Possible relationship between general and pregnancy-related anxiety during the first half of pregnancy and the birth process: a prospective cohort study

Associations Between Early-Pregnancy Vitamin D Status and Postpartum Depressive and Anxiety Symptoms

OBJECTIVE

Maternal postpartum depressive and anxiety symptoms are risk factors for subsequent maternal and child mental health problems. Little is known about the potential role of antepartum vitamin D and C-reactive protein (CRP) in the etiology of maternal postpartum affective symptoms. We investigated associations between antepartum vitamin D status and postpartum depressive and anxiety symptoms and whether antepartum CRP mediated these associations.

METHODS

In 2483 participants of the Amsterdam Born Children and their Development prospective cohort, maternal serum vitamin D and CRP were measured at a median of 13 weeks' gestation. Vitamin D status was defined as deficient (≤29.9 nM), insufficient (30-49.9 nM), sufficient (50-79.9 nM), or normal (≥80 nM). Maternal depressive symptoms (Center for Epidemiologic Studies-Depression) and anxiety (State-Trait Anxiety Inventory) were assessed 3 months postpartum.

RESULTS

After adjustments for confounders, vitamin D deficiency was only associated with increased postpartum anxiety symptoms ( B = 0.17, 95% confidence interval [CI] = 0.03-0.30, p = .017) compared to normal vitamin D levels (≥80 nM). In women not taking vitamin D supplementation ( n = 2303), vitamin D deficiency was associated with increased postpartum depressive and anxiety symptoms ( B = 0.14, 95% CI = 0.03-0.28, p = .045; and B = 0.17, 95% CI = 0.03-0.32, p = .015). Antepartum CRP did not mediate these links.

CONCLUSIONS

We found some evidence that antepartum vitamin D deficiency was associated with increased postpartum affective symptoms, especially in women not taking vitamin D supplementation. Clinical trials should determine whether vitamin D supplementation can reduce the risk for postpartum affective disorders.

The relationship between cesarean delivery and fecundability: a population-based cohort study

BACKGROUND

Previous studies have found that women who undergo cesarean delivery have fewer pregnancies. Cesarean delivery is also more common among women with lower fecundability. The potential role of cesarean delivery in reduced fecundability is not known.

OBJECTIVE

This study aimed to assess the bidirectional relationship between cesarean delivery and fecundability.

STUDY DESIGN

This was a prospective cohort study based on data from the Norwegian Mother, Father, and Child Cohort study linked with the Medical Birth Registry of Norway. We estimated the fecundability ratio (per cycle probability of pregnancy) and relative risk of infertility (time to pregnancy ≥12 months) by mode of delivery in the previous delivery among 42,379 women. For the reverse association, we estimated the relative risk of having a cesarean delivery by fecundability (the number of cycles women needed to conceive) among 74,024 women.

RESULTS

The proportion of women with infertility was 7.3% (2707/37,226) among women with a previous vaginal delivery and 9.9% (508/5153) among women with a previous cesarean delivery, yielding an adjusted relative risk of 1.21 (95% confidence interval, 1.10-1.33). Women with a previous cesarean delivery also had a lower fecundability ratio (0.90; 95% confidence interval, 0.88-0.93) than women with a previous vaginal delivery. When assessing the reverse association between fecundability and cesarean delivery, we found that women who did not conceive within 12 or more cycles had a higher risk for cesarean delivery (adjusted relative risk, 1.57; 95% confidence interval, 1.48-1.66) than women who conceived within the first 2 cycles. The associations remained after controlling for sociodemographic and clinical risk factors and were observed across parity groups.

CONCLUSION

Among women with more than 1 child, those who had a previous cesarean delivery subsequently had a lower fecundability ratio and an increased infertility risk than those who had a vaginal delivery. However, women who needed a longer time to conceive were also more prone to be delivered by cesarean delivery, indicating a bidirectional relationship between cesarean delivery and fecundability. This could suggest a common underlying explanatory mechanism and that the surgical procedure itself may not or only partly directly influence fecundability.

The perinatal health secondary to pandemic: association between women's delivery concerns and infant's behavioral problems

BACKGROUND

COVID-19 pandemic characterised a unique and vulnerable social, emotional, and health environment for pregnancy, with potential long-lasting risks to maternal and child health outcomes. In women who were pregnant at the peak of COVID-19 pandemic, we investigated the association between pandemic-related concerns about pregnancy and delivery and both the parent's (i.e. maternal parenting stress) and the infant's (i.e. emotional-behavioral problems) outcomes 12 months after birth.

METHODS

A sample of 352 Italian pregnant women completed a web-based survey from 8 April to 4 May 2020 and a follow-up at 12 months after delivery. Maternal assessment in pregnancy covered prenatal measures for: pandemic-related concerns about pregnancy and childbirth, COVID-19 stressful events exposure, pandemic psychological stress, and mental-health symptoms (i.e. depression, anxiety). The 12 months' assessment covered post-partum measures of social support, parenting stress and maternal reports of infants' behavioral problems.

RESULTS

The results of the Quasi-Poisson regression models on the association between COVID-19 related influencing factors and parenting stress and infant's behavioral problems showed that the presence of higher pandemic-related concerns about pregnancy and childbirth scores was associated with greater total and internalising behavioral problems but not with parenting stress levels.

CONCLUSION

Perinatal mother-infant health has been sensitively threatened by pandemic consequences with maternal concerns about childbirth in pregnancy being associated with 12 months' children's behavioral outcomes. There is a need to invest in psychological support for perinatal women throughout the transition to parenthood to protect risk conditions before they get chronic or severe and influence offspring development.

The Impact of Educational Sessions on Anxiety Levels among Women Undergoing Caesarean Section: A Quasi-Experimental Study

Although the Caesarean section (CS) is considered a harmless surgery, it has various complications. Women scheduled for elective CSs often have high levels of anxiety due to a lack of knowledge. The aim of this quantitative quasi-experimental study was to determine the relationship between preoperative educational sessions and anxiety levels among women undergoing CSs. The study was conducted at the antenatal unit in the King Faisal Medical Complex (KFMC) in Taif, Saudi Arabia, using a structured interview questionnaire, the State-Trait Anxiety Inventory (STAI), and satisfaction interviews. A total of 50 pregnant women participated in this study, who were divided into two groups: 25 participants in the intervention group and 25 in the control group. Most participants (92%) in the intervention group had low anxiety levels following educational sessions, and 96% of the participants were very satisfied with the preoperative information they had been given. Women in the control group (again, 92%) had high anxiety levels, and there was a significant difference in the anxiety levels of the intervention and control groups (p ≤ 0.5) after the educational sessions. Providing proper preoperative education about CSs can reduce preoperative anxiety, improve patient outcomes, and enhance patients' involvement in their care and decision-making.

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.

Interest in prenatal stress management training: association with medical risk and mental health

OBJECTIVE

The objective of this study was to document levels of interest in stress management training (SMT) during pregnancy, including differences in interest in SMT across levels of medical risk in pregnancy. We also sought to assess differences in pregnancy-specific stress, prenatal worry and depressed mood across levels of medical risk in pregnancy and investigate predictors of interest in SMT.

METHODS

We surveyed 379 English-speaking, pregnant people living in Vancouver, Canada, between November 2007 and November 2010. Questionnaires were administered during the third trimester and assessed interest and preferred format of SMT, pregnancy-specific stress, prenatal worry, depressed mood and medical risk in pregnancy.

RESULTS

Interest in stress management training programmes during pregnancy was common, with 32% of participants being quite-to-very interested. Preference was split between self-guided study (41%), group counselling (38%) and one-on-one counselling (34%). Higher pregnancy-specific stress and depressed mood, but not medical risk in pregnancy, were associated with higher interest in SMT. Participants experiencing higher stress levels or lower medical risk were more interested in one-on-one counselling.

CONCLUSION

Findings indicate that subjective distress rather than objective circumstances is a better predictor of interest in SMT. Care providers should inquire early-on about interest in SMT during pregnancy and ensure awareness of SMT options.

Patterns of Labour Interventions and Associated Maternal Biopsychosocial Factors in Australia: a Path Analysis

In Australia, nearly half of births involve labour interventions. Prior research in this area has relied on cross-sectional and administrative health data and has not considered biopsychosocial factors. The current study examined direct and indirect associations between biopsychosocial factors and labour interventions using 19 years of population-based prospective data. The study included singleton babies among primiparous women of the 1973-1978 cohort of the Australian Longitudinal Study on Women's Health. Data from 5459 women who started labour were analysed using path analysis. 42.2% of babies were born without intervention (episiotomy, instrumental, or caesarean delivery): Thirty-seven percent reported vaginal birth with episiotomy and instrumental birth interventions, 18% reported an unplanned caesarean section without episiotomy and/or instrumental interventions, and 3% reported unplanned caesarean section after episiotomy and/or instrumental interventions. Vaginal births with episiotomy and/or instrumental interventions were more likely among women with chronic hypertension (RRR(95%-CI):1.50(1.12-2.01)), a perceived length of labour of more than 36 h (RRR(95%-CI):1.86(1.45-2.39)), private health insurance (RRR(95%-CI):1.61(1.41-1.85)) and induced labour (RRR(95%-CI):1.69(1.46-1.94)). Risk factors of unplanned caesarean section without episiotomy and/or instrumental birth intervention included being overweight (RRR(95%-CI):1.30(1.07-1.58)) or obese prepregnancy (RRR(95%-CI):1.63(1.28-2.08)), aged ≥ 35 years (RRR(95%-CI):1.87(1.46-2.41)), having short stature (< 154 cm) (RRR(95%-CI):1.68(1.16-2.42)), a perceived length of labour of more than 36 h (RRR(95%-CI):3.26(2.50-4.24)), private health insurance (RRR(95%-CI):1.38(1.17-1.64)), and induced labour (RRR(95%-CI):2.56(2.16-3.05)). Prevention and management of hypertension, diabetes, and obesity during preconception and/or antenatal care are keys for reducing labour interventions and strengthening the evidence-base around delivery of best practice obstetric care.

