Cognitive-behavioral therapy-based intervention to treat symptoms of anxiety in pregnancy in a prenatal clinic using non-specialist providers in Pakistan: design of a randomised trial

Multiple mediation analysis of a task-shared psychosocial intervention for perinatal anxiety: Exploratory findings from a randomized controlled trial in Pakistan

BACKGROUND

The "Healthy Mother Healthy Baby" (HMHB) study is a phase three, single-blind randomized clinical trial conducted at Holy Family Hospital (HFH) in association with Rawalpindi Medical University (RMU). We aimed to examine the mediators of a specialized psychosocial approach based on Cognitive Behavioural Therapy principles, targeting pregnant women experiencing anxiety. The HMHB intervention was effective in treating perinatal anxiety symptoms and preventing future depressive episodes.

METHODS

The trial randomized participants into two arms: the HMHB intervention or Enhanced Usual Care (EUC), following World Health Organization guidelines. The HMHB intervention comprised strategies to strengthen social support networks, improving mother-baby bonding and strategies to deal with interpersonal conflicts, economic challenges, and societal gender preferences using cognitive and behavioural techniques and culturally resonant illustrations. Participants underwent rigorous data collection at three pivotal timepoints: baseline, third trimester, and 6-weeks postnatal. The primary outcome was anxiety symptom severity scores using the Hospital Anxiety and Depression Scale (HADS) at 6-weeks post-childbirth. Four potential mediators - social support, behavioural activation, perceived stress, and pregnancy experience - were assessed in the third trimester of pregnancy.

RESULTS

A total of 1200 participants were randomized to the HMHB and EUC arms. In the six-week follow-up time point, 379 participants remained in the EUC group, and 387 continued in the HMHB group. Post-intervention, HMHB participants displayed significant improvements in postnatal anxiety and depression scores. Mediation analyses revealed social support and pregnancy hassles as significant mediators of the intervention's effect on postnatal anxiety outcomes, while only social support emerged as a significant mediator for depression outcomes.

CONCLUSION

The HMHB intervention showed promising results in improving anxiety and depression scores among pregnant women. Significant mediation effects suggest the importance of targeting social support and managing pregnancy-related hassles for optimal intervention effectiveness.

"If it has happened once, it can happen again". The impact of previous pregnancy loss on anxious women's ongoing pregnancies: A qualitative study from Pakistan

BACKGROUND

Pregnancy loss that includes both miscarriage and stillbirth cause significant psychological distress for women including anxiety, depression, and grief that persist long after physical recovery. This study focuses on the experiences of women in Pakistan, where pregnancy loss rates are high.

OBJECTIVE

To explore how pregnant women with anxiety symptoms and a history of pregnancy loss perceive their past experiences with the loss and how it affects overall well-being in their current pregnancy.

DESIGN

Qualitative methods were used to explore the impact of previous pregnancy loss on the well-being of pregnant women.

SETTING

This qualitative research was embedded within a randomized control trial conducted in a tertiary care facility in Rawalpindi, Pakistan.

PARTICIPANTS

Data were collected through in-depth interviews with 18 pregnant women who had experienced pregnancy loss. Data was analyzed using Framework Analysis.

FINDINGS

The findings revealed several factors influencing participants' well-being during pregnancies that resulted in a loss, such as unsupportive and abusive environments, unintended pregnancies, certain superstitious beliefs, poor health, and lack of access to quality healthcare. The study also highlighted the adverse impact of previous pregnancy loss on the ongoing pregnancy, including deterioration of physical and mental health and aversion of healthcare services. However, some participants reported positive changes in medical and self-care practices and an enhanced faith and reliance on destiny in their subsequent pregnancies.

CONCLUSION

Our study highlights the lasting impact of past pregnancy loss on subsequent pregnancies, affecting overall wellbeing and leading to healthcare avoidance. We identified persistent anxiety along with positive outcomes like enhanced medical practices and strengthened faith. Results suggest the need for culturally responsive interventions to support the overall well-being of anxious pregnant women with a history of pregnancy loss in resource-constrained settings.

Perinatal Intimate Partner Violence and Maternal-Infant Bonding in Women With Anxiety Symptoms in Pakistan: The Moderating Role of Breastfeeding

Intimate partner violence (IPV) during the perinatal period can negatively affect both a woman's health and the bonding with her infant. Research on IPV among pregnant women experiencing psychological distress in South Asia is limited. We examined associations between perinatal exposure to IPV and postnatal maternal-infant bonding in Pakistani women with symptoms of anxiety and assessed if breastfeeding practices moderated these associations. Postnatal data were collected from 720 Pakistani women who reported at least mild levels of anxiety symptoms in pregnancy. We performed Poisson regression with robust variance analyses to examine the associations between IPV during pregnancy or within 6 weeks after delivery (i.e., the perinatal period) and maternal-infant bonding. Interaction terms between IPV and breastfeeding practices were included in the analytic models to examine the moderating effects. About 27% of women were exposed to at least one type of perinatal IPV. Women who were exposed to IPV were more likely to have moderate to severe postpartum anxiety (n = 57, 28.9% of IPV-exposed women), compared to those without IPV (n = 65, 12.4% of unexposed women; p value < .001). Compared to women not reporting IPV, women exposed to any IPV showed a 38% increase in Postpartum Bonding Questionnaire scores, suggesting higher likelihood of impaired bonding (risk ratio [RR] = 1.38, 95% confidence interval [CI] [1.21, 1.56]). Among women who initiated breastfeeding later than 1 hr post-delivery, IPV was associated with impaired bonding (RR = 1.09, 95% CI [1.06, 1.20]), whereas no association was present for women who initiated breastfeeding within 1 hr (RR = 1.03, 95% CI [0.98, 1.08]). In addition to the efforts to reduce IPV, encouraging IPV-exposed women to adhere to the breastfeeding guidelines (e.g., early breastfeeding) may enhance maternal-infant bonding.

Impact of an intervention for perinatal anxiety on breastfeeding: findings from the Happy Mother-Healthy Baby randomized controlled trial in Pakistan

BACKGROUND

The study examined the effects of Happy Mother-Healthy Baby (HMHB), a cognitive-behavioural therapy (CBT) intervention on breastfeeding outcomes for Pakistani women with prenatal anxiety.

