Prenatal Maternal Anxiety as a Risk Factor for Preterm Birth and the Effects of Heterogeneity on This Relationship: A Systematic Review and Meta-Analysis

Impact of unplanned pregnancy on neonatal outcomes: findings of new high-risk newborns in Peru

BACKGROUND

Unplanned pregnancy is a significant public health problem, especially in low- to middle-income countries. The objective of this study was to determine the neonatal outcomes associated with unplanned pregnancy in a public hospital in southern Peru.

METHODS

A cross-sectional analytical study was conducted from June to August 2021 among 306 mothers and their newborns selected by convenience sampling. After obtaining informed consent, mothers were surveyed during their postpartum hospitalization about their pregnancy intentions. Unintended pregnancy was considered when it was mistimed or unwanted. Neonatal outcomes were assessed by reviewing medical records prior to discharge, evaluating the presence of low birth weight, insufficient birth weight, prematurity, respiratory distress syndrome, sepsis and neonatal mortality. Association was measured in terms of prevalence ratio (PR) and beta coefficient and respective 95% CIs, crude and adjusted for variables that obtained a value of p<0.20 in the crude model (maternal age, education and parity).

RESULTS

The overall unplanned pregnancies rate was 65%, of which 40.5% were mistimed pregnancies and 24.5% unwanted pregnancies. Unplanned and mistimed pregnancies were significantly associated with insufficient birth weight [adjusted prevalence ratio (aPR)=2.14; 95% CI 1.01 to 4.56 and aPR=2.43; 95% CI 1.09 to 5.39, respectively] and unwanted pregnancies were significantly associated with preterm birth (aPR=3.49; 95% CI 1.01 to 12.11). Furthermore, adjusted analysis showed that birth weight and gestational age were lower in unplanned, mistimed and unwanted pregnancies.

CONCLUSIONS

Unplanned pregnancy was associated with lower birth weight and shorter gestational age of newborns. These data collected in a public hospital in a developing country may have significant implications today. If pregnancy intention is not included as a neonatal risk factor, insufficient birth weight and preterm birth could increase because a higher proportion of births will be unplanned.

The Pregnancy Tele-yoga Module to Combat Stress, Anxiety, and Depression Associated with Pregnancy: An Exploratory Open-label Multicentric Study

Purpose

Untreated stress, anxiety, and depression during the perinatal period can lead to adverse maternal and infant outcomes. Yoga, the practice of body-mind-spirit techniques has been shown to reduce stress, anxiety, and depression.

Aims

The aim of the study was to examine the feasibility and limited efficacy of the 4-week practice of pregnancy tele-yoga module (PTYM) delivered and monitored through an online platform.

Methodology

A multicentric, open-label, exploratory study was conducted in the antenatal clinics (ANCs) of three tertiary care hospitals in India. Pregnant women between 13 and 32 weeks of gestation were invited to participate. PTYM was taught by the trained research staff. A YouTube link demonstrating the PTYM developed by the researchers was shared with consenting participants. Using the Yoga Performance Assessment (YPA), research staff monitored the online performance of the PTYM. Pre- and postintervention, women were assessed using the Depression, Anxiety, and Stress Scale-21 (DASS-21).

Results

Preintervention, among 162 consented pregnant women, anxiety (62.34%) was the most common mental health condition, followed by stress (55.55%) and depression (45.67%). YPA at the end of week 1, week 2, week 3, and week 4 was 19.45, 21.35, 24.15, and 28.45, respectively. Postintervention anxiety, stress, and depression persisted in 19.78%, 11.44%, and 10.41% of women. Pregnant women with stress (DASS-21 ≥15; n = 90), anxiety (DASS-21 ≥8; n = 101), and depressive (DASS-21 ≥10; n = 74) symptoms after undergoing 4 weeks of PTYM reported significant reduction in the scores.

Conclusion

The current study demonstrated the feasibility and limited efficacy of PTYM in ANCs of a tertiary care hospital in India.

Epigenome-wide association studies of prenatal maternal mental health and infant epigenetic profiles: a systematic review

Prenatal stress and poor maternal mental health are associated with adverse offspring outcomes; however, the biological mechanisms are unknown. Epigenetic modification has linked maternal health with offspring development. Epigenome-wide association studies (EWAS) have examined offspring DNA methylation profiles for association with prenatal maternal mental health to elucidate mechanisms of these complex relationships. The objective of this study is to provide a comprehensive, systematic review of EWASs of infant epigenetic profiles and prenatal maternal anxiety, depression, or depression treatment. We conducted a systematic literature search following PRISMA guidelines for EWAS studies between prenatal maternal mental health and infant epigenetics through May 22, 2023. Of 645 identified articles, 20 fulfilled inclusion criteria. We assessed replication of CpG sites among studies, conducted gene enrichment analysis, and evaluated the articles for quality and risk of bias. We found one repeated CpG site among the maternal depression studies; however, nine pairs of overlapping differentially methylatd regions were reported in at least two maternal depression studies. Gene enrichment analysis found significant pathways for maternal depression but not for any other maternal mental health category. We found evidence that these EWAS present a medium to high risk of bias. Exposure to prenatal maternal depression and anxiety or treatment for such was not consistently associated with epigenetic changes in infants in this systematic review and meta-analysis. Small sample size, potential bias due to exposure misclassification and statistical challenges are critical to address in future efforts to explore epigenetic modification as a potential mechanism by which prenatal exposure to maternal mental health disorders leads to adverse infant outcomes.

Node embedding-based graph autoencoder outlier detection for adverse pregnancy outcomes

Adverse pregnancy outcomes, such as low birth weight (LBW) and preterm birth (PTB), can have serious consequences for both the mother and infant. Early prediction of such outcomes is important for their prevention. Previous studies using traditional machine learning (ML) models for predicting PTB and LBW have encountered two important limitations: extreme class imbalance in medical datasets and the inability to account for complex relational structures between entities. To address these limitations, we propose a node embedding-based graph outlier detection algorithm to predict adverse pregnancy outcomes. We developed a knowledge graph using a well-curated representative dataset of the Emirati population and two node embedding algorithms. The graph autoencoder (GAE) was trained by applying a combination of original risk factors and node embedding features. Samples that were difficult to reconstruct at the output of GAE were identified as outliers considered representing PTB and LBW samples. Our experiments using LBW, PTB, and very PTB datasets demonstrated that incorporating node embedding considerably improved performance, achieving a 12% higher AUC-ROC compared to traditional GAE. Our study demonstrates the effectiveness of node embedding and graph outlier detection in improving the prediction performance of adverse pregnancy outcomes in well-curated population datasets.

Changes in preterm and extremely preterm birth rates in Japan after the introduction of obstetrical practice guidelines in 2008

AIM

Obstetrical guidelines were established in Japan in 2008, and obstetrical diagnoses and treatments were subsequently standardized nationally. We examined changes in the preterm birth rate (PTBR) and extremely preterm birth rate (EPTBR) following the introduction of such guidelines.

METHODS

Information on 50 706 432 live births in Japan between 1979 and 2021, including Japanese reproductive medicine, the childbearing age of pregnant women, and the employment status of reproductive-age women between 2007 and 2020, were obtained from the Japanese government and academic societies. Regression analysis was used to compare chronological changes nationally and those of eight Japanese regions. Regional and national average PTBRs and EPTBRs from 2007 to 2020 were compared by using a repeated measures analysis of variance.

RESULTS

From 1979 to 2007, PTBRs and EPTBRs in Japan increased significantly. However, from 2008, the national PTBR and EPTBR decreased until 2020 (p < 0.001) and 2019 (p = 0.02), respectively. From 2007 to 2020, overall PTBR and EPTBR were 5.68% and 0.255%, respectively. A significant difference in the PTBR and EPTBR existed between the eight Japanese regions. During this period, the number of pregnancies using assisted reproductive technology increased from 19 595 to 60 381, pregnant women became older, the employment rate of those of reproductive age increased, and nonregular employment was 54%, which was 2.5 times higher than for men.

CONCLUSIONS

In Japan, after obstetrical guidelines were enacted in 2008, PTRBs decreased significantly even under the pressure of increasing preterm births. Countermeasures may be necessary for regions showing high PTBRs.