Factors associated with the intention of pregnant women to give birth with epidural analgesia: a cross-sectional study

BACKGROUND

In Belgium most women receive epidural analgesia during labour. Although, it offers satisfactory pain relief during labour, the risk on a series of adverse advents has been reported. The objective of this study was to determine factors associated with the intention of pregnant women, anticipating a vaginal birth, of requesting epidural analgesia during labour.

METHODS

A cross-sectional study, using an online self-report questionnaire was performed, including socio-demographic and personal details. Associated factors were examined with the HEXACO-60 questionnaire, the Mental Health Inventory-5, the Tilburg Pregnancy Distress Scale and the Labour Pain Relief Attitude Questionnaire for pregnant women. The level of intention to request epidural analgesia was based on two questions: Do you intend to ask for epidural analgesia (1) at the start of your labour; (2) at some point during labour? Data were collected predominantly during the second and third trimester of pregnancy. Descriptive analysis and a multiple linear regression analysis were performed.

RESULTS

949 nulliparous (45.9%) and multiparous (54.1%) pregnant women, living in Flanders (Dutch-speaking part of Belgium) anticipating a vaginal birth completed the questionnaires. Birth-related anxiety (ß 0.096, p < 0.001), the attitude that because of the impact of pregnancy on the body, asking for pain relief is normal (ß 0.397, p < 0.001) and feeling more self-confident during labour when having pain relief (ß 0.034, p < 0.001) show a significant positive relationship with the intention for intrapartum epidural analgesia. The length of the gestational period (ß - 0.056, p 0.015), having a midwife as the primary care giver during pregnancy (ß - 0.048, p 0.044), and considering the partner in decision-making about pain relief (ß - 0.112, p < 0.001) show a significant negative relationship with the intention level of epidural analgesia. The explained variability by the multiple regression model is 54%.

CONCLUSIONS

A discussion during pregnancy about the underlying reason for epidural analgesia allows maternity care providers and partners to support women with pain management that is in line with women's preferences. Because women's intentions vary during the gestational period, pain relief should be an issue of conversation throughout pregnancy.

Development of the Japanese Version of Pregnancy-Related Anxiety Questionnaire-Revised-2: Measurement and Psychometric Properties

Tools to evaluate pregnancy-specific anxiety are lacking in Japan. This study aimed to develop a Japanese version of the Pregnancy-Related Anxiety Questionnaire-Revised-2. After scale translation and cognitive interviews, we conducted a cross-sectional study among 120 ≥18-year-old, singleton (pregnant with one baby) Japanese women before 15 weeks of pregnancy, recruited from four facilities. A total of 112 women completed the questionnaires. We tested the internal consistency, measurement error and reliability, structural validity, measurement invariance across nulliparous and parous women, construct validity by calculating omega, standard error of measurement (SEM), intraclass correlation coefficient (ICC), confirmatory factor analysis (CFA), multigroup CFA, multitrait-scaling analysis, correlational analyses with other measurements, and t-test to compare nulliparous and parous groups. Omega was 0.90 for the total score. SEM was 3.4 and ICC was 0.76. The CFA revealed an optimal fit for the three-factor model based on the original scale. Multigroup CFA supported measurement invariance across the nulliparous and parous groups, and multitrait-scaling analysis revealed 100% scaling success. The correlation coefficients with other scales of childbirth anxiety and general anxiety were 0.70 and 0.24. The mean total score of the nulliparous women was higher than that of the parous women (34.5 vs. 30.3, p = 0.001). Therefore, the scale was determined to have good validity and reliability.

Validation of the German version of the pregnancy-related anxiety scale (PrAS): psychometric properties across all trimesters of pregnancy

BACKGROUND

Pregnancy-related anxiety has received greater research attention recently given its association with adverse outcomes (e.g., negative birth experiences). The Pregnancy-related Anxiety Scale (PrAS) offers the possibility to assess pregnancy-related anxiety, but no German version is available. Therefore, the aim of this study was to validate a German version of the PrAS, a comprehensive measure with eight dimensions.

METHODS

Pregnant women of any parity or gestation completed an online survey consisting of the PrAS, PRAQ-R2, and measures of anxiety, depression, and resilience. The PrAS was translated into German (PrAS-G) using the back-translation method. Data were subjected to confirmatory factor analysis and inferential statistics.

RESULTS

Complete data were provided by 443 women. Participants were predominantly German nationals, partnered, and well-educated with a planned pregnancy. Approximately half were nulliparous. The eight-factor model was well fitting and consistent with the development of the original PrAS. Criterion-related validity was demonstrated by strong correlations with similar measures (PRAQ-R2, anxiety, and depression) and lower correlations with resilience scores. Predictive validity was shown by group comparisons for: planned versus unplanned pregnancy, trimester, and parity.

CONCLUSIONS

The PrAS-G provides a broader assessment of pregnancy-related anxiety than existing measures. Initial evaluation has demonstrated convergent, divergent, and predictive validity, excellent internal consistency, and good model fit indicating promising psychometric properties. The PrAS-G offers a comprehensive assessment of pregnancy-related anxiety which will enable tailored interventions aiming to improve birth experience and well-being of expectant mothers.

The association between pregnancy-related anxiety and behavioral development in 18-month-old children: The mediating effects of parenting styles and breastfeeding methods

BACKGROUND

Pregnancy-related anxiety (PRA) is a distinct type of anxiety from general anxiety, affects many pregnant women, and is correlated with poor behavioral development in children. However, the mediation paths were unclear.

METHODS

A total of 2032 mother-infant pairs from the Ma'anshan Birth Cohort were included in the current study. Maternal PRA was assessed in the second and third trimesters. Children's behavioral development was evaluated at the age of 18 months. In addition, information on parenting styles and breastfeeding methods was obtained at postpartum. Multivariate regression and structural equation modeling were used to examine the associations between maternal PRA and children's behavioral development.

RESULTS

Significant intercorrelations were found between maternal PRA, the potential mediators (parenting styles and breastfeeding methods), and 18-month-old children's ASQ scores. Parenting styles played an intermediary role in the relationship between maternal PRA and children's behavioral development (β = 0.030, 95 % confidence interval: 0.017-0.051), and the mediating effect accounted for 29.1 % of the total effect. However, breastfeeding methods did not mediate the link between PRA and children's behavior.

LIMITATIONS

Depression and postpartum anxiety were not controlled for in our analysis, which left us unable to estimate the independent impact of PRA on children's behavior.

CONCLUSIONS

Parenting rather than breastfeeding is the mediating factor of behavioral problems in children caused by PRA.

Interaction between isolated maternal hypothyroxinemia and pregnancy-related anxiety on preschooler's internalizing and externalizing problems: A birth cohort study

BACKGROUND

Isolated maternal hypothyroxinemia (IMH) and pregnancy-related anxiety may increase the risk of offspring's emotional and behavioral problems, but little is known about their potential interactive effect on preschoolers' internalizing and externalizing problems.

METHODS

We conducted a large prospective cohort study in Ma'anshan Maternal and Child Health Hospital between May 2013 and September 2014. There were a total of 1372 mother-child pairs from the Ma'anshan birth cohort (MABC) included in this study. IMH was defined as the thyroid-stimulating hormone (TSH) level within the normal reference range (2.5-97.5th percentile) and the free thyroxine (FT₄) level below the 2.5th percentile, and negative TPOAb. The pregnancy-related anxiety questionnaire (PRAQ) was used to assess women's pregnancy-related anxiety status in the first (1-13 weeks), second (14-27 weeks) and third (after 28 weeks) trimesters of pregnancy. The Achenbach Child Behavior Checklist (CBCL/1.5-5) was used to assess preschoolers' internalizing and externalizing problems.

RESULTS

Preschoolers born of mothers with IMH and anxiety had an increased risk of anxious/depressed (OR = 6.40, 95% CI 1.89-21.68), somatic complaints (OR = 2.69, 95% CI 1.01-7.20), attention problems (OR = 2.95, 95% CI 1.00-8.69) and total problems (OR = 3.40, 95% CI 1.60-7.21). Particularly, mothers with IMH and anxiety was associated with an increased risk of preschool girls' anxious/depressed (OR = 8.14, 95% CI 1.74-38.08), withdrawn (OR = 7.03, 95% CI 2.25-21.92), internalizing problems (OR = 2.66, 95% CI 1.00-7.08), and total problems (OR = 5.50, 95% CI 2.00-15.10).

CONCLUSIONS

IMH and pregnancy-related anxiety during pregnancy may synergistically increase the risk of internalizing and externalizing problems in preschooler children. This interaction is distinct in internalizing problems of preschool girls.