METHODS

Breastfeeding practices were evaluated in a randomized controlled trial between 2019 and 2022 in a public hospital in Pakistan. The intervention group was randomized to receive six HMHB sessions targeted towards prenatal anxiety (with breastfeeding discussed in the final session), while both groups also received enhanced usual care. Breastfeeding was defined in four categories: early breastfeeding, exclusive early breastfeeding, recent breastfeeding, and exclusive recent breastfeeding. Early breastfeeding referred to the first 24 h after birth and recent breastfeeding referred to the last 24 h before an assessment at six-weeks postpartum. Potential confounders included were mother's age, baseline depression and anxiety levels, stress, social support, if the first pregnancy (or not) and history of stillbirth or miscarriage as well as child's gestational age, gender. Both intent-to-treat and per-protocol analyses were examined. Stratified analyses were also used to compare intervention efficacy for those with mild vs severe anxiety.

RESULTS

Out of the 1307 eligible women invited to participate, 107 declined to participate and 480 were lost to follow-up, resulting in 720 women who completed the postpartum assessment. Both intervention and control arms were similar on demographic characteristics (e.g. sex, age, income, family structure). In the primary intent-to-treat analysis, there was a marginal impact of the intervention on early breastfeeding (OR 1.38, 95% CI: 0.99-1.92; 75.4% (N = 273) vs. 69.0% (N = 247)) and a non-significant association with other breastfeeding outcomes (OR1.42, 95% CI: 0.89-2.27; (47) 12.9% vs. (34) 9.5%, exclusive early breastfeeding; OR 1.48, 95% CI: 0.94-2.35; 90% (N = 327) vs. 86% (N = 309), recent breastfeeding; OR1.01, 95% CI: 0.76-1.35; 49% (N = 178) vs 49% (N = 175) exclusive recent breastfeeding). Among those who completed the intervention's six core sessions, the intervention increased the odds of early breastfeeding (OR1.69, 95% CI:1.12-2.54; 79% (N = 154) vs. 69% (N = 247)) and recent breastfeeding (OR 2.05, 95% CI:1.10-3.81; 93% (N = 181) vs. 86% (N = 309)). For women with mild anxiety at enrolment, the intervention increased the odds of recent breastfeeding (OR 2.41, 95% CI:1.17-5.00; 92% (N = 137) vs. 83% (N = 123).

CONCLUSIONS

The study highlights the potential of CBT-based interventions like HMHB to enhance breastfeeding among women with mild perinatal anxiety, contingent upon full participation in the intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03880032.

Effects of a prenatal anxiety randomized controlled trial intervention on infant development in Pakistan

OBJECTIVES

Given that infant development is influenced by caregiver mental health, we tested whether an intervention to reduce antenatal anxiety could affect infant development. A secondary aim was to test depressive symptoms, maternal responsiveness, and maternal infant bonding as mediators of this relationship.

METHODS

Between 2020 and 2022, pregnant women participated in a randomized controlled trial of the Happy Mother-Healthy Baby (HMHB) program based on cognitive behavioral therapy. We collected data on child development from 202 intervention and 198 control participants in a public hospital in Pakistan. Child development was measured using the Ages and Stages Questionnaires-Version 3 at six weeks postpartum. Using intent-to-treat analyses, we examined whether the intervention was associated with performance on the five ASQ-3 domains. Causal mediation analysis was used to assess depressive symptoms, bonding, and maternal-infant responsiveness as mediators.

RESULTS

Socio-demographic characteristics were evenly distributed between study arms. Intervention arm infants showed a 2.1-point increase (95% CI: 0.12, 4.17) in communication scores compared to controls. Though not achieving statistical significance, intervention infants also showed a 2.0-point increase (95% CI:-0.06, 4.09) in gross motor development performance. Bonding, depression, and responsiveness were mediators between the intervention and infant communication (Bindirect=1.94 (95%CI: 0.86, 3.25) depression; Bindirect=0.57 (95% CI: 0.09, 1.16) bonding; Bindirect=0.53 (95% CI: 0.01, 1.21) responsiveness; and Bindirect=1.94 (95%CI: 0.86, 3.25). Bonding, responsiveness, and depression mediated 25%, 23%, and 87% of the total association, respectively.

CONCLUSIONS

HMHB positively affected infant communication at six-week follow-up. Larger studies with longer follow-up are needed to confirm and extend these findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03880032; https://clinicaltrials.gov/ct2/show/NCT03880032.

The immune phenotype of perinatal anxiety in an anxiety-focused behavioral intervention program in Pakistan

BACKGROUND

Dysregulation of the immune system has been associated with psychiatric disorders and pregnancy-related complications, such as perinatal depression. However, the immune characteristics specific to perinatal anxiety remain poorly understood. In this study, our goal was to examine specific immune characteristics related to prenatal anxiety within the context of a randomized controlled trial designed to alleviate anxiety symptoms-the Happy Mother - Healthy Baby (HMHB) study in Rawalpindi, Pakistan.

MATERIALS AND METHODS

Pregnant women (n = 117) were followed prospectively in the 1st, 2nd, and 3rd trimesters (T1, T2, T3) and at 6 weeks postpartum (PP6). Each visit included a blood draw and anxiety evaluation (as measured by the anxiety subscale of the Hospital Anxiety and Depression Scale - HADS -using a cutoff ≥ 8). We enrolled both healthy controls and participants with anxiety alone; those with concurrent depression were excluded.

RESULTS

K-means cluster analysis revealed three anxiety clusters: Non-Anxiety, High and Consistent Anxiety, and Decreasing Anxiety. Principal components analysis revealed two distinct clusters of cytokine and chemokine activity. Women within the High and Consistent Anxiety group had significantly elevated chemokine activity across pregnancy (in trimester 1 (β = 0.364, SE = 0.178, t = 2.040, p = 0.043), in trimester 2 (β = 0.332, SE = 0.164, t = 2.020, p = 0.045), and trimester 3 (β = 0.370, SE = 0.179, t = 2.070, p = 0.040) compared to Non-Anxiety group. Elevated chemokine activity was associated with low birthweight (LBW) and small for gestational age (SGA).