Evaluation of factors related to maternal anxiety during pregnancy among women referred to Tabriz primary care centers

BACKGROUND

Maternal anxiety during pregnancy is sometimes considered a normal mechanism to overcome the mother's mental preoccupation with having a child. However, stress and anxiety might become a medical condition, becoming so severe as to affect the mother's mental health. Therefore, the present study aimed to investigate factors related to maternal anxiety during pregnancy in women referring to prenatal primary care centers in Tabriz.

METHODS

The target population in the present cross-sectional study was the pregnant women referring to primary care centers affiliated with Tabriz University of Medical Sciences in 2018-2019 (n = 533). Sampling was carried out using the random cluster technique (separately for municipal centers). The data were collected using the study tools, including a questionnaire on demographic data, prenatal anxiety screening scale (PASS), and researcher-made questions on maternal anxiety during pregnancy.

RESULTS

In the present study, 37.5% of pregnant women had anxiety. Of all the demographic and background variables, income (P = 0.015), a history of preterm delivery (P = 0.018), and unintended pregnancy (P = 0.022) were significantly related to anxiety. Of the variables of income, a history of preterm delivery, and unintended pregnancy in the regression model, the odds of anxiety were 41% lower in pregnant women with somewhat adequate income than those with inadequate income after correcting for other variables (P = 0.011). In addition, the variable of unintended pregnancy increased the odds of anxiety up to 49% after correcting for other variables (P = 0.023).

CONCLUSION

The present study showed that income and unintended pregnancy significantly affect maternal anxiety during pregnancy.

TRIAL REGISTRATION

The protocol of the study was approved by the Ethics Committee of Tabriz University of Medical Sciences under the code (IR.TBZMED.REC.1398.161).

Giving Birth in the Early Phases of the COVID-19 Pandemic: The Patient Experience

Objective

Obstetrical patients are at risk of complications from COVID-19 and face increased stress due to the pandemic and changes in hospital birth setting. The objective was to describe the perinatal care experiences of obstetrical patients who gave birth during the early phases of the COVID-19 pandemic.

Methods

A descriptive epidemiological survey was administered to consenting patients who gave birth at The Ottawa Hospital (TOH) between March 16th and June 16th, 2020. The participants reported on prenatal, in-hospital, and postpartum care experiences. COVID-19 pandemic related household stress factors were investigated. Frequencies and percentages are presented for categorical variables and median and interquartile range (IQR) for continuous variables.

Results

A total of 216 participants were included in the analyses. Median participants age was 33 years (IQR: 30–36). Collectively, 94 (43.5%) participants felt elevated stress for prenatal appointments and 105 (48.6%) for postpartum appointments because of COVID-19. There were 108 (50.0%) were scared to go to the hospital for delivery, 97 (44.9%) wore a mask during labour and 54 (25.0%) gave birth without a support person. During postpartum care, 125 (57.9%) had phone appointments (not offered prior to COVID-19), and 18 (8.3%) received no postpartum care at all.

Conclusion

COVID-19 pandemic and public health protocols created a stressful healthcare environment for the obstetrical population where many were fearful of accessing services, experienced changes to standard care, or no care at all. As the pandemic continues, careful attention should be given to the perinatal population to reduce stress and improve continuity of care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-022-03495-2.

Is it Necessary to Evaluate Fear of Childbirth in Pregnant Women? A Scoping Review

OBJECTIVE

 To review concepts, definitions, and findings about fear of childbirth (FOC).

METHODS

 A bibliographic review was carried out through the main scientific databases in 2020.

RESULTS

 All 32 articles considered potentially relevant were analyzed. A recent study suggests that the global prevalence of FOC can reach up to 14%. Factors such as parity, gestational age, previous birth experience, age and nationality of the woman seem to influence FOC.

CONCLUSION

 Fear of childbirth could be related to an increased risk of adverse obstetric outcomes such as maternal request for cesarean delivery, preterm birth, prolonged labor, postpartum depression, and post-traumatic stress. These evidence highlight the importance of the discussion regarding this topic.

Maternal adverse childhood experiences and their association with preterm birth: secondary analysis of data from universal health visiting

Background

Being born before full gestation can have short-term and life-long health implications, yet it remains difficult to determine the risk of preterm birth among expectant mothers. Across different health settings, increasing attention is given to the health and behavioural consequences of adverse childhood experiences (ACEs) such as child abuse or neglect, or exposure to harmful household environments (e.g. in which caregivers abuse alcohol), and the potential value of understanding these hidden harms when supporting individuals and families. A large international evidence base describes the association between childhood adversity and early years outcomes for mothers and children. However, the relationship between maternal ACEs and preterm birth has received far less attention.

Methods

Secondary analysis was carried out on anonymised cross-sectional data from health visiting services in south and west Wales that had previously captured information on mothers’ ACEs during routine contacts. Demographic data and information on mothers’ health were extracted from the Healthy Child Wales Programme.

Results

Half of all mothers sampled had experienced at least one ACE, with a history of ACEs more common among younger, white British mothers and those residing in deprived areas. Preterm birth was significantly independently associated with retrospective reports of childhood sexual abuse (adjusted odds ratio [AOR] = 3.83, 95% confidence interval [CI] = 1.19–12.32, p = 0.025), neglect (AOR = 7.60, 95%CI = 1.81–31.97, p = 0.006) and overall ACE exposure (AOR = 2.67, 95%CI = 1.14–6.23, p = 0.024), with one in ten mothers (10.0%) who experienced ≥4 ACEs having preterm birth. Sub-analyses revealed a more pronounced relationship among mothers with no known chronic health conditions, with those with ≥4 ACEs and no known chronic condition four times more likely to give birth preterm (AOR = 3.89, 95%CI = 1.40–10.80, p = 0.009).

Conclusions

Findings highlight the importance of the entire maternal experience. The experience of childhood adversity can have a lasting impact into and beyond the prenatal period, potentially increasing the risk of preterm birth, even among otherwise healthy women. Increasing our understanding of the potential perinatal outcomes associated with ACEs can help to inform how maternity services and partners offer trauma-sensitive support to mitigate some of the risks of early parturition, as well as target intergenerational cycles of adversity and poor health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04454-z.

PredictPTB: an interpretable preterm birth prediction model using attention-based recurrent neural networks

BACKGROUND

Early identification of pregnant women at risk for preterm birth (PTB), a major cause of infant mortality and morbidity, has a significant potential to improve prenatal care. However, we lack effective predictive models which can accurately forecast PTB and complement these predictions with appropriate interpretations for clinicians. In this work, we introduce a clinical prediction model (PredictPTB) which combines variables (medical codes) readily accessible through electronic health record (EHR) to accurately predict the risk of preterm birth at 1, 3, 6, and 9 months prior to delivery.

METHODS

The architecture of PredictPTB employs recurrent neural networks (RNNs) to model the longitudinal patient's EHR visits and exploits a single code-level attention mechanism to improve the predictive performance, while providing temporal code-level and visit-level explanations for the prediction results. We compare the performance of different combinations of prediction time-points, data modalities, and data windows. We also present a case-study of our model's interpretability illustrating how clinicians can gain some transparency into the predictions.

RESULTS

Leveraging a large cohort of 222,436 deliveries, comprising a total of 27,100 unique clinical concepts, our model was able to predict preterm birth with an ROC-AUC of 0.82, 0.79, 0.78, and PR-AUC of 0.40, 0.31, 0.24, at 1, 3, and 6 months prior to delivery, respectively. Results also confirm that observational data modalities (such as diagnoses) are more predictive for preterm birth than interventional data modalities (e.g., medications and procedures).

CONCLUSIONS

Our results demonstrate that PredictPTB can be utilized to achieve accurate and scalable predictions for preterm birth, complemented by explanations that directly highlight evidence in the patient's EHR timeline.

Determinants of Pregnancy-Related Anxiety among Women Attending Antenatal Checkup at Public Health Institutions in Debre Markos Town, Ethiopia

BACKGROUND

Pregnancy-related anxiety has been associated with many pregnancy adverse outcomes including preterm birth, low birth weight, postpartum depression, and resulting in long-term sequels on the child's emotional, cognitive, and behavioral development. This study is aimed at assessing the magnitude of pregnancy-related anxiety and associated factors among pregnant women attending antenatal checkup at Debre Markos town public health institutions, Northwest Ethiopia.