Paternal pregnancy-related anxiety: Systematic review of men's concerns and experiences during their partners' pregnancies

BACKGROUND

Up to 25 % of expectant parents experience anxiety symptoms. Pregnancy-related anxiety is characterised by concerns and worries specific to pregnancy, childbirth, and the transition to parenthood. While pregnancy-related anxiety is well-researched in women, the exact nature of this construct in men is unclear. The purpose of the current review was to examine men's concerns, worries, and fears during pregnancy and gain an understanding of their experiences during pregnancy.

METHODS

An integrative review design was adopted, using thematic content analysis to synthesise findings from quantitative and qualitative studies. Quality appraisal of the quantitative studies used the AXIS appraisal tool. The Critical Appraisal Skills Program (CASP) checklist was used for the qualitative studies.

RESULTS

A comprehensive search of nine databases led to inclusion of 14 quantitative and 41 qualitative studies. Ten dimensions of paternal pregnancy-related anxiety were identified: childbirth concerns, attitudes towards childbirth, baby concerns, acceptance of pregnancy, partner concerns, relationship concerns, worry about self, transition to parenthood, attitudes towards health care professionals, and practical and financial concerns. The pregnancy transition was characterised by mixed emotions and conflicted experiences for fathers.

LIMITATIONS

Generalizability of review findings was limited by poor reporting of demographic information by many included studies, exclusion of studies not published in English, and focus on heterosexual relationships.

CONCLUSIONS

Expectant fathers may experience anxiety symptoms characterised by excessive worry across multiple domains of pregnancy-related concerns. Clinicians play an important role in identifying and supporting fathers with pregnancy-related anxiety and addressing the sense of exclusion often experienced by them.

Factors associated with the mental health status of pregnant women in China: A latent class analysis

Background

Prenatal mental health is a neglected public health issue that places pregnant women at a higher risk for mental disorders. The purpose of this study was to investigate the influencing factors of prenatal mental disorders and provide a scientific basis to guide and promote the mental health of pregnant women.

Methods

The study sample comprised 973 women in their first pregnancy, who were in their second trimester and third trimester, who underwent obstetric outpatient checkups at the Maternal and Child Health Hospital in Huai'an, who were recruited in the survey that was conducted from July to December 2017. The Chinese mental health scale (CMHS) was used to assess the mental health of pregnant women. The present study uses the chi-square test to compare the rates of class with different demographic variables, a latent class analysis to identify psychological symptoms, and multiple logistic regression analysis to examine whether the demographics predicted class membership.

Results

The chi-square test results showed that participants who reported feeling different in the perinatal period (χ² = 6.35, P = 0.04), having marital satisfaction (χ² = 15.8, P < 0.001), with an in-law relationship (χ² = 29.43, P < 0.001), with a friend relationship (χ² = 24.81, P < 0.001), with basic diseases (χ² = 8.04, P = 0.02), and taking birth control pills (χ² = 8.97, P = 0.01) have different probabilities of being classified. Three latent classes were identified: the high symptoms group (6.89%), the moderate symptoms group (20.56%), and the low symptoms group (72.56%). Pregnant women in the third trimester [odds ratio (OR) = 1.83, 95% confidence interval (CI): 1.04-3.25, P = 0.04], with a poor in-law relationship (OR = 2.82, 95% CI:1.45-5.51, P = 0.002), with a bad friend relationship (OR = 3.17, 95% CI: 1.31-7.71, P = 0.01), and who had basic diseases (OR = 1.70, 95% CI: 1.00-2.90, P = 0.04) tended to be classified under the high symptoms group than under the low symptoms group. Pregnant women with a bad friend relationship (OR = 2.15, 95% CI: 1.08-4.28, P = 0.03) and taking birth control pills (OR = 1.51, 95% CI: 1.08-2.11, P = 0.02) were more likely to be placed under the moderate symptoms group than under the low symptoms group.

Conclusions

A pregnant woman's mental health status factors include feeling different in the perinatal period, those with marital satisfaction, those with an in-law relationship, those with a friend relationship, those with basic diseases, and those taking birth control pills. To ensure a smooth progress of pregnancy and promote the physical and mental health of pregnant women, psychological screening and psychological intervention measures should be strengthened.

The relationship among pregnancy-related anxiety, perceived social support, family function and resilience in Chinese pregnant women: a structural equation modeling analysis

BACKGROUND

Accumulating evidence suggests that pregnancy-related anxiety (PRA) has adverse impacts on maternity health and infant development. A substantial body of literature has documented the important influence of family function, perceived social support and resilience on PRA. However, research identifying the mediating mechanisms underlying this relationship in China are still lacking. Therefore, the current study aimed to investigate the prevalence of PRA under the three-child policy in China, and also explore the interrelationships among perceived social support, family function, resilience, and PRA.

METHODS

In this cross-sectional study, a convenient sampling method was used to select 579 pregnant women who underwent prenatal examination at the maternity outpatient departments of the First Affiliated Hospital of Chongqing Medical University in China from December 2021 to April 2022. Participants were required to complete the following questionnaires: the demographic form, the Chinese Pregnancy-related Anxiety scale, the 10-item Connor-Davidson Resilience Scale, the APGAR Family Care Index Scale, and Multidimensional Scale of Perceived Social Support. Pearson correlation analysis was utilized to examine the rudimentary relationship among the study variables. Bootstrapping analyses in the structural equation modeling were applied to identify the significance of indirect effects.

RESULTS

There were 41.4% of pregnant Chinese women indicating PRA. Correlational analyses indicated that perceived social support, family function and resilience were negatively associated with PRA (r = - 0.47, P < 0.01; r = - 0.43, P < 0.01; r = - 0.37, P < 0.01, respectively). The results of bootstrapping analyses demonstrated significant indirect effects of perceived social support (β = - 0.098, 95% CI [- 0.184, - 0.021]) and family function (β = - 0.049, 95% CI [- 0.103, - 0.011]) on PRA via resilience.

CONCLUSIONS

Chinese pregnant women are suffering from high levels of PRA. Better family function and perceived social support might reduce the occurrence of PRA, as well as by the mediating effects of resilience. Healthcare providers must be concerned about PRA and perform corresponding actions to reduce it. By strengthening social support and improving family function, antenatal care providers could effectively reduce or prevent PRA. And more importantly, implementing resilience-promoting measures are also essential to relieve anxiety and support mental health in pregnant women.

Experiences of pregnant women with genome-wide non-invasive prenatal testing in a national screening program

Pregnant women’s perspectives should be included in the dialogue surrounding the expanding offers of non-invasive prenatal testing (NIPT), especially now that technological possibilities are rapidly increasing. This study evaluated women’s experiences with the offer of genome-wide (GW) first-tier NIPT in a national screening program. A nationwide pre-and post-test questionnaire was completed by 473 pregnant women choosing between targeted NIPT (trisomies 21, 18 and 13 only) and GW-NIPT (also other findings) within the Dutch TRIDENT-2 study. Measures included satisfaction, reasons for or against choosing GW-NIPT, anxiety, and opinion on the future scope of NIPT. Most respondents (90.4%) were glad to have been offered the choice between GW-NIPT and targeted NIPT; 76.5% chose GW-NIPT. Main reasons to choose GW-NIPT were ‘wanting as much information as possible regarding the child’s health’ (38.6%) and ‘to be prepared for everything’ (23.8%). Main reasons to choose targeted NIPT were ‘avoiding uncertain results/outcomes’ (33.7%) and ‘not wanting to unnecessarily worry’ (32.6%). Nearly all respondents received a low-risk NIPT result (98.7%). No differences were found in anxiety between women choosing GW-NIPT and targeted NIPT. Most respondents were favorable toward future prenatal screening for a range of conditions, including life-threatening disorders, mental disabilities, disorders treatable in pregnancy and severe physical disabilities, regardless of their choice for GW-NIPT or targeted NIPT. In conclusion, women who chose first-tier NIPT were satisfied with the choice between GW-NIPT and targeted NIPT, and most women were favorable toward a broader future screening offer. Our results contribute to the debate concerning the expansion of NIPT.

The Tilburg Pregnancy Distress Scale revised (TPDS-R): Psychometric aspects in a longitudinal cohort study

Pregnant women may be specifically prone to experience pregnancy-specific distress, which has been associated with adverse maternal, pregnancy and child outcomes. Accurately identifying pregnancy-specific distress is thus crucial. The Tilburg Pregnancy Distress Scale (TPDS) - translated into many different languages - was previously developed to measure pregnancy-specific distress, resulting in a 16-item screening scale with a partner involvement dimension (PI) and a negative affect dimension (NA). A critical evaluation of the psychometric properties of the TPDS-NA items and feedback from pregnant women over the last decade has led to the need to revise the TPDS. Therefore, in the current study, we describe the procedure for revision and evaluate the psychometric properties of the revised TPDS (TPDS-R). More specifically, we describe the revision of the TPDS-R-PI (4 items) and the TPDS-R-NA (10 items: five-item pregnancy and five-item childbirth subcomponent). A sample of 1081 pregnant women participating in the Brabant Study completed the TPDS-R at 12, 20 and 28 weeks of pregnancy. An exploratory factor analysis and confirmatory factor analysis, descriptive statistics and repeated measures ANOVA demonstrated good test-retest reliability, concurrent validity, internal consistency, and construct validity of the TPDS-R. The TPDS-R provides a robust screening tool to accurately identify pregnant women at risk of pregnancy-specific distress.