CONCLUSION

Our findings reveal a unique pattern of immune dysregulation in pregnant women with anxiety in a Pakistani population and offer preliminary evidence that immune dysregulation associated with antenatal anxiety may be associated with birth outcomes. The dysregulation in this population is distinct from that in our other studies, indicating that population-level factors other than anxiety may play a substantial role in the differences found. (Clinicaltrials.gov # NCT04566861).

Results of a cognitive behavior therapy-based intervention for antenatal anxiety on birth outcomes in Pakistan: a randomized control trial

Antenatal anxiety is among the risk factors for adverse birth outcomes, which are common in Pakistan. Between 2019 and 2022, we conducted a randomized controlled trial to evaluate the effects of the Happy Mother-Healthy Baby program, designed to reduce anxiety during pregnancy through use of Cognitive Behavior Therapy, on birth outcomes with 796 women in Rwalpindi, Pakistan. We performed intent-to-treat analysis and per protocol analyses. Intention-to-treat analyses showed no difference in the odds of low birthweight (LBW) (Adj. OR = 0.82, 95% CI 0.55-1.28 p = 0.37), preterm birth (PTB) (Adj. OR = 1.20 95% CI 0.83-1.71, p = 0.33) or small-for-gestational age (SGA) birth, (Adj. OR = 0.76, 95% CI 0.56-1.09, p = 0.16). Among completers who received ≥ 5 intervention sessions, the odds of LBW and SGA were 39% and 32% lower (Adj. OR = 0.61, 95% CI 0.43-0.87, p < 0.01; Adj. OR = 0.68, 95% CI 0.53-0.89, p < 0.01). The significant LBW and SGA results among the intervention completers suggest that the program may be effective when a sufficient dose is received. However, confirmation of these findings is needed due to the fact that randomization is not maintained in completer analyses.Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03880032, 19/03/2019.

Family concerns and relationship problems in anxious pregnant women and their associations with postnatal functional disability in Pakistan

OBJECTIVE

Expanding on existing research suggesting that strategies to reduce prenatal anxiety can decrease functional disability (e.g., difficulties in performing everyday activities and social participation), we examined if this effect varied by type of anxiety-producing problem (i.e., having family concerns and relationship problems versus other problems) reported during pregnancy. Further, we explored if perceived social support mediated this relationship.

METHODS

We used longitudinal data on 310 anxious Pakistani women who received any psychosocial intervention sessions as part of a program that was based on Cognitive Behavioral Therapy. The Psychological Outcome Profiles (PSYCHLOPS) was used to assess whether women had 'family concerns and relationship problems' or 'other problems.' The WHO Disability Assessment Schedule 2.0 assessed functional disability at six-weeks after delivery. Lack of support was measured using a 12-item Multi-dimensional Scale of Perceived Social Support. We employed linear regression to examine associations between types of problems reported during pregnancy and postnatal functional disability. Causal mediation analysis was used to assess whether postnatal social support mediated this relationship.

RESULTS

Of anxious pregnant women, 34% reported family concerns or relationship problems as primary problems in pregnancy. They were more likely to report higher functional disability at six-weeks after delivery than women who reported other problems (adjusted B = 2.40, 95% CI: 0.83-3.97). Lack of overall social support (Estimateindirect = 0.69, 95% CI: 0.04-1.38) and lack of support from friends (Estimateindirect = 0.62, 95% CI: 0.01-1.29) significantly mediated the relationship.

CONCLUSIONS

Findings suggest that complementing pre- and post-natal care with support programs and services that address family concerns and relationship problems, as well as enhancing social support is important to functional disability.

Self-reported problems and functional difficulties in anxious pregnant women in Pakistan: The use of a patient-generated mental health outcome measure

Anxiety during pregnancy affects women worldwide and is highly prevalent in Pakistan. The Psychological Outcome Profiles (PSYCHLOPS) questionnaire is an instrument used in therapy to assess patient-generated problems and the consequent functional difficulties. Using the PSYCHLOPS, we aimed to describe the type of problems and the consequent functional difficulties faced by anxious pregnant women in Pakistan. Secondarily, we sought to explore if a cognitive behavioral therapy (CBT)-based intervention brought about changes in the severity score for certain problems or functional difficulties. Anxious pregnant women were recruited from the Obstetrics/Gynecology Department of a tertiary hospital in Rawalpindi, Pakistan. Of 600 pregnant women randomized to receive a psychosocial intervention for prenatal anxiety delivered by non-specialist providers, 450 received ≥1 intervention session and were administered the PSYCHLOPS. Eight types of problems were identified; worries about the unborn baby's health and development (23%), concerns about family members (13%), and financial constraints (12%) were the most frequently reported primary problems. Severity scores between baseline and the last available therapy session indicated the largest decrease for relationship problems (mean = 2.4) and for concerns about family members (mean = 2.2). For functional difficulties, 45% of the participants reported difficulties in performing household chores, but the intervention showed the greatest decrease in severity scores for mental or emotional functional difficulties. Focus on certain types of patient-generated problems, e.g., relationship problems, could anchor therapy delivery in order to have the greatest impact. Tailored CBT-based intervention sessions have the potential to address important but neglected problems and functional difficulties in anxious pregnant women.

Exploring preference for delivery methods for a psychosocial intervention for prenatal anxiety: A qualitative study from a tertiary care hospital in Pakistan

Objective

This qualitative study explores therapists' and participants' preferences for delivery methods (face-to-face and phone sessions) of a cognitive behavioral therapy-based psychosocial intervention for prenatal anxiety delivered in a tertiary care hospital.

Setting

The research was conducted in a randomized controlled trial in Pakistan, where a shift from face-to-face to phone-based therapy occurred during the coronavirus disease-2019 (COVID-19) pandemic.

Participants

Twenty in-depth interviews and a focus group discussion were conducted with participants and therapists, respectively. Transcripts were analyzed using thematic analysis.

