Anxiety in the perinatal period: antenatal and postnatal influences and women’s experience of care

Experiences of postpartum anxiety during the COVID-19 pandemic: A mixed methods study and demographic analysis

INTRODUCTION

The first wave of the COVID-19 pandemic saw the reconfiguration of perinatal and maternity services, national lockdowns, and social distancing measures which affected the perinatal experiences of new and expectant parents. This study aimed to explore the occurrence of postpartum anxieties in people who gave birth during the pandemic.

METHODS

An exploratory concurrent mixed-methods design was chosen to collect and analyse the quantitative and qualitative data of an online survey during the first UK lockdown. The survey included the Postpartum Specific Anxiety Scale-Research Short Form-for use in global Crises [PSAS-RSF-C] psychometric tool, and open-ended questions in relation to changes in birth plans and feelings about those changes and giving birth in a pandemic. Differences in measured scores were analysed for the participant's ethnicity, sexual orientation and disability using independent Student's t-tests, and for age, the analysis was completed using Pearson's correlation. Qualitative data from open-ended questions were analysed using a template analysis.

RESULTS

A total of 1,754 new and expectant parents completed the survey between 10th and 24th April 2020, and 381 eligible postnatal women completed the psychometric test. We found 52.5% of participants reported symptoms consistent with a diagnosis of postnatal anxiety-significantly higher than the rates usually reported. Younger women and sexual minority women were more likely to score highly on the PSAS-RSF-C than their older or heterosexual counterparts (p<0.001). Younger participants reported anxieties in the 'infant safety and welfare' category, whilst lesbian, gay, bisexual, and pansexual participants scored highly in the 'psychosocial adjustment to motherhood' category.

DISCUSSION

Postpartum anxiety is under-reported, and demographic differences in the rates of postpartum anxiety are under-researched. This research demonstrates for the first time a difference in postpartum anxiety rates amongst sexual minority women.

Anxiety in a Specialist Perinatal Mental Health Service: patient characteristics, management, and outcomes

OBJECTIVES

To outline characteristics of patients with anxiety diagnoses attending a Specialist Perinatal Mental Health Service (SPMHS) in Ireland, the mental health care received by those patients, mental health and obstetric outcomes for those patients, and immediate neonatal outcomes for their babies.

METHODS

A retrospective chart review was conducted of patients with antenatal anxiety diagnoses who attended the SPMHS in University Maternity Hospital Limerick, from initiation of the service to the end of its first year.

RESULTS

Data were collected on 100 patients, 81 with a mental health diagnosis prior to attending the SPMHS, 32 with prior engagement with psychiatry, and 23 with a previous perinatal diagnosis. The mean age of patients was 32.4 (19-47, std 6.158). Beyond initial assessment, the Mental Health Midwife was involved in the care of 61% of patients, more than any other specialty including psychiatry. Twenty-seven patients had psychiatric medication either started or altered by the SPMHS. The most common reason for eventual discharge was that patients were well. Two patients presented in mental-health-related crisis to emergency services and one patient was admitted to an acute psychiatric ward.

CONCLUSIONS

Patients attending the SPMHS for anxiety spanned a broad spectrum of demographics and diagnoses and received varied set of interventions. A significant proportion of patients had a primary diagnosis of Pregnancy-related anxiety. The Mental Health Midwife played a key role in management of these patients. Though rates of mental health crises and admissions were low, the absence of a Mother and Baby Unit in Ireland was highlighted.

Investigating and comparing the dimensions of worry of Iranian primiparous women in each trimester of pregnancy

BACKGROUND

Pregnancy and childbirth are considered natural events in the life cycle of women. However, it is also a stressful experience along with physiological and psychological changes. Therefore, it is important to study the dimensions that cause more worry in each of the pregnant trimesters. This study aimed to determine and compare the dimensions of worry of Iranian primiparous women in each trimester of pregnancy.

METHODS

This cross-sectional study was conducted on 300 primiparous women (n = 100 in each trimester) referred to seven health centers affiliated with the Iran University of Medical Sciences, Tehran, Iran. The sampling was multistage. We collected data from a demographic and fertility questionnaire and the Cambridge Worry Scale (CWS).

RESULTS

The mean score of worry during the entire pregnancy was 28.16. The mean and standard deviation of the worry score in the first trimester was (27.35 ± 12.22). The second trimester was (27.80 ± 12.53) and the third trimester was (29.34 ± 11.11). The highest mean score of worry in the first and third trimmers was the dimension of own health. The second trimester was the dimension of socio-medical. The lowest mean score of worry in all trimmers was the dimension of relationships. Among CWS-related items, the highest mean score of worry in the first trimester was giving birth (3.34) and the possibility of miscarriage (3.22). In the second trimester was the possibility of going into labour too early (3.3) and the possibility of miscarriage (3.12), and in the third trimester was the possibility of going into labour too early (3.33) and giving birth (3.27). The lowest mean score of worry in all three trimesters was related to problems with the law.