METHODS

An institution-based cross-sectional study was conducted among 423 pregnant women at Debre Markos town, Northwest Ethiopia, from February 1^st to March 30^th, 2021. A systematic random sampling technique was used to select the study participants. Data were collected sing a structured, pretested, and interviewer-administered questionnaire. The collected data were entered with Epi-data version 4.6 and then exported to SPSS version 23. Both bivariable and multivariable logistic regression analyses were undertaken to identify significantly associated variables with pregnancy-related anxiety. The adjusted odds ratio (AOR) with its 95% confidence interval (CI) at a p value of ≤0.05 was used to claim statistical association.

RESULT

In this study, a total of 408 pregnant women participated, giving a 96.4% response rate. The prevalence of pregnancy-related anxiety was found to be 43.9% (95% CI: 39.5, 49.2). Having no formal education (AOR = 3.37; 95% CI: 1.32, 8.58), primigravida (AOR = 1.94; 95% CI: 1.17, 3.24), intimate partner violence (AOR = 2.88; 95% CI: 1.47, 5.64), and poor social support (AOR = 2.05; 95% CI: 1.18, 3.56) was significantly associated with pregnancy-related anxiety.

CONCLUSION

In this study, the prevalence of pregnancy-related anxiety was found to be high when compared to other study findings. The regional educational department should give emphasis for gender pedagogies which pay attention to the specific learning needs of girls. In addition, interventions on violence against women and social support for the women may reduce the problem.

Factors associated with pregnancy-related anxiety among pregnant women attending antenatal care follow-up at Bedelle general hospital and Metu Karl comprehensive specialized hospital, Southwest Ethiopia

Pregnancy-related anxiety (PRA) is an anxiety related to the pregnancy, involving labor and delivery, the well-being of the fetus/infant and the mother, the availability of quality of healthcare resources, and the capacity to parent. There is scarcity of study conducted on magnitude of Pregnancy-related anxiety and its associated factors among pregnant women in Ethiopia. The main objective of this research was to assess factors associated with Pregnancy-related anxiety among pregnant women attending ANC follow-up at Bedelle general and Metu Karl comprehensive specialized hospitals, Southwest Ethiopia. A hospital-based cross-sectional study design was used among pregnant women attending ANC follow-up. Data were collected from 406 sampled pregnant women who were selected through a systematic random sampling technique. Pregnancy-Related Anxiety Questionnaire-Revised (PRAQ-R2) was used to measure the outcome variable. The collected data were analyzed using Statistical Package for Social Sciences (SPSS) version 26. Logistic regression analyses were done to identify factors associated with Pregnancy-related anxiety and significance level set at p < 0.05. The overall prevalence of PRA in this study was 32.7%. Unwanted pregnancy AOR = 2.77, 95% CI [1.71, 4.54], high perceived stress AOR = 2.39, 95% CI [1.54, 3.62], young age AOR = 2.14, 95% CI [1.49, 2.83], depression AOR = 2.09, 95% CI [1.39, 2.89], low income AOR = 2.01, 95% CI [1.29, 3.14], and poor social support AOR = 1.79, 95% CI [1.14, 3.37] were significantly associated with Pregnancy-related anxiety. The findings of this study showed that the prevalence of Pregnancy-related anxiety was high in the study area and positively associated with young age, low income, poor social support, high perceived stress, depression, and unwanted pregnancy. This finding suggests that clinicians should integrate screening for Pregnancy-related anxiety into clinical standards, more efforts should be made in the future to reduce the anxiety among pregnant women who had an unwanted pregnancy, young women, and poor social support. Also, it is good to encourage the pregnant mother to enhance their social connectedness by creating a self-help group, and increasing early identification of mental health problems throughout their daily ANC follow-up.

Partner delivered relaxation massage to support mild antenatal anxiety; views of participants

BACKGROUND

Approximately one-fifth of pregnant women suffer from anxiety and/or depression. These mental health conditions are associated with increased infant and maternal morbidity. Relaxation massage has the potential to improve mental health and may provide a vaulable option for pregnant women. This paper reports on participants' experiences of partner delivered massage as a technique to manage mild antenatal anxiety.

METHODS

We conducted a feasibility study with 44 pregnant women who self-assessed as mildly anxious. The women were randomised into massage therapy (14 women/partner dyads) or to an active control group (13 women). 4-6 weeks after the birth of their baby, massage group participants were invited to be interviewed about their experiences; twelve women and four partners agreed. The qualitative data was analysed using reflective thematic analysis.

RESULTS

Four themes emerged from the data; Supporting mental health, Connecting, Useful and adaptable and Making it happen. Partner delivered massage was an accessible and practical method to manage mild anxiety for pregnant women in this study. The massage program also provided useful skills for participants to apply in their lives after the birth of their child, which has the potential to continue to support maternal mental health as well as partner connection.

CONCLUSION

Partner delivered massage offers low-cost, accessible option for pregnant women to manage their mild anxiety. These findings have particular relevance in the context of the COVID-19 pandemic, where anecdotal reports indicate that antenatal stress is increasing and women may have limited access to healthcare services.

Global Mental Health and Nutrition: Moving Toward a Convergent Research Agenda

Both malnutrition and poor mental health are leading sources of global mortality, disease, and disability. The fields of global food security and nutrition (FSN) and mental health have historically been seen as separate fields of research. Each have undergone substantial transformation, especially from clinical, primary care orientations to wider, sociopolitical approaches to achieve Sustainable Development Goals. In recent years, the trajectories of research on mental health and FSN are further evolving into an intersection of evidence. FSN impacts mental health through various pathways such as food insecurity and nutrients important for neurotransmission. Mental health drives FSN outcomes, for example through loss of motivation and caregiving capacities. They are also linked through a complex and interrelated set of determinants. However, the heterogeneity of the evidence base limits inferences about these important dynamics. Furthermore, interdisciplinary projects and programmes are gaining ground in methodology and impact, but further guidance in integration is much needed. An evidence-driven conceptual framework should inform hypothesis testing and programme implementation. The intersection of mental health and FSN can be an opportunity to invest holistically in advancing thinking in both fields.

A prognostic model, including quantitative fetal fibronectin, to predict preterm labour: the QUIDS meta-analysis and prospective cohort study

BACKGROUND

The diagnosis of preterm labour is challenging. False-positive diagnoses are common and result in unnecessary, potentially harmful treatments (e.g. tocolytics, antenatal corticosteroids and magnesium sulphate) and costly hospital admissions. Measurement of fetal fibronectin in vaginal fluid is a biochemical test that can indicate impending preterm birth.

OBJECTIVES

To develop an externally validated prognostic model using quantitative fetal fibronectin concentration, in combination with clinical risk factors, for the prediction of spontaneous preterm birth and to assess its cost-effectiveness.

DESIGN

The study comprised (1) a qualitative study to establish the decisional needs of pregnant women and their caregivers, (2) an individual participant data meta-analysis of existing studies to develop a prognostic model for spontaneous preterm birth within 7 days in women with symptoms of preterm labour based on quantitative fetal fibronectin and clinical risk factors, (3) external validation of the prognostic model in a prospective cohort study across 26 UK centres, (4) a model-based economic evaluation comparing the prognostic model with qualitative fetal fibronectin, and quantitative fetal fibronectin with cervical length measurement, in terms of cost per QALY gained and (5) a qualitative assessment of the acceptability of quantitative fetal fibronectin.

DATA SOURCES/SETTING

The model was developed using data from five European prospective cohort studies of quantitative fetal fibronectin. The UK prospective cohort study was carried out across 26 UK centres.

PARTICIPANTS

Pregnant women at 22⁺⁰-34⁺⁶ weeks' gestation with signs and symptoms of preterm labour.

HEALTH TECHNOLOGY BEING ASSESSED

Quantitative fetal fibronectin.

MAIN OUTCOME MEASURES

Spontaneous preterm birth within 7 days.