Results

Participants generally preferred face-to-face sessions for rapport building, communication, and comprehension. However, barriers like venue accessibility, childcare, and lack of family support hindered engagement. Telephone sessions were favored for easy scheduling and the comfort of receiving the session at home, but there were challenges associated with phone use, distractions at home, and family members' limited mental health awareness. A mix of face-to-face and telephone sessions was preferred, with rapport from in-person sessions carrying over to telephone interactions.

Conclusion

This study underscores the need for adaptable intervention delivery strategies that consider cultural norms, logistical challenges, and individual family dynamics. By combining the benefits of both delivery methods, mental health interventions can be optimized to effectively address prenatal anxiety and promote well-being in resource-constrained settings like Pakistan.

Social Support and Spousal Relationship Quality Improves Responsiveness among Anxious Mothers

Maternal responsiveness, a mother's ability to consistently identify infant cues and then act on them, is critical for healthy child development. A woman's social support and spousal relationship may affect responsiveness to an infant, especially among mothers with anxiety. We assessed how social support and spousal relationship quality is associated with responsiveness among anxious mothers, and if postpartum depression (PPD) moderated these associations. Cross-sectional data were collected from 2019 to 2022 in a public hospital in Pakistan from 701 women at six-weeks postpartum. Eligible women had at least mild anxiety in early- to mid- pregnancy. Linear regression analyses assessed if spousal relationship quality and social support from family and friends were associated with maternal responsiveness, measured using the Maternal Infant Responsiveness Instrument. Interaction terms were used to examine if PPD moderated these associations. Spousal relationship quality (B = 2.49, 95% CI: 1.48, 3.50) and social support (B = 1.07, 95% CI: 0.31, 1.83) were positively related to maternal responsiveness to the infant. Emotional support from a spouse was positively associated with responsiveness (B = 1.08, 95% CI: 0.12, 2.03 depressed; B = 2.96, 95% CI: 1.34, 4.58 non-depressed), and conflict with the spouse was negatively associated with responsiveness (B=-1.02, 95% CI: -1.94, -0.09 depressed; B=-2.87, 95% CI: -4.36, -1.37 non-depressed). However, social support was related to responsiveness only in non-depressed women (B = 2.61, 95% CI: 1.14, 4.07). While spousal relationships and social support enhance maternal responsiveness, for depressed women, spousal relationships were particularly critical. In considering maternal-infant interventions to improve child development outcomes, our study indicates the importance of supportive relationships that foster effective responsiveness.

The Elephant in the Room: A Systematic Review of the Application and Effects of Psychological Treatments for Pregnant Women with Dual Pathology (Mental Health and Substance-Related Disorders)

PURPOSE

Maternal mental health and substance use, referred to as dual pathology, represent significant concerns associated with adverse pregnancy and birth outcomes, a prevalence higher than commonly anticipated. Nonetheless, a notable dearth exists ofevidence-based treatment protocols tailored for pregnant women with dual pathology.

METHODS

A systematic review, adhering to the PRISMA methodology, was conducted.

RESULTS

Out of the 57 identified papers deemed potentially relevant, only 2were ultimately included. Given the limited number of studies assessing the efficacy of psychological interventions utilizing randomized controlled trials (RCTs) for both mental health and substance misuse, and considering the diverse objectives and measures employed, definitive conclusions regarding the effectiveness of psychological interventions in this domain prove challenging.

CONCLUSIONS

Maternal mental health appears to be the proverbial "elephant in the room". The development of specialized and integrated interventions stands as an imperative to effectively address this pressing issue. As elucidated in the present review, these interventions ought to be grounded in empirical evidence. Furthermore, it is essential that such interventions undergo rigorous evaluation through RCTs to ascertain their efficacy levels. Ultimately, the provision of these interventions by psychology/psychiatric professionals, both within clinical practice and the RCTs themselves, is recommended to facilitate the generalizability of the results to specialized settings.

An investigation into the correlation between early-to-mid pregnancy exercise combined with cognitive behavioral therapy and anxiety levels and quality of life in patients

OBJECTIVE

The aim of this study was to investigate the effects of exercise combined with cognitive behavioral therapy (CBT) on anxiety and quality of life in pregnant women.

METHODS

This study adopted a prospective randomized controlled trial design, and divided 60 pregnant women in the first and second trimesters into two groups. The control group received routine prenatal education, and the experimental group added moderate exercise and CBT on the basis of routine prenatal education. All participants completed the Hamilton Anxiety Rating Scale (HARS) and World Health Organization Quality of Life-BREF (WHOQOL-BREF) at the start of the study (baseline) and at 6 weeks after the intervention.

RESULTS

Baseline data, scores on HARS, and scores on WHOQOL-BREF were found to be consistent among the two groups of patients prior to the intervention (all P > 0.05). Following the intervention, the implementation of exercise combined with CBT resulted in significant improvements in anxiety levels within the experimental group, particularly with respect to aspects such as anxious mood, tension, insomnia, cognitive function, cardiovascular symptoms, and gastrointestinal symptoms (all P < 0.05). Similarly, the combination of exercise and CBT led to significant enhancement in the quality of life in the experimental group, particularly in areas such as physical health, psychological health, and environmental factors (all P < 0.05). Nevertheless, no significant disparities were observed between the two groups in terms of fears, depressive mood, muscular and sensory somatic symptoms, respiratory symptoms, genitourinary symptoms, autonomic symptoms, behavior during the interview, and social relationships (all P > 0.05).

CONCLUSION

Exercise combined with CBT can effectively reduce the anxiety of pregnant women and improve their quality of life, which has important clinical significance for improving the mental health and quality of life of pregnant women in the first and second trimesters.