CONCLUSION

pregnancy worry in the third trimester was more than the other two trimesters, and worrying about own health was the most important dimension of worry for pregnant women. Paying attention to the dimensions of worry of pregnant women helps design appropriate interventions to increase the mental and physical health of pregnant women.

Depression, Anxiety, and Stress in Pregnancy and Postpartum: A Longitudinal Study During the COVID-19 Pandemic

INTRODUCTION

Symptoms of depression, anxiety, and stress in pregnant women are generally highest in the first trimester and then decrease throughout pregnancy, reaching their lowest point in the postpartum period. Pregnant women are a high-risk population for mortality and mental health symptoms due to COVID-19. However, the extent to which the chronic stress of the COVID-19 pandemic alters the trajectory of depression, anxiety and stress symptoms in pregnant/postpartum women is unknown.

METHODS

Women (N=127) who were pregnant or who had given birth less than one month prior were recruited via online advertising during the COVID-19 pandemic. Participants were assessed up to three times during the pregnancy and at 1-month postpartum for depression (Edinburgh Postnatal Depression Scale), anxiety, and stress (Depression, Anxiety, and Stress Scale-21). Random intercepts models examined symptom change over time as well as predictors of elevated postpartum psychopathology.

RESULTS

On average, women completed their surveys at 8.5 weeks (first trimester), 21 weeks (second trimester), 32 weeks (third trimester) and 7-weeks postpartum. Women reported mild-moderate levels of depression, anxiety, and stress throughout pregnancy. There was a significant change in symptoms of depression and anxiety over time which was best represented by a quadratic rather than linear trajectory: symptoms increased until week 23-25 and then decreased. Stress levels remained consistently elevated over time. Higher symptom levels at 1-month postpartum were predicted by younger age, lower social support, and worry about going to a healthcare facility. Change in routine due to COVID-19 was not predictive of symptom trajectory from pregnancy to postpartum.

CONCLUSIONS

During COVID-19, symptoms of depression and anxiety increased from early to mid-pregnancy but then declined slightly while stress levels remained elevated. Observed reductions in symptoms were small. Given the substantial persistent impact of perinatal distress and poor mental health on maternal and fetal health, providers should be aware of heightened levels of these symptoms in pregnant women during large-scale external health stressors such as COVID-19, and should implement screening procedures to identify and appropriately intervene with at-risk women.

Identifying postnatal anxiety: comparison of self-identified and self-reported anxiety using the Edinburgh Postnatal Depression Scale

BACKGROUND

Identifying women with perinatal anxiety is important in order to provide timely support and prevent adverse outcomes. Self-report instruments are commonly used in maternity settings. An alternative is to ask women directly whether they self-identify as having anxiety. We examine the agreement between self-reported and self-identified anxiety at 3 months postpartum and compare the characteristics of women with self-reported and self-identified anxiety.

METHODS

A secondary analysis of national maternity surveys conducted in 2014 in England and Northern Ireland was conducted. Self-reported anxiety was assessed using the Edinburgh Postnatal Depression Scale anxiety subscale (EPDS-3A). Agreement between self-reported and self-identified anxiety was measured using Cohen's kappa. Logistic regression was used to identify characteristics of women in each group.

RESULTS

In our sample of 6752 women, 14.2% had self-reported anxiety, 5.9% had self-identified anxiety and 3.5% were positive on both measures. Among those with self-identified anxiety, 58.1% also had self-reported anxiety. Of those with self-reported anxiety, 24.4% also had self-identified anxiety. Statistical agreement between the two measures was minimal with Cohen's kappa 0.283 at an EPDS-3A threshold of ≥6. Among both self-identified and self-reported anxiety groups, psychological factors were the strongest associated factors. Women with self-reported anxiety had higher odds of being from Northern Ireland (OR 1.81); having a mixed or unhappy reaction to the pregnancy (OR 1.65); living without a partner (aOR 1.37); and antenatal depression (aOR 1.32). Women with self-identified anxiety had higher odds of physical problems (OR 1.84); and being of Black or minority ethnicity (OR 0.39).

CONCLUSIONS

Asking postnatal women directly whether they self-identify as having anxiety identifies a different group of women from those who score highly on self-report measures. Women with self-identified anxiety may benefit from further follow-up and support.

COVID-19-Related anxieties and parenting stress among first-time mothers and fathers in their first year of parenthood

INTRODUCTION

The changes accompanying the transition to parenthood, joined by the fears aroused by the COVID-19 pandemic, may lead to high levels of parental anxieties and stress, particularly among parents of young infants. This study, conducted in the midst of the crisis, explores the level of COVID-19-related anxieties and parenting stress of Israeli parents in their first year of parenthood.