RESULTS

The individual participant data meta-analysis included 1783 women and 139 events of spontaneous preterm birth within 7 days (event rate 7.8%). The prognostic model that was developed included quantitative fetal fibronectin, smoking, ethnicity, nulliparity and multiple pregnancy. The model was externally validated in a cohort of 2837 women, with 83 events of spontaneous preterm birth within 7 days (event rate 2.93%), an area under the curve of 0.89 (95% confidence interval 0.84 to 0.93), a calibration slope of 1.22 and a Nagelkerke R ² of 0.34. The economic analysis found that the prognostic model was cost-effective compared with using qualitative fetal fibronectin at a threshold for hospital admission and treatment of ≥ 2% risk of preterm birth within 7 days.

LIMITATIONS

The outcome proportion (spontaneous preterm birth within 7 days of test) was 2.9% in the validation study. This is in line with other studies, but having slightly fewer than 100 events is a limitation in model validation.

CONCLUSIONS

A prognostic model that included quantitative fetal fibronectin and clinical risk factors showed excellent performance in the prediction of spontaneous preterm birth within 7 days of test, was cost-effective and can be used to inform a decision support tool to help guide management decisions for women with threatened preterm labour.

FUTURE WORK

The prognostic model will be embedded in electronic maternity records and a mobile telephone application, enabling ongoing data collection for further refinement and validation of the model.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015027590 and Current Controlled Trials ISRCTN41598423.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 52. See the NIHR Journals Library website for further project information.

Maternal low-intensity psychosocial telemental interventions in response to COVID-19 in Qatar: study protocol for a randomized controlled trial

Introduction

As COVID-19 is spreading, new psychological health problems are suspected to be emerging among pregnant women. Higher maternal mental health distress, including perinatal anxiety, depression, and COVID-19-specific phobia, is supposed to be increasing during the pandemic, which impacts pregnant women’s health and their infants and calls for intervention. Due to the social distancing protocols posed by the pandemic, telemental health interventions have fast become the most common form of psychosocial support for maternal mental health. However, there is no evidence of the effectiveness of maternal low-intensity psychosocial telemental interventions in improving mental health outcomes. The trial’s objective is to evaluate the clinical efficacy of telemental low-intensity psychosocial interventions in pregnant and postpartum women attending the Women Wellness and Research Centre in Qatar in the era of the COVID-19 pandemic.

Methods and analysis

The clinical trial is randomized in which pregnant women will be assigned equally through block randomization between two arms: (1) a control group and (2) an intervention group. The primary endpoint is the perinatal psychological distress, including perinatal depression, anxiety, and COVID-19 phobia in their third trimester; the secondary, tertiary, fourth, and fifth endpoints will be in the postnatal period (3–5 weeks, 2–4 months, 5–7 months, and 8–10 months). This trial involves pregnant women in their second trimester with no mental health illness history who communicate in English and Arabic and consent to participate. A sample size of 58 (29 participants per arm) is targeted.

Discussion

This study will provide recommendations about the efficacy of low-intensity psychosocial maternal telemental interventions to be implemented as a preventive service.

Trial registration

2a-ClinicalTrials.gov NCT04594525. Registered on October 20, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05339-w.

Assessment of anxiety during pregnancy: are existing multiple anxiety scales suitable and comparable in measuring anxiety during pregnancy?

BACKGROUND

This study examined the performance of multiple anxiety scales in measuring anxiety during pregnancy, an important issue due to the possible effect of pregnancy-related symptoms on the measurement of anxiety.

METHODS

Secondary data on anxiety, measured by the State-Trait Anxiety Inventory-State (STAI-S) 20-item and six-item scales, the Edinburgh Postnatal Depression Scale-Anxiety Subscale (EPDS-3A) and the Symptoms Checklist-90-Anxiety Subscale (SCL-90), were obtained from two pregnancy cohort studies. Both cohorts completed the EPDS-3A, while 3341 women completed the STAI-S and 2187 women completed the SCL-90, with 231 women participating in both cohorts. Data were analyzed using confirmatory factor analysis and Spearman correlation.

RESULTS

The STAI-6 had adequate model fit, while the STAI-20 and the SCL-90 had inadequate model fit. Model fitness for the EPDS-3A could not be assessed due to its low number of items. The correlation between the STAI-20 and STAI-6 was excellent (r = 0.93). The correlation of EPDS-3A with other anxiety scales was low to moderate (r (STAI-20) = 0.57, r (STAI-6) = 0.53 and r (SCL-90) = 0.44). The correlation of SCL-90 with both STAI-20 and STAI-6 was low (r < 0.50).

CONCLUSION

Findings indicate that these scales do not measure anxiety as a single dimension and that these scales are incomparable and may conceptualize anxiety differently.

Effect of cognitive behavioral therapy-based counseling on perceived stress in pregnant women with history of primary infertility: a controlled randomized clinical trial

BACKGROUND

Given the prevalence of infertility and consequences of stress, anxiety, and depression during pregnancy and after childbirth, this study aimed to determine the effect of group cognitive behavioral therapy (CBT)-based counseling on perceived stress (primary outcome), anxiety, depression, and quality of life (QoL) of pregnant women with a history of primary infertility.

METHOD

This controlled randomized clinical trial was conducted on 56 pregnant women with a history of primary infertility referred to Infertility Clinic of Al-Zahra Teaching Hospital of Tabriz. The participants were divided into the intervention (n = 28) and control (n = 28) groups using block randomization. The intervention group received group CBT-based counseling after the 14th week of the pregnancy: six in-person sessions and two telephone sessions once per week. The control group received routine care. The Perceived Stress Scale (PSS), Edinburgh Postnatal Depression Scale (EPDS), Van den Bergh's Pregnancy-Related Anxiety Questionnaire (PRAQ), and Quality of Life in Pregnancy (Gravidarum) (QOL-GRAV) were completed through interviews before and 4 weeks after the intervention by the researcher.

RESULTS

There was not any between-group difference in socio-demographic characteristics, except the gestational age and husband educational level (p > 0.05). Both of these variables were adjusted in ANCOVA. After the intervention, the mean scores of perceived stress (mean difference: - 7.3; confidence interval: 95%, from - 0.9 to - 5.6; p < 0.001) and anxiety (mean difference:-14.7; confidence interval: 95%. from - 20.6 to - 8.8; p < 0.001) were significantly lower in the intervention group. The mean depression score in the intervention group was lower than the control; however, this between-group difference was not significant (mean difference: - 1.95; confidence interval: 95% from - 3.9 to 0.2; p = 0.052). The mean score of quality of life in pregnancy was significantly higher in the intervention group than the control (mean difference: - 5.4; confidence interval: 95% from 3.4 to 7.4; p < 0.001).

CONCLUSION

CBT counseling can affect the perceived stress, anxiety, and quality of life of pregnant women with a history of primary infertility. As a result, this counseling approach is recommended along with other counseling approaches to improve the mental health of pregnant women with a history of infertility.

TRIAL REGISTRATION

IRCT Registration Number: IRCT20111219008459N12 , registered on 10/11/ 2018.

Pregnancy and Delivery Outcomes Following Benzodiazepine Exposure: A Systematic Review and Meta-analysis

OBJECTIVE

Understanding the effects of benzodiazepines (BZDs) on maternal/fetal health remains incomplete despite their frequent use. This article quantifies the effects of antenatal BZD exposure on delivery outcomes.

DATA SOURCES

Medline, PsycINFO, CINAHL, Embase, and the Cochrane Library were searched till June 30, 2018.

STUDY SELECTION

English-language cohort studies comparing antenatal BZD exposure to an unexposed group on any delivery outcome were eligible. In all, 23,909 records were screened, 56 studies were assessed, and 14 studies were included.

DATA EXTRACTION

Two reviewers independently assessed quality and extracted data. Estimates were pooled using random effects meta-analysis. Sub-analyses examined several potential moderators including timing of exposure.

RESULTS

There were 9 outcomes with sufficient data for meta-analysis. Antenatal BZD exposure was significantly associated with increased risk of 6 outcomes initially: spontaneous abortion (pooled odds ratio = 1.86; 95% confidence interval [CI], 1.43 to 2.42), preterm birth (1.96; 95% CI, 1.25 to 3.08), low birth weight (2.24; 95% CI, 1.41 to 3.88), low Apgar score (2.19; 95% CI, 1.94 to 2.47), Neonatal Intensive Care Unit (NICU) admission (2.61; 95% CI, 1.64 to 4.14), and induced abortion (2.04; 95% CI, 1.23 to 3.40). There was significant heterogeneity between studies for most outcomes without consistent moderators. Birth weight (mean difference [MD]: -151.35 g; 95% CI, -329.73 to 27.03), gestational age (-0.49 weeks; 95% CI, -1.18 to 0.19), and small for gestational age (SGA; 1.42; 95% CI, 1.00 to 2.01) did not show significant associations although after adjusting for publication bias, gestational age, and SGA became significant, totaling 8 significant outcomes.