Anxiety of pregnant women in time of catastrophic events, including COVID-19 pandemic: a systematic review and meta-analysis

PURPOSE

In March 2020, daily life was disrupted by the new virus SARS-CoV-2, which causes COVID-19. Pandemic-related prenatal anxiety could lead to depression, a risk factor for adverse pregnancy outcomes and abnormal neonatal development. This study aimed to investigate the impact of anxiety on the mental health of pregnant women exposed to catastrophic events as compared to those without such exposure.

MATERIALS AND METHODS

PubMed/MEDLINE, Web of Science, Cochrane Library, Scopus, and EMBASE were searched for relevant studies. This study compared the prevalence of anxiety among pregnant women during a catastrophic event.

RESULTS

Fifteen full texts were assessed for inclusion, with 3 included, 10 excluded for not meeting criteria, and 2 excluded for other reasons. The included studies were published before the current COVID-19 pandemic but included the SARS 2003 outbreak. During the current COVID-19 pandemic, 10 further studies were conducted, but they failed to meet the inclusion criteria. A meta-analysis of two studies using STAI revealed that women exposed to a catastrophic event had a higher mean STAI score of 1.82 points (95% CI: 0.47-3.18 points).

CONCLUSION

Women with complications during pregnancy should be assessed for anxiety independently from catastrophic events. During financial crises, environmental or other disasters, special attention should be given to women with low risk, normal pregnancies.

Exploring social complexities of the COVID-19 pandemic on maternal anxiety: A mixed-methods observational cohort study

INTRODUCTION

The aim of this mixed-methods, small-scale observational cohort study was to examine if anxiety in pregnant women increased during the COVID-19 pandemic and to examine the subsequent impact on birth outcomes and psychological well-being. This research was conducted across two hospital sites in North London, with participation from 194 pregnant women.

METHODS

The GAD-7 questionnaire assessed for mild, moderate and high anxiety at one time point during the antenatal period and was repeated 6 weeks postnatally. Women with moderate to high scores on the GAD-7 were invited to participate in semi-structured interviews. The primary outcome measure was assessment of antenatal and postnatal anxiety. Secondary outcome measures assessed if women with moderate/high GAD-7 scores were more likely to develop a mental health condition during pregnancy, or up to 6 weeks postnatally, and if risk of preterm birth (<37 weeks gestation) and instrumental birth or cesarean section increased.

RESULTS

Pearson’s correlation indicated a positive and significant correlation between the COVID-19 pandemic, and increased self-reported antenatal GAD-7 anxiety scores (r=0.47, n=194, p<0.001). GAD-7 scores were higher during pregnancy compared to the postnatal period [t(193)=4.63; p=0.001; 95% CI: 0.87–2.16]. Logistic regression did not show an increased likelihood of preterm birth [χ²(1, n=184)=0.999; p=0.971] or instrumental/cesarean section birth in women who scored moderately to highly on the antenatal GAD-7 [χ²(1, n=184)=2.73; p=0.165]. Qualitative analysis was carried out within a social constructionist framework and identified the following themes: anxiety, maternity care, social impact, and coping.

CONCLUSIONS

Pregnant women self-reported an increase in antenatal anxiety during July 2020 to April 2021 of the COVID-19 pandemic. Moderate to high anxiety scores were not found to increase the likelihood of preterm birth and birth intervention or developing a mental health condition up to 6 weeks postnatally.

The role of body dissatisfaction and self-compassion in pregnancy-related anxiety

BACKGROUND

Women undergo significant physical, physiological, and psychological changes during pregnancy. They are also exposed to sociocultural pressure to meet appearance-related ideals. These pregnancy-related changes and sociocultural appearance-related pressures may place pregnant women at greater vulnerability to developing body dissatisfaction and psychological distress. To date, however, little is known about how sociocultural pressure may influence pregnancy-related anxiety, or factors that may protect against such distress during pregnancy. This study examined whether body dissatisfaction mediated the relationship between appearance-related sociocultural pressure and pregnancy-related anxiety, and whether this relationship was moderated by self-compassion and/or self-criticism.

METHOD

A cross-sectional sample of 253 pregnant women (M_age = 26.28, SD_age = 4.43) completed an online questionnaire measuring sociocultural pressure, body dissatisfaction, pregnancy-related anxiety, and self-compassion.

RESULTS

Moderated mediation analyses revealed body dissatisfaction fully mediated the relationship between sociocultural pressure and pregnancy-related anxiety. Analyses confirmed the moderating role of self-compassion and self-criticism on the relationship between sociocultural pressure and body dissatisfaction, but not on the relationship between body dissatisfaction and pregnancy-related anxiety.

LIMITATIONS

The cross-sectional nature of this study limits confirmation of the direction of relationships between sociocultural pressure, body dissatisfaction and pregnancy-related anxiety.

CONCLUSIONS

While the findings of this study need to be replicated in prospective and longitudinal studies, they suggest that sociocultural pressure to meet appearance-related standards contribute to body dissatisfaction, which in turn may facilitate pregnancy-related anxiety. Self-compassion may protect the body image of pregnant women against negative effects of appearance-related sociocultural pressure.

Persistent Pregnancy-Related Anxiety Reduces Breastfeeding Exclusiveness and Duration: A Prospective Cohort Study

Objective: Most research has focused on the role of prenatal mental health difficulties on breastfeeding practices, whereas pregnancy-related anxiety (PrA) has been less studied, despite its high prevalence. Identifying new vulnerable subgroups in which the breastfeeding rate remains low is important for health care workers to implement targeted interventions. This study is aimed to explore the association between PrA and breastfeeding practices. Materials and Methods: A total of 3,033 parent-infant dyads from the Ma'anshan Birth Cohort study were included in this research. PrA was assessed by the PrA questionnaire at the second and third trimesters. Breastfeeding practices including the initiation of breastfeeding, delayed lactation, exclusive breastfeeding (EBF), and the duration of breastfeeding were collected at 1, 4, 6, and 12 months postpartum. The associations between PrA and breastfeeding practices were evaluated by multinomial logistic regression and a multivariable Cox proportional hazards model. Results: In total, 9.26% (281/3,033) of participants reported PrA in both trimesters, indicative of persistent PrA. Compared with participants who never suffered from PrA, participants with persistent PrA had a higher risk of giving up EBF at 4 and 6 months postpartum, and a shorter duration of breastfeeding. These results remained the same after excluding participants who gave up EBF due to depression postpartum. Conclusion: Persistent PrA was negatively associated with breastfeeding exclusivity and duration. Addressing PrA might contribute to improved rates of breastfeeding.

Behavioral Inhibition in the Second Year of Life Is Predicted by Prenatal Maternal Anxiety, Overprotective Parenting and Infant Temperament in Early Infancy

Background

Behavioral inhibition, characterized by shyness, fear and avoidance of novel stimuli, has been linked with internalizing personality traits in childhood, adolescence and early adulthood, and particularly later social anxiety disorder. Little is known about the relevance of potential prenatal precursors and early predictors for the development of inhibited behavior, such as infant vulnerability and family risk factors like parental anxiety and overprotection. Pregnancy-related anxiety has been associated with both infant temperament and maternal overprotective parenting. Thus, the aim of this study was investigating the predictive relevance of prenatal pregnancy-related anxiety for behavioral inhibition in toddlerhood, by considering the mediating role of maternal overprotection and infant distress to novelty.

Materials and Methods

As part of a longitudinal pregnancy cohort, behavioral inhibition at 24 months postpartum was assessed in N = 170 mother-child pairs. Maternal pregnancy-related anxiety was examined in the third trimester of pregnancy, and maternal overprotection and infant distress to novelty at 12 months postpartum.

Results

Mediation analysis with two parallel mediators showed that the significant direct effect of pregnancy-related anxiety on child behavioral inhibition was fully mediated by infant distress to novelty p < 0.001 and maternal overprotection (p < 0.05). The included variables explained 26% of variance in behavioral inhibition. A subsequent explorative mediation analysis with serial mediators further showed a significant positive association between distress to novelty and maternal overprotective parenting (p < 0.05).

Conclusion

Results indicate a predictive relevance of both infant and maternal factors for the development of behavioral inhibition in toddlerhood. Mothers who perceived more pregnancy-related anxiety showed more overprotective parenting and had infants with more distress to novelty. Further, mothers being more overprotective reported their child to be more inhibited in toddlerhood. Our findings also indicate the stability of reported infant distress to novelty as one aspect of later behavioral inhibition. Addressing specific forms of parental anxiety from pregnancy on and in interaction with child-related variables seems to be a promising approach for future studies and clinical interventions.

Antenatal Classes in the Context of Prenatal Anxiety and Depression during the COVID-19 Pandemic

Perinatal maternal anxiety and depression negatively affect intrauterine fetal development, birth outcome, breastfeeding initiation, duration, and milk composition. Antenatal classes potentially reduce the anxiety of pregnant women and may thus contribute to healthy infant development. The study investigates the relationship between participation in online or in-person antenatal classes and levels of anxiety and depression in Polish women during the COVID-19 pandemic. The study group included 1774 adult, non-smoking pregnant women. We compared the state anxiety (STAI-State) and depression levels (EPDS) in women who (i) attended antenatal classes in-person, (ii) attended online classes, and (iii) did not attend any of them. The statistical analyses included a GLM model and trend analysis, while controlling for maternal trait anxiety, age, pregnancy complications, trimester of pregnancy, previous pregnancies, and COVID-19 infections. We observed statistically significant differences in the level of anxiety (and depression). Women who did attend antenatal classes in person had the lowest levels of anxiety and depression. Considering the importance of maternal mental well-being on fetal development, birth outcome, and breastfeeding, in-person participation in antenatal classes should be recommended to pregnant women.