METHODS

First-time mothers (n = 469) and fathers (n = 137), aged 21-50, completed self-report questionnaires in April, 2020. They were divided into two groups: parents of younger infants (aged 3-6 months); parents of older infants (aged 7-12 months).

RESULTS

The levels of all COVID-19-related anxieties were quite high, with the greatest concern aroused by public transportation and public places, followed by concerns over the possible infection of family members and the infant, going for infant check-ups, getting the virus themselves, and the health of the infant. In both groups, mothers reported higher COVID-19-related anxieties than fathers. Fathers of older infants reported higher parenting stress than mothers.

DISCUSSION

The results highlight the need to be attentive to the double stress of new parents in the first year of parenthood in a time of crisis, and to the potentially greater vulnerability of fathers of older infants.

Pregnancy-related anxiety symptoms and associated factors amongst pregnant women attending a tertiary hospital in south-west Nigeria

Background

Pregnancy can be associated with anxiety symptoms because of anticipated uncertainty.

Aim

This study investigated pregnancy-related anxiety symptoms (PRASs) and their associated factors amongst pregnant women.

Setting

Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria.

Methods

This cross-sectional survey involved 230 pregnant women attending antenatal clinic at a tertiary teaching hospital in Nigeria. Pregnancy-related anxiety symptoms, maternal worries, personality traits and social support were measured by using Perinatal Anxiety Screening Scale (PASS), Cambridge Worry Scale (CWS), Big Five Personality Inventory (BFI-10) and Maternal Social Support Scale (MSSS) respectively. Socio-demographic and obstetric details were also obtained. The Chi-square, t-test and logistic regression were used.

Results

Respondents’ mean age was 28.2 ± 5.4 years, whilst 192 (83.5%) were of Yoruba ethnicity. Twenty-four respondents (10.4%) were in the first trimester, 85 (37.0%) in the second and 121 (52.6%) in the third trimester. Some 154 (67.0%) were parous. The prevalence of PRAS and major maternal worries were 43.5% and 55.7% respectively. The socio-demographic factors significantly associated with PRAS were age (p = 0.004), ethnicity (p = 0.001), educational level (p = 0.011) and living arrangement (p = 0.029). Associated obstetric factors include trimester (p = 0.01), hypertension (p = 0.006), past miscarriage(s) (p = 0.013) and past pregnancy complication (p = 0.030). Significant psychosocial factors were partner social support (p = 0.038), maternal worries (p < 0.001) and extraversion (p = 0.016). Factors that contributed significantly to regression models were older maternal age and socio-medical worries.

Conclusion

High level of PRAS and major maternal worries were common amongst antenatal clinic attendees of a tertiary teaching hospital in Nigeria. Older maternal age and socio-medical maternal worries are important predictors of PRAS.

Perinatal Anxiety and Depression in Minority Women

Depression and anxiety are common during pregnancy and are experienced at higher rates among women who are racial and ethnic minorities. Because depression and anxiety influence maternal and infant outcomes, intervening to improve perinatal mental health should be a priority for all healthcare providers. However, in the United States, a number of barriers including lack of mental health providers, lack of perinatal behavioral health systems, and stigma, limit access to care. Universal screening has been recommended and here we examine how universal screening can help nurses improve the mental health of childbearing women. Interventions that are currently in use to improve perinatal anxiety and depression are reviewed and include: psychopharmacology, cognitive behavioral therapy, interpersonal psychotherapy, and mindfulness. Recommendations for future research and healthcare system changes are made.

Perinatal Resilience for the First 1,000 Days of Life. Concept Analysis and Delphi Survey

Background

The ability to cope with challenges and stress in life is generally understood as resilience. Pregnancy and parenthood are challenging times. The concept of resilience is receiving increasing interest from researchers, clinicians, and policy staff because of its potential impact on health, well-being, and quality of life. Nevertheless, the concept is less studied during the perinatal period.

Objectives

The aim of this study is to understand the concept of perinatal resilience, including the underlying processes and more specifically for the first 1,000 days of life.

Methods

A concept analysis according to the Walker and Avant (2011) framework was used, to investigate the basic elements of the concept. Concurrently, a two-round Delphi survey involving researchers, clinicians, epidemiologists, mothers, and fathers (N = 21), was conducted to prioritize the terms associated with perinatal resilience. Data collection took place between January and April 2019.

Results

Through concept analysis and Delphi survey, five defining attributes for perinatal resilience were identified: social support, self-efficacy, self-esteem, sense of mastery and personality. The additional terms, rated important by the Delphi survey, were linked to the consequences of being resilient during the perinatal period for the individual and his/her family. Specifically, highlighted were the experiences of families in personal growth and achieving family balance, adaptation, or acceptance.