CONCLUSIONS

Antenatal BZD exposure appears to be statistically associated with increased risk of several adverse perinatal outcomes. Although confounds cannot be ruled out, NICU admission does appear clinically relevant and consistent with the antidepressant literature.

Generalized and pregnancy-related anxiety prevalence and predictors among pregnant women attending primary health care in Qatar, 2018-2019

Background

Cumulative evidence suggests that early identification of anxiety in pregnancy is important, given that antenatal anxiety has been linked to morbid outcomes in expecting mothers and their offspring. However, the burden of antenatal anxiety is not yet known in Qatar. This research aims to measure the prevalence and determinants of generalized and pregnancy-related anxiety among pregnant women.

Methods

Eight hundred pregnant women completed a structured interview and self-administrated questionnaires after being selected through probability sampling from nine primary healthcare centers distributed across Qatar. We subjected the data to Binary and Multiple Logistic Regression Analysis. Furthermore, we conducted a Confirmatory Factor Analysis for the utilized scales.

Results

Out of eight hundred participants, 26.5% reported high pregnancy-related anxiety, while 16.4% had a generalized anxiety disorder. A high level of perceived social support and resilience was shown to mitigate generalized and pregnancy-related anxiety. However, we revealed that different determinants influence the two types of anxiety.

Limitations

There is no recognized optimal cut-off point to distinguish ‘high risk’ in pregnancy-related anxiety scales.

Conclusions

Pregnancy-related anxiety is more prevalent than generalized anxiety among pregnant women in Qatar, indicating that stakeholders must include screening for pregnancy-related anxiety in Qatar's clinical guidelines. Tailored interventional studies could focus on increasing resilience and social support to decrease the burden of antenatal anxiety.

Relation between Mother's Taekyo, Prenatal and Postpartum Depression, and Infant's Temperament and Colic: A Longitudinal Prospective Approach

This longitudinal cohort correlational study aimed to confirm the relation among taekyo or traditional prenatal practice, prenatal depression, postpartum depression, maternal-fetal interaction, and infant temperament and colic using a prospective design. We recruited 212 women 16-20 weeks pregnant from July 2017 to September 2018; they were followed up until six months postpartum. Data from 97 participants were used in the final analysis. We used the Edinburgh Postnatal Depression Scale, Cranley's Maternal-Fetal Attachment Scale, and What My Baby Is Like as measurement tools. We observed a significant correlation between prenatal maternal depression in the first to third trimesters and 6-8 weeks and six months postpartum. In addition, infant temperament at six months old showed a significant negative correlation with prenatal and postpartum depression: the higher the prenatal and postpartum depression level, the more difficult the infant's temperament. Taekyo practice was significantly related to maternal-fetal attachment (r = 0.45-0.68, p < 0.001). Difficult infants showed more colic episodes than any other type of infant (χ2 = 18.18, p < 0.001). Prenatal and postnatal maternal depression affected infants' temperament and colic episodes. The management of mothers' mental health before and after pregnancy is important for infants' and mothers' health.

Prenatal anxiety and obstetric decisions among pregnant women in Wuhan and Chongqing during the COVID-19 outbreak: a cross-sectional study

OBJECTIVES

To investigate the mental status of pregnant women and to determine their obstetric decisions during the COVID-19 outbreak.

DESIGN

Cross-sectional study.

SETTING

Two cities in China--Wuhan (epicentre) and Chongqing (a less affected city).

POPULATION

A total of 1947 pregnant women.

METHODS

We collected demographic, pregnancy and epidemic information from our pregnant subjects, along with their attitudes towards COVID-19 (using a self-constructed five-point scale). The Self-Rating Anxiety Scale (SAS) was used to assess anxiety status. Obstetric decision-making was also evaluated. The differences between cities in all of the above factors were compared and the factors that influenced anxiety levels were identified by multivariable analysis.

MAIN OUTCOME MEASURES

Anxiety status and its influencing factors. Obstetric decision-making.

RESULTS

Differences were observed between cities in some background characteristics and women's attitudes towards COVID-19 in Wuhan were more extreme. More women in Wuhan felt anxious (24.5 versus 10.4%). Factors that influenced anxiety also included household income, subjective symptom and attitudes. Overall, obstetric decisions also revealed city-based differences; these decisions mainly concerned hospital preference, time of prenatal care or delivery, mode of delivery and infant feeding.

CONCLUSIONS

The outbreak aggravated prenatal anxiety and the associated factors could be targets for psychological care. In parallel, key obstetric decision-making changed, emphasising the need for pertinent professional advice. Special support is essential for pregnant mothers during epidemics.

TWEETABLE ABSTRACT

The COVID-19 outbreak increased pregnant women's anxiety and affected their decision-making.

"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.

Adverse Childhood Experiences and Changing Levels of Psychosocial Distress Scores Across Pregnancy in Kenyan Women

Background: Adverse childhood experiences (ACEs) have been associated with deleterious effects on mental health in pregnancy. Methods: The ACE International Questionnaire (ACE-IQ) was used to measure neglect, abuse, and household dysfunction. Longitudinal mixed effect modelling was used to test the effect of ACEs on pregnancy-related anxiety, depressive symptoms, and perceived stress at two time points (12–19 and 22–29 weeks) during pregnancy. Results: A total of 215 women who were predominantly married (81%) and had attained tertiary education (96%) were enrolled. Total ACEs were significantly associated with depressive symptoms (r = 0.23, p < 0.05) and perceived stress (r = 0.18, p < 0.05). As depressive symptoms decreased, t (167) = −8.44, p < 0.001, perceived stress increased, t (167) = 4.60, p < 0.001, and pregnancy-related anxiety remained unchanged as pregnancy progressed. Contact sexual abuse (p < 0.01) and parental death or divorce (p = 0.01) were significantly associated with depression over time (p < 0.01). Total ACEs in this study were associated with depressive symptoms early but not late in pregnancy. Conclusions: Higher total ACEs were positively associated with depressive symptoms and perceived stress during pregnancy, suggesting that mental disorders may have an impact on pregnancy outcomes and ought to be addressed. Further validation of the Edinburgh Postnatal Depression Scale (EPDS) tool in local settings is required.

Ethnic disparity and exposure to supplements rather than adverse childhood experiences linked to preterm birth in Pakistani women

BACKGROUND

Adverse childhood experiences (ACEs) are associated with prenatal mental health and negative pregnancy outcomes in high income countries, but whether the same association exists in Pakistan, a low- to middle-income (LMI) country, remains unclear.

METHODS

Secondary data analyses of a prospective longitudinal cohort study examining biopsychosocial measures of 300 pregnant women at four sites in Karachi, Pakistan. A predictive multiple logistic regression model for preterm birth (PTB; i.e., <37 weeks' gestation) was developed from variables significantly (P < 0.05) or marginally (P < 0.10) associated with PTB in the bivariate analyses.

RESULTS

Of the 300 women, 263 (88%) returned for delivery and were included in the current analyses. The PTB rate was 11.1%. We found no association between ACE and PTB. Mother's education (P = 0.011), mother's ethnicity (P = 0.010), medications during pregnancy (P = 0.006), age at birth of first child or current age if primiparous (P = 0.049) and age at marriage (P = 0.091) emerged as significant in bivariate analyses. Mother's ethnicity and taking medications remained predictive of PTB in the multivariate model.

LIMITATIONS

Findings are limited by the relatively small sample size which precludes direct testing for possible interactive effects.

CONCLUSIONS

In sum, pathways to PTB for women in LMI countries may differ from those observed in high-income countries and may need to be modelled differently to include behavioural response to emotional distress and socio-cultural contexts.

Physical activity and blood pressure during pregnancy: Mediation by anxiety symptoms

BACKGROUND

During pregnancy, physiological systems and psychological perceptions vary across individuals. Prenatal physical activity has been linked to reduced anxiety symptoms and lower blood pressure values. However, whether anxiety symptoms can mediate the relationship between physical activity and blood pressure during pregnancy remains unclear.