Anxiety-focused cognitive behavioral therapy delivered by non-specialists to prevent postnatal depression: a randomized, phase 3 trial

Anxiety experienced by women during pregnancy is highly prevalent, especially in resource-poor settings and strongly predicts postnatal common mental disorders (CMDs), anxiety and depression. We evaluated the effectiveness of an anxiety-focused early prenatal intervention on preventing postnatal CMDs. This study was a phase 3, two-arm, single-blind, randomized controlled trial conducted in Pakistan with women who were ≤22 weeks pregnant and had at least mild anxiety without clinical depression. Participants were randomized to the Happy Mother-Healthy Baby program, based on cognitive behavioral therapy, consisting of six one-on-one intervention sessions in pregnancy delivered by non-specialist providers, or to enhanced care alone. The primary outcome was major depression, generalized anxiety disorder or both at 6 weeks after delivery. Overall, 755 women completed postnatal assessments (380 (50.3%), intervention arm; 375 (49.7%) enhanced-care arm). The primary outcomes were met. Examined jointly, we found 81% reduced odds of having either a major depressive episode (MDE) or moderate-to-severe anxiety for women randomized to the intervention (adjusted odds ratio (aOR) = 0.19, 95% CI 0.14-0.28). Overall, 12% of women in the intervention group developed MDE at 6 weeks postpartum, versus 41% in the control group. We found reductions of 81% and 74% in the odds of postnatal MDE (aOR = 0.19, 95% CI 0.13-0.28) and of moderate-to-severe anxiety (aOR = 0.26, 95% CI 0.17-0.40), respectively. The Happy Mother-Healthy Baby program early prenatal intervention focusing on anxiety symptoms reduced postpartum CMDs. ClinicalTrials.gov identifier NCT03880032 .

Pregnancy stressors and postpartum symptoms of depression and anxiety: the moderating role of a cognitive-behavioural therapy (CBT) intervention

Background

Little is known about the association between stressors (especially positive stressors) during pregnancy and postpartum depression and anxiety.

Aims

We investigated the association between positive and negative stress events during different stages of pregnancy and postpartum mental health outcomes among low-income pregnant women with symptoms of anxiety in Pakistan and evaluated whether an intervention based on cognitive-behavioural therapy (CBT) had a regulatory effect.

Methods

Participants were 621 pregnant Pakistani women with mild anxiety. Using the Pregnancy Experience Scale-Brief Version, six scores were created to assess positive and negative stressors. We performed a multivariate linear regression to examine whether these six scores, measured both at baseline and in the third trimester, were associated with postpartum anxiety and depressive symptoms. The effect of the intervention on this relationship was examined by adding an interaction term to the regression model.

Results

Hassles frequency measured in the third trimester was positively associated with depression (B=0.22, 95% confidence interval (CI): 0.09 to 0.36) and anxiety (B=0.19, 95% CI: 0.08to 0.30). At the same timepoint, uplifts intensity was negatively associated with symptoms of depression (B=-0.82, 95% CI: -1.46 to -0.18) and anxiety (B=-0.70, 95% CI: -1.25 to -0.15), whereas hassles intensity was positively related to symptoms of depression (B=1.02, 95% CI: 0.36 to 1.67) and anxiety (B=0.90, 95% CI: 0.34 to 1.47). The intensity ratio of hassles to uplifts reported in the third trimester was positively related to both depression (B=1.40, 95% CI: 0.59 to 2.20) and anxiety (B=1.26, 95% CI: 0.57 to 1.96). The intervention strengthened the overall positive effects of uplifts and the negative effects of hassles. Pregnancy experiences at baseline during early pregnancy to mid-pregnancy were not associated with mental health outcomes.

Conclusions

Stressors in the third trimester but not earlier in pregnancy were associated with postpartum symptoms of anxiety and depression. The CBT intervention modified the association between pregnancy stressors and postpartum mental health outcomes. Programmes that promote positive experiences and reduce negative experiences, especially in late pregnancy, may mitigate postpartum mental health consequences.

Trial registration number

NCT03880032.

Perceived Social Support and Women's Empowerment and Their Associations with Pregnancy Experiences in Anxious Women: A Study from Urban Pakistan

OBJECTIVES

Psychological distress in pregnancy is associated with adverse postnatal outcomes. We aimed to identify how social support and women's empowerment are associated with pregnancy-specific daily experiences among women suffering antenatal anxiety in Pakistan.

METHODS

Data were collected as part of a randomized controlled trial of a psychosocial intervention for antenatal anxiety in a tertiary hospital in Pakistan. We included 594 women in early pregnancy (≤ 22 weeks) who endorsed mild to severe anxiety symptoms. Generalized linear regression models were used to analyze the associations of perceived social support and women's empowerment in relation to pregnancy-specific daily hassles and uplifts using a culturally adapted and psychometrically validated version of the Pregnancy Experience Scale-Brief.

RESULTS

High social support was positively associated with frequency and intensity of positive pregnancy-specific experiences (B = 0.39, 95% CI 0.23-0.54 uplifts frequency; and B = 0.17, 95% CI 0.12-0.22 uplifts intensity), and was inversely associated with frequency of negative pregnancy-specific experiences (B = - 0.44, 95% CI - 0.66, - 0.22). Women's household empowerment was associated with greater uplifts frequency and intensity (B = 0.55, 95% CI 0.20-0.90 frequency; and B = 0.28, 95% CI 0.17-0.40 intensity). High social support and household empowerment were inversely related to PES hassle-to-uplift ratio scores.

CONCLUSIONS FOR PRACTICE

Greater social support and household empowerment were associated with positive pregnancy-specific experiences in the context of antenatal anxiety in Pakistan.

Biological Mechanisms in Pregnant Women With Anxiety (Happy Mother-Healthy Baby Supplement Study): Protocol for a Longitudinal Mixed Methods Observational Study

BACKGROUND

Anxiety and depression are common in the perinatal period and negatively affect the health of the mother and baby. Our group has developed "Happy Mother-Healthy Baby" (HMHB), a cognitive behavioral therapy-based psychosocial intervention to address risk factors specific to anxiety during pregnancy in low- and middle-income countries (LMICs).

OBJECTIVE

The purpose of this study is to examine biological mechanisms that may be linked to perinatal anxiety in conjunction with a randomized controlled trial of HMHB in Pakistan.