Conclusion

Based on the results of the concept analysis and Delphi survey, we describe perinatal resilience for the first 1,000 days as a circular process towards a greater well-being in the form of personal growth, family balance, adaptation or acceptance, when faced with stressors, challenges or adversity during the perinatal period. The presence of resiliency attributes such as social support, sense of mastery, self-efficacy, and self-esteem enhance the capacity to be resilient and probably prevent mental health problems.

[Determinants of Anxiety Symptoms, Depression and Peri-traumatic Distress in Immediate Postpartum Women's mental health]

OBJECTIVES

The aims of this study were to identify the determinants and the vulnerability factors of women's mental health in the immediate postpartum period by investigating the first symptoms of anxiety, depression and peri-traumatic distress.

METHODS

256 women participated in this cross-sectional and descriptive study. They responded during their stay in the maternity ward to a set of questionnaires between the 1st and the 6th day after delivery. This included an anamnestic questionnaire as well as different scales that evaluated generalized self-efficacy feeling (GSES), marital adjustment (DAS), perceived sense of control during labor and delivery (LAS), birth experience (QEVA), anxiety manifestations (STAI-Y), depressive symptoms (EPDS) and peri-traumatic distress (PDI).

RESULTS

Symptoms of anxiety, depression and peri-traumatic distress in the immediate postpartum period, as indicators of women's mental health, are predicted by different determinants. An anxious personality and perceived complications during childbirth for the woman or baby have been shown to be significant predictors of postpartum anxiety. Symptoms of depression are related to a history of depression, a low overall sense of general efficacy and lower satisfaction in the marital relationship. Peri-traumatic distress is related to certain dimensions of the childbirth experience, such as perceived sense of control, perceived complications and emotions felt during birth.

CONCLUSIONS

Symptoms of depression, anxiety and peritraumatic distress are linked to aspects of the prenatal period, but also to the experience of childbirth. More specific prevention, screening and care measures, depending on the woman's symptomatology, can be implemented during pregnancy or at the maternity. Further research seems essential to better understand the interactions between the prenatal period, childbirth and postpartum in explaining women's mental health in the immediate postpartum period.

Psychosocial factors, mental health symptoms, and disordered eating during pregnancy

OBJECTIVE

The impact of disordered eating extends beyond women with a diagnosed eating disorder. Scarce research to date has investigated disordered eating in a general perinatal population, including the complex interplay between psychosocial factors, mental health symptoms, and disordered eating at numerous pregnancy periods. Specifically, maternal attitudes and relationship satisfaction are psychosocial factors that have been identified as a gap in the literature.

METHOD

Pregnant women completed an online questionnaire between 18 and 24 weeks gestation (T1, n = 258) and again between 30 and 32 weeks gestation (T2, n = 159). Structural equation modeling was used to test an interrelated model of psychosocial factors-attitudes to pregnancy, attitudes to motherhood, and relationship satisfaction-and disordered eating, mediated by either depressive or anxiety symptoms. Invariance testing examined whether model weights differed between primiparous and multiparous women at each time point.

RESULTS

While at T1 and T2, there were significant direct associations between psychosocial factors and disordered eating, only at T2 were the associations between psychosocial factors and disordered eating mediated by depressive and anxiety symptoms. Furthermore, at T2, multiparous women were at greater risk of an association between maladaptive attitudes to pregnancy and motherhood, depressive symptoms, and disordered eating.

DISCUSSION

The present study highlights the need to investigate the relationships between psychosocial factors and disordered eating, while accounting for the unique antenatal needs of women during different pregnancy periods and across differing parity. The mediating effect of depressive and anxiety symptoms have implications for future research and clinical care.

Maternal age as a main factor influencing prenatal distress in Indonesian Primigravida

OBJECTIVES

Pregnancy is a maturation crisis, especially for primigravida, which affects both mother and fetus well-being. This study aimed to identify prenatal distress in primigravida and its relationship with maternal age, educational background, income level, gestational age, social support, previous traumatic experiences, satisfaction with paternal support, and pregnancy planning.

METHODS

This cross-sectional study involved 214 primigravidas in Serang City, Banten Province, Indonesia. Translated instruments, such as a socio-demographic questionnaire, PTSD Symptom Scale (PSS), the Multidimensional scale of perceived social support (MSPSS), London Measure of Unplanned Pregnancy Instrument (LMUP), Marital Adjustment Test (MAT), and Prenatal Distress Questionnaire (PDQ), were applied.

RESULTS

The results revealed that most respondents experienced severe distress (55.6%). Maternal age is the most dominant factor influencing prenatal distress in primigravida (OR=10.31; 95% CI: 4.7-22.6).