METHODS

In this prospective cohort study, 1275 pregnant women enrolled in Nanjing, China. Life behaviours and anxiety symptoms were investigated during the first trimester. Anxiety symptoms were measured by the Self-Rating Anxiety Scale. Blood pressure values were taken during the third trimester. Multivariate linear regression models were used to estimate the associations of physical activity with anxiety symptoms and blood pressure, and mediating effect models were used to detect the regulating effect by anxiety.

RESULTS

The participants were assigned to 3 groups based on their frequency and intensity of physical activity, and those who engaged in regular physical activity had lower blood pressure values. Anxiety symptoms were milder in the regular group than in the insufficient group. Partial mediating effect of anxiety on the association between regular physical activity and systolic blood pressure was significant after accounting for some confounders.

LIMITATIONS

The participants' physical activity and anxiety symptoms were self-reported, as well as the lack of details of physical activity during pregnancy may restrict the power of our findings.

CONCLUSIONS

Regular physical activity might be beneficial for anxiety and blood pressure. Physical activity likely stabilises systolic blood pressure by alleviating anxiety symptoms. Our research could provide a positive theoretical reference for guiding prenatal care.

DNA methylation patterns in T lymphocytes are generally stable in human pregnancies but CD3 methylation is associated with perinatal psychiatric symptoms

Objectives

To determine whether DNA methylation patterns in genes coding for selected T-lymphocyte proteins are associated with perinatal psychiatric distress or with complications of pregnancy.

Methods

T lymphocyte DNA was obtained from pregnant women across three time points in pregnancy and the postpartum period and epigenetic patterns were assessed using Illumina 450 ​K Methylation Beadchips. Seven selected genes critical for T cell function were analyzed for methylation changes during pregnancy and for associations of methylation patterns with psychiatric distress or with pregnancy complications, with particular attention paid to spatial aggregations of methyl groups, termed ‘hotspots,’ within the selected genes.

Results

In the candidate gene approach, DNA methylation density within a single cluster of 9 contiguous CpG loci within the CD3 gene was found to be strongly associated with anxiety and depression in mid- and late pregnancy, and weakly associated with the presence of complications of pregnancy. Average DNA methylation density across each of the seven genes examined, and assay-wide, was found to be relatively stable across pregnancy and postpartum, but methylation within the CD3 hotspot was more malleable and changes over time were coordinated across the nine cytosines in the hotspot. CD3 CpGs did not pass array-wide tests for significance, but CpG clusters in two other genes, DTNBP1 and OXSR1, showed array-wide significant associations with anxiety.

Conclusions

Despite the need for tolerating the fetal hemi-allograft, overall DNA methylation patterns in T lymphocytes are generally stable over the mid to late course of human pregnancies and postpartum. However, site-specific changes in DNA methylation density in CD3 appear linked to both symptoms of depression and anxiety in pregnancy and, less strongly, to adverse pregnancy outcomes.

•

Associations exist between DNA methylation density in T cells and measures of stress and mental health in pregnant women.

•

Global DNA methylation density is generally stable over the course of pregnancy.

•

A subregion within the CD3 gene has unusually variable DNA methylation density and is associated with anxiety and depression.

•

Spatial and gene specificity may be important elements of epigenetic regulation of immune function in pregnancy.

Neighbourhood socioeconomic status modifies the association between anxiety and depression during pregnancy and preterm birth: a Community-based Canadian cohort study

OBJECTIVE

This study examined the association of anxiety alone, depression alone and the presence of both anxiety and depression with preterm birth (PTB) and further examined whether neighbourhood socioeconomic status (SES) modified this association.

DESIGN

Cohort study using individual-level data from two community-based prospective pregnancy cohort studies (All Our Families; AOF) and Alberta Pregnancy Outcomes and Nutrition (APrON) and neighbourhood SES data from the 2011 Canadian census.

SETTING

Calgary, Alberta, Canada.

PARTICIPANTS

Overall, 5538 pregnant women who were <27 weeks of gestation and >15 years old were enrolled in the cohort studies between 2008 and 2012. 3341 women participated in the AOF study and 2187 women participated in the APrON study, with 231 women participated in both studies. Women who participated in both studies were only counted once.

PRIMARY AND SECONDARY OUTCOME MEASURES

PTB was defined as delivery prior to 37 weeks of gestation. Depression was defined as an Edinburgh Postnatal Depression Scale (EPDS) score of ≥13, anxiety was defined as an EPDS-anxiety subscale score of ≥6, and the presence of both anxiety and depression was defined as meeting both anxiety and depression definitions.

RESULTS

Overall, 7.3% of women delivered preterm infants. The presence of both anxiety and depression, but neither of these conditions alone, was significantly associated with PTB (OR 1.6, 95% CI 1.1 to 2.3) and had significant interaction with neighbourhood deprivation (p=0.004). The predicted probability of PTB for women with both anxiety and depression was 10.0%, which increased to 15.7% if they lived in the most deprived neighbourhoods and decreased to 1.4% if they lived in the least deprived neighbourhoods.

CONCLUSIONS

Effects of anxiety and depression on risk of PTB differ depending on where women live. This understanding may guide the identification of women at increased risk for PTB and allocation of resources for early identification and management of anxiety and depression.

Interleukin-17A and Chronic Stress in Pregnant Women at 24-28 Weeks Gestation

BACKGROUND

Allostatic load (AL) is a biopsychosocial model that suggests chronic psychosocial stress leads to physiological dysregulation and poor outcomes. The purpose of this study was to examine AL in pregnant women operationalized using proinflammatory cytokines and psychosocial indicators and perinatal outcomes.

OBJECTIVES

The aim of the study was to identify relationships between circulating cytokines/chemokines and the Prenatal Distress Questionnaire, the Maternal Antenatal Attachment Scale, the Emotional Quotient Inventory, the Life Experiences Scale, and demographics in pregnant women.

METHODS

A cross-sectional design was used to recruit pregnant women between 24 and 28 weeks of gestation. Blood and stress/emotional indicators were obtained after informed consent. Plasma was abstracted to simultaneously measure 29 cytokines/chemokines using a multiplex array. Cytokine/chemokine levels were compared with continuous variables using Spearman's rho and with categorical variables using Mann-Whitney U.

RESULTS

Twenty-five women with medically high-risk (n = 16) and low-risk (n = 9) pregnancies consented. Most women were White (68%) with a mean age of 29 years (SD = 5.9). Although several cytokines and chemokines showed significant correlations with the stress/emotional indicators, only interleukin-17A (IL-17A) was significantly associated with all of the indicators (Prenatal Distress Questionnaire: rs = .528, p = .012; Maternal Antenatal Attachment Scale: rs = -.439, p = .036; Emotional Quotient Inventory total: rs = -.545, p = .007), Life Experiences Scale (rs = .458, p = .032), birth weight (rs = -.499, p = .013), and race (p = .01).

DISCUSSION

Increased levels of IL-17A, a known cytokine associated with chronic stress and with poor perinatal outcomes, were associated with high prenatal distress, low maternal attachment, and lower emotional intelligence in pregnant women. Increased levels of IL-17A also were associated with lower birth weight and non-White race. Results support the model of AL in pregnant women and highlight IL-17A as a potential biomarker of AL during pregnancy.

A systematic review and meta-analysis of the effects of antenatal anxiety on postpartum outcomes

To systematically review and meta-analyze research investigating the association between maternal anxiety during pregnancy and outcomes for mother and baby following the immediate delivery period. MEDLINE, Medline In-Process & Other Non-Indexed Citations, PsycINFO, Embase, CINAHL, and the Cochrane library were searched. English-language, prospective studies providing data on outcomes following delivery in women with and without antenatal anxiety (defined by clinical diagnosis or score on validated scale) were included. Three-hundred-fifty-eight articles were retrieved and 13 were included. Titles and abstracts were screened; two reviewers independently reviewed full text articles, conducted quality assessments, extracted, and checked the data. Where available for > 2 studies, random effect meta-analysis was conducted and heterogeneity was quantified. Subanalyses explored moderators, regardless of heterogeneity, including type of anxiety assessment and timing, among others. There were two outcomes that were amenable to meta-analysis. Antenatal anxiety was significantly associated with postpartum depression (PPD) measured within 6 months postpartum (pooled odds ratio [OR] = 2.64, 95% CI 2.02-3.46; 8 studies), regardless of restricting analyses to those studies controlling for prenatal depression (2.45, 1.77-3.39; 6 studies). Associations were also significant when PPD was measured at 1-3 months (2.57, 1.94-3.40; 7 studies) and 6-10 months (4.42, 1.45-13.49; 3 studies). Maternal anxiety was also associated with reduced odds of breastfeeding (0.63, 0.53-0.74; 5 studies). Antenatal anxiety is associated with PPD up to the first 10 months, independent of prenatal depression, and with lower odds of breastfeeding.