Parents of young infants report poor mental health and more insensitive parenting during the first Covid-19 lockdown

BACKGROUND

The Covid-19 pandemic has put an unprecedented pressure on families with children. How parents were affected by the first Covid-19 lockdown during the early postpartum period, an already challenging period for many, is unknown.

AIM

To investigate the associations between Covid-19 related stress, mental health, and insensitive parenting practices in mothers and fathers with young infants during the first Dutch Covid-19 lockdown.

METHODS

The Dutch Covid-19 and Perinatal Experiences (COPE-NL) study included 681 parents of infants between 0 and 6 months (572 mothers and 109 fathers). Parents filled out online questionnaires about Covid-19 related stress, mental health (i.e. anxiety and depressive symptoms), and insensitive parenting. Hierarchical regression models were used to analyze the data.

RESULTS

Parents of a young infant reported high rates of Covid-19 related stress, with higher reported stress in mothers compared to fathers. Additionally, the percentages of mothers and fathers experiencing clinically meaningful mental health symptoms during the pandemic were relatively high (mothers: 39.7% anxiety, 14.5% depression; fathers: 37.6% anxiety, 6.4% depression). More Covid-19 related stress was associated with more mental health symptoms in parents and increased insensitive parenting practices in mothers.

CONCLUSIONS

The results emphasize the strain of the pandemic on young fathers' and mothers' mental health and its potential negative consequences for parenting. As poor parental mental health and insensitive parenting practices carry risk for worse child outcomes across the lifespan, the mental health burden of the Covid-19 pandemic might not only have affected the parents, but also the next generation.

Review of Mobile Apps for Women With Anxiety in Pregnancy: Maternity Care Professionals' Guide to Locating and Assessing Anxiety Apps

Background

Mental health and pregnancy apps are widely available and have the potential to improve health outcomes and enhance women’s experience of pregnancy. Women frequently access digital information throughout their pregnancy. However, health care providers and women have little information to guide them toward potentially helpful or effective apps.

Objective

This review aimed to evaluate a methodology for systematically searching and reviewing commercially available apps that support pregnant women with symptoms of anxiety in order to assist maternity care professionals in identifying resources that they could recommend for these women.

Methods

A stepwise systematic approach was used to identify, select, describe, and assess the most popular and highly user-rated apps available in the United Kingdom from January to March 2021. This included developing a script-based search strategy and search process, writing evaluation criteria, and conducting a narrative description and evaluation of the selected apps.

Results

Useful search terms were identified, which included nonclinical, aspirational, and problem-based phrases. There were 39 apps selected for inclusion in the review. No apps specifically targeted women with anxiety in pregnancy. Of the 39 apps included in the review, 33 (85%) focused solely on mind-body techniques to promote relaxation, stress reduction, and psychological well-being. Only 8 of the 39 (21%) apps included in the review reported that health care professionals had contributed to app development and only 1/39 (3%) provided empirical evidence on the effectiveness and acceptability of the app. The top 12/39 (31%) apps were evaluated by 2 independent reviewers using the developed criteria and scores. There was a small negative correlation between the reviewers’ scores and app user rating scores, with higher user rating scores associated with lower reviewer scores.

Conclusions

App developers, publishers, and maternity care professionals should seek advice from women with lived experience of anxiety symptoms in pregnancy to locate, promote, and optimize the visibility of apps for pregnant women. There is a lack of resources that provide coping strategies based on current evidence for the treatment of anxiety in pregnancy. Maternity care providers are limited in their ability to locate and recommend acceptable and trustworthy apps because of the lack of information on the evidence base, development, and testing of apps. Maternity care professionals and women need access to libraries of trusted apps that have been evaluated against relevant and established criteria.

Factors Affecting Primiparous Women’s Breastfeeding Self-Efficacy Levels

INTRODUCTION

The aim of this study is to reveal the factors affecting primiparous pregnant women’s breastfeeding self-efficacy levels. This is a descriptive correlational study.

METHOD

The sample included 512 primiparous pregnant women. A personal information form, the Prenatal Breastfeeding Self-Efficacy Scale (PBSES), the Multidimensional Scale of Perceived Social Support (MSPSS) and the Pregnancy-Related Anxiety Questionnaire–Revised (PRAQ-R2) were used for data collection.

RESULTS

The pregnant women’s mean total PBSES scores were found to differ significantly based on their descriptive and obstetric characteristics. There was a positive correlation between their mean PBSES scores and their MSPSS total and subscale mean scores. Additionally, there was a negative correlation between the participants’ mean total PBSES scores and their mean total PRAQ-R2 and “concern about own appearance” subscale scores. Place of residence for the longest time, pregnancy risk group, folic acid use before pregnancy, perceived family support, perceived support from friends and concern about own appearance were significant factors in explaining the variance in the pregnant women’s PBSES total scores.

DISCUSSION

Both descriptive and obstetric characteristics of the primiparous pregnant women affected their breastfeeding self-efficacy levels. Social support was also determined to affect the participants’ breastfeeding self-efficacy levels positively, and whereas anxiety affected these levels negatively.

Population birth outcomes in 2020 and experiences of expectant mothers during the COVID-19 pandemic: A 'born in Wales' mixed methods study using routine data

BACKGROUND

Pregnancy can be a stressful time and the COVID-19 pandemic has affected all aspects of life. This study aims to investigate the pandemic impact on pregnancy experience, rates of primary childhood immunisations and the differences in birth outcomes in during 2020 to those of previous years.

METHODS

Self-reported pregnancy experience: 215 expectant mothers (aged 16+) in Wales completed an online survey about their experiences of pregnancy during the pandemic. The qualitative survey data was analysed using codebook thematic analysis. Population-level birth outcomes in Wales: Stillbirths, prematurity, birth weight and Caesarean section births before (2016-2019) and during (2020) the pandemic were compared using anonymised individual-level, population-scale routine data held in the Secure Anonymised Information Linkage (SAIL) Databank. Uptake of the first three scheduled primary childhood immunisations were compared between 2019 and 2020.

FINDINGS

The pandemic had a negative impact on the mental health of 71% of survey respondents, who reported anxiety, stress and loneliness; this was associated with attending scans without their partner, giving birth alone, and minimal contact with midwives. There was no significant difference in annual outcomes including gestation and birth weight, stillbirths, and Caesarean sections for infants born in 2020 compared to 2016-2019. There was an increase in late term births (≥42 weeks gestation) during the first lockdown (OR: 1.28, p = 0.019) and a decrease in moderate to late preterm births (32-36 weeks gestation) during the second lockdown (OR: 0.74, p = 0.001). Fewer babies were born in 2020 (N = 29,031) compared to 2016-2019 (average N = 32,582). All babies received their immunisations in 2020, but there were minor delays in the timings of immunisations. Those due at 8-weeks were 8% less likely to be on time (within 28-days) and at 16-weeks, they were 19% less likely to be on time.

INTERPRETATION

Whilst the pandemic had a negative impact on mothers' experiences of pregnancy. Population-level data suggests that this did not translate to adverse birth outcomes for babies born during the pandemic.

Gender-specific associations of pregnancy-related anxiety with placental epigenetic patterning of glucocorticoid response genes and preschooler's emotional symptoms and hyperactivity

BACKGROUD

We have recently reported that maternal prenatal pregnancy-related anxiety predicts preschoolers' emotional and behavioral development in a gender-dependent manner. This study aims to test for this gender-specific effect in a different cohort and investigate whether the gender difference was specific to placental methylation of genes regulating glucocorticoids.

METHODS

A total of 2405 mother-child pairs from the Ma'anshan Birth Cohort Study were included in present study. The maternal pregnancy-related anxiety symptoms were evaluated with the Pregnancy-Related Anxiety Questionnaire in the third trimester of pregnancy. Child neurobehavior was assessed with the Strengths and Difficulties Questionnaire at 4 years old. Placental methylation of FKBP5, NR3C1 and HSD11B2 genes was quantified using the MethylTarget approach in 439 pregnant women. After exploratory factor analysis, the associations between methylation factor scores and pregnancy-related anxiety and child neurobehavior were examined using logistic regression analysis.

RESULTS

After controlling for confounding factors, pregnancy-related anxiety in the third trimester of pregnancy increased the risk of hyperactivity only in boys and emotional symptoms only in girls. Decreased scores of the factor characterized by FKBP5 methylation were associated with maternal pregnancy-related anxiety only in boys. Furthermore, increased scores of the factors characterized by NR3C1 and HSD11B2 methylation were associated with hyperactivity (NR3C1: adjusted OR = 1.80, 95%CI = 1.15-2.83) and emotional symptoms (HSD11B2: adjusted OR = 0.53, 95%CI = 0.29-0.97; NR3C1: adjusted OR = 1.64, 95%CI = 1.03-2.59) only in boys. However, the scores of the factor characterized by FKBP5, NR3C1 and HSD11B2 did not mediate the relationship between maternal pregnancy-related anxiety and preschoolers' emotional symptoms and hyperactivity.