CONCLUSIONS

The younger the mother, the greater the extent of the psychosocial problems. A higher maternal age is assumed to be associated with greater adaptation to the changes occurring during pregnancy. Healthcare providers should be aware that pregnancy can lead to distress, especially in young primigravidas. Programs to maintain mental health during pregnancy should be implemented.

Antenatal Anxiety: Prevalence and Patterns in a Routine Obstetric Population

Introduction: Expectant mothers may appear anxious even during healthy pregnancies. Unfortunately, little is known about antenatal anxiety, and affected women may remain undetected and untreated. This study aimed to examine the prevalence, incidence, course and associations of high state anxiety in routine obstetric care. Materials and Methods: This was an observational prospective cohort study at a large maternity unit. Obstetric outpatients with low-risk singleton pregnancies were recruited during first trimester consultations. Participants provided sociodemographic data and completed the State-Trait Anxiety Inventory (STAI) and Edinburgh Postnatal Depression Scale. The STAI was re-administered at each subsequent trimester. Results: Prevalence and incidence of  high state anxiety among 634 completers were 29.5% (95% CI 25.6%-33.6%) and 13.9% (95% CI 9.9%-18.0%), respectively. Anxiety was persistent in 17.0% (95% CI 14.3%-20.2%) and transient in 26.3% (95% CI 23.1%-29.9%). Only persistently anxious participants had high mean second trimester state anxiety scores. Odds for anxiety of greater persistence increased by 29% (95% CI 24%-35%) per 1-point increase in first trimester depression scores, and decreased by 36% (95% CI 7%-56%) with tertiary education. Conclusion: Antenatal anxiety symptoms are common even in normal pregnancies, especially among women with depression and lower education. Our study indicates value in exploring diagnostic criteria and quantitative measures for antenatal anxiety. Key words: Depression, Pregnancy, State-Trait Anxiety Inventory

Care associated with stillbirth for the most disadvantaged women: A multi-method study of care in England

BACKGROUND

Most research on women experiencing stillbirth relies on online user group surveys or qualitative interviews. The objective of this study was to investigate the experience of women who are at a higher risk of stillbirth, living in areas of greatest deprivation, and are commonly not well represented.

METHODS

This study used birth and death registrations in 2012-2013 to identify a sample of mothers whose babies had died as a result of stillbirth. These women were sent a survey 6-9 months after the stillbirth. We undertook descriptive analysis of quantitative data and used binary logistic regression with the Index of Multiple Deprivation as a measure of disadvantage. We used thematic analysis to describe free text responses.

RESULTS

The survey response rate was 30% (N = 473). Ethnic minority, younger age, and single parenthood were associated with disadvantage. Women residents in the most deprived areas perceived care more negatively: during labor they were significantly less likely to be spoken to by medical staff so they could understand (73% compared with 90%, adjusted odds ratio [aOR] 0.33 [95% confidence interval {CI} 0.18-0.65]), or treated with respect by midwives (79% compared with 90%, aOR 0.41 [95% CI 0.22-0.77]). The qualitative themes identified were: "Difficulty in accessing care," "More could have been done," "Ineffective communication," and "Cared for and not cared for" which support the quantitative findings.

CONCLUSION

Women living in the most deprived areas reported poorer experiences of care compared with more advantaged women. All women need compassionate and sensitive care around the time of a stillbirth.

Attachment and Mental Help-Seeking in the Perinatal Period: The Role of Stigma

This study aimed at (1) examining how women's attachment representations influence their intentions to seek formal help for their emotional problems, either directly or by affecting attitudes towards professional help-seeking (stigma and psychological openness), and (2) examining whether these effects are moderated by the presence of clinically significant psychopathological symptoms. A cross-sectional online survey including 226 women during the perinatal period was conducted. Results showed that, when clinically significant psychopathological symptoms were present, women's more insecure attachment representations were associated with lower intentions to seek professional help, and this influence occurred throughout a decrease in women's indifference to stigma associated with mental healthcare. These results support both the intra and interpersonal nature of the help-seeking process, and highlight the importance of implementing stigma reduction strategies (e.g., awareness campaigns, health professional's non-judgmental questioning of emotional difficulties), particularly in women with clinically significant psychopathological symptoms.

Care and self-reported outcomes of care experienced by women with mental health problems in pregnancy: Findings from a national survey

BACKGROUND

mental health problems in pregnancy and the postnatal period are relatively common and, in pregnancy, are associated with an increase in adverse outcome. It is recommended that all women are asked about their emotional and mental health and offered treatment if appropriate.

OBJECTIVES

to describe the care received by women self-identifying with mental health problems in pregnancy, and to describe the effects of support, advice and treatment on outcomes in the postnatal period.