METHODS

We are recruiting 120 pregnant women from the Holy Family Hospital, a public facility in Rawalpindi, Pakistan. Participants are assessed for at least mild anxiety symptoms using the Hospital Anxiety and Depression Scale (ie, a score ≥8 on the anxiety scale is necessary for inclusion in the anxiety groups and <8 for inclusion in the healthy control group). Women who meet the criteria for an anxiety group are randomized into either the HMHB intervention group or an enhanced usual care (EUC) control group. Participants receive HMHB or EUC throughout pregnancy and undergo blood draws at 4 time points (baseline, second trimester, third trimester, and 6 weeks post partum). We will assess peripheral cytokine concentrations using a multiplex assay and hormone concentrations using gas chromatography and mass spectrometry. The statistical analysis will use generalized linear models and mixed effects models to assess the relationships across time among anxiety, immune dysregulation, and hormone levels, and to assess whether these biological factors mediate the relationship between anxiety and birth and child development outcomes.

RESULTS

Recruitment started on October 20, 2020, and data collection was completed on August 31, 2022. The start date for recruitment for this biological supplement study was delayed by approximately half a year due to the COVID-19 pandemic. The trial was registered at ClinicalTrials.gov (NCT03880032) on September 22, 2020. The last blood samples were shipped to the United States on September 24, 2022, where they will be processed for analysis.

CONCLUSIONS

This study is an important addition to the HMHB randomized controlled trial of an intervention for antenatal anxiety. The intervention itself makes use of nonspecialist providers and, if effective, will represent an important new tool for the treatment of antenatal anxiety in LMICs. Our biological substudy is one of the first attempts to link biological mechanisms to antenatal anxiety in an LMIC in the context of a psychosocial intervention, and our findings have the potential to significantly advance our knowledge of the biological pathways of perinatal mental illness and treatment efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03880032; https://clinicaltrials.gov/ct2/show/NCT03880032.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43193.

Non-specialist-delivered psychosocial intervention for prenatal anxiety in a tertiary care setting in Pakistan: a qualitative process evaluation

OBJECTIVES

A manualised cognitive-behavioural therapy-based psychosocial intervention for prenatal anxiety called Happy Mother Healthy Baby is being tested for its effectiveness through a randomised control trial in Pakistan. The aim of this study was to evaluate the intervention delivery process and the research process.

DESIGN

Qualitative methods were used to explore in depth the intervention delivery and research process.

SETTING

This process evaluation was embedded within a randomised control trial conducted in a tertiary care facility in Rawalpindi, Pakistan.

PARTICIPANTS

Data were collected through in-depth interviews (n=35) with the trial participants and focus group discussions (n=3) with the research staff. Transcripts were analysed using a Framework Analysis.

RESULTS

The evaluation of the intervention delivery process indicated that it can be effectively delivered by non-specialist providers trained and supervised by a specialist. The intervention was perceived to be culturally acceptable and appropriately addressing problems related to prenatal anxiety. Lack of awareness of 'talking' therapies and poor family support were potential barriers to participant engagement. The evaluation of the research process highlighted that culturally appropriate consent procedures facilitated recruitment of participants, while incentivisation and family involvement facilitated sustained engagement and retention. Lack of women's empowerment and mental health stigma were potential barriers to implementation of the programme.

CONCLUSION

We conclude that non-specialists can feasibly deliver an evidence-based intervention integrated into routine antenatal care in a tertiary hospital. Non-specialist providers are likely to be more cost effective and less stigmatising. Inclusion of family is key for participant recruitment, retention and engagement with the intervention.

TRIAL REGISTRATION NUMBER

NCT03880032.

Cultural adaptation and psychometric validation of the Pregnancy Experience Scale–Brief version (PES-Brief) in Pakistani women with antenatal anxiety symptoms

Background

Pregnancy experiences influence fetal and birth outcomes. There is scarcity of locally validated tools to assess pregnancy experiences. We aimed to validate the Pregnancy Experience Scale-Brief (PES-Brief) in pregnant Pakistani women with anxiety symptoms.

Methods

A two-step process was used including 1) adaptation via translation/back-translation followed by cognitive interviewing with 10 participants and 2) factor analysis and validation with 605 women in Rawalpindi Pakistan who had mild-moderate symptoms of anxiety, attended the antenatal clinic, and were ≤22 weeks of gestation and ≥18 years old. We calculated internal consistency and reliability and conducted exploratory and confirmatory factor analyses.

Results

Cultural adaptation led to inclusion of one item of the hassles subscale and exclusion of one item in the uplifts subscale, resulting in 9 uplifts and 11 hassles. Exploratory factor analysis supported a two-factor structure, with the adapted items exhibiting loading values of ≥0.24 for their respective factors. Internal consistency was demonstrated for uplifts (Cronbach's alpha = 0.89) and hassles (Cronbach's alpha = 0.85) subscales. Uplift intensity was moderately correlated with the Hospital Anxiety and Depression Scale anxiety subscale (r = 0.54, 95% CI:0.30-0.77).

Conclusion

The Urdu PES-Brief is a reliable and valid tool for use in Pakistani pregnant women with antenatal anxiety. Future studies on its validity are needed on women without symptoms anxiety.

'Those whom I have to talk to, I can't talk to': Perceived social isolation in the context of anxiety symptoms among pregnant women in Pakistan

Anxiety during pregnancy is highly prevalent in low- and middle-income countries. The relative importance of different sources and types of perceived support in the Pakistani context is unknown. We explored social support during pregnancy and the role of social isolation in Pakistani women's experiences of antenatal anxiety. We conducted semi-structured interviews with 19 pregnant women with symptoms of anxiety and 10 female healthcare providers at a public urban hospital. We used inductive and deductive thematic coding to analyse the data. Many pregnant women reported feelings of physical and social isolation, even when living in joint families with larger social networks. Often fearing censure by their in-laws and peers for sharing or seeking help with pregnancy-related anxieties, women reported relying on husbands or natal family members. Normative expectations around pregnancy such as male gender preference, perceived immutability of wives' domestic responsibilities and expectations of accompanied travel by women may serve as sources of disconnectedness in the antenatal period. Providers viewed social isolation and deficits in social support during pregnancy as contributing to worse anxiety symptoms, reduced access to care and poorer health behaviours. One limitation is that the hospital setting for this study may have resulted in underreporting of abuse or neglect and limited inclusion of pregnant women who do not utilise facility-based antenatal care. In conclusion, husbands and natal families were key in reducing social isolation in pregnancy and mitigating anxiety, while in-laws did not always confer support. Targeted strategies should enhance existing support and strengthen in-law family relationships in pregnancy.