CONCLUSIONS

Our results suggested that pregnancy-related anxiety in the third trimester of pregnancy predicted preschoolers' emotional symptoms and hyperactivity in a gender-dependent manner. Although we did not find the mediation role of the placental methylation of genes regulating glucocorticoids, we found it was associated with both maternal pregnancy-related anxiety and preschoolers' emotional symptoms and hyperactivity in a gender-dependent manner.

Postpartum women's experiences of social and healthcare professional support during the COVID-19 pandemic: A recurrent cross-sectional thematic analysis

Problem

Disrupted access to social and healthcare professional support during the COVID-19 pandemic have had an adverse effect on maternal mental health.

Background

Motherhood is a key life transition which increases vulnerability to experience negative affect.

Aim

Explore UK women’s postnatal experiences of social and healthcare professional support during the COVID-19 pandemic.

Methods

Semi-structured interviews were conducted with 12 women, approximately 30 days after initial social distancing guidelines were imposed (T1), and a separate 12 women were interviewed approximately 30 days after the initial easing of social distancing restrictions (T2). Recurrent cross-sectional thematic analysis was conducted in NVivo 12.

Findings

T1 themes were, ‘Motherhood has been an isolating experience’ (exacerbated loneliness due to diminished support accessibility) and ‘Everything is under lock and key’ (confusion, alienation, and anxiety regarding disrupted face-to-face healthcare checks). T2 themes were, ‘Disrupted healthcare professional support’ (feeling burdensome, abandoned, and frustrated by virtual healthcare) and ‘Easing restrictions are bittersweet’ (conflict between enhanced emotional wellbeing, and sadness regarding lost postnatal time).

Discussion

Respondents at both timepoints were adversely affected by restricted access to informal (family and friends) and formal (healthcare professional) support, which were not sufficiently bridged virtually. Additionally, the prospect of attending face-to-face appointments was anxiety-provoking and perceived as being contradictory to social distancing guidance. Prohibition of family from maternity wards was also salient and distressing for T2, but not T1 respondents.

Conclusion

Healthcare professionals should encourage maternal help-seeking and provide timely access to mental health services. Improving access to informal and formal face-to-face support are essential in protecting maternal and infant wellbeing.

Trends In Primary Cesarean Section Rates Among Women With And Without Perinatal Mood And Anxiety Disorders

Reducing the rate of cesarean sections among women considered at low risk for delivery by that method is a goal of Healthy People 2030. Prior research suggests that perinatal mood and anxiety disorders increase the risk for cesarean section, but data are limited. This cross-sectional study of commercially insured women examined the relationship between perinatal depression and anxiety disorders and primary (first-time) cesarean section rates, using administrative claims data for US in-hospital deliveries from the period 2008-17. Of the 360,225 delivery hospitalizations among 317,802 unique women, 24.0 percent included a delivery by primary cesarean section, and 3.1 percent carried a diagnosis of depression, anxiety, or both made during the index pregnancy. Using an adjusted generalized estimating equation, we found that the predicted probability of primary cesarean section was 3.5 percentage points higher, on average, among women with these disorders compared with those without them. Our findings confirm the importance of pursuing research to identify mechanisms by which perinatal depression and anxiety disorders increase the risk for primary caesarean section among women otherwise considered at low risk for delivery by that method, as well as effective interventions.

Polish Adaptation of the Pregnancy-Related Anxiety Questionnaire-Revised 2 for All Pregnant Women

Pregnancy-related anxiety (PrA) is a specific type of anxiety characteristic of the perinatal period. PrA can affect pregnancy and birth. However, no validated tool exists to measure PrA in Polish obstetric practice. The aim of this study was to translate the Pregnancy-Related Anxiety Questionnaire-Revised 2 (PRAQ-R2) into Polish and to evaluate its reliability and factorial and construct validity. This study was conducted in Poland as an online questionnaire in April 2020 and included 175 healthy women. To validate the PRAQ-R2, we used standardized tools for the measurement of general anxiety: the modified Visual Analog Scale (VAS), the Ten-Item Personality Inventory (TIPI), and the Hospital Anxiety and Depression Scale (HADS). Scale reliability was assessed using Cronbach's alpha. Concurrent validity was evaluated by calculating Spearman's rho correlation coefficients. Statistical analyses were performed using R ver. 4.0.2. Values for comparative fit index >0.90, Tucker-Lewis index >0.90, and root mean square error of approximation <0.08 indicated acceptable model fit, confirming the reliability of the three-factor structure of the translation. The subscales and total scores had good consistency (α > 0.7), and convergent validity was demonstrated. The PRAQ-R2 as translated into Polish represents the first validated tool in Poland to measure PrA for all pregnant women.

Psychosocial and peripartum determinants of postpartum depression: Findings from a prospective population-based cohort. The ABCD study

BACKGROUND

Postpartum depression is prevalent and concerns a serious health problem for women and their families. The current large-scale birth cohort study investigated: (1) the associations of various potential determinants of postpartum depression using a multidimensional approach, and (2) the individual contribution of obstetric and perinatal determinants and pregnancy-specific anxiety to the risk of postpartum depression.

METHODS

This study was based on a large-scale birth cohort study in Amsterdam, the Netherlands (ABCD-study). In 5109 women depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (cut-off ≥16 indicating high risk of postpartum depression). Determinants were assessed using self-report or perinatal registries.

RESULTS

In the final multivariable model, other-Western and non-Western ethnic background, increased antepartum depressive symptoms, increased antepartum anxiety, increased pregnancy-specific anxiety, being unemployed, poor sleep quality, unwanted pregnancy, abuse, multiparity, and congenital abnormality were all independently related to an increased risk of postpartum depression. The strongest risk factors for postpartum depression were antepartum depressive symptoms (adjusted odds ratio (AOR) = 3.86, 95% confidence interval (CI) 3.02-4.92), having a baby with a congenital abnormality (AOR = 2.33, 95% CI 1.46-3.73), and abuse (AOR = 1.95, 95% CI 1.02-3.73). The final model accounted for 24.5% of the variance.

LIMITATIONS

Our dataset did not provide information on social support or maternal and family history of depression. Next to these determinants, future research should include biological factors.

CONCLUSIONS

The determinants identified provide opportunities for the development of multidimensional early screening and early intervention strategies for women with an increased risk of postpartum depression.

"I'm not doing what I should be doing as a midwife": An ethnographic exploration of central fetal monitoring and perceptions of clinical safety

BACKGROUND

Central fetal monitoring systems transmit cardiotocograph data to a central site in a maternity service. Despite a paucity of evidence of safety, the installation of central fetal monitoring systems is common.

AIM

This qualitative research sought to explore whether, and how, clinicians modified their clinical safety related behaviours following the introduction of a central monitoring system.

METHODS

An Institutional Ethnographic enquiry was conducted at an Australian hospital where a central fetal monitoring system had been installed in 2016. Informants (n=50) were midwifery and obstetric staff. Data collection consisted of interviews and observations that were analysed to understand whether and how clinicians modified their clinical safety related behaviours.

FINDINGS

The introduction of the central monitoring system was associated with clinical decision making without complete clinical information. Midwives' work was disrupted. Higher levels of anxiety were described for midwives and birthing women. Midwives reported higher rates of intervention in response to the visibility of the cardiotocograph at the central monitoring station. Midwives described a shift in focus away from the birthing woman towards documenting in the central monitoring system.

DISCUSSION

The introduction of central fetal monitoring prompted new behaviours among midwifery and obstetric staff that may potentially undermine clinical safety.

CONCLUSION

This research raises concerns that central fetal monitoring systems may not promote safe intrapartum care. We argue that research examining the safety of central fetal monitoring systems is required.

Preferences of women with low obstetric risk for cesarean or vaginal birth in Poland: Areas for intervention

BACKGROUND

In Poland, the rate of cesarean birth (CB) is 43%, which is much higher than the European average of 27%. Optimizing the CB birth rate is of critical importance, especially among women with low-risk pregnancies. However, the determinants of cesarean preference among low-risk women in Poland have not been well explored.

METHODS

This cross-sectional study included 1011 pregnant women and aimed to identify associations between selected determinants of women's preferences for CB vs. vaginal birth (VB) in Poland. A descriptive questionnaire was distributed online, and a theoretical model was validated against empirically gathered data. Group comparisons were performed using the Welch t test for continuous data or chi-square test for categorical data. All statistical analyses were performed using R (R Core Team, 2018).

RESULTS

The mean age of women preferring CB (30.46 years) was 1.25 years higher than that of women preferring VB (29.21 years). Pregnant women who expressed a preference for CB tended to be multigravid, inhabited cities, and were characterized by higher levels of anxiety and depression. Moreover, the majority of women who underwent a previous CB asserted their intention to repeat the procedure for the current pregnancy.

CONCLUSIONS

The primary factors that were correlated with high CB preference among the low-risk group included age, previous childbirth experiences, and anxiety. The underlying reasons that drive birth preferences remain poorly understood. However, women who have previously undergone difficult childbirth experiences and are afraid of pain require specialized care.

Association of Stress-Related Factors With Anxiety Among Chinese Pregnant Participants in an Online Crisis Intervention During COVID-19 Epidemic

Background: Previous systematic review indicated the prevalence of prenatal anxiety as 14–54%. Pregnant women are a high-risk population for COVID-19. However, the prevalence of anxiety symptoms and related factors is unknown in Chinese pregnant women during COVID-19 outbreak.

