Prenatal Anxiety and Depression: Treatment Uptake, Barriers, and Facilitators in Midwifery Care

Stress-related eating in pregnancy? An RCT examining links between prenatal stress and food choices

BACKGROUND

Diet quality during pregnancy is important for maternal health and offspring development. However, national dietary recommendations are not always met. A potential barrier for healthy food choices might be the experience of stress. Previous literature in non-pregnant populations suggests a negative effect of acute stress on diet quality. This preregistered study is the first to test whether an acute stressor leads to unhealthy food choices in pregnancy and examine the moderating role of stress, depressive and anxiety complaints in daily life.

METHOD

Pregnant women (N = 110, 3rd trimester) completed online self-reported surveys measuring stress, depressive and anxiety complaints in daily life. Hereafter, participants were invited for a laboratory visit, in which they were exposed to the Trier Social Stress Test or a control task. After this manipulation, self-reported and actual food choices and food intake were assessed. At the end of the visit, a hair sample was collected. Throughout the visit, visual analogue scales on negative affect were completed and saliva samples were collected.

RESULTS

The stress group experienced significantly more psychological stress than the control group during the experimental manipulation. Main regression analyses showed that the acute laboratory stressor did not cause unhealthy food choices in the third trimester of pregnancy. In fact, the stress group chose fewer unhealthy foods and consumed fewer kilocalories compared to the control group. Additionally, the findings point at a moderating role of depressive and stress complaints in daily life on food choices within the control group: higher scores were related to more unhealthy food choices and more kilocalories consumed.

DISCUSSION

As this was the first study to test the effect of an acute stressor on food choices in pregnant women, more research is needed to obtain a better understanding of stress-related eating in pregnancy. This knowledge may inform future interventions to support pregnant women in improving their diet quality.

Perceived Parenting Stress Is Related to Cardiac Flexibility in Mothers: Data from the NorBaby Study

Heart rate variability (HRV) is an indicator of autonomic nervous system activity, and high levels of stress and/or depressive symptoms may reduce HRV. Here, we assessed whether (a) parental stress affected HRV in mothers during the perinatal period and whether this is mediated by bonding and (b) whether antenatal maternal mental states, specifically repetitive negative thinking, depressive symptoms, and pregnancy-related anxiety, have an impact on infant HRV, and lastly, we investigated (c) the relationship between maternal HRV and infant HRV. Data are from the Northern Babies Longitudinal Study (NorBaby). In 111 parent-infant pairs, cardiac data were collected 6 months after birth. In the antenatal period, we used the Pregnancy-Related Anxiety Questionnaire-Revised, the Edinburgh Postnatal Depression Scale, and the Perseverative Thinking Questionnaire; in the postnatal period, we used the Parenting Stress Index and the Maternal Postnatal Attachment Scale. Higher levels of perceived parenting stress but not depressive symptoms were associated with lower HRV in mothers (τ = -0.146), and this relationship was not mediated by maternal bonding. Antenatal maternal mental states were not associated with infant HRV. There was no significant correlation between maternal HRV and infant HRV. Our observational data suggest that perceived stress reduces cardiac flexibility. Future studies should measure HRV and parenting stress repeatedly during the perinatal period.

Prenatal anticipatory stress: Baby preparation and worry scale-revised in the Dutch context

BACKGROUND

Prenatal distress encompasses a range of different emotions, worries, and experiences of stress. The Baby Preparation and Worry Scale (Baby-PAWS) was recently developed to target anticipatory worries during pregnancy about the postnatal period. However, the Baby-PAWS questionnaire was only examined in the United States of America, limiting the questionnaire's generalizability to different countries. To address this issue, we performed a psychometric evaluation of the questionnaire in a Dutch sample and examined associations between the Baby-PAWS questionnaire and established measures of maternal distress (i.e., EPDS, STAI, PRAQ-R) and infant temperament (i.e., IBQ-R).

METHODS

Healthy pregnant women (N = 521) completed questionnaires during their third trimester and postnatally, including the Baby-PAWS and distress measures. A subsample of mothers (N = 194) also reported on infant temperament at 12 weeks postpartum.

RESULTS

Exploratory factor analysis suggested a four-factor structure for the 16-item questionnaire in our Dutch sample, as compared to the expected three-factor structure found in the original psychometric evaluation with the American sample. The total Baby-PAWS score was related to pre-and postnatal depression, anxiety, stress, and specific scales of infant temperament. American women scored higher on the Baby-PAWS items than Dutch women.