Maternal mental health of adolescent mothers: a cross-sectional mixed-method study protocol to determine cultural and social factors and mental health needs in Lilongwe, Malawi

INTRODUCTION

Adolescence marks a transition of life from childhood to adulthood. Becoming a mother during adolescence presents unique challenges that have a significant mental and physical burden and may increase the likelihood of developing common mental disorders (CMDs). Untreated CMDs have serious effects on both the mother and her child. Culture constitutes an important context for most experiences, and affects how individuals seek help. However, there is limited research that has investigated how culture and social factors influence the adolescent mother's mental health during the postpartum period in Malawi.

METHODS/DESIGN

A cross-sectional sequential mixed methods design will be carried out in four phases. Phase one will include the preparatory phase and scoping review. The second phase will comprise a survey with adolescent mothers. The sample for the survey consists of adolescent postpartum mothers aged 14-19 years (with infants of up to 6 months of age) who have the capacity to consent for the study. Phase three will be a qualitative study in which in-depth interviews and focus group discussions will be employed to collect data from health workers and informal healthcare providers in the community (eg, traditional healers, traditional birth attendants). The fourth phase will involve developing recommendations for policy and practice ETHICS AND DISSEMINATION: This study will provide an understanding of the impact of culture and social factors that influence adolescent mother's mental health and well-being, including the identification of potential risk and protective factors. The findings will inform recommendations for an appropriate, culturally accepted spectrum of interventions, including universal, selective and indicated prevention strategies. The findings will be disseminated to stakeholders working in maternal health in Malawi. Ethical approval was received from the Curtin University Human Research Ethics Committee (HRE2021-0223) and (P.05/21/575) Malawian Ethics Board National Committee on Research Ethics in the Social Sciences and Humanities.

Effect of short-term psychological intervention on anxiety of pregnant women with positive screening results for chromosomal disorders: a randomized controlled trial

BACKGROUND AND AIM

Prenatal diagnosis of fetal abnormalities is a critical and stressful event for women. Most pregnant women are concerned about fetal abnormalities and screening tests. Due to the importance of anxiety reduction in pregnant women, this study was conducted to determine the effect of short-term psychological intervention on the anxiety of pregnant women with positive screening results for chromosomal disorders.

METHODS

A randomized clinical trial was performed on women referred to Akbarabadi Hospital in Tehran, Iran, who had positive screening results for chromosomal abnormalities. Participants were selected from eligible individuals by a continuous method and were assigned to two groups of cognitive-behavioral training (n = 46) and control (n = 46), using the block balanced randomization method. Participants in the cognitive-behavioral training group received 4 sessions of individual counseling. The control group received routine pregnancy visits. The Spielberger State-Trait Anxiety Inventory was completed before the intervention and immediately at the end of the intervention (before receiving the amniocentesis result). The analysis of intervention effects was performed as intention-to-treat and per-protocol analysis.

RESULTS

There was a statistically significant difference in post-intervention state anxiety scores and trait anxiety scores (p <  0.001) between the intervention and control groups, when their means were adjusted for pre-intervention scores for both intention-to-treat and per-protocol analysis. Also, there was a large effect size between the groups in terms of state (ITT: ηp2 = 0.63, PP: ηp2 = 0.71) and trait (ITT: ηp2 = 0.72, PP: ηp2 = 0.75) anxiety scores clinically for both intention-to-treat and per-protocol analysis. The intervention group had a statistically significant and large decrease in state and trait anxiety scores from pretrial to post-trial. In contrast, the control group had a statistically significant and medium increase in state and trait anxiety scores from pretrial to post-trial.

CONCLUSION

The results showed that cognitive-behavioral training reduced the anxiety of pregnant women with positive screening results for chromosomal disorders. According to the results, it is recommended to hold cognitive-behavioral training classes to reduce the anxiety of pregnant women with a positive screening result for chromosomal disorders.

TRIAL REGISTRATION

IRCT.ir: IRCT20180427039436N7 ; date of registration: 24/08/2020 2020-08-24.

"Efficacy of Cognitive Behavioral Therapy in Post-traumatic Stress Disorder Among Spinal Cord Injury Patients: A Randomized Controlled Pilot Study"

"Post-Traumatic Stress Disorder (PTSD) develops after exposure to or witnessing traumatic events. PTSD is very common among the Spinal Cord Injury (SCI) patients. PTSD can be successfully treated with the Cognitive Behavioral Therapy (CBT). However, CBT is mostly used in the western countries, so its efficacy in the eastern culture is still not fully known. Keeping this in view, the current study has determined the efficacy of CBT in the treatment of PTSD among the SCI patients in Pakistan. Using a Randomized Controlled Pilot Study design, data were collected through the Clinician-Administered PTSD Scale for DSM-5 from thirty patients admitted to the Paraplegic Center. Trauma-focused CBT(TF-CBT) protocol was applied through fourteen sessions. Data were analyzed by descriptive and multivariate statistics. Findings show that the level of PTSD symptoms gradually decreased from high at baseline (CAPS-5 Mean Scores μ= 3.6) to low during follow-up stage (CAPS-5 Mean Scores μ= 0.89). Results obtained from the present study on the efficacy of CBT are in concurrence with the research findings in other countries. This study supports the efficiency CBT intervention among Pakistani patients who had developed PTSD symptoms after suffering from SCI. Therefore, CBT can be widely used in the management of PTSD in Pakistan."