DESIGN

this study used cross-sectional survey data collected in 2014 which described women's experience of maternity care.

SETTING

England PARTICIPANTS: a random sample of women who had a live birth in January 2014.

MEASUREMENTS

the questionnaire asked about sociodemographic characteristics, whether women were asked about emotional and mental health in pregnancy, support and treatment offered, about postnatal wellbeing, and questions relating to attachment to their baby. Descriptive statistics and logistic regression were used to examine the associations between mental health and outcomes taking account of sociodemographic characteristics.

FINDINGS

the survey response rate was 47%. Women with antenatal mental health problems were significantly more worried at the prospect of labour and birth, had lower satisfaction with the experience of birth, worse postnatal mental health, and indications of poorer attachment to their baby. They received substantially more care than other women but they did not always view this positively. Support, advice and treatment for mental health problems had mixed effects.

CONCLUSIONS

this study describes the significant additional care provided to women self-identifying with mental health problems in pregnancy, the mixed effects of support, advice and treatment, and the poor perception of staff interaction among women with mental health problems.

IMPLICATIONS FOR PRACTICE

health care professionals may need additional training to effectively support women with mental health problems during the perinatal period.

Music interventions to reduce stress and anxiety in pregnancy: a systematic review and meta-analysis

BACKGROUND

Stress and anxiety are common in pregnancy and shown to have adverse effects on maternal and infant health outcomes. The aim of this review and meta-analysis was to assess the effectiveness of music-based interventions in reducing levels of stress or anxiety among pregnant women.

METHODS

Six databases were searched using key terms relating to pregnancy, psychological stress, anxiety and music. Inclusion criteria were randomised controlled or quasi-experimental trials that assessed the effect of music during pregnancy and measured levels of psychological stress or anxiety as a primary or secondary outcome. Two authors independently assessed and extracted data. Quality assessment was performed using The Cochrane Collaboration risk of bias criteria. Meta-analyses were conducted to assess stress and anxiety reduction following a music-based intervention compared to a control group that received routine antenatal care.

RESULTS

Five studies with 1261 women were included. Music interventions significantly reduced levels of maternal anxiety (Standardised Mean Difference (SMD): -0.21; 95% Confidence Interval (CI) -0.39, -0.03; p = 0.02). There was no significant effect on general stress (SMD: -0.08; 95% CI -0.25, 0.09; p = 0.35) or pregnancy-specific stress (SMD: -0.02; 95% CI -0.19, 0.15; p = 0.80). The methodological quality of included studies was moderate to weak, all studies having a high or unclear risk of bias in allocation concealment, blinding and selective outcome reporting.

CONCLUSIONS

There is evidence that music-based interventions may reduce anxiety in pregnancy; however, the methodological quality of the studies was moderate to weak. Additional research is warranted focusing on rigour of assessment, intensity of interventions delivered and methodological limitations.

Supporting women with postpartum anxiety: exploring views and experiences of specialist community public health nurses in the UK

Anxiety is common among postpartum women and can have adverse effects on mother's and child's somatic and psychological health if left untreated. In the UK, nurses or midwifes with a specialisation in community public health nursing, also called health visitors (HVs), work with families who have children younger than 5 years of age and are therefore in a key position to identify and support women with postpartum mental health issues. Until recently, postpartum mental health support provided by HVs mainly focused on identifying and managing depression, but the updated clinical guidance by the National Institute for Health and Care Excellence also includes guidance regarding screening and psychological interventions for perinatal anxiety. This study therefore aimed to explore HVs' experiences of supporting women with postpartum anxiety and their views on currently available care. Using a qualitative approach, in-depth semi-structured interviews were conducted with 13 HVs from the UK between May and October 2015. Participants were interviewed in person at their workplace or on the phone/Skype. Using thematic analysis, four main themes emerged: identification and screening issues; importance of training; service usage; and status of current service provision. Women with postpartum anxiety were commonly encountered by HVs in their clinical practice and described as often heavily using their or other related healthcare services, which puts additional strain on HVs' already heavy workload. Issues with identifying and screening for postpartum anxiety were raised and the current lack of perinatal mental health training for HVs was highlighted. In addition, HVs described a current lack of good perinatal mental health services in general and specifically for anxiety. The study highlights the need for HV perinatal mental health training in general and postpartum anxiety specifically, as well as better coverage of specialist mental health services and the need for development of interventions targeted at postpartum anxiety.