Prediction of recurrent preterm delivery in asymptomatic women- an anxiety reducing measure?

OBJECTIVES

The QUiPP application is used to predict the risk of recurrent preterm birth (PTB) in asymptomatic high risk women with a previous PTB. Our study aims to evaluate the impact of the use of the QUiPP app on maternal anxiety levels.

STUDY DESIGN

A retrospective cohort study on asymptomatic pregnant women attending the Prevention of Preterm Birth Clinic in a busy tertiary unit. Women included in the study had a history of previous PTB. The study assessment occurred at approximately 4 weeks prior to the gestation of the earliest previous PTB and included measurement of cervical length and vaginal fetal fibronectin. Data was inputted into the QUiPP application, which in turn estimated risk of preterm delivery at specific intervals. Measured outcomes were gestation at delivery, time from risk assessment to delivery, infant birth weight, NICU admission and length of stay. In addition, maternal anxiety levels were retrospectively assessed using a questionnaire with a Likert scale.

RESULTS

Seventy six women were included in the study. All women were asymptomatic for preterm labour at assessment. The mean gestation at the time of risk assessment was 27 weeks, the mean time from risk assessment to delivery was 72 days. Average gestation at time of delivery was 37 weeks (range 22-42 weeks). The preterm birth rate was 29% (n = 22).Seventy seven percent of women who delivered <37 weeks, and 80% who delivered <34 weeks were given QUiPP scores predicting a ≥5% chance of PTB within four weeks of their actual delivery date. Sixteen percent of infants were admitted to NICU (n = 12) with a mean length of stay of 21 days. All infants went home well with their parents.Eighty four percent of respondents to our questionnaire reported feeling anxious about their pregnancy prior to attending the clinic. After receiving a QUIPP score 90% said they felt reassured and 79% reported that the felt less anxious.

CONCLUSION

In asymptomatic women, the use of the QUiPP app helps to predict, prevent, and optimise PTB. This surveillance has a beneficial role for maternal mental well-being in that it reduces anxiety at a key time during a pregnancy.

Validation of an anxiety scale for prenatal diagnostic procedures

OBJECTIVE:

To perform a cross-cultural adaptation of the Prenatal Diagnostic Procedures Anxiety Scale questionnaire for application in the Brazilian cultural context.

METHODS:

The translation and back translation processes followed internationally accepted criteria. A committee of experts evaluated the semantic, idiomatic, experimental and conceptual equivalence, proposing a pre-final version that was applied in 10.0% of the final sample. Afterwards, the final version was approved for the psychometric analysis. At that stage, 55 pregnant women participated which responded to the proposed Brazilian version before taking an ultrasound examination at a public hospital in Santa Catarina, in the year of 2017. The Edinburgh Postnatal Depression Scale was used as an external reliability parameter. The internal consistency of the instrument was obtained by Cronbach's alpha. Validation was performed by exploratory factorial analysis with extraction of principal components by the Kaiser-Guttman method and Varimax rotation.

RESULTS:

The Cronbach's alpha value of the total instrument was 0.886, and only the percentage of variance from item 2 (0.183) was not significant. The Kaiser-Guttman criterion defined three factors responsible for explaining 78.5% of the variance, as well as the Scree plot. Extraction of the main components by the Varimax method presented values from 0.713 to 0.926, with only item 2 being allocated in the third component.

CONCLUSIONS:

The Brazilian version is reliable and valid for use in the diagnosis of anxiety related to the performance of ultrasound procedures in prenatal care. Due to the lack of correlation with the rest of the construct, it is suggested that item 2 be removed from the final version.

Placental FKBP51 mediates a link between second trimester maternal anxiety and birthweight in female infants

Prenatal distress is associated with adverse outcomes in affected offspring. Alterations in placental glucocorticoid signalling and subsequent foetal overexposure to glucocorticoids have been implicated as an underlying mechanism. Infant sex is emerging as an important factor in disease susceptibility. This study aimed to examine the effects of maternal distress across pregnancy on birth outcomes and placental glucocorticoid genes in a sex-dependent manner. Participants completed psychological distress questionnaires throughout pregnancy. Placental HSD11B2, NR3C1 and FKBP51 were analysed by real time PCR and cortisol was measured in new-born hair. Second trimester stress was negatively correlated with birthweight in males and positively correlated with placental NR3C1 mRNA in females. Second trimester anxiety was negatively correlated with birthweight and placental FKBP51 mRNA in females. In mediation analysis, placental FKBP51 mRNA expression was found to mediate the link between prenatal anxiety and birthweight. New-born cortisol was negatively correlated with second trimester anxiety and positively correlated with female placental FKBP51 mRNA levels. Again, FKBP51 mRNA was found to mediate the link between anxiety and new-born cortisol. These results highlight a role for FKBP51 in the placental response to prenatal distress in females. The precise role that placental FKBP51 has in foetal and infant development has not been extensively studied and warrants further investigations.

The Microbiome and Preterm Birth: A Change in Paradigm with Profound Implications for Pathophysiologic Concepts and Novel Therapeutic Strategies

Preterm birth poses a global challenge with a continuously increasing disease burden during the last decades. Advances in understanding the etiopathogenesis did not lead to a reduction of prematurely born infants so far. A balanced development of the host microbiome in early life is key for the maturation of the immune system and many other physiological functions. With the tremendous progress in new diagnostic possibilities, the contribution of microbiota changes to preterm birth and the acute and long-term sequelae of prematurity have come into the research focus. This review summarizes the latest advances in the understanding of microbiomes in the amniotic cavity and the female lower genital tract and how changes in microbiota structures contribute to preterm delivery. The exhibition of these highly vulnerable infants to the hostile environment in the neonatal intensive care unit necessarily entails the rapid colonization with a nonbalanced microbiome in a situation where the organism is still very prone and at an early stage of development. The global research efforts to decipher pathologic changes will pave the way to new pre- and postnatal therapeutic concepts.

Is there an association between maternal anxiety propensity and pregnancy outcomes?

Background

Several studies have shown inconsistent associations between anxiety during pregnancy and adverse pregnancy outcome. This inconsistency may be due to lack of controlling for the timing and type of maternal anxiety. We aimed to isolate a specific type of anxiety - maternal anxiety propensity, which is not directly related to pregnancy, and evaluate its association with adverse pregnancy outcome.

Methods

We conducted a prospective observational study of 512 pregnant women, followed to delivery. The trait anxiety scale of the State-Trait Anxiety Inventories was used in order to detect a propensity towards anxiety. The association between anxiety propensity (defined as trait-anxiety subscale score above 38) and adverse pregnancy outcome was evaluated. Primary outcome was a composite outcome including preterm birth prior to 37 gestational weeks, hypertensive disorders in pregnancy, small for gestational age newborn and gestational diabetes mellitus. Secondary outcomes were each one of the above mentioned gestational complications.

Results

There were no significant between-group differences in adverse pregnancy outcomes, including the rate of preterm birth, hypertensive disorders, small for gestational age, gestational diabetes or a composite outcome of them all.

Conclusion

Anxiety propensity is not associated with adverse pregnancy outcome.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1925-8) contains supplementary material, which is available to authorized users.