LIMITATIONS

Our participants had higher-than-average socioeconomic status, limiting the generalizability of the findings.

CONCLUSION

The current analyses indicate good validity of the Baby-PAWS in a Dutch sample. Furthermore, our results highlight cross-cultural differences in perinatal mental health and show the importance of examining instrument structure of context-dependent constructs, such as prenatal worries.

Maternal anxiety during pregnancy is associated with weaker prefrontal functional connectivity in adult offspring

BACKGROUND

The connectome, constituting a unique fingerprint of a person's brain, may be influenced by its prenatal environment, potentially affecting later-life resilience and mental health.

METHODS

We conducted a prospective resting-state functional Magnetic Resonance Imaging study in 28-year-old offspring (N = 49) of mothers whose anxiety was monitored during pregnancy. Two offspring anxiety subgroups were defined: "High anxiety" (n = 13) group versus "low-to-medium anxiety" (n = 36) group, based on maternal self-reported state anxiety at 12-22 weeks of gestation. To predict resting-state functional connectivity of 32 by 32 ROIs, maternal state anxiety during pregnancy was included as a predictor in general linear models for both ROI-to-ROI and graph theoretical metrics. Sex, birth weight and postnatal anxiety were included as covariates.

RESULTS

Higher maternal anxiety was associated with weaker functional connectivity of medial prefrontal cortex with left inferior frontal gyrus (t = 3.45, pFDR < 0.05). Moreover, network-based statistics (NBS) confirmed our finding and revealed an additional association of weaker connectivity between left lateral prefontal cortex with left somatosensory motor gyrus in the offspring. While our results showed a general pattern of lower functional connectivity in adults prenatally exposed to maternal anxiety, we did not observe significant differences in global brain networks between groups.

CONCLUSIONS

Weaker (medial) prefrontal cortex functional connectivity in the high anxiety adult offspring group suggests a long-term negative impact of prenatal exposure to high maternal anxiety, extending into adulthood. To prevent mental health problems at population level, universal primary prevention strategies should aim at lowering maternal anxiety during pregnancy.

Barriers and facilitators for referring women with positive perinatal depression screening results in China: a qualitative study

BACKGROUND

Timely screening and referral can improve the outcomes of perinatal depression (PND). However, uptake rates of referral after PND screening are low in China and the reasons are unclear. The aim of this article is to explore the barriers and facilitators for referring women with positive results of PND screening in the Chinese primary maternal health care system.

METHODS

Qualitative data were collected from four primary health centers located in four different provinces of China. Each of the four investigators conducted 30 days of participant observations in the primary health centers from May to August 2020. Data were collected via participant observations and semi-structured in-depth interviews with new mothers who had positive results of PND screening, their family members, and primary health providers. Two investigators analyzed qualitative data independently. A thematic analysis was conducted, and data were framed using the social ecological model.

RESULTS

A total of 870 hours of observation and 46 interviews were carried out. Five themes were identified: individual (new mothers' knowledge of PND, perceived need to seek help), interpersonal (new mothers' attitudes towards providers, family support), institutional (providers' perception of PND, lack of training, time constraints), community (accessibility to mental health services, practical factors), and public policy (policy requirements, stigma).

CONCLUSIONS

The likelihood of new mothers accepting PND referral is related to factors in five areas. Intervention strategies can be developed around these themes and may include educating new mothers and their families about PND, training primary health providers to improve their awareness of condition and indication for referral, building mental health support in routine postpartum home visits, and providing support through mobile technology.

Postpartum experiences among individuals with suspected and confirmed prenatal generalized anxiety disorder during the COVID-19 pandemic: Implications for help-seeking