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS

PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

The Impact of the COVID-19 Pandemic on Pregnant Women with Perinatal Anxiety Symptoms in Pakistan: A Qualitative Study

The impact of coronavirus disease 2019 (COVID-19) on people with existing mental health conditions is likely to be high. We explored the consequences of the pandemic on women of lower socioeconomic status with prenatal anxiety symptoms living in urban Rawalpindi, Pakistan. This qualitative study was embedded within an ongoing randomized controlled trial of psychosocial intervention for prenatal anxiety at a public hospital in Rawalpindi. The participants were women with symptoms of anxiety who had received or were receiving the intervention. In total, 27 interviews were conducted; 13 women were in their third trimester of pregnancy, and 14 were in their postnatal period. The data were collected through in-depth interviews and analyzed using framework analysis. Key findings were that during the pandemic, women experienced increased perinatal anxiety that was linked to greater financial problems, uncertainties over availability of appropriate obstetric healthcare, and a lack of trust in health professionals. Women experienced increased levels of fear for their own and their baby's health and safety, especially due to fear of infection. COVID-19 appears to have contributed to symptoms of anxiety in women already predisposed to anxiety in the prenatal period. Efforts to address women's heightened anxiety due to the pandemic are likely to have public health benefits.

Resilience mediates the effect of self-efficacy on symptoms of prenatal anxiety among pregnant women: a nationwide smartphone cross-sectional study in China

Background

Prenatal anxiety is one of the most prevalent mental disorders during pregnancy. This study assessed the prevalence of prenatal anxiety and examined whether resilience could play the mediating role in the association between self-efficacy and symptoms of prenatal anxiety among pregnant women in China.

Methods

A nationwide smartphone cross-sectional study was carried out in three cities (Shenyang of Liaoning Province, Zhengzhou of Henan Province and Chongqing Municipality) in China from July 2018 to July 2019. The questionnaire consisted of questions on demographic characteristics, the Generalized Anxiety Disorder Scale (GAD-7), the Chinese version of General Self-efficacy Scale (GSES), and the 14-item Wagnild and Young Resilience Scale (RS-14). A total of 665 pregnant women were recruited in this study. A hierarchical multiple regression model was employed to explore the associate factors and mediators of symptoms of prenatal anxiety. A structural equation model was employed to test the hypothesis that resilience mediates the association between self-efficacy and symptoms of prenatal anxiety.

Results

The prevalence of symptoms of prenatal anxiety was 36.4% in this study. Self-efficacy was negatively correlated with symptoms of prenatal anxiety (r = -0.366, P < 0.01). Resilience had a significant positive correlation with self-efficacy (r = 0.612, P < 0.01) and had a negative correlation with symptoms of prenatal anxiety (r = -0.427, P < 0.01). The hierarchical multiple regression model indicated that self-efficacy and resilience were the main factors associated with symptoms of prenatal anxiety and contributed to 11.9% and 6.3% to the variance of symptoms of prenatal anxiety, respectively. Resilience served as a mediator between self-efficacy and symptoms of prenatal anxiety (a*b = -0.198, Bias-corrected and accelerated bootstrap 95% Confidence interval: -0.270, -0.126).

Conclusions

Self-efficacy was a negative predictor of symptoms of prenatal anxiety among pregnant women. Moreover, resilience mediated the relation between self-efficacy and symptoms of prenatal anxiety among pregnant women in China. It was observed in this study that psychological interventions might be beneficial for pregnant women to relieve symptoms of prenatal anxiety through improved self-efficacy and resilience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03911-5.

Intersections between patient-provider communication and antenatal anxiety in a public healthcare setting in Pakistan

This study explores pregnant women’s and healthcare providers’ perspectives on the role of patient-provider communication in experiences of antenatal anxiety within a low-resource setting. In 2017–18, we consecutively sampled pregnant women (n = 19) with at least mild anxiety and purposively sampled antenatal care providers (n = 10) from a public hospital in Punjab Province, Pakistan. We then conducted in-depth interviews and thematically coded them with a combination of inductive and deductive coding methodologies. We found that patients expressed a desire for warm, empathetic communication from providers who demonstrate respect, attentiveness, and a shared lived experience. Providers revealed an awareness that their heavy caseloads, high stress levels, and discourteous tones adversely influenced communication with pregnant women and may exacerbate their anxieties, but also reported that compassionately addressing women’s concerns, providing financial problem-solving and/or assistance, and moderating conflicting healthcare desires between patients and their families could alleviate anxiety in pregnant women. Patients reported feelings of anxiety stemming from a belief that they received lower quality communication from antenatal providers at public hospitals than patients received from antenatal providers at private hospitals, an experience that they partially attributed to their low socioeconomic status. Meanwhile, some providers disclosed potentially stigmatizing views of women from particular sociocultural backgrounds or low socioeconomic status, including perceptions that appeared to shape communication with these patients in antenatal care encounters. Our findings provide preliminary evidence that communication between pregnant women and antenatal providers that is warm, normalizes patient fears, and integrates patients’ interpersonal and financial considerations can mitigate pregnant women’s experiences of anxiety and reduce barriers to accessing antenatal care in Pakistan’s public healthcare facilities.

"A Woman Is a Puppet." Women's Disempowerment and Prenatal Anxiety in Pakistan: A Qualitative Study of Sources, Mitigators, and Coping Strategies for Anxiety in Pregnancy

Common mental disorders are highly prevalent among pregnant women in low- and middle-income countries, yet prenatal anxiety remains poorly understood, particularly in the sociocultural context of South Asia. Our study explored sources, mitigators, and coping strategies for anxiety among symptomatic pregnant women in Pakistan, particularly in relation to autonomy in decision-making and social support. We interviewed 19 pregnant married women aged 18-37 years recruited from 2017-2018 at a public hospital in Rawalpindi who screened positive for anxiety. Thematic analysis was based on both inductive emergent codes and deductive a priori constructs of pregnancy-related empowerment. Gender norms emerged as an important dimension of Pakistani women's social environment in both constraining pregnancy-related agency and contributing to prenatal anxiety. Women's avenues of self-advocacy were largely limited to indirect means such as appeals to the husband for intercession or return to her natal home. The levels of autonomy during pregnancy depended on the area of decision-making, and peer/family support was a critical protective factor and enabling resource for maternal mental health. Women's disempowerment is a key contextual factor in the sociocultural experience of prenatal maternal anxiety in South Asia, and further examination of the intersections between empowerment and perinatal mental illness might help inform the development of more context-specific preventive approaches.