Prevalencia de Trastorno de Ansiedad Generalizada según el Trimestre de Embarazo

Introducción: El trastorno de ansiedad generalizado (TAG) es una entidad clínica caracterizada por preocupación excesiva y no controlada que puede causar discapacidad funcional, durante un período mínimo de 6 meses. La prevalencia global de TAG en las pacientes en estado de gestación es de 8.5% a 10.5%, la cual es mayor en comparación a la población general (reportada de 1.2% a 6.4%). Entre los factores de riesgo se incluyen: bajo nivel educacional y socioeconómico, pobreza, desintegración familiar, etc. Se ha reportado como complicaciones de TAG durante el embarazo: incremento de consumo de alcohol, riesgo de parto pre término, bajo peso al nacer, etc. Objetivo: Determinar la prevalencia de trastorno de ansiedad generalizada según el trimestre de embarazo en mujeres gestantes de San Juan Sacatepéquez ya que no existen datos de dicha población. Metodología: Se empleó la escala GAD-7. Se escogió como población a pacientes que asistieron a la consulta externa del Centro de Salud Bárbara durante el mes de junio del 2018.  Resultados: La prevalencia de TAG hallada fue: 7.40% en el primer trimestre, 8.82% en el segundo trimestre y 7.31% en el tercer trimestre.

Factors associated with pregnancy-related anxiety in Tanzanian women: a cross sectional study

OBJECTIVE

To identify factors predictive of pregnancy-related anxiety (PRA) among women in Mwanza, Tanzania.

DESIGN

A cross-sectional study was used to explore the relationship between psychosocial health and preterm birth.

SETTING

Antenatal clinics in the Ilemela and Nyamagana districts of Mwanza, Tanzania.

PARTICIPANTS

Pregnant women less than or equal to 32 weeks' gestational age (n=212) attending the two antenatal clinics.

MEASURES

PRA was measured using a revised version of the 10-item PRA Questionnaire (PRA-Q). Predictive factors included social support (Multidimensional Scale of Perceived Social Support), stress (Perceived Stress Scale), depression (Edinburg Postpartum Depression Scale) and sociodemographic data. Bivariate analysis permitted variable selection while multiple linear regression analysis enabled identification of predictive factors of PRA.

RESULTS

Twenty-five per cent of women in our sample scored 13 or higher (out of a possible 30) on the PRA-Q. Perceived stress, active depression and number of people living in the home were the only statistically significant predictors of PRA in our sample.

CONCLUSIONS

Our findings were contrary to most current literature which notes socioeconomic status and social support as significant factors in PRA. A greater understanding of the experience of PRA and its predictive factors is needed within the social cultural context of low/middle-income countries to support the development of PRA prevention strategies specific to low/middle income countries.

Exposure to different intrauterine environments: implications for telomere attrition in early life

Objective: Studies focusing on telomere attrition in newborns and what factors could be involved in this issue are sparse; most reports have been in adult populations. Thereby, the aim of this study was to present an overview of what is currently known about the relationship between environmental exposure of the fetus during pregnancy and telomere length outcomes in early life. Methods: The MEDLINE (via PubMed) and Bireme databases were searched for studies published until 1 June 2016. Studies that reported telomere length measurement from birth to age 1 year were included. Results: Fifteen articles were selected that evaluated possible relationships between maternal smoking, hyperglycemia, hypertension, sleep apnea, psychological stress, folate concentration in early pregnancy, and radiation, in addition to small-for-gestational-age status and preterm birth. We found that sleep apnea, psychological stress, and folate concentration in early pregnancy were associated with telomere shortening in the newborn. No association was found with radiation, small-for-gestational-age status, or preterm birth. Results for maternal smoking, hyperglycemia, and hypertension were conflicting, and further studies should be considered. Conclusion: The actual clinical implications of these findings have yet to be investigated.

Prenatal Maternal Anxiety in South Asia: A Rapid Best-Fit Framework Synthesis

Background: Most research efforts toward prenatal maternal anxiety has been situated in high-income countries. In contrast, research from low- and middle-income countries has focused on maternal depression and prenatal maternal anxiety in low- and middle-income countries remains poorly understood. Objectives: To examine whether dimensions and attributes of current maternal anxiety assessment tools appropriately capture South Asia women's experiences of perinatal distress during pregnancy. Design: We conducted a rapid review with best fit framework synthesis, as we wished to map study findings to an a priori framework of dimensions measured by prenatal maternal anxiety tools. Data Sources: We searched MEDLINE, PsycINFO, and CINAHL and gray literature in November 2016. Studies were included if published in English, used any study design, and focused on women's experiences of prenatal/antenatal anxiety in South Asia. Review Methods: Study quality was assessed using the Effective Public Health Practice Project Quality Assessment Tool and Critical Appraisal Skills Programme Qualitative Checklist. Study findings were extracted to an a priori framework derived from pregnancy-related anxiety tools. Results: From 4,177 citations, 9 studies with 19,251 women were included. Study findings mapped to the a priori framework apart from body image. A new theme, gender inequality, emerged from the studies and was overtly examined through gender disparity, gender preference of fetus, or domestic violence. Conclusions: Gender inequality and societal acceptability of domestic violence in South Asian women contextualizes the experience of prenatal maternal anxiety. Pregnancy-related anxiety tools should include domains related to gender inequality to better understand their influence on pregnancy outcomes.

The Role of Body, Mind, and Environment in Preterm Birth: Mind the Gap

Preterm birth continues to be a problem affecting low-, middle-, and high-income countries, with rates increasing in some areas despite ongoing efforts to reduce the incidence. This emphasizes the need for more effective interventions, particularly if we aim to achieve the broad health targets of the Sustainable Development Goals (SDGs) by 2030. The current focus on medically-oriented interventions such as reducing nonmedically-indicated induction of labor, cesarean birth, and multiple embryo transfers associated with assisted reproductive technologies, as well as the application of cervical cerclage and use of progesterone therapy, though important, are likely only partial solutions to the complex phenomenon of preterm birth. Preterm birth has multiple etiologies. The biologic mechanisms involved in preterm labor and how it may be triggered are not well understood. There is growing evidence to suggest some of these triggers may also be related to stress and environmental conditions. In this review, we focus on evidence concerning psychosocial (mind) and environmental factors (environment) as well as briefly review the evidence related to maternal and fetal factors (body) associated with the risk of preterm birth, with reference to some of the SDGs. We also assess emerging evidence regarding the interaction of the body, mind, and environment in relation to preterm birth, currently a gap in our knowledge, and how these interactions could impact clinical practice. Findings suggest that multidisciplinary expertise and approaches will be needed to develop effective interventions to address the complex etiologies of preterm birth, as opposed to single-risk-factor mitigation. Clinicians and researchers will play key roles in identifying many of these risk factors and shaping interventions that address this complex issue. Addressing the interlinkages between body, mind, and environment through the integration of research and clinical practice is critical to reducing the risk of preterm birth and contributing to the achievement of the SDGs.

Pregnancy-related anxiety and depressive symptoms are associated with visuospatial working memory errors during pregnancy

BACKGROUND

Cognitive deficits, especially in memory and concentration, are often reported during pregnancy. Similar cognitive dysfunctions can also occur in depression and anxiety. To date, few studies have investigated the associations between cognitive deficits and psychiatric symptoms during pregnancy. This field is of interest because maternal cognitive functioning, and particularly its higher-order aspects are related to maternal well-being and caregiving behavior, as well as later child development.

METHODS

Pregnant women (N =230), reporting low (n =87), moderate (n =97), or high (n =46) levels of depressive, general anxiety and/or pregnancy-related anxiety symptoms (assessed repeatedly with EPDS, SCL-90/anxiety subscale, PRAQ-R2, respectively) were tested in mid-pregnancy for their cognitive functions. A computerized neuropsychological test battery was used.

RESULTS

Pregnant women with high or moderate level of psychiatric symptoms had significantly more errors in visuospatial working memory/executive functioning task than mothers with low symptom level. Depressive symptoms throughout pregnancy and concurrent pregnancy-related anxiety symptoms were significant predictors of the performance in the task. General anxiety symptoms were not related to visuospatial working memory.

LIMITATIONS

Cognitive functions were evaluated only at one time-point during pregnancy precluding causal conclusions.

CONCLUSIONS

Maternal depressive symptoms and pregnancy-related anxiety symptoms were both associated with decrements in visuospatial working memory/executive functioning. Depressive symptoms seem to present more stable relationship with cognitive deficits, while pregnancy-related anxiety was associated only concurrently. Future studies could investigate, how stable these cognitive differences are, and whether they affect maternal ability to deal with demands of pregnancy and later parenting.