Objective: To investigate the prevalence of anxiety symptoms and the related factors in Chinese pregnant women who were attending crisis intervention during the COVID-19 pandemic.

Methods: The data of this cross-sectional study were collected in about 2 months (February 28 to April 26, 2020). Data analysis was performed from April to May 2020. Participants completed a set of questionnaires via the Wechat Mini-program before starting the online self-help crisis intervention for COVID-19 epidemic. A total of 2,120 Chinese pregnant women who were attending a self-help crisis intervention participated in this study. A survey was developed to address possible stress-related factors in pregnant women during the COVID-19 outbreak, including demographic, socioeconomic, and pregnancy-related factors, as well as COVID-19 related factors. Generalized Anxiety Disorder-7 (GAD-7) scale and the 10-item perceived stress scale were, respectively, employed to measure anxiety and stress-related factors.

Results: A total of 21.7% (459) of pregnant women reported at least mild anxiety (≥5 on the GAD-7 scale), and only 82 women reported moderate to severe anxiety (≥10 on the GAD-7 scale). Factors associated with at least mild anxiety included living in Hubei province (OR = 1.68, 95% CI = 1.32–2.13), nobody providing everyday life support (OR = 1.81, 95% CI = 1.18–2.77), pelvic pain or vaginal bleeding (OR = 1.67, 95% CI = 1.32–2.09), and higher perceived stress (OR = 6.87, 95% CI = 5.42–9.02). Having relatives or neighbors with a diagnosis of COVID-19 was not associated with anxiety (p > 0.05).

Conclusions and Relevance: Our findings indicate that evaluation and intervention for maternal and infant health are necessary in pregnant women with anxiety during COVID-19 epidemic, especially those with higher perceived stress, less everyday life support, or vaginal bleeding. Interactions among these related medical, social and psychological factors need to be investigated in future studies.

Childbirth and motherhood in women with motor disability due to a rare condition: an exploratory study

Background

Rare diseases may result in motor impairment, which in turn may affect parenthood. Our purpose was to evaluate perinatal outcomes, parenting needs, mother-infant interactions and infant development in a set of volunteer women with motor impairment due to a rare disease. In a parenting support institution, we recruited a consecutive series of 22 volunteer pregnant women or young mothers, recorded perinatal outcomes, and followed mother-infant interaction and relationship and infant development up to 14 months postpartum. Cases with intellectual or psychic disability were not included.

Results

There were 11 genetic diseases (2 Spinal Muscular Atrophy, 1 Charcot-Marie-Tooth, 1 autosomal dominants myopathy, 1 mitochondrial disease, 2 Elhers-Danlos, 1 Friedreich ataxia, 1 spinocerebellar ataxia, 1 tetrahydrobiopterine deficiency,1 Ectrodactyly), and 11 rare non-genetic conditions (2 spine tumors, 2 strokes, 1 juvenile chronic arthritis, 3 birth injuries, 1 inflammatory myopathy, 1 congenital amputation, and 1 traumatic amputation). These resulted in 10 impairments of four limbs, 4 impairments of both lower limbs, 7 unilateral impairments, and one distal tremor. Social deprivation Epices score, Cutrona social support scale, Edinburg Postnatal Depression scale, and Spielberger State/Trait Anxiety Inventory were unremarkable. Perinatal outcome: 4 gestational diabetes, 1 pre-eclampsia, 9 caesareans, 6 assisted and 7 spontaneous vaginal deliveries, 20 term live-births and 2 premature deliveries (35–36 weeks). Twelve women declared they were self-sufficient for daily activities; six declared they were self-sufficient to provide basic care to their baby. Distribution of the Brunet-Lezine child development score was normal. The parent-infant relationship global assessment scale (PIR-GAS) was well adapted in 2 cases, adapted in 8, perturbed in 7, significantly perturbed in 2, and distressed in 3 (mean 71.8; 95% CI 49.6–93.9). This was unrelated to any somatic or emotional characteristics of the participants. Coding interactive behavior revealed that infant engagement was lower and infant avoidance greater than in controls (p < 0.05).

Conclusion

Infant development was normal, but mother-infant interactions were altered in half of the participants independently from the degree of motor impairment, underscoring the need for parenting support, even for parents who are self-sufficient in daily activities.

Do stress and anxiety in early pregnancy affect the progress of labor: Evidence from the Wirral Child Health and Development Study

Introduction

Despite widespread belief that anxiety causes longer labor, evidence of association is inconsistent. Data gathered as part of a prospective epidemiological longitudinal study were used to investigate associations between antenatal anxiety and pregnancy‐specific stress, and labor progression was assessed by duration and use of augmentation.

Material and methods

Pregnant primiparous women completed measures for anxiety and pregnancy‐specific stress at 20 weeks’ gestation (n = 1145). Birth outcome data were extracted from medical records. Regression analyses and a path analysis assessed associations between antenatal anxiety and pregnancy‐specific stress, and indices of labor progression (labor duration and augmentation).

Results

Anxiety/pregnancy‐specific stress were not directly associated with duration of stage 1 labor (HIGH/LOW anxiety: mean difference = 13.94 minutes, SD = 20.66, 95% CI −26.60 to 54.49, P < .50)/(HIGH/LOW pregnancy‐specific stress: mean difference = 12.05 minutes, SD = 16.09, 95% CI −19.52 to 43.63, P < .45). However, anxiety/pregnancy‐specific stress were associated with epidural use (HIGH/LOW anxiety: 39% vs 31%, P < .042; HIGH/LOW pregnancy‐specific stress: 38% vs 29%, P < .001), which was itself associated with longer labor (mean difference: 158.79 minutes, SD = 16.76, 95% CI 125.89‐191.68, P < .001). Anxiety and pregnancy‐specific stress were associated with increased likelihood of augmentation but these associations were nonsignificant after accounting for epidural, which was itself highly associated with augmentation. However, path analysis indicated an indirect effect linking pregnancy‐specific stress, but not general anxiety, to labor duration and augmentation: elevated pregnancy‐specific stress led to greater use of epidural, which was linked to both increased rates of augmentation, and increased labor duration.

Conclusions

Contrary to general belief, general anxiety and specific pregnancy stress were not directly linked to longer duration of stage one labor. However specific pregnancy stress was associated with epidural use, which in turn was significantly associated with risk of augmentation, and longer stage one labor. Identification of pregnancy‐specific stress could help to identify women for whom psychological interventions could improve birth experience.

Gender-specific effect of pregnancy-related anxiety on preschooler's emotional and behavioral development: A population-based cohort study

BACKGROUND

Pregnancy-related anxiety plays a major role in shaping offspring's neural development. However, its gender-specific effect on children's emotional and behavioral development is controversial and the knowledge of critical period is limited. This study aims to examine gender-specific effect of pregnancy-related anxiety on preschooler's emotional and behavioral development.

METHODS

This study was based on the China-Anhui Birth Cohort Study (C-ABCS). A total of 3443 mother-child pairs were included in final data analysis. Pregnancy-related anxiety was assessed by Pregnancy-Related Anxiety Questionnaire respectively in the 1^st and 3^rd trimester of pregnancy. Strengths and Difficulties Questionnaires (SDQ) were completed by parents to assess preschool emotional and behavioral development in boys and girls. Logistic regression models were used to examine the association between pregnancy-related anxiety and preschoolers' emotional and behavioral problems.

RESULTS

The overall prevalence of pregnancy-related anxiety was 31.6%. Compared with those whose mothers without pregnancy-related anxiety in either 1^st or 3^rd trimester, preschool boys born of mothers with pregnancy-related anxiety in the 1^st trimester and in the 3^rd trimester had an increased risk of conduct problems. Pregnancy-related anxiety in the 1^st, 3^rd trimester and in both trimesters all related with preschool boys' hyperactivity and total difficult problems. Pregnancy-related anxiety in the 1^st trimester and in both 1^st and 3^rd trimester increased the risk of preschool girls' emotional problems and total difficult problems.

CONCLUSION

Pregnancy-related anxiety may relate with preschool boys' externalizing problems in early and late of pregnancy and increase the risk of internalizing problems in girls in early pregnancy.

LIMITATIONS

There was no data on pregnancy-related anxiety in the second trimester.

Psychometric evaluation of the pregnancy-related anxiety scale: Acceptance of pregnancy, avoidance, and worry about self subscales

BACKGROUND

Increasingly pregnancy-related anxiety is acknowledged as a distinct anxiety type, characterised by specific fears/worries. The Pregnancy-related Anxiety Scale (PrAS) screens for this distinct anxiety and refinements to the scale have prompted further validity examination. This study aims to: replicate findings that distinguished pregnancy-related anxiety from general anxiety/depression using the PrAS; confirm the PrAS's factor structure, and examine the validity of the PrAS subscales: Acceptance of Pregnancy, Avoidance and Worry About Self.

METHODS

Pregnant women (N = 608) were recruited online and completed the PrAS, Pregnancy Acceptance Questionnaire, Ways of Coping Questionnaire, Cambridge Worry Scale, Parenting Sense of Competence Scale, State Trait Anxiety Inventory and the Edinburgh Depression Scale.

RESULTS

Multiple regression analysis confirmed general anxiety/depression contributed little to the PrAS's variance, supporting the scale's validity and distinctiveness of pregnancy-related anxiety. Structural equation modelling confirmed the PrAS's factor structure, and the three PrAS subscales generally correlated more highly with convergent measures than the discriminant measures.