Unplanned pregnancy and subsequent psychological distress in partnered women: a cross-sectional study of the role of relationship quality and wider social support

BACKGROUND

Research into the impact of unintended pregnancy on the wellbeing of women tends to focus on pregnancies ending in either termination or lone motherhood. Unintended pregnancy is common in partnered women, but little is known about the association between unintended pregnancy and postpartum affective disorders, such as depression and anxiety in this group. Poor relationship quality and lack of social support are considered risk factors for psychological distress (PD). We examined the association between unplanned motherhood and subsequent PD in partnered women, for whom evidence is sparse, accounting for the role of relationship quality and social support.

METHODS

Data for 12,462 partnered mothers were drawn from the first survey of Millennium Cohort Study, completed at 9 months postpartum. Women reported whether their baby was planned, and how they felt when they discovered that they were pregnant. Pregnancy intention is categorised as "planned", "unplanned/happy", "unplanned/ambivalent" and "unplanned/unhappy". PD was assessed using the modified 9-item Rutter Malaise Inventory. Social support was measured by a composite score for perceived support, and a measure of actual support from friends and family. Relationship quality was assessed using a modified Golombok-Rust Inventory of Marital State. The effect of pregnancy intention on the odds of PD at 9 months was estimated, adjusting for potential confounding factors. All analyses were weighted for response and design effects.

RESULTS

In total 32.8%(weighted) (4343/12462) of mothers reported an unplanned pregnancy: 23.3 wt% (3087) of mothers felt happy, 3.5 wt% (475) ambivalent, and 6.0 wt% (781) unhappy upon discovery. Unplanned pregnancy was associated with a significantly increased odds of PD compared to planned (OR 1.73 (95%CI: 1.53, 1.95)). This was more pronounced among women who reported negative or ambivalent feelings in early pregnancy (OR 2.72 (95%CI:2.17, 3.41) and 2.56 (95%CI:1.95, 3.34), respectively), than those who reported positive feelings (OR 1.39 (95%CI:1.21, 1.60)). Adjustment for relationship quality, in particular, reduced odds of PD after unplanned pregnancy (e.g. from 2.19 (95%C: 1.74, 2.74) to 1.63 (95% CI: 1.29, 2.07 in the unplanned, unhappy group compared to the planned).

CONCLUSIONS

A third of partnered mothers reported that their pregnancy was unintended, yet this group is under-researched. Unplanned motherhood was associated with increased risk of PD at 9 months postpartum, particularly among women who felt unhappy or ambivalent at the start. The roles of relationship quality and social support require further investigation, as possible means to intervene and improve maternal wellbeing.

Mothers' accounts of the impact on emotional wellbeing of organised peer support in pregnancy and early parenthood: a qualitative study

BACKGROUND

The transition to parenthood is a potentially vulnerable time for mothers' mental health and approximately 9-21% of women experience depression and/or anxiety at this time. Many more experience sub-clinical symptoms of depression and anxiety, as well as stress, low self-esteem and a loss of confidence. Women's emotional wellbeing is more at risk if they have little social support, a low income, are single parents or have a poor relationship with their partner. Peer support can comprise emotional, affirmational, informational and practical support; evidence of its impact on emotional wellbeing during pregnancy and afterwards is mixed.

METHODS

This was a descriptive qualitative study, informed by phenomenological social psychology, exploring women's experiences of the impact of organised peer support on their emotional wellbeing during pregnancy and in early parenthood. Semi-structured qualitative interviews were undertaken with women who had received peer support provided by ten projects in different parts of England, including both projects offering 'mental health' peer support and others offering more broadly-based peer support. The majority of participants were disadvantaged Black and ethnic minority women, including recent migrants. Interviews were audio-recorded and transcripts were analysed using inductive thematic analysis.

RESULTS

47 mothers were interviewed. Two key themes emerged: (1) 'mothers' self-identified emotional needs', containing the subthemes 'emotional distress', 'stressful circumstances', 'lack of social support', and 'unwilling to be open with professionals'; and (2) 'how peer support affects mothers', containing the subthemes 'social connection', 'being heard', 'building confidence', 'empowerment', 'feeling valued', 'reducing stress through practical support' and 'the significance of "mental health" peer experiences'. Women described how peer support contributed to reducing their low mood and anxiety by overcoming feelings of isolation, disempowerment and stress, and increasing feelings of self-esteem, self-efficacy and parenting competence.

CONCLUSION

One-to-one peer support during pregnancy and after birth can have a number of interrelated positive impacts on the emotional wellbeing of mothers. Peer support is a promising and valued intervention, and may have particular salience for ethnic minority women, those who are recent migrants and women experiencing multiple disadvantages.

Who is actually asked about their mental health in pregnancy and the postnatal period? Findings from a national survey

BACKGROUND

Pregnancy and the postnatal period is a period of potential vulnerability for women and families. It is UK policy that all women are asked about their mental health and wellbeing early in pregnancy and following the birth to help detect potential problems and prevent serious adverse outcome. However, identification of mental health problems in pregnancy may be less than 50 %. The aim of the study was to find out which women are asked about their mood and mental health during pregnancy and postnatally, and about offer and uptake of treatment.

