) 38.26 (1.65) 38.60 (1.57) −1.25 173 .21
a
Infant gestational age

< 37 weeks 14(11.4) 4(7.7) .59

ࣙ 37 weeks 109(88.6) 48(92.3)

a
Infant birth weight

< 2,500 grams 15(12.2) 3(5.8) .28

ࣙ 2,500 grams 108(87.8) 49(94.2)

Type of delivery

Vaginal delivery 68(55.3) 30(57.7) .77

C-section 55(44.7) 22(42.3)

Note. CESD = Center for Epidemiological Studies-Depression Scale.

a
Fisher’s Exact test.
The average monthly income per household for the whole country of Thailand is approximately $700 (Office for National Statistics, 2013).
∗
p < .05.

440 JOGNN, 43, 435-444; 2014. DOI: 10.1111/1552-6909.12466 http://jognn.awhonn.org

Sanguanklin, N. et al. RESEARCH

Table 3: Hierarchical Multiple Regression Analysis for the Interaction Term between Dis-
placement and Social Support, Controlling for Maternal Parity, Job Title, Being Displaced, De-
pression Symptoms, and Perceived Social Support, Explaining Infant Birth Weight (N = 175)

95% Confidence Interval

Variable b SE b β p Value Lower Upper

Step 1

Parity –161.09 68.92 –.176 .021 −297.15 −25.04

Job title −153.88 70.29 −.171 .030 −292.64 −15.12

Displacement −194.01 72.50 −.197 .008 −337.14 −50.89

Depression symptoms 41.69 75.29 .044 .580 −106.94 190.33

Social support −7.25 5.27 −.171 .171 −17.65 3.16

Step 2

Displacement X Support 13.41 6.46 .252 .039 .658 26.16

Note. R = .081; F(5, 169) = 2.965, p = .014.

2

 R2 = .023; F(6, 168) = 3.237, p = .005

already explained by the main effects (see Discussion

Table 3). Figure 1 illustrates the moderating ef-
fect of perceived social support on the relationship
between displacement and infant birth weight.
Perceived social support had a positive effect on
the infant birth weight of the displaced women, but
it had a small effect on the infant birth weight of
the nondisplaced women.
Our findings demonstrated the effect of the 2011
flood in Thailand on antenatal depression symp-
toms and birth outcomes and illustrated the role
of perceived social support on the displacement-
infant birth weight relationship. As hypothesized,
the infant birth weight of the displaced women was
significantly lower than that of the nondisplaced

Figure 1. Regression lines illustrating the interaction of displacement condition and social support in their effects on infant birth
weight