LIMITATIONS

Limitations included the cross-sectional design of the study and the use of some convergent/discriminant measures that lacked validity evidence for prenatal use.

CONCLUSIONS

This study provides evidence of the distinctiveness of pregnancy-related anxiety from state/trait anxiety and depression and also adds to the psychometric properties of the PrAS. The PrAS is a useful screening scale that can be used for antenatal screening potentially reducing the risk of adverse outcomes associated with pregnancy-related anxiety. The PrAS is also a useful research tool providing a more comprehensive assessment of pregnancy-related anxiety.

Childhood abuse, pregnancy-related anxiety and the mediating role of resilience and social support

Physical, sexual and psychological abuse were examined as risk factors for pregnancy-related anxiety with resilience and social support as mediators. Pregnant women ( n = 638) completed measures of pregnancy-related anxiety, resilience, perceived social support and childhood abuse. Women with an abuse history had higher pregnancy-related anxiety scores ( m = 64.40) than other women ( m = 55.36). All abuse types independently predicted pregnancy-related anxiety; resilience and social support were mediators. Results highlight the value of antenatal screening for pregnancy-related anxiety including specific risk factors such as child abuse. Programs such as the Midwife Continuity of Care are useful in encouraging disclosure.

Prenatal pregnancy-related anxiety predicts boys' ADHD symptoms via placental C-reactive protein

Many modes of stress (i.e. life events, catastrophic events) during pregnancy have been found to increase the risk of externalizing behaviors, and probably in a sex-specific way. Maternal immune activation may be the sex-difference mechanism, but direct evidence that assess three factors in conjunction -- maternal stress, maternal immune activation, and offspring neurodevelopment --from human beings is lacking. This prospective study followed 2926 pregnant women from early pregnancy to 36 months after delivery. Pregnancy-related anxiety symptoms assessment was completed three times using the Pregnancy-Related Anxiety Questionnaire; child attention deficit hyperactivity disorder (ADHD) symptoms were assessed by the parent version of the Conners' Hyperactivity Index. More importantly, nine inflammatory cytokines were detected in placental tissues for the sex-difference mechanism investigation. Our results showed that after controlling for confounding factors, pregnancy-related anxiety during at least two trimesters of pregnancy increased the risk of ADHD for boys (adjusted odds ratio (aOR) = 3.37, 95 % confidence interval (95 % CI) = 1.78-6.38), but not for girls (aOR = 1.02, 95 %CI = 0.44-2.38), which confirmed previous findings. Besides, the structural equation models revealed that placental C-reactive protein (CRP) mRNA expression significantly mediated the association between pregnancy-related anxiety and ADHD for boys (indirect effect: β = 0.025, P = 0.022), but not for girls (indirect effect: β = 0.005, P = 0.589). This prospective study suggested that frequent pregnancy-related anxiety during pregnancy and its induced-placental inflammation partially contributed to the sex-bias of ADHD symptoms.

Pregnancy-Related Anxiety, Perceived Parental Self-Efficacy and the Influence of Parity and Age

Pregnancy-related anxiety is contextualised by pregnancy and is a health concern for the mother and child. Perceived parental self-efficacy is associated with this anxiety and age and parity are identified as influential factors. This research, therefore, predicted that negative perceptions of parental self-efficacy would predict greater pregnancy-related anxiety, moderated by parity and age. Participants (N = 771) were recruited online and assessed for perceived parental self-efficacy, pregnancy-related anxiety, and demographics. Moderation models showed that the psychosocial and sociodemographic factors combined predicted up to 49% of the variance. Parental self-efficacy predicted anxiety in the areas of body image, worry about themselves, baby concerns, pregnancy acceptance, attitudes towards medical staff and childbirth, and avoidance. Parity predicted pregnancy-related anxiety both overall and in childbirth concerns, worry about self, baby concerns and attitudes towards childbirth. Age predicted baby concerns. There was a significant moderation effect for pregnancy acceptance indicating that primiparous women with low perceptions of parental self-efficacy are less accepting of their pregnancy. Results suggest that parity and parental self-efficacy may be risk factors for first-time mothers for pregnancy-related anxiety.

The Pregnancy Anxiety Questionnaire Revised-2

Abstract. Pregnancy-related anxiety is an important risk factor for adverse pregnancy outcomes and postnatal parental well-being, to a greater extent than general anxiety, calling for a reliable and validated measure for its assessment. The current paper aimed to validate the Pregnancy Anxiety Questionnaire – Revised-2 (PRAQ-R2; Huizink et al., 2016 ) in a sample of Italian women, by testing its psychometric properties, and checking for Italian–Finnish measurement invariance. Additionally, the association with general anxiety and depression was examined. Participants included 348 Italian pregnant women and 348 Finnish pregnant women. Results showed that the Italian version of PRAQ-R2 presents satisfying psychometric proprieties. Data supported a three-factor solution including fear of giving birth, w orries about bearing a handicapped child, and concern about own appearance. Invariance across countries was confirmed. The primiparous condition was associated with a higher level of pregnancy anxiety only for fear of giving birth. A moderate correlation was found between pregnancy anxiety and general anxiety and depression, providing evidence for concurrent validity, as well as for the existence of a specific pregnancy anxiety dimension.

A comparison of the Fear of Childbirth Scale with the Tilburg Pregnancy Distress Scale to identify childbirth-related fear in a sample of Dutch pregnant women: a diagnostic accuracy comparative cross-sectional study

BACKGROUND

Because of the considerable negative effects of women's childbirth-related anxiety, fear and worries, and the time constraints that midwives perceive to assess women's antenatal emotional wellbeing, it is important that midwives can identify women with a more severe fear of birth with an easy to administer, validated tool.

OBJECTIVE

To investigate the ability of the two-item Fear of Childbirth Scale (FOBS) to discriminate between pregnant women with and without birth-related fear, compared with the 16-item Tilburg Pregnancy Distress Scale (TPDS).

METHODS

A diagnostic accuracy comparative cross-sectional study was performed, comparing two screening tests. Sensitivity, specificity, positive and negative predictive values and accuracy and discriminant property of the FOBS were determined and compared with the TPDS and with the negative affect 11-items TPDS (TPDS-NA) subscale. The TPDS and TPDS-NA were treated as reference standard to establish the discriminative potential of the FOBS for the presence or absence of antenatal birth-related fear.

PARTICIPANTS

A sample of 396 Dutch women with uncomplicated pregnancies.

RESULTS

When compared with the 16-items TPDS, the FOBS showed a higher specificity (95%) than sensitivity (70%) to detect fear of childbirth. The FOBS items had a good predictive ability for fear and worries about the forthcoming birth (79%) and a conclusive ability for negative case-finding (92%). The FOBS showed good accuracy (89%). The FOBS discriminated women who were or were not classified as being fearful according to the TPDS (AUC .86). When compared with the 11 items TPDS-NA subscale, the FOBS validity and accuracy decreased: sensitivity: 51%; specificity 92%; positive predictive ability 65%; negative predictive ability 88%; accuracy 83%; AUC .82.

CONCLUSION

When compared with the 16-items TPDS, the two-item FOBS shows to be an accurate tool for identifying the presence of antenatal birth-related fear in a sample of Dutch women with uncomplicated pregnancies.

Perinatal outcomes of frequent attendance in midwifery care in the Netherlands: a retrospective cohort study

BACKGROUND

Over the last decade, a trend towards high utilisation of primary maternity care was observed in high-income countries. There is limited research with contradictory results regarding frequent attendance (FA) and perinatal outcomes in midwifery care. Therefore, this study examined possible associations between FA in midwifery care and obstetric interventions and perinatal outcomes.

METHODS

A retrospective cohort study was performed in a medium-sized midwifery-led care practice in an urban region in the Netherlands. Frequent attenders (FAs) were categorised using the Kotelchuck-Index Revised. Regression analyses were executed to examine the relationship between FAs and perinatal outcomes, stratified by antenatal referral to an obstetrician. Main outcomes of interest were Apgar score ≤ 7 and perinatal death, birth weight, mode of delivery, haemorrhage, place of birth, transfer during labour, and a requirement for pain relief.

RESULTS

The study included 1015 women, 239 (24%) FAs and 776 (76%) non-FAs, 538 (53%) were not referred and 447 (47%) were referred to an obstetrician. In the non-referred group, FA was significantly associated with a requirement for pain relief (OR 1.98, 95% CI 1.24-3.17) and duration of dilatation (OR 1.20, 95% CI 1.04-1.38). In the referred group, FA was significantly associated with induction of labour (OR 1.86, 95% CI 1.17-2.95), ruptured perineum (OR 0.50, 95% CI 0.27-0.95) and episiotomy (OR 0.48, 95% CI 0.24-0.95). In the non-referred and the referred group, FA was not associated with the other obstetric and neonatal outcomes. Due to small numbers, we could not measure possible associations of FA with an Apgar score ≤ 7 and perinatal death.

CONCLUSION

In our study, perinatal outcomes differed by FA and antenatal referral to an obstetrician. In the non-referred group, FA was significantly associated with medical pain relief and duration of dilatation. In the referred group, FA was significantly associated with induction of labour, ruptured perineum, and episiotomy. Further research with a larger study population is needed to look for a possible association between FA and primary adverse birth outcomes such as perinatal mortality.