Adverse and benevolent childhood experiences and depression among women in rural Pakistan

Adverse childhood experiences (ACEs) are associated with maternal depression, including during the perinatal and postpartum periods when women face elevated risk. Benevolent childhood experiences (BCEs) may buffer negative effects of ACEs and promote mental health, yet evidence on their joint effects remains limited, particularly in low-resource settings. We investigated the joint effects of ACEs and BCEs on maternal depression from the third trimester of pregnancy through eight years postpartum among 804 women in rural Pakistan. Childhood experiences were characterized using both aggregated scores and latent class analysis to capture overall burden and item-level patterns. We tested the linear interaction term of ACEs and BCEs and utilized subgroup analysis to assess non-linear interactions. Overall, more than half (58.5%) of women experienced at least one ACE, and 6.2% of women experienced four or more ACEs. Commonly reported ACE domains were home violence (39.3%), neglect (19.7%) and family psychological distress (15.2%). Nearly half (45.3%) of women experienced all ten BCEs, and over half (51.5%) experienced 6-9 BCEs. Some BCE items had a very high prevalence, including liking themselves/feeling comfortable with themselves (96.6%), having at least one caregiver with whom they felt safe (96.5%), and having good neighbors (94.9%). Adjusting for ACEs, higher levels of BCEs were independently associated with fewer depressive symptoms (β = -0.25; 95% CI: -0.45, -0.05) and the promotive effects were consistent across ACE domains. Evidence of interaction suggested that BCEs buffered the adverse effects of ACEs among women with 1-3 ACEs (β = -0.56; 95% CI: -0.86, -0.26), but not among those with four or more ACEs. The associations between exposure to ACEs and depressive symptoms were weaker among women with higher levels of BCEs. Latent class analysis identified four distinct childhood experience profiles: Low-ACE/High-BCE (58.6%), High ACE/High BCE (19.5%), Low ACE/Low BCE (13.8%), High ACE/Low BCE (8.1%), with women in the High ACE/Low BCE class experiencing the greatest depressive symptom burden. Findings suggest that both adverse and benevolent childhood experiences are important for understanding maternal depression in low-resource settings, and informing interventions that reduce adversity exposure and foster positive developmental resources.