METHODS

Secondary analysis of a national maternity survey carried out in 2014 which asked about sociodemographic factors, care in pregnancy, childbirth, and the postnatal period with specific questions on emotional and mental health.

RESULTS

The usable response rate to the survey was 47 % (4571 women). Most women recalled being asked about their mental health in pregnancy (82 %) and in the postnatal period (90 %). However, antenatally, Asian and older women were less likely to be asked and to be offered treatment. In the postnatal period, differences were more marked. Non-white women, those living in more deprived areas, and those who had received less education were less likely to be asked about their mental health, to be offered treatment, and to receive support. Women with a trusting relationship with their midwife were more likely to be asked about their mental health.

CONCLUSION

The inequities described in this study suggest that the inverse care law is operating in relation to this aspect of maternity care. Those women most likely to be in need of support and treatment are least likely to be offered it and may be at risk of serious adverse outcomes.

Worries About Labor and Birth: A Population-Based Study of Outcomes for Young Primiparous Women

BACKGROUND

Pregnancy at a young age is a continuing public health concern strongly associated with socioeconomic deprivation, social isolation, and stigma. The objectives were to see whether, compared with women aged 21 or more, women aged 20 years or younger worried more about labor and birth, and had poorer maternal outcomes. Another objective was to investigate the extent to which worries about labor and birth mediated the associations between young age and outcomes.

METHODS

A secondary analysis of data was conducted relating to 2,598 primiparous women's experience of maternity care in England in 2010. The survey collected data on care in the antenatal, intrapartum, and postnatal periods, and sociodemographic factors. A validated checklist measured worries about labor and birth.

RESULTS

Compared with women aged 21 or more, women aged 20 years or younger worried more about labor and birth. The pain and duration of labor worried all women and those aged 20 years or younger were particularly worried about the uncertainty of labor onset, cesarean section birth, and about embarrassment. In logistic regression, after adjusting for potential confounders, young age was a significant independent risk factor for worries about pain and distress in labor, and self-reported depression at 1 and 3 months. However, young age was also significantly associated with having a normal vaginal delivery.

CONCLUSIONS

It may be appropriate to focus support on women experiencing multiple disadvantage, rather than young age alone.

Sociodemographic, pregnancy, obstetric, and postnatal predictors of postpartum stress, anxiety and depression in new mothers

BACKGROUND

The purpose of this paper was to evaluate relationships between sociodemographic, pregnancy, obstetric, and postnatal variables and postpartum depression, anxiety and stress levels in new mothers.

METHOD

One-hundred-thirty-nine women completed the baseline questionnaire and 105 completed the follow-up questionnaire at 4-6 months postpartum. Sociodemographic and pregnancy factors were assessed at baseline, birth and postnatal factors were assessed at time 2, and depression, anxiety, and stress were assessed at both time points.

RESULTS

Caesarean delivery was associated with high postpartum depression, anxiety, and stress levels. Child sleep problems was related to depression, child health problems were related to anxiety, more SLE related to high stress, and maternal sleep problems were related to PPD. However, the results became non-significant after controlling for antenatal distress levels. Finally, women who underwent caesarean delivery had higher antenatal stress, anxiety, and depression levels, relative to women who did not undergo the procedure.

CONCLUSION

Psychological stress and distress tended to persist in the women from the third-trimester of pregnancy to 4-6 months postpartum. It tended to occur in the context of caesarean delivery, maternal sleep problems, child's health and sleep problems, and stressful life-events.

Emotion and mood adaptations in the peripartum female:complementary contributions of GABA and oxytocin

Peripartum hormones and sensory cues from young modify the maternal brain in ways that can render females either at risk for, or resilient to, elevated anxiety and depression. The neurochemical systems underlying these aspects of maternal emotional and mood states include the inhibitory neurotransmitter GABA and the neuropeptide oxytocin (OXT). Data from laboratory rodents indicate that increased activity at the GABA(A) receptor contributes to the postpartum suppression of anxiety-related behaviour that is mediated by physical contact with offspring, whereas dysregulation in GABAergic signalling results in deficits in maternal care, as well as anxiety- and depression-like behaviours during the postpartum period. Similarly, activation of the brain OXT system accompanied by increased OXT release within numerous brain sites in response to reproductive stimuli also reduces postpartum anxiety- and depression-like behaviours. Studies of peripartum women are consistent with these findings in rodents. Given the similar consequences of elevated central GABA and OXT activity on maternal anxiety and depression, balanced and partly reciprocal interactions between these two systems may be essential for their effects on maternal emotional and mood states, in addition to other aspects of postpartum behaviour and physiology.