JOGNN 2014; Vol. 43, Issue 4 441

RESEARCH Effects of the 2011 Flood in Thailand on Birth Outcomes and Perceived Social Support
Among displaced women during pregnancy, higher levels of
perceived social support were associated with higher infant
birth weights.
women. The lower infant birth weight among dis-
placed women may be related to inadequate nu-
trient and prenatal care (Badakhsh, Harville, &
Banerjee, 2010). During the flood, food shortage
was a major problem because more than 7,700
square miles of farmland in Thailand were dam-
aged (Department of Disaster Prevention and Mit-
igation, 2012). Meanwhile, food and required sup-
plies could not be transported to grocery stores
due to the impassible roads for many months.
Thus pregnant women experienced a prolonged
shortage of food. Pregnant women may also have
shared the food they had with other family mem-
bers. Based on the conversations with the partic-
ipants, some reported that they did not have pre-
natal care during the flood due to the difficulty in
traveling. Another possible reason for the low birth
weight was that eating may have become a less
important issue for the displaced women whereas
there were other urgent issues that needed to be
taken care of, for example, cleaning up after the
flood and renovating their houses.
As a potential intervention for reducing the neg-
ative effects of a disaster on birth outcomes,
perceived social support had a moderating ef-
fect on infant birth weight, particularly among
the displaced women. Consistent with the stress-
buffering hypothesis of Cohen and Wills (1985),
adequate social support may help pregnant
women redefine a stressful situation or eliminate
the stress reaction. Perceived social support may
motivate positive healthy behaviors in pregnant
women and in turn increase infant birth weight
(Feldman, Dunkel-Schetter, Sandman, & Wadhwa,
2000).
In this study, we found that not only displacement
condition, but also parity and job characteristics
influenced infant birth weight. The infants of the
displaced women that were primiparous and had
been working as semiskilled workers were approx-
imately 500 grams fewer than the infants of the
nondisplaced women who were multiparous and
had been working as skilled workers. More specif-
ically, the semiskilled workers had significantly
less education and fewer supporters compared
to the skilled workers. Lower infant birth weight
presents a higher risk of infant mortality, morbidity,
developmental problems in childhood, and vari-
442 JOGNN, 43, 435-444; 2014. DOI: 10.1111/1552-6909.12466
ous diseases in adulthood (Wilcox, 2001). A large
U.K. cohort study illustrated that higher infant birth
weight was correlated with higher cognitive ability
of children throughout adulthood. In addition, in-
fants with higher birth weight were more likely to
attain higher education (Richards, Hardy, Kuh, &
Wadsworth, 2001).
The prevalence of antenatal depression symp-
toms between the displaced and nondisplaced
women was not significantly different. Similarly,
Xiong et al. (2010) found that the rate of depres-
sion among pregnant women in New Orleans and
Baton Rouge, Louisiana, was almost the same
even though the women in Baton Rouge were less
exposed to Hurricane Katrina. One possible ex-
planation for the results of this study was that preg-
nant women who were not directly exposed to the
disaster may have been genuinely concerned and
grieved over family members, friends, and fellow
citizens or might have experienced stress by hear-
ing about the flood through the media (Harville,
Xiong, & Buekens, 2009).
Antenatal depression symptoms did not explain
the variance in the infant birth weight or gesta-
tional age in this sample because these symptoms
were evaluated only one time during the preg-
nancy. Therefore any changes that occurred after
this evaluation were not perceived, and as a result,
the factors or resources (i.e., coping strategies)
that could help to alleviate depression symptoms
were not examined. The cesarean section rate in
the study hospital is relatively high because the
hospital allows the pregnant women to choose a
specific, private-practice obstetrician and to re-
ceive care from that obstetrician from the prebirth
to the postbirth stage. These pregnant women
are also allowed to choose their delivery method.
A cesarean section is the preferred choice be-
cause there is a common belief in Thailand that
one should have an auspicious date and time for
giving birth; Thai pregnant women and their fam-
ilies believe that the delivery date and time can
control one’s destiny. Moreover, many of the preg-
nant women in this study had a previous cesarean
section.
Limitations
Several limitations of this study should be consid-
ered. All of the participants in this study were em-
ployed pregnant women; job-related uncertainty
during the flood might have caused the high
prevalence of antenatal depression symptoms.
Sixteen percent of the birth outcome data were not
http://jognn.awhonn.org
Sanguanklin, N. et al.
accessible because the participants gave birth
outside the study hospital. Therefore, potential se-
lection bias may have occurred. Antenatal de-
pression symptoms and perceived social support
are subjective measures, and reporting bias can-
not be ruled out. Specific information related to
the lack of prenatal care during the flood or in-
duced deliveries that may have affected infant
birth weight was not collected. The data were col-
lected from one of the university-affiliated hospi-
tals in the central part of Thailand, and therefore
the results might not be generalized to other Thai
women that experienced the flooding disaster in
other regions. Other known factors related to infant
birth weight were not measured and were not con-
trolled for in the analyses, such as prepregnancy
body mass index and maternal weight gain. The
exclusion of these factors may have affected the
estimation of the flood effect.
Implications for Practice
The 2011 flood in Thailand and Hurricane Kat-
rina were forecasted for days before the severe
weather and flooding. However, many people, es-
pecially the poor, did not prepare resources to deal
with the floods. If pregnant women live in areas
of frequent flooding, health care providers should
include disaster preparedness as a part of their
care. Previous studies, particularly those of Ewing,
Buchholtz, and Rotanz (2008), have provided use-
ful information for health care providers to as-
sist pregnant women in dealing with a disaster,
for example, preparing drinking water, food and
supplies, and planning for a place to evacuate
if needed. Pregnant women should retain their
personal prenatal care records, and plan for a
place to deliver their babies if their usual hospi-
tal is not accessible. Preparation would enhance
a sense of control on the part of pregnant women
(Badakhsh, Harville, & Banerjee, 2010). In addi-
tion to physical needs and childbearing prepara-
tion, psychological resources are needed as well
(Savage et al., 2010). Screening for psychological
distress in pregnant women (e.g., anxiety, depres-
sion, and posttraumatic stress disorder) should be
implemented as part of antenatal care services,
particularly among pregnant women that have
experienced a disaster. And finally, using preg-
nant women’s networks to enhance social support
could be beneficial.
Acknowledgment
Supported by the Midwest Nursing Research So-
ciety (MNRS); Sigma Theta Tau, Alpha Lambda
JOGNN 2014; Vol. 43, Issue 4
RESEARCH
Chapter; and PhD alumni of the University of Illi-
nois at Chicago, College of Nursing.
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