Prenatal generalized anxiety disorder (GAD) is a common and underdiagnosed condition with negative health consequences to both the pregnant individual and child. Here we studied the relationship between diagnosis and treatment status of GAD during pregnancy (no GAD diagnosis, suspected but not diagnosed, diagnosed but not treated, diagnosed and treated) during the COVID-19 pandemic and postpartum mental health outcomes, while considering the potential influence of individual psychological factors such as distress tolerance and resilience and the role of COVID-19-related health worries. In this sample of predominantly highly educated and white birthing individuals, one in five respondents experienced GAD during pregnancy and another one in six suspected GAD but was not diagnosed. Amongst those with a GAD diagnosis, 30% did not receive treatment. We found that those with a GAD diagnosis during pregnancy who did not receive treatment showed the highest levels of postpartum anxiety and depressive symptoms in the postpartum, even after controlling for covariates, and experienced the most COVID-19-related health worries. In comparison, individuals with a GAD diagnosis during pregnancy who received treatment experienced significantly lower anxiety symptom burden and depressive symptom burden, with a symptom burden similar to those without a confirmed or suspected diagnosis after controlling for individual psychological factors. We conclude that clinicians should strongly consider screening for and treating prenatal anxiety to prevent suboptimal postpartum mental health outcomes.

The Impact of Maternal Prenatal Stress Related to the COVID-19 Pandemic during the First 1000 Days: A Historical Perspective

The COVID-19 pandemic has a major impact on society, particularly affecting its vulnerable members, including pregnant women and their unborn children. Pregnant mothers reported fear of infection, fear of vertical transmission, fear of poor birth and child outcomes, social isolation, uncertainty about their partner's presence during medical appointments and delivery, increased domestic abuse, and other collateral damage, including vaccine hesitancy. Accordingly, pregnant women's known vulnerability for mental health problems has become a concern during the COVID-19 pandemic, also because of the known effects of prenatal stress for the unborn child. The current narrative review provides a historical overview of transgenerational effects of exposure to disasters during pregnancy, and the role of maternal prenatal stress. We place these effects into the perspective of the COVID-19 pandemic. Hereby, we aim to draw attention to the psychological impact of the COVID-19 pandemic on women of reproductive age (15-49 year) and its potential associated short-term and long-term consequences for the health of children who are conceived, carried, and born during this pandemic. Timely detection and intervention during the first 1000 days is essential to reduce the burden of transgenerational effects of the COVID-19 pandemic.

Positively Pregnant: Development and piloting of a mobile app for social and emotional well-being in pregnancy

This paper describes development of a mobile e-health application, Positively Pregnant, which provides tools to meet the psychological challenges of pregnancy and transition to parenthood. Positively Pregnant was developed with input from maternity carers and consumers, incorporating local cultures and contexts as well as international research on effective interventions for stress management and mental well-being. The prototype app was piloted with 88 New Zealand women. Participants in the pilot used an average of 11.96 (SD = 7.44) components, and most were satisfied (45.1%) or neutral (40.3%) regarding the app. For 23 of the 26 interactive components, the majority of those who tried the component reported that they found it helpful. Participants reported a significant reduction in subjective stress (η²  = .088, p = .023). Feedback from pilot participants was incorporated in a version of the app that was publically launched as a free tool to support developing families. Mobile e-health applications are a promising medium for providing preventative interventions and psychoeducation about the social and emotional challenges of pregnancy and early parenting; Positively Pregnant is an example of a tool, grounded in strength-based, empirically supported strategies, to provide parents with support and information at this critical time.

The risk and protective factors of heightened prenatal anxiety and depression during the COVID-19 lockdown

While pregnant women are already at-risk for developing symptoms of anxiety and depression, this is heightened during the COVID-19 pandemic. We compared anxiety and depression symptoms, as indicators of psychological distress, before and during COVID-19, and investigated the role of partner, social network and healthcare support on COVID-19-related worries and consequently on psychological distress. A national survey, conducted during the first lockdown in The Netherlands, assessed COVID-19 experiences and psychological distress (N = 1421), whereas a comparison sample (N = 1439) was screened for psychological distress in 2017-2018. During COVID-19, the percentage of mothers scoring above the questionnaires' clinical cut-offs doubled for depression (6% and 12%) and anxiety (24% and 52%). Women reported increased partner support during COVID-19, compared to pre-pandemic, but decreased social and healthcare support. Higher support resulted in lower COVID-19-related worries, which in turn contributed to less psychological distress. Results suggest that a global pandemic exerts a heavy toll on pregnant women's mental health. Psychological distress was substantially higher during the pandemic than the pre-pandemic years. We identified a protective role of partner, social, and healthcare support, with important implications for the current and future crisis management. Whether increased psychological distress is transient or persistent, and whether and how it affects the future generation remains to be determined.